Lloyd I. Sederer, MD

Edited by C.V. Haldipur, James L. Knoll IV, and Eric v.d. Luft; Oxford, UK: Oxford University Press, 2019
	324 pages • $44.95 (hardcover)

I was a first-year psychiatric resident at Upstate Medical Center, at the SUNY in Syracuse. I would be dazzled and envious sitting in a seminar with the by then legendary, Dr Thomas Szasz. Everyone seemed to regard him in either a hallowed or contentious way since his book, 

, was published almost 10 years earlier. My envy, by the way, came from wanting to have a mind like his: I was ready to make a deal with the devil if I were suddenly able to think as well as he did. His capacity to formulate, articulate, and argue ideas was as keen as was this lean, diminutive (in size) Eastern European who never lost his accent.

The seminar would end, as would my academic cocoon. It was time for me to leave the classroom and run a few blocks to the state psychiatric hospital, where my on-call would begin at 5 pm. Breathless, I arrived at the admitting office to find the Syracuse police waiting for me. They were surrounding a 250-pound agitated, psychotic man. Sometimes there would be two patients. However many, patients were generally exceptionally displeased to be held against their will. The local cops smiled and said, “Hey Doc, you’re late. Here’s your patient. We’re outta here.”

“Myth” certainly confronted the reality I experienced at that moment. As it did throughout my career as a psychiatrist. I have had to wrestle with Szasz’s ideas, especially during my years as Medical Director of 

, Mental Health Commissioner for NYC, and, for the past 12 years, as Chief Medical Officer of the largest state mental health agency in the United States. I am grateful for Szasz’s influence on me, which has insisted that I take no ideas for granted, recognize the social power I can exercise, and try to do the right thing, even if that sometimes meant running counter to his teachings.

C.V. Haldipur, James L. Knoll IV, and Eric v.d. Luft have written what might be considered, in the best sense of the term, an 

. They have compiled an extraordinary group of psychiatrists, philosophers, ethicists, social scientists, researchers, humanists, and forensic experts-many who knew Dr Szasz personally or who had debated him in public or on paper, or both. Yet this edited compilation is not hagiography; instead, it is a penetrating, deep, and intrepid exploration of Szasz’s oeuvre, and the indelible impact he has had on the practice of psychiatry, in this country and abroad. Even if younger members of my profession (and philosophers of history and science) do not know his work, they live under its long and fulsome shadow.

Szasz’s intellectual tools were history, philosophical argument, ethics, logic, and humanism. He was a master at demonstrating how metaphor can take on the power of fact, and how it was used in ways that could erode liberty. The most renowned, and enduring, of his metaphors is the “myth of mental illness.” His work in the book so titled, and some 30 volumes and hundreds of papers that followed, brought him the mantle of being “anti-psychiatry.” But he was not; he was a libertarian who held the importance of freedom over everything else (and he was clear to also say that with liberty came personal responsibility).

Haldipur and colleagues unbundle Szasz’s vast range of intellectual productions in 19 chapters divided into three book sections in 

Intellectual Roots of Szasz’s Thought; The Concept of Mental Illness

; and Szasz’s Larger Impact, as well as a superb summary epilogue by Dr Haldipur. The writings consider not just the material Szasz produced but the man and his compelling, often disruptive, rhetoric. The chapters draw from psychiatry, psychoanalysis (Szasz was formally trained as an analyst in Chicago before moving east), forensics, social contract theory, values, ethics, language, communications theory, and good old clinical wisdom.

The contributors do not shy away from some of Dr Szasz’s most contentious claims, including: his highly vocal opposition to involuntary hospitalization and treatment of people with mental illness; his unwavering position that suicide was a right, not to be denied people under any circumstances (hard to bear since we know the compulsion to kill oneself is usually transient-not necessarily in thinking but in action, which can result in an irrevocable act-and that those who do not die are almost always grateful they survived); that “doctoring” was inimical to helping people with “problems in living,” as was prescribing psychoactive medications; to allowing people with mental disorders to “

; and the inanity of the insanity defense.

Thomas Szasz was born in Budapest, Hungary. His educated, Jewish parents fled their native country to the United States in 1938, when Hitler invaded Austria. They understood that Hungary was next in the Nazi’s sights (as it later would be oppressed by Communism). Szasz was 18 and multilingual when he arrived in this country, speaking French and German in addition to his native Hungarian, but he spoke not a word of English. You would never know because it was in the English language he immediately excelled in medical school and medicine.

Tom Szasz, whom I knew and learned from for 50 years, was a man whose persona was warm and engaging, except when publicly delivering his polemical arguments. He meant to admonish about the unintended consequences of would-be good intentions-that individuals needed to be protected from the power of the collective. His aim was to stir, not lull, the minds of all of us entrusted with the privilege of serving people with mental (and addictive) disorders. You may not have agreed with him, but he would surely put your assumptions and conventions to the test. There was no such thing as casual thinking or parroted instruction when in a conversation with him. That was a gift, whether you felt it or not, to all who knew, read, and debated him over the decades of his intellectual prowess.

in 2012 at the age of 92. I wonder what he would think of this comprehensive, intellectually challenging, carefully and clearly written analysis of his work? While I cannot imagine what he might say from a podium, I believe, privately, he would have appreciated the rigor, range, and intelligence brought to bear in this book. For those who knew or read this extraordinary man, your reading 

 will light up your remembrances. For those who barely know him or his work, you will surely be amazed by his contributions, whether you think them right or not (or some of both).

The Addiction Solution: Treating Our Dependence on Opioids and Other Drugs

 (Scribner, 2018), is now available in paperback.

Mental Illness vs Brain Disorders: From Szasz to DSM-5

This article was originally published 4/24/19 and has since been updated.

Dr Sederer is Adjunct Professor, Department of Epidemiology, Columbia University Mailman School of Public Health, and Distinguished Psychiatrist Advisor to the New York State Office of Mental Health (OMH). The author reports no conflicts of interest concerning the subject matter of this article.

 Appelbaum PS, Gutheil TG. “Rotting with their rights on”: constitutional theory and clinical reality in drug refusal by psychiatric patients. 

Articles

A penetrating, deep, and intrepid exploration of Szasz’s oeuvre, and the indelible impact he has had on the practice of psychiatry, in this country and abroad.

Thomas Szasz: An Appraisal of His Legacy

Dr Sederer is Adjunct Professor, Department of Epidemiology, Columbia University Mailman School of Public Health, Distinguished Psychiatrist Advisor to the New York State Office of Mental Health (OMH) and Director, Columbia Psychiatry Media. 

We owe to American psychologist, Dr Bruce Alexander, the understanding that addiction is about far more than any drug. That a person, or animal in his studies, is an active ingredient in their interaction with a drug. To stand a chance beating the opioid and other drug epidemics we have, we will be far better equipped if we follow his lead.

Alexander’s experiments, in the 1970s, have 

 Researchers had already proved that when rats were placed in a cage, all alone, with no other community of rats, and offered two water bottles-one filled with water and the other with heroin or cocaine-the rats would repetitively drink from the drug-laced bottles until they all overdosed and died. Like pigeons pressing a pleasure lever, they were relentless, until their bodies and brains were overcome, and they died.

But Alexander wondered: is this about the drug or might it be related to the setting they were in? To test his hypothesis, he put rats in “rat parks,” where they were among others and free to roam and play, to socialize and to have sex. 

they were given the same access to the same two types of drug laced bottles. When inhabiting a “rat park,” they remarkably preferred the plain water. Even when they did imbibe from the drug-filled bottle, they did so intermittently, not obsessively, and 

overdosed. A social community beat the power of drugs.

 the biggest problem with the powerful, ubiquitous psychoactive drugs 

(meaning those that work on our brains and minds), is that 

 In immediate and powerful ways, they change how we feel, think, relate, and behave. Or transport us away from loneliness and isolation. That is why we use them! It is also why campaigns of “just saying no” are naÃ¯ve and ineffective, and why the dilemma of drug-taking, legal and illicit, has become one of the most dominant societal dilemmas we face in the 21st century.

The rates of overdose deaths, especially but not only from opioids, in this country continue to climb. In my 

, I described how prescribing clinicians can help people stay alive-until they enter an effective, individually shaped, recovery program.

 This article means to convey that there is a totally low-tech way of enabling people with addiction to (figuratively) prefer to ingest water rather than addicting drugs.

What we can do, a needed and effective approach, derives from what has Alexander taught us. Humans, not just rats, need to be part of a community, encouraged to relate and experience the support of others. This is about as basic a psychological truth as exists, yet does it find application in clinicians’ offices?

How many of us, during clinical encounters with patients, focus on their families, their social communities, their sources of human contact and support?

Do we ask questions like: Who do you care about in your life? Who cares about you? When was the last time you spent time with people who are good for you-instead of those who hurt you and foster your drug taking?

These questions may lead to others, such as: Who can you call or spend time with in the next couple of days? What gives you pause in calling or making the kind of human contact needed to enable recovery? What do you imagine these people would think and feel if you did make contact? How might that encounter go-where it was not about asking for help, or money, but instead simply, and most importantly, about re-igniting their friendship, their attachment to you, and their wish for your life to go well? Their interest is one way to achieve the dignity, purpose, meaning, and life of contribution so critical to the hard work of recovery.

And so on, as the conversation may continue.

The science of medicine, with the exceptional value it attributes to symptoms, diagnoses, and evidence-based therapies, has had the unintended effect of eclipsing what we know and can do about the benefits of human interaction and attachment.

Please understand, I have been in practice for a long time. I am not naÃ¯ve about the complexities of human relationships and the fears and challenges they present. Perhaps that is one reason we eschew the questions I offer above. They open essential doors, but that means we clinicians, not just our patients, have to pass through those doors as well.

Mother Theresa, not someone often quoted in medical journals, said, “If you want to change the world, go home and love your family.” I think the Beatles said the same thing. And when we see people and families who are keeping their emotional heads above the often roiling waters of everyday life, who are not compulsively imbibing on drug-laced concoctions, or pathologically gambling or playing video games and the like, we will see that they lead their lives in the light of relationships, in human parks, not alone.

The Addiction Solution: Treating Our Dependence on Opioids and Other Drugs 

(Scribner, 2018), is now available in paperback. Follow him on Twitter: 

The author reports no conflicts of interest concerning the subject matter of this article.

1. Alexander BK, Beyerstein BL, Hadaway BF, Coombs RB. 

Effect of Early and later colony housing on oral ingestion of morphine in rats

2. Sederer LI. The medical irony of the deadly opioid epidemic. 

https://www.psychiatrictimes.com/substance-use-disorder/medical-irony-deadly-opioid-epidemic

What Does “Rat Park” Teach Us About Addiction?

Dr Sederer is Adjunct Professor, Department of Epidemiology, Columbia University Mailman School of Public Health, Distinguished Psychiatrist Advisor to the New York State Office of Mental Health (OMH), and Director, Columbia Psychiatry Media.

My goal in this article is to persuade you, doctors and nurses who have prescribing authority, to save lives by prescribing an opioid drug for the opioid epidemic-namely buprenorphine. Including those practicing psychiatry, primary care, neurology, pain medicine, and so on. While you are at it, don’t miss the chance to help your patients (and their families) obtain the opioid reversal drug, naloxone.

The irony here is that prescribing (or assisting in dispensing) these (often highly stigmatized) drugs will forestall more drug deaths in the next few years than 

 else doctors can do. Not a week passes where I do not meet grieving family members who have lost a loved one to a drug overdose, some still recently in its wake, the others who can never forget. Their loved one, or friend, had been smoking, vaping, or injecting heroin (they are beyond pills) or its synthetic close relative OxyContin. Dealers now increasingly lace whatever they are selling with fentanyl. Laboratory synthesized (often in China), this opioid is 50 times more powerful than heroin, 100 times more powerful than morphine. The potency of the opioid was beyond the drug dependent person’s tolerance: first they experienced respiratory distress and then followed an abrupt cessation of breathing.

These are preventable deaths. Despite reductions in medical prescribing of opioids (eg, OxyContin, Vicodin, Percodan), overdose deaths in the US continue to rise. Opioid overdoses annually eclipse motor vehicle deaths and now dwarf the loss of lives from the entire HIV/AIDS epidemic as well as the Vietnam War.

 traces its roots in good part to doctors’ efforts to change what had been regarded as their under-prescribing of pain medications. Pain became the fifth vital sign. Regulatory agencies expected doctors to administer patient self-reports of pain, which of course demanded a response when scores were high, as they often were. With too little time to spend with patients and a wish to help, the most immediate solution for a physician lay there on the desk-the prescription pad. Patients, too, were seeking a simple and fast solution to their pain. The icing on this not-at-all sweet clinical cake was the prominent Pharma marketing that opioids were not addictive. Doctors, in effect, with no ill intent, believed these drugs were a safe solution to the problem of pain. But their common prescription soon fostered addiction and fueled the growth of the opioid epidemic.

Pain is ubiquitous. Everyone’s body feels it. For some it becomes chronic, potentially disabling. But there is more to this epidemic than arthritic joints, broken bones, tumors, and other dolorous conditions. We now recognize what we call the social determinants of physical, mental, and addictive illnesses. These include unemployment, poverty, housing instability, trauma, and domestic and neighborhood violence. You probably have heard the term, “deaths by despair”? These are deaths from suicide, drug overdoses, and the long-term complications of alcoholism and other addictions. We doctors are in a position to keep people alive until there are prospects for their future (and that of their children), safety, or opportunity to find purpose-until they can enter recovery and rebuild what addiction eroded.

 was FDA approved in the US in 2002. In the 1990s, it had reduced drug overdose death by 80% in France (through ready access in primary care). Its use in the US has been terribly impaired by the social stigma of addiction as well as its being the only drug that requires an 8-hour training course and obtaining a DEA number suffix to prescribe it. OxyContin and fentanyl have no such burdensome requirements.

Buprenorphine (Suboxone and others) is an opioid agonist, which means it fills the mu (opioid) brain receptor, impeding another opioid from attaching. Moreover, buprenorphine has a “ceiling effect”-its capacity to produce intoxication and narcosis is limited, unlike other opioids where the more someone takes, the higher they get, until they stop breathing. In effect, this medication provides a safe substitute for a deadly street opioid, while quelling drug cravings. There is no need, as well, to steal, deal, or prostitute oneself to obtain a drug supply, as is the case for all illegally trafficked substances.

Opioid overdoses, too many fatal, are dramatically reduced once someone begins buprenorphine. Doctors and nurses, please take heed. This is a life-saving medication that needs you to prescribe it.

, in most states, does not need a prescription. It is an opioid antagonist, the “reversal” drug that immediately blocks the action of any opioid in the body. Breathing resumes, and a life is saved if handy, and administered in time in adequate dosage. Which is why its presence should be everywhere, in any home, office, public building, your briefcase, and in my backpack. Since its nasal spray preparation was introduced, there is no need for an injection, even an auto-pen stabbed into the thigh. Our job as clinicians is to help patients and their families get a supply of naloxone, learn how to use it (which is very simple), and have it nearby should the need arise. Some public health clinics dispense it, like condoms.

 mean to suggest that medications alone are the answer to the opioid epidemic raging in this country. Complex problems call for comprehensive solutions, including motivational enhancement (readiness for change), 12-step recovery, cognitive therapy, family education and support, and taking care with what we eat and how we sleep, mindfulness and meditation, and finding people who can help rather than harm you.

Our job as clinicians, our privilege, is to help our patients stay alive until they can engage in and benefit from good treatment, and, in time, recover a life of relationships, contribution, purpose, and meaning. The doctor’s (or nurse’s) prescription pad is the most immediate and effective way to do so. We may have contributed, unintentionally, to the opioid epidemic, but we can, intentionally, help to remedy it.

This article was originally published 5/15/2019 and has since been updated.

Our job as clinicians, our privilege, is to help our patients stay alive until they can engage and benefit from good treatment.

The Medical Irony of the Deadly Opioid Epidemic

In this Q&A, Lloyd Sederer, MD, interviews Paul Summergrad, MD, Chair of Psychiatry at Tufts University Medical School and Past-President of the American Psychiatric Association (APA). Dr Summergrad will discuss spirituality and mental health at the 2019 APA Annual Meeting in San Francisco.

Dr Sederer is Adjunct Professor, Department of Epidemiology, Columbia University Mailman School of Public Health, Distinguished Psychiatrist Advisor to the New York State Office of Mental Health (OMH), and Director, Columbia Psychiatry Media. Dr Sederer’s most recent book, 

Lloyd Sederer, MD: Faith, spirituality, even religion, seem an uncommon subject in the psychiatric office. I know you have thought about this matter a great deal. How do you understand their absence?

Including spiritual or religious information in medical training or exams is limited. It may appear in a perfunctory way in the review of systems, but since it is rarely an etiological factor in general medical practice, its role is limited. In that sense, psychiatry is not particularly unique. If there is a distinctive discomfort in psychiatry with spirituality it may derive, in part, as a vestige of the traditional psychoanalytic view of religion being almost a culturally sanctioned form of neurosis. Today, psychoanalysis does not have the power it once did, and it surely is no longer ubiquitous. Another challenge for psychiatry is more obscure: which is that in certain psychiatric disorders-mania and schizophrenia to name two-it is not uncommon to have delusions with religious or spiritual elements, phenomena which may make spirituality seem more suspect than other considerations.

Lloyd Sederer, MD: How do you define spirituality? How is it different from religion?

 I am not sure that I have an exact distinction. In general, I would suggest that spirituality is linked to a sense of meaning, purpose, ineffability, or (potentially) experiences of unity with the world, even grace. While religious experiences may include all of these elements, religions are often viewed as a specific set of beliefs, often within a ritual or communal canon, including accompanying texts and an ordained clergy.

Lloyd Sederer, MD: Do you think psychiatry has an implicit bias about religion? Not just Freud and his followers. If so, what are we foreclosing from our clinical conversations with patients, given that religion (or faith) is so highly prevalent, especially in the US?

 I don’t know if it is implicit. But it can be, at times, uncomfortable to discuss. First, it is not scientific per se, in that it doesn’t derive from experiment, clinical observation, human biology, or controlled clinical trials. The essence of religious experience is just that, namely experiential, and further refracted through individual consciousness. This seems especially so in the founding of religions. But eschewing religion in psychiatric practice does, I think, risk alienating psychiatrists and other mental health professionals from many patients and their families. Because of the great comfort or meaning they can derive from religious communities as well as the capacity to seek solace from pastors, priests, rabbis, Imams, and others.

Lloyd Sederer, MD: If a bias exists, how can we recognize it? What are we missing as a result?

 It is a general principle of good care to meet people where they are. If they are medically ill, we may see them on a medical unit or an ICU. In communities, we may encounter patients in clinics or in outreach to underserved areas. Or it may be on college campuses. And in jails and prisons. Those patients who are religious, or members of their faith communities, are no different and should not be deprived of our or other physicians’ and clinicians’ expertise. Especially in the United States, where religious belief and the seeking of guidance from religious leaders is a more frequent event than in many other countries. It is, thus, essential that we have an effective means of communication with religious communities.

Lloyd Sederer, MD: Have effective service partnerships been achieved between clergy and psychiatrists? How can each group benefit when that happens?

 First, by communication and establishing (where possible) a common language-or at least understanding differing perspectives. That was certainly the goal when I was president-elect of the American Psychiatric Association (APA), when we convened a gathering of clergy, other faith leaders, patients, and patient advocates with a group of distinguished psychiatric leaders. Our first goal, which remains the same, was to establish a dialogue and recognize common goals. Our work group developed a guide for faith-based leaders, which can be found and downloaded without cost from the APA website at 

https://www.psychiatry.org/psychiatrists/cultural-competency/faith-community-partnership

Lloyd Sederer, MD: While human suffering is ubiquitous, must it derive from having a mental illness?

 I think we need to be very circumspect in attributing all psychic suffering to mental disorders. There is certainly great suffering that is associated with mental disorders, and the boundary between mental disorders, and existential, developmental, or spiritual suffering can be hard to define. There is, as well, considerable intrinsic suffering associated with being alive, as a result of illness, loss, disappointment, and mortality. Some of that can lead to what we would think of as psychiatric disorders. But not always. So, we need to remain humble in the face of the great complexity of human life and, frankly, its many mysteries. It is similar to what the Pali canon, the earliest strata of Buddhist scriptures, call 

Lloyd Sederer, MD: How do you understand the role of faith and spirituality in recovery? In recovery from addiction, mental illness, and trauma (including human and natural caused disasters)?

I don’t have an answer for this. If we accept, as we must, that there is tragedy, limitation, and pain intrinsic to life due to loss and the impermanence of all phenomena, then achieving some sense of meaning or purpose in the face of suffering becomes a needed and necessary activity. While faith and religion-or the sense of a larger surround of meaning or purpose-may support people through difficult times, there are of course many other things that can do this as well-by helping to establish community (including religious communities) and, when needed, excellent psychiatric care as well.

Lloyd Sederer, MD: How did spirituality gain its important place in your life, as a man and as a doctor?

Certainly, it was part of the existential and developmental crisis when I was in college during the 1960s. That began my burgeoning interest in spirituality. I came from a very Jewish but secular background, yet found that I needed to explore, in a personal and extended way, my deepest beliefs about the world, myself, and what I understood was my purpose in the world. I spent several years doing intensive Zen Buddhist meditation, which paradoxically led me back to a long-standing interest in psychiatry as well as my resurgent connection to Judaism as a religious tradition. I have written about this and also discussed it at some length in an interview I did with Ram Dass in 2014: 

https://www.youtube.com/watch?v=NhlTrDIOcrQ&t=5s

Lloyd Sederer, MD: You and I have had some interesting conversations about psychedelic drugs, like psilocybin and LSD. A powerful mystical experience from ingesting these agents seems to be a predictor of overcoming severe depression and anxiety (including OCD), fear of death in terminally ill patients, and addiction to tobacco and perhaps other substances of abuse. What do you think is going on in the mind and brain when that happens?

 This is certainly a very interesting area and one that is now getting far more intensive research, including clinical trials and neuroimaging. It is a complex undertaking in part due to the schedule 1 nature of these compounds. We have a large body of evidence about psychedelic agents in the US during the 1960s. We also have learned about their use in traditional religious ceremonies in several native US and South American cultures. The likelihood of their clinical benefit will be determined by well-designed clinical trials. Our understanding of their impact on human consciousness and neurocircuitry will, likewise, depend on the replication of some early findings that suggest that intensely spiritual experiences are associated with clinical improvement in depression and anxiety. In addition, such intense experiences are associated with neuroimaging findings of resetting the default mode network. Certainly, in part, the interest in these compounds has come at a time when we greatly need new agents in clinical neuroscience. Examples include work already underway with existing compounds like ketamine, MDMA, as well as classic psychedelic agents, like psilocybin and LSD.

Lloyd Sederer, MD: Why has this subject seemed to have surfaced more so recently? How do you understand its prominent focus at this year’s Annual Meeting of the American Psychiatric Association?

I am not sure of how much this is gathering attention at present, although I do think there is greater comfort in the culture in general with personal or self-disclosure.

Lloyd Sederer, MD: Might you want to offer a closing comment?

I am grateful for the opportunity to talk with you and especially for the chance to practice psychiatry and work with so many wonderful colleagues, trainees, and patients. If I hadn’t had the chance to undergo what I experienced early in my life, I am not sure it would have all felt as right or meaningful.

Does psychiatry have an implicit bias about religion?

Spirituality in the Psychiatric Office

If readers would like their comment to be considered for posting 

Medical doctors, inadvertently and meaning to serve their patients, too often overprescribed opioid pain pills, like OxyContin, Vicodin, and Percodan. Coupled with misleading information about the safety of these drugs and a growing focus to not undertreat pain, the opioid epidemic began. The plague of overdose deaths continues today. Doctors need to be part of the solution, and we can be.

With any complex problem, as is addiction to powerful drugs like opioids, there are many questions that doctors (and other clinicians) face. I’ve outlined below seven common questions about addiction I have regularly heard-and provide the answers. These may be of interest to you.

Does making naloxone (Narcan, the drug that immediately reverses an opioid overdose) easily available encourage drug users to keep using? Is it a “moral hazard”?

A: No. People with addiction continue to use drugs (and alcohol) because they have a disease. They use to escape physical and emotional pain or to mitigate the distinctly awful state of withdrawal. They are not thinking of someone being handy with a dose of Narcan.

A: Doctors, advance practice nurses (APNs), and physician assistants (PAs) can prescribe one of three FDA-approved medications that can save lives, reduce cravings, and enable a more productive life: methadone, buprenorphine (Suboxone), and naltrexone (Vivitrol). Maintenance methadone requires a special program, so patients can’t get it in a general practitioner’s office. Prescribing is not limited to addiction experts however. Once they have a waiver from the DEA (after taking an 8-hour training), physicians, NPAs, and PAs can prescribe buprenorphine for a month as daily film tabs or give weekly or monthly subcutaneous injections. Doctors can also prescribe and administer by injection intramuscularly a monthly dose of the non-opioid (so, not addicting) naltrexone, which reduces craving for opioids and alcohol.

A: No. As with any chronic disease, medication alone seldom does the job. For addiction, recovery groups such as Narcotics Anonymous and Alcoholics Anonymous as well as family education and support are additive in helping someone manage his or her addiction. Therapy can also be very useful, particularly cognitive behavioral therapy (CBT), which can help both with depression and in managing “triggers,” those moments when a person sees, hears, even smells something that triggers use.

Many chronic pain patients are on opioids (eg, OxyContin, Percodan), some on high doses. What should doctors do?

A: Patients with addiction are seen in every doctor’s office. I would start by asking how well is the medication working in relieving their pain. Many will say, “not so well.” We know that opioids can be effective for acute but often not for chronic pain. That’s the start of the conversation. Patients, not doctors, must start believing they are not getting what they need, and that higher doses are not the answer. If the patient says, “not so well,” I would follow that by asking is it causing you problems, like constipation, sleepiness, imbalance? If it is, the patient then has told you the treatment is not working and he or she is paying a price because of the adverse effects. Your last question can be, “Do you want to try to do something about it, and if so, what might that be?” This is the clinical moment when getting off opioids and trying alternative pain management treatments becomes possible.

 Do you support needle exchange programs and safe injection sites?

A:  Yes and yes. These are both forms of harm reduction; they keep people from contracting HIV/AIDS and hepatitis C. They keep people alive until they turn the corner into recovery, as many people eventually do-we’re just not good at predicting when.

Many clinicians see recidivist patients in their emergency rooms and crisis services-opioid users who overdose or are drug-seeking. Some doctors come to resent them: after managing their overdose or refusing to write a new prescription, they’re back within days. What’s your advice?

A: That dilemma is felt by ER doctors around the country, especially in epicenters of the opioid epidemic. In many ways, these return visitors are like people with diabetes and asthma who don’t manage their illness. Our job is to help them see a different, more successful way of living. But there is one important difference with opioid addiction-the patient is in withdrawal and if that is not treated they will leave the ER seeking a fix. Some ERs prescribe a few days of buprenorphine to quiet the withdrawal so that a drug dependent person can stay away from immediate drug seeking and overdose, and perhaps even enter treatment.

There’s some recent research about using the psychedelic psilocybin to treat addiction. Is that using a drug to treat a drug problem?

A: Yes and no. It is a drug, but it has no addictive properties and usually it takes only one, maybe two, psychedelic trips. In other words, it is not a maintenance “treatment,” as we use with so many chronic illnesses. The trip is a means, for some, of profoundly changing their perspective on life, of finding meaning, a sense of wonder and the universal nature of our lives. We need new and different treatments for addiction, and this is a promising one to research.

For a long time, doctors thought prescribing an opioid for pain was the right thing, that opioids did not have the addictive power they have. We have learned differently since then. As a profession, we now need to be part of reversing the epidemic we inadvertently helped to foster. That will and can happen every day in medical offices, clinics, emergency rooms and hospitals. And the more information the public has about what works and doesn’t work in combatting addiction, the better.

Our country has overcome many an epidemic. Doctors, nurses, and other medical professionals can be part of making that happen for today’s opioid epidemic. The sooner, the better.

In his Q & A regarding opioids for chronic pain, Dr. Sederer says that when these patients come to a doctor's office, he would "start by asking how well is the medication working in relieving their pain" and he makes no mention of asking about how well they're functioning. The problem with this is that when it comes to any treatment for chronic pain including opioids, the most important question is how well the patient is functioning.  Even if the patient says he is getting excellent relief from the pain, if his functioning isn't improving, the treatment is not working. . . I think this is a very important point because many patients say they are getting relief of their pain from the opioids in order to keep being prescribed them but there is no evidence of improvement in their functioning with the drugs.
-Steven King, MD

Dr Lloyd Sederer is a psychiatrist, public health doctor and medical journalist. His new book is The Addiction Solution: Treating Our Dependence on Opioids and Other Drugs (Scribner, 2018). 

Seven common questions about addiction clinicians regularly hear-as well as the answers.

Questions and Answers for Clinicians Facing the Opioid Epidemic

Never before has it been so timely and important to improve health care for people with mental and substance use disorders in the US. The urgency of enhancing mental health care has been underscored by glaring social maladies, including homelessness, suicide among military personnel and veterans, incarceration, opiate addiction, and mass violence, which have galvanized public attention to mental illness. Political challenges notwithstanding, this article highlights the significant common ground that supports an agenda for transformative improvement of mental health care in the US.

Our “broken” mental health care system adversely affects large segments of the US population. People with serious mental illnesses (SMI), including depression, bipolar disorder, PTSD, schizophrenia, autism, and Alzheimer disease, experience severe distress and disability, require high levels of costly health services, and have substantially shortened lifespans due to excess medical comorbidity and increased suicide rates. Included in this population are people with addictions, such as victims of the recent opioid epidemic most prevalent in rural America. Deficiencies in mental health and addiction services are so longstanding and profound in the US that they cannot be simply characterized as unmet clinical needs or health care disparities: they represent what former Congressman Patrick Kennedy has called a “violation of civil rights.”

The economic burden of these illnesses is tremendous. The estimated annual costs of depression in 2010 totaled $210.5 billion, including both direct costs and indirect costs such as mortality arising from depression-related suicides as well as the effects of depression in the workplace (eg, absenteeism).

 The cost of opioid use disorders in 2013 was estimated at $78.5 billion.

 Furthermore, the Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that mental and substance use disorder treatment spending from all public and private sources for direct costs alone will rise to a total of $280.5 billion in 2020, an increase from $171.7 billion in 2009.

 These figures do not include additional costs to the criminal justice system, which houses large populations of people with inadequately treated mental illness and substance use disorders.

Improving mental health care is-and has been-a bipartisan issue. The New Freedom Commission, convened by President George W. Bush in 2002, sounded a “clarion call for this and future administrations to pursue dramatic improvements in the mental health care delivery system.”

 However, “fragmentation, stigma, [and] frozen budgets” largely thwarted this effort. Since then, legislation such as the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), as well as President Barack Obama’s health care reform bill, the Patient Protection and Affordable Care Act, have pushed forward expanded funding for mental health and substance use services. Yet previous efforts to address unmet public mental health needs have not succeeded in fulfilling their goals of broad access to quality care.

Piecemeal progress in our current mental health delivery system is insufficient. That is why a comprehensive approach to mental illness and substance use disorders should be enacted, as has been done with cardiovascular and infectious disease. This strategy targets populations in need, including those affected with and at risk for mental disorders, and would provide proven interventions to reduce morbidity and mortality. Such a mental health care plan would be comprehensive, multifaceted, and diverse and include the following core elements: universal access and broad geographic distribution, dissemination and implementation of evidence-based treatments, multidisciplinary team-based care, workforce development and deployment, alignment of financing systems, and assessment of cost-effectiveness with clear and meaningful quality and outcome metrics.

The election of Donald J. Trump to the presidency and a Republican majority in both chambers of Congress affords such an opportunity. Fortuitously, in the national election’s aftermath, an enlightened and deftly orchestrated bipartisan effort by the Senate and House leadership resulted in an extraordinary victory for both parties. The resulting legislation, 21st Centuries Cures Act (HR6), sponsored by Congressman Fred Upton, a Republican from Michigan, and Congresswoman Diana DeGette, a Democrat from Colorado, incorporated many important elements of the Helping Families in Mental Health Crisis Act (HR2646, authored by Representatives Tim Murphy, a Republican from Pennsylvania, and Eddie Bernice Johnson, a Democrat from Texas). If reconciled with the Senate’s companion bill, the Mental Health Care Reform Act (S2640, sponsored by Senators Chris Murphy, a Democrat from Connecticut, and Bill Cassidy, a Republican from Louisiana), along with the Mental Health and Safe Communities Act (S2002, sponsored by Senator John Cornyn), HR6-if fully funded and implemented-could have a transformative impact on our nation’s mental health system and enhance access to and quality of mental health services.

This extraordinary governmental action during a “lame duck” session revealed the broad understanding and strong interest of the Congress and administration in addressing this urgent and longstanding problem. Buoyed by this congressional success and with the hope of providing the Trump Administration and new Congress an agenda to continue to improve mental health care in the US, we offer the following provisional proposals.

Dissemination and implementation of evidence-based programs

Advances in behavioral and neuroscience research have led to evidence-based treatments and models of service delivery that can substantially improve outcomes and reduce the burden of illness and costs of caring for those affected by mental illness and addiction. To be effective, evidence-based treatments for mental illness and substance use disorders must be appropriately and consistently delivered. Such services are optimally implemented by multidisciplinary treatment teams (as opposed to individual practitioners) in light of shortages in the workforce and geographic distribution of mental health professionals, as well as the diverse expertise needed for management of mental and substance use disorders. To facilitate this process, mental health care education and training curricula will need to be adapted, and training and supervision provided on a range of skills integral to evidence-based practices.

Special efforts must be made to ensure access to care for people with substance use disorders, among whom currently only 1 in 10 receives any form of treatment. Medication-assisted treatments such as buprenorphine or extended-release injected naltrexone should be more widely made available, as has been demonstrated successfully in Vermont.

Creation of portals of entry for all in need

Portals of access to mental health care in the public and private sector stakeholders (providers, payers, patients, employers) must be established for each segment of the population in need. These portals would be located in, or have liaisons with, hospitals, clinics, medical practices and offices, educational institutions, work settings, and community organizations. Services for common conditions such as depression, anxiety, and alcohol and drug use disorders are more accessible when embedded in primary care settings and the workplace, while schools and universities are well positioned to detect learning disabilities, eating disorders, and early stages of psychotic and mood disorders and engage students in care.

People with SMI are more likely to benefit from dedicated, specialty mental health centers because of their complex service needs. Community institutions, such as places of worship, and clergy may provide additional points of entry. Adults and children in rural and remote areas who face regional shortages in mental health services require technology innovations such as telehealth and virtual support from academic centers. Children and adolescents may best be reached through school-based programs or pediatric and family practices.

A critical portal of entry to behavioral health care must be considered for people with SMI involved with the criminal justice system, particularly during transitions between the community and jails or prisons. For example, mental health courts are effective at diverting people with SMI from becoming incarcerated as well as reducing rates of recidivism and violence.

 These services must also be extended to juveniles at high risk for mental illness and substance use disorders.

Alignment of financing systems with assessment of outcomes and value-based care

As described, the financial burden of mental and substance use disorders for both public and private payers as well as ancillary social services and the criminal justice system should be a major incentive for pursuing payment redesign. Amendments to existing, or new, legislation can encourage alignment of insurance financing systems to new models of mental health care and services by health care providers. While this objective will initially entail reimbursement to personnel from diverse disciplines, ultimately these costs must be incorporated into new payment models, including bundled payments and risk-adjusted, population-based payments.

Measurement-based care, where treatment is tied to outcomes-as already developed in payment for the care of diabetes, hypertension, congestive heart failure, and other nonpsychiatric medical conditions-must be utilized throughout the mental health care system and woven into its payment models. The National Academy of Medicine has released Vital Directions, which calls for improved and innovative payment models that align with evidence-based treatments.

Modernization of health information technology

Health information technology (HIT) offers a major opportunity for improvements in mental health care. Computerized clinical decision support for treating patients who are not responding to initial medication trials, telemedicine, and computer-guided adaptations of psychosocial treatments for people with SMI are innovations awaiting greater utilization. In addition, integration of and training in HIT within behavioral health settings is essential to achieve interdisciplinary and cross-provider collaboration.

Scientific advances, social progress, mental health literacy, and federal legislation have created a strong foundation for the transformation of mental health care in America. This article has laid out a viable agenda for next steps. But that is not enough: political leadership and strategy are also necessary, along with support of biomedical research in brain disorders and investment in the development of new, more effective treatments.

President Trump signaled that health care reform will be a top priority in the first year of his administration. We expect that this would include mental health care. With this article’s agenda at the ready, and the momentum from the expanded 21st Century Cures Act, the Trump Administration, with the participation and support of Congress and other stakeholders, has a unique opportunity to mobilize the necessary political will to engage in a bipartisan effort to enact a “Mental Health Plan for America” to deliver quality mental health services for all those in need.

Dr. Lieberman is Lawrence C. Kolb Professor and Chairman, Columbia University Department of Psychiatry, New York; Dr. Goldman is Resident Physician, Columbia University Department of Psychiatry; Dr. Olfson is Professor, Columbia University Department of Psychiatry; Dr. Pincus is Professor and Vice Chair, Columbia University Department of Psychiatry; Dr. Sederer is Adjunct Professor, Department of Epidemiology, Columbia University Mailman School of Public Health.

The authors report no conflicts of interest concerning the subject matter of this article.

 Greenberg PE, Fournier A-A, Sisitsky T, et al. The economic burden of adults with major depressive disorder in the United States (2005 and 2010). 

 Florence CS, Zhou C, Luo F, Xu L. The economic burden of prescription opioid overdose, abuse, and dependence in the United States, 2013. 

 Substance Abuse and Mental Health Services Administration. Projections of National Expenditures for Treatment of Mental and Substance Use Disorders, 2010-2020. 

http://store.samhsa.gov/shin/content//SMA14-4883/SMA14-4883.pdf

 Robertson AG, Swanson JW, Lin H, et al. Influence of criminal justice involvement and psychiatric diagnoses on treatment costs among adults with serious mental illness. 

 Iglehart JK. The mental health maze and the call for transformation . N Engl J Med . 2004;350:507-514.

 Crossing the Quality Chasm: A New Health System for the 21st Century. 2001. 

http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf

 McNiel DE, Binder RL. Effectiveness of a mental health court in reducing criminal recidivism and violence . 

 Knickman J, Rama Krishnan KR, Pincus HA, et al. Improving Access to Effective Care for People Who Have Mental Health and Substance Use Disorders: A Vital Direction for Health and Health Care. 2016. 

https://nam.edu/improving-access-to-effective-care-for-people-who-have-mental-health-and-substance-use-disorders-a-vital-direction-for-health-and-health-care/

The authors outline the ingredients for the transformation of mental health care in America.

Improving Mental Health Care in America: An Opportunity for Comprehensive Reform

“Subtypes (some of which are coded in the fifth digit) and specifiers are provided for increased specificity. Subtypes define mutually exclusive and jointly exhaustive phenomenological subgroupings within a diagnosis.”

It’s too bad that so many experts-in medicine and in other professions-can’t write for a lay audience. They may be fine writing for journals and textbooks but fail in communicating beyond a small circle of colleagues.

Lives can be profoundly affected-maybe even lost-when professional knowledge is not effectively articulated by experts. Many important decisions are made only with a Google search-decisions that often determine our health, the health of our families and our communities, as well as wealth!

For those who aim to improve their craft, here is my list of 8 enemies of good writing, with examples.

 Good writers know the first sentence needs to grip the reader. And the next sentence needs to tighten the grip.

“The data suggest both positive and negative movement in the underlying segments of the population that, in total, kept the overall uninsured rate almost flat,” wrote a public health official, perhaps thinking he was saving the best for last?

Burying the lead is aptly termed because your reader will have fallen asleep or expired before the subject appears. Doctors are especially prone to this enemy, fond as they are for a lengthy exegesis before getting to the point.

The Anxious Professional Syndrome (aka The Biggest List):

 Professionals are prone to write as if they are taking an exam, with admonitions bellowing in their head: Show how much you know! Don’t risk omitting anything a professor might ask!

An example would waste your time (and my word limit!). Get to the point-lay readers want to know what is important to them-not to 

The New England Journal of Medicine or The Law Review

 Clutter comes in many forms. One is using 2 or more words when one will do, like “dangerously toxic” or “in light of the evidence.”

Clutter is also using unnecessary phrases like “An important thing to note . . .” or “I want to add” or complex words (or terms) when simple will do, such as “prioritize” for select, “issuance of protocol” forrules, “preparatory activities” for initial work, and “heterogeneous” for different.

Clutter can numb the reader or dodge frank expression, as in “collateral damage,” “meaningful discussions were had,” or “the reported side effects included obtunded thinking and anaphylactic shock.”

The answer to clutter is mercilessly discarding unnecessary words and phrases. It is taking pleasure in pruning your prose.

“Empirical studies, scientific data, and anecdotal evidence demonstrate that absent any other deficit, disease, or injury, it generally follows that if you play with, talk to, teach, and otherwise actively engage your baby, his/her brain tends to develop optimally, in large part through more vigorous ideal myelin formation.” Might simply say: “We have ample proof that playing with an infant promotes brain development.”

 Using technical nouns or phrases is another common error by professionals. Write in everyday English: if your mother would think the writing is another language, it probably is!

My colleagues in mental health and neuroscience are sweet on terms like object relations, genomics, urban drift, neurocircuitry, unconscious representations, and cognitive dissonance. These are jargon: they confound more than explain.

If you have doubts about how to tell good writing, keep in mind: “. . . [b]eyond a certain point complexity is fraud . . . when someone creates a system in which you can’t tell whether you’re being fooled, you’re being fooled.”

Long sentences and long paragraphs are enemies to be conquered.

Short sentences full of lively nouns and action verbs carry the reader forward, effortlessly. Short paragraphs allow the mind to rest, absorb what has been written, and then move along.

Be kind, rewind: go back and shorten your sentences. Find places to shorten sentences and where pressing “Enter” within a paragraph will give everyone a break.

 Is the writer personable, respectful, and kind-or distant, haughty, or mean? Does the writer help or not?

“An inability to smile or express emotion through the face is so characteristic of the disease [of schizophrenia] that it was given the name of affective flattening or a blunt affect.” Where is the person in this sentence, or why it is helpful?

The highest praise I have had as an author was when a family member told me that reading my work was like being at her kitchen table talking about what is important.

“The conclusion section is very easy to write: all you have to do is to take your abstract and change the tense from present to past,” wrote someone who read too many medical papers yet kept his sense of humor.

Endings are your way to come full circle: sum up, in new and memorable words, what you want your reader to be left thinking. Some of the best endings deliver a quote that hits the message out of the park (when the article has set the reader up for the home run). Endings that deliver a note of surprise are a delight for the reader who has followed you to the end.

“This is not the beginning of the end-but the end of the beginning,” Winston Churchill said upon the Americans entering World War II. And this is the end of our beginning discussion of this subject.

I am a psychiatrist and public health advocate. For the past 8 years, a week or so at a time, my wife and I have walked the ancient Santiago de Compostela pilgrimage trail that goes from central France to the coast of western Spain. We have completed over 1000 km of the 1600-km hike. I speak French, so I was good in France but had to dust off my junior high school Spanish for the long hike in Spain!

It was on this pilgrimage trail in late October 2015 that I had the inspiration for my latest book, 

Improving Mental Health: Four Secrets in Plain Sight

, which I wrote in France during Christmas break last year.

I have served as Medical Director of McLean Hospital, a Harvard teaching hospital in Belmont, Massachusetts, Director of the Division of Clinical Services for the American Psychiatric Association, and Mental Health Commissioner for New York City. I am currently Chief Medical Officer of the New York State Office of Mental Health, Medical Editor for Mental Health at 

, and an Adjunct Faculty Member at Columbia University’s Mailman School of Public Health. I have published 10 books for both professional and lay audiences, and my writing has been featured in the 

Dr. Sederer is Adjunct Professor at Columbia University Mailman School of Public Health; Chief Medical Officer, The New York State Office of Mental Health; and author of several books (see profile below). For more, follow him on Twitter: @askdrlloyd. He reports that he receives book royalties from the American Association Publishing Co.

It’s too bad that so many experts-in medicine and in other professions-can’t write for a lay audience. Here's some help.

Eight Enemies of Good Writing for the Lay Reader

We all want our work to have an impact, to make a difference.

Trying to change behavior-in programs as well as people-often evokes tenacious resistance. Writing for the better can become a vehicle for that change.