Allan Tasman, MD

The social determinants of mental health surround us. You only need to take a look around to see them. For instance, consider the following scenarios.

 “He shot my friend and his little boy as they were going into their house. I had just been walking with my friend when that guy walked right by me and shot them. I had just said goodbye on their front steps and was only about 20 feet away. My friend was a few years older, and I looked up to him. His son was 6. We both knew the guy who shot him, but I have no idea why it happened. I started feeling really depressed a few weeks later and made an appointment at the clinic.”

This is what the patient I (AT) was seeing, in consultation with his treating resident, told me when I asked him why he decided to come to our clinic. The resident said that the patient, who he had been seeing monthly for medical checks, met the DSM-5 criteria for 

 and did not meet the DSM-5 criteria for acute stress. Assuming the patient’s symptoms were due to grief, he had started the patient on antidepressants 3 months prior, but there was no improvement. As the patient was talking with me, I agreed that his symptoms met the criteria for 

. But something in the way he was talking made me feel as if he was holding something back. I apologized for perhaps being presumptuous, as we had not met before, and asked if my feeling made sense to him. After a moment’s hesitation, he said, “Yes, there is something. I just keep thinking about what happened, and I feel guilty. I think about it all night and can’t sleep. I should have done something to keep him and his son from being killed.” He did have a stress disorder, and the mood changes were part of it.

 Not long ago, a patient who had been working hard on her recovery from 

, depression, and opiate use came to see me (KST) and said, “I want to get a job. I want a real paycheck. But I’m afraid to apply. What will I do when they ask me about the big gaps in my résumé? I know they won’t hire me.”

What tools can I use during treatment to help her learn to confront the stigma and discrimination she faces? What resources might there be to help her find work?

 I (KST) was part of a project that created a treatment and recovery program in a shelter. It was successful. People got better.

Unfortunately, the patients soon realized there was no housing available for them, and they felt overwhelming disappointment. They “got all dressed up and had nowhere to go.” My team and I were distraught that we could only find housing for 1 of 10 participants. There just was not enough affordable housing to go around.

Need for advocates on a larger, more political scale.

 I (KST) recently had a call from a friend of mine who has decided to run for Congress. He wants to help the people in Pittsburgh who have been left behind by the economy and further injured by the pandemic. He knows that 20% of the children in the district live in poverty. He knows about the deaths of despair due to opiates, 

, and alcohol—the wages of deindustrialization. He wants to do the critical things necessary to improve our region’s health and well-being. What does he need to think about?

All of these scenarios present a number of questions. How did that resident—a very good one—miss a key emotional aspect of his patient’s world? How do we help people deal with the 

 and other kinds of discrimination? How did we lose sight of the fact that people who are homeless need housing and that unemployed people want jobs? How often do we think about the importance of eliminating child poverty for the mental health of 

? What in our psychiatric training and practice prepares us to really offer meaningful public policy advice that will equitably promote physical health, mental health, and well-being?

Where Has the Social in Biopsychosocial Been?

Should these questions come as a surprise to us? Of course not. Although science and experience have long made clear that social factors are a significant determinant of mental health and illness (as well as physical illness), we have often assumed there is little that we, as psychiatrists, can do about them. This has been particularly true for the last 40 years, with the rise of biological psychiatry and reaction against the social activism of the 1960s. It has resulted in omitting key aspects of the social in the 

 to psychiatric practice. This, in turn, has resulted in an inadvertent imprinting in our training programs and psychiatric practice with the belief that because there is little we can do about those factors at the societal level, there is little reason to address them with our patients, in our profession, or with society.

But what if it’s not true that there is little we can do? What if we just haven’t found the most productive ways to act on behalf of our patients and the society in which we all live? Fortunately, in part due to the events of the past 2 years, the field has been thinking harder about this challenge. Our scientific evidence and our experience have made abundantly clear that psychiatric challenges are not randomly distributed among people. We now know that 

. We also know that social identity and the experiences and exposures that constitute it plays a role—it is the water in which we swim.

Findings from innumerable studies in medical and psychiatric epidemiology have demonstrated a clear stepwise gradient at the population level between the burden of physical and psychiatric disorder and social class. Data from other studies have demonstrated how rates of disorders and treatments vary inequitably by age, geography, gender, sexual identity, disability, and race. These findings have brought a renewed focus on these experiences and exposures in a process we might compare to the efforts to map the genome.

 16 Categories of Social Determinants of Mental Health, in 4 Broad Buckets

In this regard, the work of Ruth S. Shim, MD, MPH, and Michael T. Compton, MD, MPH, and their colleagues stands out (

 incorporates years of study that directs our attention to the social determinants of general health and well-being. In the book, Shim and Compton outline some of the critical elements we must consider to better understand the social determinants of mental health in a way that is thorough, if not exhaustive. They include issues such as discrimination and adverse life experiences including exposure to 

, poor education, neighborhood deprivation, housing, unemployment, and more. They describe the impact of each of these on mental health with critically important ideas about how to address them at the clinical, public health practice, and policy levels.

Just as crucial as this new understanding of the problem is the growing willingness to act on it, fueled by a desire for social justice and to ensure that all people can thrive. Although distress over inequitable treatment on account of race, class, and gender has been around for a long time, only recently has the focus shifted to the much more ambitious desire to minimize, or ideally eliminate, inequities in the health status of different populations. The goal of achieving health equity goes far beyond that of ensuring health care for all. It reflects the growing awareness that health care has only a limited role in the production of health. This new pursuit of health equity requires a keen focus and action on the social determinants of mental health and well-being.

How can we do this? Where do we begin to enhance psychiatric training and practice to incorporate these issues? How can we better address the basic needs patients bring to us in practice? How can we develop a 

 to mental health and create and implement primary prevention interventions? How can we begin to understand how social policies affect mental health, and where can we learn about and practice public policy development and implementation? Answering these questions will involve a sustained major effort throughout our profession.

We know that our largest professional organizations have withdrawn from addressing these issues, perhaps responding to harsh criticism of our social activism in the 1960s and 1970s. This moment, however, is different. If the events of the last decade—especially in the past 2 years—have taught us anything, it is that, as practicing psychiatrists, we cannot stick to narrowly defined “medical necessity.” We cannot take care of people and expect the world in which they live to take care of itself.

We need to know enough about their world to understand the challenges they face and address those during treatment. We have to learn what we can do to make that world a better place for them to be. And it goes beyond this. It is not just about our patients. It also includes the people who are not our patients (yet). We need to do all we can to help prevent psychiatric disorders and to equitably promote mental health and well-being. Of course, we cannot do this alone. We will need help from each other and from our whole society.

To accomplish this, our profession must lead the charge. Not only do we have the knowledge that requires action, we also have a social position that demands it. As a group of privileged professionals, psychiatrists live very well in our current social structure. We certainly earn it, but much of our income results in part from the suffering our society generates. To not recognize and respond to this fact risks making us complicit with the inequities we see every day.

Fortunately, our largest and most important professional organization has, although belatedly, started stepping up. Vivian B. Pender, MD, president of the American Psychiatric Association (APA), has initiated the special Task Force on the Social Determinants of Mental Health. This group’s charge is to help catalyze action on the goals addressed in a position paper regarding social determinants endorsed by the APA Board of Trustees and Assembly in 2018

 The APA’s Position Statement on Social Determinants

While, to date, there has been little action to implement the positions approved in 2018, task force work groups are currently considering how the APA can better promote and implement the positions approved by the board of trustees 3 years ago.

To ensure that the work of the task force does not become just another paper on a shelf, the task force submitted a proposal to the APA board to fund a fulltime staff director position so that our most important professional organization can more effectively focus on the 

. This proposal was rejected as premature by the APA budget committee in November 2021, and the future for APA action in this regard is not known as we write this column.

Author David Foster Wallace famously observed that just as fish do not recognize the water in which they swim, people often have little awareness of the world in which we all inhabit. It is too close—too overwhelming. It takes a great deal of effort and time to gain enough perspective to see the incredibly complex social aspects of our world and to learn how they can be shaped for ourselves and others.

It is our hope that, as you read this, you have already learned that the APA—the flagship organization of our profession—has better understood the water around us and has not missed the boat to begin a new journey toward more effective training, practice, and advocacy regarding the social determinants of mental health.

is medical director and founder of the Pennsylvania Psychiatric Leadership Council and former medical director of the Center for Mental Health Services at the Substance Abuse and Mental Health Services Administration. 

is emeritus John J. and Ruby B. Schwab Endowed Chair in Social, Community and Family Psychiatry and a professor at the University of Louisville School of Medicine, past president of the APA, and editor emeritus of 

Both authors are members of the APA Task Force on the Social Determinants of Mental Health, but the perspectives and opinions expressed in this article are their own and not necessarily those of the task force.

1st ed. American Psychiatric Publishing; 2015.

Position statement on mental health equity and the social and structural determinants of mental health.

Articles

Here's why we need more effective training, practice, and advocacy regarding the social determinants of mental health.

This Is the Water: The Social Determinants of Mental Health and the Future of Psychiatry

With one breath, with one flow
	You will know Synchronicity

A sleep trance, a dream dance,
	A shared romance, Synchronicity

A connecting principle, Linked to the invisible
	Almost imperceptible, Something inexpressible, Science insusceptible.
	Logic so inflexible, Causally connectible
	Yet nothing is invincible. . . .

If you act, as you think,
	The missing link, Synchronicity.

In a brief experience of synchronicity, just before I sat down to write this last editorial in my capacity as Editor in Chief of 

 about the author’s feeling privileged to speak with several individuals who had written a Psychiatric Advanced Directive (PAD).

 The writer felt humbled by those individuals’ willingness to speak with her about their illness. Having had few such discussions, she was struck by how much the individuals she interviewed were aware of their own mental states. To me, though, it was clear that something about the relationship the writer had developed with those individuals fostered their willingness to share their inner worlds with her.

The experience of learning to know another’s inner self is one of the most difficult, but most gratifying parts of our clinical work, and I’ve written about this in 

 and elsewhere and lectured about it, on many occasions. To me, this capacity is at the heart of successful work with our patients and learning about it is the most difficult but important skill for psychiatrists.

One of my first experiences as a third-year medical student during my first rotation, in psychiatry, was learning that it is possible to understand a patient even in the most severe psychotic state. When the chief resident asked a patient with schizophrenia how he was doing, the patient responded with an angry tirade about how Lyndon Johnson was burning and killing defenseless babies in Vietnam. I was taken aback at the patient’s vehemence, but our chief resident calmly asked if our patient felt someone had been mean to him that morning. Yes, the patient replied, he thought the nurse was angry when she gave him his medications. Our chief said that the nurse was very busy and wasn’t angry with him at all. The patient visibly relaxed with this brief reality testing, nonpsychotic interchange.

A few weeks ago, I had a similar experience with being in synchronicity with a patient. I was asked to join a resident in speaking with a young man who had been unsuccessfully treated with medications for an acute onset of depression and anxiety several months following the shooting death of two close relatives. After speaking with him only for several minutes, I felt there was likely something that he hadn’t spoken about that was bothering him.

Was it his body language, open, but holding back at the same time; his affect, the worried expression on his face; or something more? I can’t really say. But I felt something was missing and I asked if he knew why he felt so bad, even beyond the fact that the two deaths were so understandably and horribly upsetting. Yes, he said with no hesitation, he felt guilty.

“Why?” I asked. “Because I should have been able to prevent it,” he responded. This led to a brief conversation in which I began to better understand the origin of his ongoing guilt. As he told me the specific details of what had happened, I thought his guilt was in reality unjustified. His response to my subsequent question about whether he had told anyone about his guilt led to his revealing that he had not because he felt so ashamed.

I’ve been doing clinical work for over four decades, and I still can’t explain how at certain moments with certain patients I feel in tune with them. It’s my and their state of consciousness within our relationship that in some way seems to help them to reveal something about their inner lives to me. When I teach residents and students, I talk about this state as learning to listen not as an external observer but as an empathic listener. I’m not sure, though, that description completely captures what is happening.

I still can’t really explain what allows us to inhabit, even though briefly and incompletely, the hidden self of another person. Is it a finely tuned mirror neuron neural network, or quantum mind and entangled electrons, or something else? I just don’t know, although I do know that we can enhance our ability with time and effort and self-reflection. And, it may be that Heinz Kohut was right when he asserted that empathic connection and understanding, this sharing of souls, this synchronicity, is the curative transmuting component of our psychological treatments. And, that it is likely to affect the outcome of all treatments.

Outside of a science fiction story, we still don’t have an expeditious way to enhance the capacity for developing empathic connections. At present, developing this skill requires lengthy practice. But, who can say what the future holds. Our neuroscience research findings about brain function are growing too fast to keep up with. What the near and distant learning path will be for this and other related and critically important aspects of the curative process is hard to predict. I think there’s a long road ahead, one that may take another generation to travel. I’ll likely not be working, or perhaps not even alive by the time the full understanding is discerned.

. . . I’ve finally decided my future lies

There are so many issues we deal with and so many barriers, from too few psychiatrists, to lack of knowledge and inadequate skills, to societal, governmental, and health system matters, that an apparently unending array of work remains to be done. I am honored and appreciative, and fortunate, that I’ve had a chance to highlight some of this ongoing work through my position at 

There are still many patient populations that have little access to psychiatric care, including children, the elderly, those living in urban core or rural areas, service veterans, and members of minority racial, ethnic, gender, and immigrant groups. Of great concern is that suicide rates continue what appears to be an inexorable rise, including those at both the younger and older ends of the life cycle. And, the CDC just reported that that gun deaths were the highest in the 2017 reporting cycle than in decades, or possibly ever in the US. On the other hand, the government, although not nearly quickly or thoroughly enough, is beginning to take concrete steps to address the opiate addiction and overdose death epidemic.

 has addressed all these issues and many more. And, I’m proud that during my tenure as Editor in Chief, we’ve begun to implement a number of initiatives to continue improving the quality of the articles you read both in print and on our website. It has been gratifying that the publishing staff have been responsive to a number of ideas from Michelle Riba, our deputy editor who also is stepping down from her editorial leadership position, and me.

We’ve taken steps to diversify the editorial board in keeping with national best practices to improve equitability, diversity, and inclusiveness of historically underrepresented voices. We instituted an editorial advisory board comprised of residents and recent graduates to open editorial access to the newest generation of our colleagues.

We also are quite proud of the formal alliances we’ve formed with a number of important subspecialty organizations in psychiatry. The expert contributions that have come from these relationships have clearly raised the bar for our content. In addition, we’ve benefitted from regular contributions from psychiatrists with a very diverse array of interests and expertise such as Fuller Torrey, Allen Frances, Harvey Greenberg, Tom Kosten, and Ron Pies to name just a few. David Pollack and his colleagues, as another recent example, have begun what will be an ongoing series on the psychiatric issues related to climate change. Ongoing work will assure that 

 continues to achieve greater diversity in our regular contributors.

One of the most important collaborations I’ve been fortunate to have over my career has been the one with Michelle Riba. I know that her creativity, diligence, advocacy, and commitment to excellence in every aspect of her work have helped make me a better psychiatrist, scholar, editor, and person than I would otherwise have been. While I know we’ll both miss working together at Psychiatric Times, we also know there will be other collaborations down other roads.

Another important reason my work at Psychiatric Times has been so meaningful to me is not only the opportunity to help advance our field, but also to work with such a terrific and dedicated professional staff. I continue to feel lucky that Susan Kweskin, our former staff leader who I worked with through most of my tenure, convinced me to take the role of Editor in Chief. Although Susan left her position at Psychiatric Times in the spring, we have a connection that is ongoing.

As you may be aware, the ownership of UBM changed recently and that time of transition has seemed to me a good time for me to make my transition from the Editor in Chief role I’ve filled since 2014. In addition to that transition, and Susan Kweskin’s departure, there have been other staff transitions. Guiding the ship through all these changes have been three talented and hardworking people whose behind-the-scenes work rarely gets public notice.

Natalie Timoshin has done an incredible job steering the 

 ship as executive editor since Susan’s departure. Heidi Duerr has always done an amazing job with our special reports and other major content and now is outdoing herself. And, Laurie Martin has used her magical skills to oversee our website’s incredible array of content, a job which normally would need to be carried out by several people.

The most important acknowledgement and thank you goes to my wife Cathy. My appreciation reflects not only her tolerating the many hours I’ve spent on 

 that otherwise would have been spent with her. Cathy has been my most supportive (and critical) editor since I began to write lectures, editorials, and other publications four decades ago. The quality and readability of my work is due to her unflinchingly direct and honest editorial review and advice, well before I submit anything for publication. One of the things I’ll miss the most about stepping aside as Editor in Chief of Psychiatric Times is the time we’ve spent together fine tuning (and sometimes more than that) my monthly editorials.

There’s so much more work remaining for our field, and 

 will, I trust, continue to play an important role in both highlighting our progress and reminding us of what still remains unfinished. I have unbounded pride that 

 remains the most widely read psychiatric publication by psychiatrists in the US for a good reason.

There are so many of our readers I’ll never meet and benefit from through personal contact, but the relationship with our readers is something I already miss. I’ll simply close with this:

I couldn’t feel, so I tried to touch . . . .

I’ve told the truth, I didn’t come to fool you.

 Belluck P. Gaining Access to a Subject’s Mind. 

"The experience of learning to know another’s inner self is one of the most difficult, but most gratifying parts of our clinical work," writes Allan Tasman, MD.

Sting Meets Elton and Leonard

Over my summer vacation, I found myself thinking a good deal about the nature of reality, more than usual, because of two books I read. The first, 

 by Blake Crouch, is a sci-fi novel about a scientist who becomes trapped in a series of alternate universes trying to find his way home. The second, is 

, aptly titled by Adam Becker, PhD, an astrophysicist. This non-fiction work explores the century-old debate among theoretical physicists about the nature of the universe (or universes). On one side were the adherents of Einstein’s theory of special relativity and on the other were the quantum mechanics group led by Niels Bohr.

The debate focused in part on whether phenomena that are not observable, but only hypothesized, should be used in theory building and testing. The evolution of these discussions led to sophisticated mathematics support for theories about the existence of alternate co-existing realities (universes). The questions about knowable reality clearly resonated with me as a psychiatrist dealing with such questions in the clinical setting.

“Toto, I’ve a feeling we’re not in Kansas anymore.”

Physics was my least favorite subject in college, which is somewhat surprising to me since I’ve been a fan of science fiction since I was in fourth grade. I guess discussions about the nature of the universe and reality turn out to be more enjoyable to me when my grade in physics isn’t affecting my acceptance into medical school. After all, the question of whether light is a wave or a particle is still pretty fascinating. At times it behaves like a wave and sometimes like a particle but doesn’t behave like both simultaneously, at least according to Dr Becker.

This duality of light’s nature has allowed me to spend many hours over the years watching TV, the technology of which relies on light functioning in both ways at different instants. My TV viewing has included annual screenings of 

 both with or without my kids. I mention the Wizard of Oz in case you’re wondering about the title of this column.

I’m doing my best to make sense of the current preoccupation with what actually is consensually determined reality as embodied in our current political and communications environment. But, I’ve about given up on this major cultural phenomenon, which is affecting anyone with a TV, cell phone, computer, or who reads print media. I find myself turning instead to thinking about something that makes sense to me, the work we do to understand our patients’ internal realities and how in our own work we try to discern clues about that internal reality only from what we learn from them since we have no other tools available.

The work continually involves thinking about the tension between consensually agreed-upon external reality and our patients’ internal reality. That task usually requires a good deal of effort on our part. And, we often rely on research findings to help us have a frame of reference from which to work. But even that turns out to be complicated, and we can’t always assume those research findings are real.

 emphasizes this point. The report highlights recent studies, which reveal that published results of research are often influenced by the investigator inappropriately altering the research protocols or the initial hypotheses during the research study. The motivation was found tied to the researchers’ wishes to produce results that reached statistical significance in support of their hypotheses-whether they were actually the initial ones or added later during the research.

While I’m unaware that his theory has been tested using modern research techniques, David Winnicott’s

 1965 article, “Ego Distortion in Terms of True and False Self,” highlights an intrinsic quality of human behavior that makes it so difficult to fully understand another person’s internal world. To Winnicott, social adaptation involves the evolving development of boundaries between what is revealed to another person, what he called the false self, and the internal mental reality of the individual, what he called the true self.

Although using the term “false self” might imply pathology, Winnicott didn’t see this aspect of mental function as innately maladaptive; in fact, he believed the opposite. He believed the false self was, except in situations of significant psychopathology, the adaptive socially interactive aspect of our selves we present to others. From this perspective, it’s easy to see why psychotherapeutic work is so difficult: It involves finding the hidden true self, often hidden not just from the therapist but to some extent from the patient as well.

Our work with psychotic patients also requires a good deal of work in discerning the internal reality hidden by the veil of psychotic cognition. A patient I’ve discussed and written about before told me, in response to my question about his current life, that he spent all his time travelling in outer space in his invisible (to others) one-person space ship.

In my interview with that specific patient, it didn’t take much time or effort to understand that he was telling me that in his real life he felt lonely and isolated. We know that often it’s much harder to decipher a communication from someone who is psychotic.

The psychotherapeutic work we do with our patients involves helping them alter their internal mental reality to one that allows them to think, feel, and/or behave in ways that are more adaptive for them. Of course, unlike in sci-fi or spy novels, we have no unusual powers, complicated machinery, or the ability to alter the physical world to accomplish these changes.

But we do listen carefully and use our empathic ability to both understand and provide support. This work is often at the heart of helping our patients become more reflective and gain the capacity to make adaptive changes in their internal realities. It’s incredibly gratifying but arduous, and it’s a good thing that we can usually take some time in the summer to relax.

By the way, before anyone starts posting on our website that I’m biased against Kansas, let me assure everyone that’s not my belief. My mom was born in Kansas City (of course you’re asking which Kansas City, the one in Missouri or the one in Kansas), and I’ve spent a lot of time there over the years visiting my grandmother, aunts and uncles, and cousins. I’m as certain as can be that by any common experience of reality, it’s a real place.

movie (spoiler alert for those who don’t-if there are any), Oz turns out to be just a dream of Dorothy’s. And that dream is full of day residue, and manifest and latent content, with a happy ending that makes every child and most psychanalysts happy.

What seems to be Dorothy’s reality turns out not to be real at all unless our dream worlds are real outside our minds. Phillip K. Dick, the science fiction writer whose ongoing concern was the nature of reality, often wondered about the reality of our internal world and how it could alter external reality. He would be having a field day in our current world were he alive and still writing. It is, though, entirely possible that, in an alternate reality, he still is.

Send your comments to Dr Tasman
at editor@psychiatrictimes.com

 News at a Glance. Sloppy science more widespread. 

 Winnicott DW. Ego distortion in terms of true and false self. In: Winnicott DW, Ed. 

The Maturational Processes and the Facilitating Environment: Studies in the Theory of Emotional Development.

We listen carefully and use our empathic ability to both understand and provide support to our patients. This work is often at the heart of helping them become more reflective and gain the capacity to make adaptive changes in their internal realities.

Is Kansas a Real Place?

In my generation, a common riddle for 10-year-olds was, “What’s black and white and read all over?” Because you only heard it spoken, you thought the word “read” was actually the color “red,” and the first time around you didn’t know the answer was “newspaper.” Of course, when you were 10 that’s why it was funny the first 50 times someone asked you. Then it was just dumb. I used the word red in my headline because the news folks ought to be red-in-the-face embarrassed and that’s not funny either.

 was titled “The Crazy Talk About Asylums.”

 They rightly aired concerns that the solutions to the wave of mass school shootings in the US was not to have more psychiatric asylums, as had been advocated by President Trump following the Parkland, Florida shootings.

did say a number of things that make a lot of sense, but which are hardly “news” in the sense that these are new ideas that are worth attention. They cited the concerns about whether current legal standards for involuntary commitment to care are worth re-examining, the need for more mental health services which embody a true continuum of care, and the need for implementation of mental health parity laws.

 raised thoughtful questions about these thorny issues, the answers to each of which might improve access to mental health care. And, in some cases, the availability of services might mitigate the likelihood of another Parkland. Of course, many psychiatrists would say these reforms, which have been ongoing topics of conversation in professional circles for many years, are long overdue. We appropriately ask why it takes an assertion by the President to raise these concerns in such a prominent way as on the editorial page.

Where are the crusading editorial boards who decide that the inadequacy of mental health care is such a public health emergency that ongoing investigative journalism is needed? A single editorial, no matter how righteous, is unlikely to have any effect on public policy. That’s why I think they ought to be red in the face with embarrassment, because the news IS read all over, either online or in print, and journalism with a sustained focus can make a difference.

The other topic I want to emphasize regarding the absence of sustained news coverage is the epidemic of suicide in the US. I wrote about this in my February 

 but that was before the CDC released their most recent data which shows that suicide rates in the US continue to climb, now with around 45,000 suicide deaths each year. The majority of those are from self-inflicted gunshots. And while the mass shootings appropriately gain a great deal of coverage, there is little mention that of all the gun violence deaths in the US each year, most of them are suicides.

Until the suicide deaths of 55-year-old fashion designer Kate Spade and celebrity chef and TV star 61-year-old Anthony Bourdain in the same week in early June, I didn’t really see much coverage of the public health emergency that is represented not only by suicide, but by the approximately 10-fold greater numbers of attempts. Where’s the ongoing media coverage of that? The week after these two celebrity deaths, NBC News at least showed the phone number for the National Suicide Lifeline on their nightly broadcast. But that’s about it from the media.

We’re in the middle of a long hot summer, likely to break another heat record, and the public interest in these topics understandably has waned. I was sad about Anthony Bourdain’s death, because I’ve been a fan of his TV shows. But my level of sadness can hardly be compared with the level of lasting distress suffered by friends, colleagues, and families of those who have committed suicide or been killed.

What psychiatrists can do about these ongoing problems is unclear beyond the care we provide for those in severe distress. In some cases, local training programs for police departments have had some salutary effects on individual cases of gun violence or potential suicide. But there obviously hasn’t been an effective national set of policies to address these problems, as I’ve said before.

These omissions are worth pondering, since these days, other than personality politics, there seems to be little beyond the 24-hour news cycle that gets sustained coverage. That’s not good for the body politic, no matter what the issue.

The National Suicide Prevention Lifeline provides 24/7, free and confidential support for people in distress: 1-800-273-8255

 New York Times Editorial Board. The Crazy Talk About Bringing Back Asylums. 

https://www.nytimes.com/2018/06/02/opinion/trump-asylum-mental-health-guns.html

 Tasman A. The Wrong Way on a Long and Winding Road: Suicide in the US. 

Where are the crusading editorial boards who decide that the inadequacy of mental health care is such a public health emergency that ongoing investigative journalism is needed?

Black and White and Red All Over

There was a lot to digest from the recent APA Annual Meeting in New York, and I’m still at it. There were many terrific aspects of what I believe is by far the most diverse, comprehensive, innovative, and overwhelming psychiatric convention in the world. I still remember that I felt the same way at my first APA convention in Anaheim (“Psychiatrists in Fantasyland” was the headline in Time magazine). And that program probably had about 20% of the presentations and presenters as this year’s meeting. Thanks go to this year’s scientific program chair, Linda Worley, and to Phil Muskin, current APA secretary, who during his long tenure as scientific program chair introduced many of the innovations in format from which we’ve all benefitted.

Before I get to other content, please indulge me as I take a few lines to show some avuncular pride. The Convocation of Fellows is one of the most beloved parts of the meeting, as hundreds of members are honored for their professional accomplishments. Among the most important of these recognitions are the annual Distinguished Service awards.

My heart swelled as I saw on the stage one of this year’s awardees, Michelle Riba. Most of you know Michelle as a past president of APA, a transformative leader in consultation liaison psychiatry, and the Deputy Editor of Psychiatric Times, but I know her also as one of my former trainees when I was residency director at the University of Connecticut.

A special honor is bestowed on the person selected to give the Convocation Lecture. I was filled with pride when I learned Elinore McCance-Katz was selected this year. Most of you know Ellie for her public mental health and substance abuse leadership roles in several states and as the new Assistant Secretary for Mental Health and Substance Abuse. She’s the first office holder for this newly created position, the senior administrator at SAMHSA and the highest ranking psychiatrist in the federal government. I was nearly overwhelmed during her lecture when I was mentioned as the mentor who helped her decide on a career in psychiatry during medical school and in her future career path when she was my resident at UConn.

Nights like that one come rarely in life so I had to reflect here on the convocation. I hope you’ll excuse me for that indulgence, but now on to some comments about the rest of the meeting presentations. This is of course a very personal and extremely abbreviated list.

I was pleased to see a burgeoning presence of discussions of cultural issues in psychiatric diagnostic assessment, treatment, and training. As much as we might talk about it, I don’t think we talk about it nearly enough. One reason such attention is necessary is that this is the period of the largest mass migration of people in recorded history due to many natural and man-made disasters, making these conversations more urgent than ever. Even in a moderate-size city in the Midwest like Louisville, we use translators in our clinic for over 50 languages. It’s gratifying this topic has increasing visibility with the aim to increase our cultural competence.

There is, though, another aspect of this topic that is under-represented: implicit bias. Those of us who practice any form of psychotherapy spend a good deal of our time with patients in trying to understand how they are affected by unconscious motivations, affects, and cognitions. And, we acknowledge that to do that work well we must maximize our own self-awareness and self-reflective capacities. But self-reflection alone isn’t often enough to better understand our own implicit biases: racial, ethnic, gender, sexual, gender orientation etc. I was pleased that this was an important topic in the Presidential Symposium, Diversity issues in Psychotherapy, in which I participated.

For example, I’ve been asking myself for years why there are so few African American psychiatrists in the US, and many fewer in leadership. When I was a residency director, granted perhaps too long ago to reference, one prevailing theory was that this recruitment gap reflected the high level of stigma about mental illness in the African American community, which was not adequately addressed for that student population during medical school.

I’ve been pretty sure that’s not the only reason, and that implicit bias in academia plays some role. If you find this hard to believe, you would have been convinced otherwise by listening to the presentation in our symposium delivered by Deborah Cabaniss, a faculty member at Columbia, and her resident supervisee, Rachel Talley. This is an area of discussion that needs much more presence throughout the field, not only in our academic programs or the APA meeting.

I’m certainly not suggesting implicit bias reflects any psychopathology or conscious malintent; biases are an intrinsic part of human nature. I’m only suggesting that better self-awareness is always helpful especially when it pertains to often touchy subjects such as subtle racial, ethnic, gender, sexual orientation, and similar areas. We unfortunately already know only too well how unrecognized racial bias has played a corrosive role in medical research.

There also were fascinating discussions in New York about the emerging use of augmented reality in training, and the use of increasing digital complexity and capability throughout psychiatry. One presenter talked about a virtual reality based standardized patient education experiences-the technology now exists to subtly alter patient characteristics such as personality traits, mood, cognition, and facial expressions to provide small alterations in the patient’s presentation. Thus, a very sophisticated training experience in diagnostic assessment, interviewing skills, and psychotherapy skills could be implemented. This is only one example of an exploding area of psychiatry.

A number of presentations on collaborative/integrated care were on the program, although we’re still a long way from finding a single best model for both implementation and sustainability. There was again a paucity of presentations about any new breakthrough medications, with the possible exception of ketamine. New medications, other than minor tinkering with existing compounds, still seem off in the future. And, while burnout was a priority of Anita Everett, the APA immediate past president, and although there were a large number of sessions devoted to this topic, there’s still no generalizable solution for any individual psychiatrist. In fact, in my work on addressing burnout in my own medical school, what I’ve learned is that without systemic and institutional level changes, individual interventions are likely to be incompletely effective (think electronic health record, or EHR).

There’s one more area that was notable for its lack of prominence or sense of urgency: suicide prevention, especially regarding adolescents. To illustrate, in the new research listing of topics in the program guide, suicide and risk prevention had one of the smaller number of presentations. And, suicide was the topic of only one of the keynote lectures, and that was on development of subtyping biomarkers.

 editorial I wrote about the burgeoning suicide rate in the US.

 I emphasized how the adolescent suicide rate had been increasing and had reached nearly a 30-year high. The news in recent weeks has had many stories about how the rate has increased yet again. Furthermore, the news in May about a medical student suicide and a psychiatric resident suicide within several days of each other at NYU medical school is alarming. It shouldn’t take having a Surgeon General like David Satcher to do something about this personal, familial, and public health emergency. I think the APA needs to make this a priority, as I’m pretty sure there’s not currently any other source of impetus that would carry as much weight.

So, like every year, there’s more food for thought and action at the APA meeting than is easily or quickly metabolized. And there’s a great deal I didn’t have enough space to discuss. Summer’s a good time to digest and reflect on the richness of our field and how we can implement advances in our own work. I hope you have a chance to do that.

 Tasman A. The wrong way on a long and winding road: suicide in the US. 

No better time than the summer to digest and reflect on the richness of our field and how we can implement advances in our own work.

APA Dreamin’, on a Summer’s Day

Introduction: Lies, Dam Lies, and Statistics, by Allan Tasman, MD

I titled this column using the famous quote from Benjamin Disraeli, not because this column is about lying, but to illustrate the complexity of determining the validity of a statistical analysis. I’m referring specifically to a recent change implemented by NIMH regarding its assessment of the percentage of the population with schizophrenia, discussed in the accompanying analysis of the change by 

. While this might seem like an arcane academic issue, there are potentially very distressing real-world consequences.

Imagine, for example, if federal and state or local officials who fund already financially strapped community mental health centers (CMHCs) decided to make significant reductions in funding if they believe the actual numbers of patients with schizophrenia are much lower than those on which they calculated their original budget allocations. Since CMHC’s bear much of the burden of ambulatory care of those with schizophrenia, the impact could be devastating.

commentary by NIMH Director, Joshua A. Gordon, MD, PHD

, who explains the context of the NIMH decision-making process and the next steps.

HOCUS POCUS: How the NIMH Made 2 Million People With Schizophrenia Disappear, by E. Fuller Torrey, MD and Elizabeth Sinclair

A RESPONSE FROM THE NIMH DIRECTOR: On the Prevalence of Schizophrenia and Transforming Care Through Research, by  Joshua A. Gordon, MD, PhD

is Founder of the Treatment Advocacy Center and Associate Director for Research at the Stanley Medical Research Institute. 

is a Research Associate at the Treatment Advocacy Center.

Although he has been the Director of the National Institute of Mental Health (NIMH) for less than 2 years, Dr. Joshua A. Gordon has made 2 million individuals with schizophrenia disappear. NIMH has not said where they went but officially, they no longer exist. This is a remarkable accomplishment, especially given the lack of attention NIMH has given serious mental illness

Until November 2017, NIMH had claimed that the 1-year prevalence of schizophrenia in adults in the US was 1.1%. In other words, in any given year approximately 11 out of every 1,000 adults would be diagnosed with this disease of the brain. The Bureau of the Census estimated in 2017 that there were 252.1 million adults in the US; thus approximately 2.8 million would have been diagnosed with schizophrenia.

This estimate was based on the last major epidemiological study of serious mental illness in the US, the Epidemiologic Catchment Area (ECA) study. This NIMH-funded study sampled 5 areas (Los Angeles, St. Louis, New Haven, Baltimore, and rural counties in North Carolina) in the early 1980s. At least 3,000 adults living in households and 500 individuals living in mental hospitals, prisons, nursing homes and other institutions were directly interviewed in each area, then surveyed by telephone 6-months later and re-interviewed another 6-months after that. The results are considered to be the most accurate mental illness prevalence data available for the US. In 1993, at the request of the US Senate Committee on Appropriations, the ECA data were given to the Senate so that they could be used to assess the costs of these disorders. The ECA data have thus been the standard in the US for the past 3 decades.

Inexplicably, in November 2017, NIMH changed its website and declared that the 1-year prevalence of schizophrenia is now 0.3%, or 3 cases in 1,000 adults. Based on the current census estimates, this means that there are now only approximately 750,000 adults with schizophrenia each year in the US. Since there were 2.8 million previously, just over 2 million have been made to disappear.

How does NIMH justify this remarkable feat? They no longer make any mention of the ECA study and instead cite as the basis of their estimate a National Comorbidity Survey carried out in 2001-2003. This survey was a sampling of 9,282 people living at home and specifically excluded individuals in institutions, including in psychiatric or other hospitals, nursing homes, jails, prisons, homeless shelters, or individuals living on the street. Thus the official count of individuals with schizophrenia in the US now excludes anyone not living at home. The refusal rate for participating in the survey was 29%, and the authors cite a study reporting that people with paranoid symptoms are more likely to refuse to participate in such surveys. For screening their original sample of 9,282 people living at home, the study used the Composite International Diagnostic Interview (CIDI), a screening tool known to be poor in identifying individuals with schizophrenia. Among the original 9,282 persons, 2,382 had some psychiatric symptoms and were then screened using an instrument for non-affective psychosis (schizophrenia, schizoaffective disorder, delusional disorder, non-affective psychosis not otherwise specified). The final psychiatric diagnoses for this survey were based on telephone interviews with 73 people.

NIMH then tries to justify the use of a schizophrenia adult prevalence rate of 0.3% per year by citing 2 summaries of a worldwide prevalence study. This study included 188 prevalence studies, including the ECA study, carried out in 46 countries, some as early as 1935. The main finding of this study was the very wide range of prevalence in different countries, with the US being among the highest. Many of the studies were carried out in developing and rural countries that have reported a low prevalence of schizophrenia until recent years. Taking the median prevalence from these 188 studies to justify a current estimate for the US is scientifically irresponsible.

The new estimates from NIMH are also egregiously inconsistent with the majority of other prevalence estimates, even within the federal government. The latest data from the Substance Abuse and Mental Health Services Administration (SAMHSA) state that schizophrenia accounts for 22% of people with serious mental illness, or about 2.3 million adults based on current estimates. The Centers for Medicare and Medicaid Services reports that 4% of all Medicare beneficiaries have schizophrenia, increasing to 11.2% all individuals who are dual-eligible for Medicare and Medicaid. In addition, widely-cited academic literature has prevalence estimates consistently between 0.9%–1.1%.

Why did NIMH wish to massively reduce the official prevalence of schizophrenia in the US? In the past 2 years, members of Congress have become much more interested in problems associated with untreated severe mental illness. With the passage of the 21st Century Cures Act and appointment of the nation’s first Assistant Secretary for Mental Health in the Department of Health and Human Services, it seems likely that federal mental health agencies like NIMH may be held accountable in a way that they have not been previously. Having to account for 750,000 people with schizophrenia is much easier than having to account for 2.8 million. In addition, NIMH has already been widely criticized for ignoring the needs of individuals with schizophrenia, specifically by failing to support research on the development of new medications and other effective treatments.

It should also be noted that NIMH has not funded a major study to determine the current prevalence of schizophrenia since the ECA study in the early 1980s-more than 30 years ago. Thus we really have no idea whether the prevalence of schizophrenia has increased, decreased, or stayed the same. The lack of data in the US on this question stands in sharp contrast to almost every European country. In England, for example, 7 major studies on the prevalence of schizophrenia were carried out between 1986 and 2009, including studies of whether the prevalence is increasing; why the prevalence is so high among certain immigrant groups; and whether there are regional differences in prevalence. A measure of England’s interest in these issues is a 258-page report, “Systematic Review of the Incidence and Prevalence of Schizophrenia and Other Psychoses in England,” prepared for the Department of Health in 2012. The Scandinavian countries, of course, have even more sophisticated prevalence studies based on their national case registers. Compared with these countries, the data available in the US on the prevalence of schizophrenia are equivalent to the data available in some developing countries.

The last major study of the prevalence of schizophrenia in the US was carried out in the early 1980s. The results from that study have been used for 3 decades to estimate the annual prevalence of schizophrenia at 1.1% (11 in 1,000 adults). For unknown reasons, NIMH decided in November 2017 to no longer use that data. Instead, it adopted a 2001–2003 study that only assessed schizophrenia in people living at home. Individuals who are hospitalized, in nursing homes, in jail or prison, or homeless are no longer included in the measure of prevalence, which NIMH claims to now be 0.3% (3 in 1,000 adults). This decreases the number of people estimated to have schizophrenia in the US from approximately 2.8 million to 750,000. The very fact that NIMH would make such a change is a measure of the institute’s lack of interest and expertise on this important issue.

We have 2 recommendations that the agency should take to address this major discrepancy. First, it should restore the previous estimate of the prevalence of schizophrenia (1.1% annual rate for adults) until more updated data become available. Second, NIMH, perhaps in collaboration with SAMHSA, should undertake a major new study of the prevalence of schizophrenia, including individuals in psychiatric hospitals, in jails or prisons, and who are homeless. When Dr. Gordon became the Director of NIMH, he stated that his highest priority was to support good science. Let us hope that making individuals disappear is not representative.

Mental illnesses affect tens of millions of people in the US each year. As the lead federal agency for research on mental illnesses, the mission of the National Institute of Mental Health (NIMH) is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure. NIMH, part of the National Institutes of Health (NIH), strives to provide the public with up-to-date, accurate information on our understanding of mental illnesses and the tremendous burden these illnesses pose to individuals and their families. To this end, we include prevalence statistics on our public-facing website to provide a framework for understanding the scope and impact of mental illnesses.

NIMH recently undertook an effort to refresh the statistics pages on our website, with respect to both design and content. For all statistics we report, our goal is to use the most accurate data available, which includes consideration of the most recent findings, as well as quality of the data. To help users understand and interpret the statistics we present, we aim to be rigorous and transparent by providing adequate background and context, as well as information on relevant strengths and limitations of the data sources. In the case of the refreshed schizophrenia statistics page, we used findings from several papers to approximate an estimate for the prevalence of schizophrenia. We now recognize, in retrospect, that we did not provide sufficient context to understand or justify the selected prevalence estimate, nor did the number we settled on reflect the full spectrum of knowledge available in the relevant literature.

Accurate and stable estimates of the prevalence of schizophrenia are made challenging by many factors. Comparisons across studies are hindered by inclusion of varying combinations of diagnostic criteria (eg, schizophrenia/schizophreniform; schizophrenia and other psychotic disorders; non-affective psychotic symptoms). The very definition of schizophrenia itself has changed over time since the DSM-III-based Epidemiologic Catchment Area (ECA) paper reported the prevalence of 1.1% in 1981.1 More recent surveys might under-count those with serious mental illness for many reasons, including the fact that many of these individuals decline to participate in surveys, or are homeless or incarcerated or otherwise difficult to reach. However, in the years since the ECA, a large number of studies, including several in the US, have clearly demonstrated that the 1.1% figure is no longer scientifically defensible.

But that does not mean the new figure we initially arrived upon – 0.3% – necessarily reflects the full picture. We are in the process of expeditiously reviewing and updating the information presented on our webpage to more fully reflect the available data on schizophrenia prevalence. We anticipate providing an estimated range, rather than a single point estimate; reporting such results will require inclusion of relevant caveats and limitations. More broadly, timely and accurate information on the prevalence of schizophrenia and other mental illnesses is important to multiple Department of Health and Human Services agencies beyond NIMH, including the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Centers for Disease Control and Prevention. By working together toward a solution to address the difficulties in estimating prevalence for schizophrenia and other serious mental illnesses, we can accomplish far more for our key stakeholders. NIMH looks forward to continuing to work collaboratively to advance these important objectives. I thank Dr. Torrey and Ms. Sinclair for bringing the need for this more thorough treatment of schizophrenia prevalence to our attention.

At the same time, I feel compelled to counter the notion that NIMH does not devote sufficient attention to serious mental illness. NIMH supports a diverse portfolio of research aimed at improving care for, and the lives of, individuals living with a serious mental illness. This research spans basic and translational sciences aimed at identifying and developing the breakthrough treatments of tomorrow, as well as services and intervention sciences aimed at optimizing and implementing the effective treatments of today.

For example, neurocognitive dysfunction is a hallmark of schizophrenia and represents an important, and untreated, component of the disability associated with the disorder. NIMH supports several cognitive remediation studies for individuals with psychosis aimed at improving cognition and functional outcomes. We are also supporting the development and testing of 3 novel compounds for their long-term potential to improve cognition in patients with schizophrenia.

NIMH funds several large-scale effectiveness trials of practical interventions to reduce premature mortality in people with serious mental illness by addressing health risk factors. Recognizing that modifiable health risks associated with premature mortality appear early, NIMH also funds research capitalizing on opportunities for early intervention with young people at high risk. Additional efforts test interventions aimed at improving overall functioning by focusing on employment, social engagement, and community integration. These are but a sampling of the many research projects of relevance to serious mental illness supported by NIMH.

Notably, NIMH-supported research is impacting people now. For example, the NIMH-funded Recovery After an Initial Schizophrenia Episode (RAISE) project, a large-scale comparative effectiveness research study, demonstrated that coordinated specialty care early in the course of treatment for first episode psychosis was superior to usual care in reducing symptoms, improving school and work functioning, and increasing quality of life. Importantly, the intervention tested in RAISE was found to be cost-effective. Based on results from RAISE, the Centers for Medicaid & Medicare Services extended Medicaid coverage for coordinated specialty care and SAMHSA set aside 10% of its Mental Health Block Grant allocation for each state to support evidence-based programs that target first episode psychosis. Today over 200 coordinated specialty care programs operate in 49 states, representing an unprecedented translation of scientific findings into services that directly benefit persons with early serious mental illness.

Most importantly, we must keep in mind that statistics, while useful, do not tell the full story of the tremendous burden shouldered by individuals and families living with schizophrenia, and the outsized impact this burden has on our society. NIMH will continue to aggressively support novel approaches to biological understanding, therapeutics development, and services and intervention delivery, all aimed at reducing this burden.

. Regier DA, Narrow WE, Rae DS, et al. The de facto US mental and addictive disorders service system. Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry. 1993;50:85-94.

Here's a debate about a statistic the NIMH has posted on its website that, says one critic, significantly underestimates the number of adults with schizophrenia in the US and potentially affects their care. The Director of the NIMH responds.