Ronald W. Pies, MD

Oregon’s Governor Kulongoski has vetoed a bill that would have allowed psychologists to practice clinical medicine without adequate training-otherwise known by the euphemism of “prescribing.” The Governor’s rationale was precisely the one opponents of the bill, such as I, had advocated.

Readers who know me well will not be surprised by my citing the Tao Te Ching-but some may be taken aback by my quoting football legend, Kurt Warner, who announced his retirement recently.1 Mr Warner had some wise things to say about leaving a job under your own steam, while you are still in good health-and preferably, before you are shown the door. As I prepare to step down from the editor in chief position at Psychiatric Times in June, I believe I can honestly claim that these conditions apply to my departure. The “hail and farewell!” is intended to encompass both my leave-taking from the helm and my greetings to the incoming editor in chief-my friend and colleague, James Knoll, MD.

In 5 minutes, so much can be accomplished.

Almost the first memory I have of a physician is our family doctor at my bedside, leaning over to press his warm fingers against my neck and beneath my jaw. I’m 5, maybe 6 years old. I have a fever and a sore throat, and Dr Gerace is carefully palpating my cervical and submandibular lymph nodes. In my family, Dr Gerace’s opinion carried a lot of weight. It was the 1950s, and my mother did not quite trust those new-fangled antibiotics. She usually tried to haggle with the doctor over the dose-“Can’t the boy take just half that much?”-but even my mother would ultimately bow to Dr Gerace’s considered opinion.

Oregon’s Governor Kulongoski has vetoed a bill that would have allowed psychologists to practice clinical medicine without adequate training-otherwise known by the euphemism of "prescribing." The Governor's rationale was precisely the one opponents of the bill, such as myself, had advocated.

It is safe to say that few authors of mental health–related books would introduce themselves by presenting these credentials:

Writer Jonah Lehrer caused quite a stir with his recent article in the New York Times Magazine, with the unfortunate title, “Depression’s Upside.” I have a detailed rejoinder to this misleading article posted on the Psychcentral website.

The issues being debated here have important long-term implications for psychiatry, and we are pleased to present these revised versions of 2 principal presentations.

Arlington, VA, March 2 (compiled from AP reports)-Officials at the American Psychiatric Association (APA) confirmed today that their national headquarters had been taken over by “very, very large English and literature teachers,” according to a spokesperson for APA President, Dr Alan Schatzberg. Schatzberg himself was unavailable for comment and was reported to be in seclusion “…brushing up his Shakespeare.”

Quick-which screening test or instrument has greater specificity for the target condition: the PSA (prostate specific antigen) test for prostate cancer, or the BSDS (Bipolar Spectrum Diagnostic Scale), for bipolar disorders?

Another lifetime ago-just after leaving residency-I took a job as a psychiatric consultant at a large, university mental health center. Had I known the poisoned politics of the place, I would have headed for someplace safe-like, say, Afghanistan.

“The exclusion of symptoms judged better accounted for by Bereavement is removed because evidence does not support separation [or] loss of loved one from other stressors.”1

Imagine, as a psychiatrist, hearing this story from a beloved friend or relative:

In 2 previous editorials-“The ‘McDonaldization’ of Psychiatry” and “Doctor, Are You ‘Drugging’ or Medicating Your Patients?”-I focused on some serious problems in current psychiatric practice and on various shortcomings in our treatments. In the third “panel” of this editorial triptych, I want to take note of the considerable good that psychiatric treatment may bring to those who suffer with devastating illnesses.

There are 2 rooms a physician should never enter, or even go near: the executioner’s chamber and the interrogator’s cell. I’m speaking figuratively, but I have very concrete circumstances in mind. Indeed, in recent years, psychiatrists have been drawn into controversies related to both these “rooms”-one involving the physician’s role in capital punishment cases; the other, in cases related to the interrogation of suspected terrorists.

In a very long essay in the Sunday (1/10/10) New York Times Magazine entitled, “The Americanization of Mental Illness,” Ethan Watters suggests that a kind of psychiatric-cultural imperialism has been foisted on other countries and cultures by “the West.”

The most rigorous scientific review of “medical marijuana” to date was carried out by the Institute of Medicine in 1999, under the direction of Drs John A. Benson Jr and Stanley J. Watson Jr.1 The institute’s conclusions were considerably more nuanced and qualified than those of the US Drug Enforcement Administration.2 The institute report found that:

Hired guns.” “Whores.” “Greedy, insensitive bastards.“ These are some of the more printable epithets used to describe psychiatric physicians who (allegedly) have “sold out to Big Pharma.”

As a general proposition, most scientists and physicians prefer sharpness to fuzziness, at least when it comes to defining terms. I generally share this view, as regards psychiatric diagnosis, but only up to a point. That point is defined by the well-being of my patient - and sometimes, this may call for a “fuzzy” diagnosis.

Psychosurgery. For some, the word connotes all the promising therapeutic applications of modern neuroscience; for others, it connotes all the baneful excesses of unregulated pseudoscience.

The press reported it in various ways-either as a “brutal gang rape” or, more forensically, as a “21/2-hour assault” on the Richmond High School campus. Any way you look at it, the horrendous attack on a 15-year-old girl raises troubling questions for theologians, criminologists and, of course, psychiatrists. How do we understand an act as brutal as rape? What factors and forces in the rapist’s development can possibly account for such behavior? And how on earth do we explain the apparent indifference of the large crowd that watched the attack in Richmond, Calif, and allegedly did nothing to stop it-or even, to report it?

The debate within the medical profession over “conflicts of interest” (COIs) has often been shrill, and sometimes seems to be based on misunderstandings or myths about what COIs entail. In this psychiatrist’s view, it is helpful to step back from confident proclamations, acknowledge that the issues involved are complex, and aspire to some semblance of humility. Nobody has cornered the market on “the right way” to deal with COI in the realms of medical research, publication, and education.1 At the same time, as Alan Stone, MD, has noted (personal communication, August 27, 2009), ethical considerations lie at the heart of any debate on COI-in particular, the ancient dictum, “Do no harm.” Indeed, ethicist James M. DuBois has pointed out a direct connection between some types of COI and harm to the general public: “Mental health consumers are at risk when studies that involve questionable scientific and publication practices are translated into therapeutic practice.”1(p205)

Some would ask whether the psychiatric system at Ft. Hood adequately assessed the mental state of Army Maj Nidal Malik Hasan, the man accused of yesterday's shooting rampage on the base.

The press reported it in various ways-either as a “brutal gang rape” or, more forensically, as a “2½-hour assault” on the Richmond High School campus. Anyway you look at it, the horrendous attack on a 15-year old girl raises troubling questions for theologians, criminologists, and, of course, psychiatrists.

You have read the blogs and seen the placards a dozen times: doctors prescribe too many “drugs” for too many patients. Psychiatrists, in particular, are popular targets of politically motivated language that seeks to conflate the words “medication” and “drug”-thereby tapping into the public’s understandable fears concerning “drug abuse” and its need to carry out a “War on Drugs.”

What safeguards does Psychiatric Times build into its review policies to avoid conflicts of interest (COIs)? Do these policies apply to the “supplements” sometimes mailed out with the regular publication?

The editorial board and staff of Psychiatric Times wish to announce, with much regret, the retirement of Max Fink, MD, from our journal’s editorial board. Dr Fink-who is emeritus professor of psychiatry and neurology at the State University of New York at Stony Brook-has been a valued member of our board since 2002, and a regular contributor to the journal for many years before that.

>I greatly enjoyed Dr Ron Pies’ editorial “What Should Count as a Mental Disorder in DSM-V?”1 in which he encouraged framers of DSM-V to critically examine the boundaries of mental illness and to more carefully distinguish between diseases, disorders, and syndromes. As I have noted elsewhere, current plans to integrate a “spectrum” approach into DSM-V require a careful consideration of these issues that must be defensible to critics of diagnostic expansion within psychiatry.2

After a stellar academic career of 44 years, Dr Domeena Renshaw has announced her retirement from Loyola University, where she has been professor of psychiatry and behavioral neurosciences. We are sad to say that Dr Renshaw will also be retiring from the editorial board of Psychiatric Times, on which she has served diligently for many years.

We at Psychiatric Times wish to note, with great sadness, the passing of our colleague and editorial board member, Dr Gene Usdin, at the age of 87.