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Posttraumatic stress disorder (PTSD) can be exceptionally 

. But recent studies have suggested the efficacy of a surprising option: 

For PTSD, 3,4-methyl​enedioxy​methamphetamine (MDMA) appears to be especially 

. In this Mental Health Minute, Devon Christie, MD, CCFP, IFMCP, RTC discusses her latest study results on this topic and what might be in the future for psychedelic-assisted psychotherapy.

is a family physician, a certified therapist, and medical and therapeutic services director at 

Do you have patients who might benefit from MDMA-assisted psychotherapy? 

Share comments with your colleagues by emailing 

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

A growing body of scientific evidence suggests that mind-altering drugs, combined with psychotherapy, are effective treatments for some of the most stubborn psychiatric disorders.

What Does the Future Hold for Psychedelic-Assisted Psychotherapy?

Existing treatments for posttraumatic stress disorder (PTSD) are few in number and, too often, ineffective. Although still classified as a Schedule I drug, methylenedioxymethamphetamine (MDMA) has improved symptoms PTSD in 

In this Mental Health Minute, Tiago Reis Marques, MD, PhD, shares the results of 

, in which the MDMA-assisted arm of the study outperformed the placebo by 35%. He revisits the history of MDMA and looks to the future, when this Schedule I drug may be approved as a legal treatment.

is a senior clinical fellow on the Faculty of Medicine at Imperial College London, an instructor at the Institute of Psychiatry in King’s College, and the CEO of Pasithea Therapeutics.

Would you prescribe a psychedelic like MDMA? 

The latest trial results for MDMA-assisted therapy are in—and they are eye-catching.  

New Hope for PTSD Treatment?

“There’s more to trauma than physicality,” Rachel Yehuda, PhD told attendees at the 2021 American Psychiatric Association (APA) Annual Meeting. “For decades we have been talking about how to integrate pharmacotherapy with psychotherapy. But we haven’t understood how to do it.” 

For patients with posttraumatic stress disorder (PTSD), one possibility is combining therapy and mind-altering drugs, like 3,4-methyl​enedioxy​methamphetamine (MDMA), panelists explained.

Mark Bates, PhD, former branch chief for Psychological Health Promotion in the Department of Defense’ Psychological Health Center of Excellence, presented findings from 6 phase 2 trials of combined MDMA and psychotherapy in the 

 The studies included 103 participants who had experienced treatment-resistant PTSD symptoms on average for more than 15 years.

Participants progressed through several types of sessions in all of the studies. First, participants and clinicians conducted an initial, 90-minute interview, preparing the participants for the MDMA-assisted sessions and discussing their PTSD. Then participants underwent 8-hour MDMA-assisted or placebo sessions. During this time, participants wore eyeshades and listened to music, and had the option of discussing their troubling experiences.

The participants who received MDMA experienced an altered mental state, which was believed to make the discussion easier on them as compared with those in the placebo group. “One of the most important features,” Bates said, “is this reduced fear response in combination with increased empathy, trust, and closeness. In the words of one participant, ‘it’s like being in a box full of puppies.’ You can actually feel safe to bring up things that were otherwise very uncomfortable.”

Participants and therapists debriefed for 90 minutes the day after the MDMA session. Integration, Bates explained, helps “the patients retrieve and consolidate much of what happened during the dosing session and integrate it into their daily lives.”

The results of the studies were encouraging, he reported. Among participants who received MDMA, 56% no longer met PTSD criteria by the end of the study and, at a 12-month follow-up, that number rose to 67%.

 Mean change on participants’ Clinician Administered PTSD Scale (CAPS-IV) fell around 45 points. Meanwhile, 23% of participants who received the placebo did not meet criteria for PTSD by the end of the study.

Robert Koffman, MD, dug deeper into the science behind MDMA’s potential effects. “We really don’t know how it is that MDMA actually works,” admitted Koffman, first senior consultant for integrative medicine and behavioral health at the National Intrepid Center of Excellence. He noted research indicates that MDMA seems to create the exact opposite effects of PTSD: Whereas PTSD is associated with increases in amygdalar activity, heightened fear responses, decreased hippocampal activity, emotional numbness and distrustful hypervigilance, MDMA is associated with reduced amygdalar activity, increased hippocampal activity, reductions in fear and defensiveness, and higher feelings of 

 In short, Koffman said, “MDMA increases access to these traumatic memories without the kind of flooding and emotional numbing characterized by the speechless terrors” that usually accompany PTSD.

However, Koffman noted the altered mental state induced by MDMA is not enough to achieve positive results. “What we are really discussing in this talk,” he said, “is the relationship between the drug and the therapy.” In addition, the therapy involves additional training to be successful, he cautioned. A therapist should not try to understand the patients’ problems rationally and then use specific techniques to change their situation; instead, he explained, therapist’ goal should be to mediate their patient’s access to deep states of their psyches and facilitate “a powerful transformational experience of a 

During the Q and A session Yehuda, who is director of the Center for Psychedelic Psychotherapy and Trauma Research at Mount Sinai School of Medicine, said that psychedelic-assisted psychotherapy raised important questions about the nature of psychiatric healing. “This is almost treasonous for a psychiatry meeting,” she admitted, “but the actual molecule and neurochemical effects are probably a lot less important to the healing than the fact that you have provided an opportunity to look at something that [the patient] couldn’t see, because it was either too painful or it was blocked.”

“The future is here,” Koffman concluded. Although MDMA is currently a Schedule 1 drug, the Multidisciplinary Association for Psychedelic Studies “fully expects MDMA to be rescheduled by 2023, possibly even by next year.”

In fact, MDMA treatments are about to pass another important milestone. Next month 

will publish results of a phase 3 trial in which 67% of participants no longer met criteria for PTSD after 2 months of treatment with 

“We are so comfortable with our molecules and our neurochemistry,” said Yehuda. “But I know enough to know that the answers are not just in the molecule. It has to do with the entire healing process. The good news is that makes clinicians really important.”

1. Jerome L, Feduccia AA, Wang JB, et al. Long-term follow-up outcomes of MDMA-assisted psychotherapy for treatment of PTSD: a longitudinal pooled analysis of six phase 2 trials. 

2. Mithoefer MC, Wagner MT, Mithoefer AT, et al. The safety and efficacy of {+/-}3,4-methylenedioxymethamphetamine-assisted psychotherapy in subjects with chronic, treatment-resistant posttraumatic stress disorder: the first randomized controlled pilot study. 

3. Feduccia AA, Mithoefer MC. MDMA-assisted psychotherapy for PTSD: Are memory reconsolidation and fear extinction underlying mechanisms? 

Prog Neuropsychopharmacol Biol Psychiatry

4. Mithoefer, MD. A manual for MDMA-assisted psychotherapy in the treatment of posttraumatic stress disorder. Multidisciplinary Association for Psychedelic Studies. August 19, 2015. Accessed May 5, 2021. 

5. Nuwer R. A psychedelic drug passes a big test for PTSD treatment. 

New research find altered states of consciousness may allow veterans and other patients with PTSD to face unspeakable experiences and find peace. 

Looking to the Future of MDMA-Assisted Psychotherapy

The initial wave of COVID-19 flooded New York City hospitals with patients who urgently needed medical attention. Despite the potential dangers, psychiatrists and other physicians rushed to their aid. There were examples of inspiring teamwork and mutual support everywhere. At the same time, many physicians found themselves in new and unfamiliar roles, sometimes without the necessary mental health resources to cope with what they were seeing and doing.

, hosts Angela Coombs, MD, and Jennifer Sotsky, MD, talk to 

, about their experiences in the early days of the pandemic.

Many physicians have undergone traumatic experiences during the COVID-19 pandemic. If you or anyone you know needs mental health resources, consider contacting the 

Substance Abuse and Mental Health Services Administration

’s national hotline (800-662-HELP) or the 

is an anesthesiology Critical Care Medicine Fellow at University of California, Los Angeles Health

is a PGY 3 resident and co-chair of the Psychiatry Residents Diversity Alliance at Columbia University Medical Center.

is a board-certified psychiatrist and assistant professor in Clinical Psychiatry at Columbia University Medical Center and the New York State Psychiatric Institute. She serves as the medical director and team psychiatrist at ONTrackNY Washington Heights Community Service clinic. She completed her public psychiatry fellowship and adult psychiatry residency at Columbia University where she was a chief resident and co-organized the curriculum on racial/ethnic mental health disparities. In addition to her clinical work in the public sector, she also works in Columbia's psychiatric emergency room and has a private practice in Upper Manhattan.

is a fellow in consultation-liaison psychiatry at Columbia University Irving Medical Center with a part time private practice. She was formerly a chief resident at Columbia’s psychiatry residency program. Before medical training, she received an MS in Narrative Medicine, an interdisciplinary field that studies illness through a humanities lens. She is co-author of

Conquering Lyme Disease: Science Bridges the Great Divide

and has interests in medical education, psychotherapy, and medical humanities.

Thanks to Columbia University Department of Psychiatry for allowing us to present the Breakthrough Session podcast with experts in the field of psychiatry

In the early days of the COVID-19 pandemic, physicians were thrust into unfamiliar roles, where they sometimes had to make life and death decisions. Here are a few of their stories. 

Teamwork and Trauma: a Conversation With Kasey Grewe, MD, and Niesha Voigt, MD

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

 is the Dr Frances S. Arkin professor and chairman of the department of psychiatry, professor of psychiatry and medicine at Tufts University School of Medicine, and psychiatrist-in-chief at Tufts Medical Center. Dr Summergrad served as the 141st president of the American Psychiatric Association from 2014 to 2015. He is also a past president of the American Association of Chairs of Departments of Psychiatry and is Secretary for Finances of the World Psychiatric Association and a member of the WPA executive committee. Dr Summergrad’s research focuses on mood disorders, medical-psychiatric comorbidity, and health system design. He received the Distinguished Faculty Award from Tufts University School of Medicine in 2015 and the Leadership award of the American Association of Chairs of Departments of Psychiatry in 2018. He was elected to the Honorary Fellowship of the Royal College of Psychiatrists, their highest honor, in 2020. He is the lead editor of the 

 (2020, American Psychiatric Association Publishing).

In many ways, Dr Summergrad exemplifies the best of psychiatric leadership. He has a charismatic and warm persona, an in-depth knowledge of psychiatry’s history, an appreciation of its pluralistic roots in medicine as well as psychoanalysis, and a preference for taking the long view of psychiatry’s development as a field. I was pleased to be able to speak to Dr Summergrad about his intellectual development, his views on psychiatry’s identity, and the challenges facing the medical model and psychiatric classification.

 Perhaps we can begin with the trajectory of your intellectual and philosophical understanding of psychiatry, particularly how you have navigated the psychoanalytic as well as neuroscientific aspects of psychiatry over the course of your career?

 I have been thinking a lot about this, and I do not know that I can separate any of this from certain cardinal experiences of my life. So, I think we will have to take a little detour into my life story and how I entered medicine and psychiatry.

I am a child of the 60s in the sense that I was in college during the 60s. That was an extremely disruptive time in American history for a variety of reasons, and it became a disruptive time in my own life as well. I had been interested in psychiatry well before that, probably since I was 14 or 15 years old. For some reason, I was just pulled towards psychiatry. Maybe it was because I read 

in high school, or because I had also worked at a camp run by a Jewish social welfare organization. There was a cohort of kids at the camp who had emotional and social difficulties. As part of that experience, we learned a bit about how to work with kids who had emotional difficulties, and that also reinforced my interest in psychiatry.

I started college in 1967. Looking back on it, I doubt that I was clinically depressed, but it was definitely an emotionally turbulent period of my life. I was significantly thrown off both by where I was living as well as by my living circumstances. I hated Buffalo and its winters. Going outside in the winter there seemed like crossing Siberia to a New York City native. I was not really prepared for it. And I was a freshmen male living in gender segregated rental housing off campus. During that year, I took a course on the 

, which as you know is one of the foundational texts of Buddhism. I was very much drawn to that course, as well as to another course on Chinese history, but otherwise I felt very disconnected from school. Like probably a lot of other college students at that time, I started smoking cannabis. In the spring of that year, I took LSD—I am certainly not advocating for the casual use of psychedelics or cannabis here—and I had a profoundly religious experience. It was as if I had been dropped into Nirvana, perfection, holiness, oneness. It was a deeply mystical experience, and it also changed my thinking about the 

. It made me think a lot about neurobiology and consciousness, because if a tiny dose of a drug like this could change one’s perception so profoundly, what did that mean regarding how we understand the mind-brain relationship, and relevant to psychiatry, the etiology of mental illness?

Partly as a result of that, I then went on to study Zen Buddhism and considered training as a Buddhist monk. I ended up spending a couple of years doing very intensive Zen Buddhist meditation at a training center in Rochester, New York. There was no drug use of any kind and a fairly ascetic lifestyle. Towards the end of that period, I spent a year in a self-imposed isolation, in a liminal state, because I really felt that I needed to cut out the external messages of the dominant culture to discover what I really wanted to be and do. At the end of this period, I had a couple of important dreams and one of the dreams was extraordinarily powerful, a great dream in the Jungian sense, which basically resolved my dilemma. I woke up and my crisis was over. I knew exactly what I wanted to do and how to integrate the various strands of my life. I knew I wanted to go to medical school and to likely become a psychiatrist.

In medical school it turned out that I really liked medicine, and I ended up training in internal medicine for 3 years before I trained in psychiatry. The medical training left a deep influence. I was impacted by being in a medical setting where neuropsychiatric conditions were among the most common admitting diagnoses. When I was an intern, probably a third of the admissions to the medical service were due to altered mental status. I realized that in practically every rotation, the only thing I really cared about was the neuropsychiatric consequences of the medical conditions I was studying. So, I really could no longer resist the siren song of psychiatry, but I was impacted by my medical training, such that for me, the boundary between medicine and psychiatry has always been very porous.

 What sort of notion of psychiatry did you have at that time, and how was it influenced by your earlier mystical and meditative experiences?

: My sense of psychiatry was in part tied to depth psychology and psychoanalysis. Given my Jewish background, and given Freud’s own cultural Jewish identification, there was a pull towards psychoanalysis from a cultural standpoint, but there was also a pull towards it as being somehow central to psychiatry. 

 provided me with a way to merge my experiences with dreams, meditation, and psychedelics with my interests in medicine and science.

I went on to undertake psychoanalytic training at the Boston Psychoanalytic Society and Institute. Despite my psychoanalytic training, I thought psychiatry had to be profoundly anchored in medicine, and by medicine I am broadly including here internal medicine, neurology, as well as the neurosciences. For my residency I went to the most medically oriented psychiatric program in the United States, which was Massachusetts General Hospital. Tom Hackett, MD, was the chief there when I was a trainee. His view was that if psychiatry was not anchored in medicine, it was kind of homeless, from a clinical as well as operational standpoint, and I agree with that. I think it is unfortunate that a lot of the time as psychiatrists we end up giving away our connection to the rest of medicine and neurology. The other side of it is the risk that we may justify our existence as physicians by overvaluing what seemed to me to be a narrower 

. I think if we were more secure in our relationship with medicine, we might not see quite this tension within the profession.

 How did you reconcile psychoanalysis and neuroscience in your mind?

 Early in his career, prior to the development of psychoanalysis, Freud wrote a book called 

, which was officially published in 1950, well after his death. I felt that my interests in neurobiology and psychology came together in 

 which mirrors, especially in its critical seventh, metapsychological chapter, 

 Freud was really struggling with how to place his interest in depth psychology in the context of the burgeoning neurobiology of the late 19th century. The late 19th century was a fertile period: the neuron doctrine was being established. 

 produced his first drawings of neurons around that time. Freud attempts in 

 to use what he understood as the accepted neurobiological model and tried talk about how this whole apparatus works to generate mental states. I thought that he engaged with that issue in that book in a much more profound way than psychoanalysis has subsequently. Freud was severely limited by the neuroscience of his times, but he was convinced that a scientific explanation of psychological phenomena in terms of neurobiological phenomena was possible. He basically thought of psychologic states in parallel to the physiology of the brain that, while separate, they were “dependent concomitants,”

 and I think this central idea provides a potential means of reconciliation.

 In the mid-20th century, the psychiatrist 

 was commissioned by the World Health Organization to review existing psychiatric classifications. He noted in 

Recently, the attitude of many psychiatrists towards the conventional type of classification has become one of ambivalence, if not of cynicism… classifications based on the Kraepelinian system have continued to be used in some form or other all over the world. Many psychiatrists have done so under protest and expressing their disbelief in the working hypotheses underlying that system.

This description strikes me as quite applicable to our own times. The controversy surrounding the development of DSM-5 and the on-going search for alternative classification frameworks reveals just how deep the dissatisfaction is. What are your thoughts on why attitudes towards classification continue to be ambivalent in the psychiatric community, and what do you see as the path forward?

 The dynamic as described by Stengel does seem to exist. I think that we tend to get into a lot of unnecessary battles around classification, regarding how we classify and what we classify, as if these were not constructs imposed on real conditions. It is not that psychiatric disorders are not real. They are terribly real. All you need to do is take care of someone who is experiencing a severe episode of mania or catatonia, to know that they are profoundly and powerfully real. I tend to see psychiatric classification as more of a tentative and open-ended iterative process, subject to revision by evolving data and models of disorders. . This is a difficult task, as you know, we are dealing with things at multiple levels of observation. Take Research Domain Criteria (RDoC), for example. Even if you are going to use RDoC to do a research study, you still need to select and study a group of patients using some form of clinical categorization, whether it is something broad as mood disorders, or specific symptoms such as anhedonia, etc. There was recognition in the 1960s and 1970s, by the group of psychiatrists at Washington University in St. Louis as well as Robert Spitzer, MD, and colleagues that there needed to be some operational criteria to ensure reliability of observations. This recognition emerged in the context of many studies which had showed the poor reliability of various diagnoses at the time, such as the differences between the diagnoses of bipolar disorder vs schizophrenia in 

I think the development of our current nosologies in the 1970s was an understandable reaction against a lack of scientific rigor, at least around reliability. It starts becoming a problem when the operational constructs become reified as real, as valid. This will be relevant to our discussion regarding the medical model as well, because mental disorders are profoundly personal and intimate, and they affect one’s deepest sense of who one is. A psychiatric diagnosis can be heard as somebody saying that it is as if your intrinsic being is somehow medically defective or genetically defective; it is not just that your body is diseased, but that 

 are diseased, with the implication that you may be unchangeable.

Tensions emerge from well-reasoned and well-intentioned attempts to get closer to the truth about the causes, etiologies, and the treatments of disorders. I think that to a great extent, our diagnostic systems, whether it is DSM or ICD, have been helpful with regards to clinical practice and research, in allowing us to do systematized studies, because after all, we want to know whether the interventions are actually going to help somebody or not. We want to know with some degree of medical certainty whether we can recommend electroconvulsive therapy for the treatment of catatonia or for certain kinds of major depression, or whether we can or cannot recommend antidepressants for individuals who have bipolar depression. We cannot do that, we cannot really tell whether we are going to help patients or hurt them, unless we utilize reliable categories. These practical considerations are one of our primary obligations.

Again, I think that we struggle with this in part because the problem is so difficult, philosophically and intellectually, because it relates to the very things that we experience as the most intimate parts of ourselves, and also because we do not fully understand how the brain and the mind interrelate and interact. In fact, setting these difficulties aside, even if you look at general medicine, things are bit more clear-cut, but a large number of patients who present to general medical clinics have medically unexplained symptoms or they remain undiagnosed in terms of etiology. So, things are not always straightforward in rest of medicine either.

 The impression I get from your description of classification is that we need to take it a little less seriously. That we need enough that we can do our practical and scientific work with some structure and reliability, but it becomes problematic when we start to ascribe metaphysical importance to these operational constructs.

 Yes, that is right. When we reify these categories, we almost make them unchangeable objects. In order to begin to approximate validity, we need to be able to formulate hypotheses and then test them, and the only way we can do so is if we begin with some reliable way of describing the phenomena. Our diagnostic categories and our rating scales have a lot of limitations. We are relying on self-report, communications, physician observations. So, we always have to approach them with some degree of humility.

 Going back to your personal experience, when you were 18 years old and in that phase of emotional and existential turmoil, someone could very well have suggested that you were suffering from clinical depression and that you needed to see a psychiatrist. How do you think you would have reacted to that?

: In fact, I did get that message. That I was clinically depressed, and that I just needed to see a psychiatrist and be on the right antidepressant, and all of this would go away. I strongly rejected that message. The very last thing I was going to do at that time was to go see a psychiatrist. So, I understand where some of this resistance against the so-called medical model comes from.

If you had taken me at age 18 or 19, and had tried to look at my experiences at that time through the lens of a diagnostic or medical model, I would have agreed with the critics that the medical model was not the best frame for this. But if I had had to drop out of school because of intrusive obsessional thoughts or compulsions that may be quite different, and the medical model is in my view an appropriate frame of inquiry. Or perhaps I just do not have an accurate view of my 18-year-old self. I think that one critique of the medical model, as it is understood by many, is driven by a concern that we are judging individuals, pushing them away, not listening to their experience, and distancing ourselves from them by labeling them. We always have an obligation to listen and to be prepared to revise our thinking,

 The medical model in psychiatry is facing considerable opposition from many prominent critics. How to best understand the medical model is a complex issue, something we briefly touched on in your interview for 

 and in this series I have talked about the medical model in detail with 

 A question I would like to ask you is about the limits of the medical model. The concern around medicalization reflects a growing anxiety that more and more of our lives are being viewed through the medical gaze. It is perhaps to be expected that as medical practitioners we tend to focus on the ways in which the medical model can improve lives, but at what point does medicine say to itself, “Maybe we are not the best professionals to address this. Maybe this is a situation where we should let our colleagues in psychology and social work take the lead. Maybe this is a situation where the medical understanding of a condition should not dominate over or should not exclude a more psychological, social, or existential understanding of the phenomenon”? How can medicine be more reflective over its own limits and boundaries?

 Everything depends on what we mean by the medical model. To me, in its most basic form, the medical model is a hypothesis-generating method, the roots of which can be traced back to 

 among others. The basic idea is that there are signs and symptoms that assort together more likely than would be expected by chance, and we recognize them as syndromes. If we properly define what the syndrome is, we can begin to then investigate what causes it and how to treat it. This is an incredibly fertile thread that runs through all of medicine. This is the sort of thinking that serves as the foundation for 

’s pathological studies. It is a syndromic model, which leads to a hypothesis, which leads to investigation, and then the results of these investigations may force us to redefine our syndromes or redefine our hypothesis, so it is an iterative process as well. In this iterative process, diagnoses can be lumped together, or they may be split further, or rearranged in other unique ways. The syndromes are intended to have parsimonious explanations, to achieve

, “the supreme goal of all theory is to make the irreducible basic elements as simple and as few as possible.”

When individuals use the term medical model in psychiatry, I think what they mean is that psychiatrists are ascribing a medical cause to an individual’s experience or feelings. So when we, as psychiatrists, ascribe a medical cause to the feelings and experiences, we are referring to some ineluctable and unchangeable element about the individual, with the implication that their very essence is dysfunctional or pathological. That is, in my view, a mistaken understanding.

Do I believe that some of the experiences in the realm of psychic suffering are better understood as existential rather than medical? Absolutely, I do. I do not believe that every form of mental suffering or emotional suffering is a mental disorder, but do I believe that there are mental disorders which are best understood through the syndromic lens. DSM is a variant of this syndromic model, and it is a very useful tool to categorize mental disorders, a tool that also provides us with ways to validate our constructs, with validators such as course of illness, family history, genetics, biology, and a variety of other things that have been well-described by 

, among others. These validators help us put some guardrails around what we are postulating through the syndromic lens.

 I think the thing that concerns or worries many critics is that when something is viewed through that syndromic lens it tends to crowd out other ways of understanding it.

 It is an important worry, but it is not a necessary consequence of the syndromic view. Do all human experiences fall within the realm of medicine or psychiatry? I do not think they do, or that they should. I think that would be a mistake. In other words, there is definitely a risk that our diagnostic concepts can be over-extended and that everyday life can be medicalized. That is something we have to guard against.

I do think we have both an obligation to say, 

this is our best evidence of what is effective for this kind of entity

, and an obligation to recognize that not all emotional or mental states are best understood through this syndromic medical model. Neither the profession nor the general public is well-served by medicalizing ordinary human experience. It also does not mean that psychotherapy cannot be beneficial for developmental or existential concerns. It can be. Freud viewed the goal of psychoanalysis as converting neurotic “misery” into “common unhappiness.”

 The challenge we face is not to convert human unhappiness, what my Buddhist teachers would call, in the Pali Canon, 

 I really liked something you said in your presidential address to the APA

My bias is to look at the long, far view, if for no other reason than change is hard, complex, and always takes longer than we expect. We tend to look for instant transformation, analysis, and understanding, which is not always forthcoming, reliable, or desirable. This is especially true at times of great upheaval and uncertainty, which we are certainly experiencing in the sciences related to psychiatry, and more broadly in technology and culture.

It seems to me that the discourse in psychiatry has tended to fluctuate between extremes of enthusiasm and disillusionment, with this cycle repeating every 30 to 50 years. Do you think adopting the long view can help us avoid getting trapped in this cycle?

: Part of the reason why I think the long view is useful is that it allows you to see the changes that have actually happened. If we are too close to the events in question, it is hard to know whether meaningful or long-lasting change has taken place or not. I think if you take the long-view, the comfort that exists in contemporary culture with regards to talking about mental illness, the protections that exist within law, the reimbursement of care from insurance companies for psychiatric conditions (imperfect as it is), and the increased awareness regarding human rights in psychiatric care, all of those things to me represent advances in the course of history, but you cannot see them if you are too close to them. There is this story of Henry Kissinger, PhD, meeting with Zhou Enlai, the great Chinese prime minister, during the opening to China in the early 1970s. The story goes that they were making small talk before the visit and Kissinger asked Zhou, “What do you think of the impact of the French Revolution?” Zhou paused, and replied, “Too soon to tell.” I think that captures well my own sentiments.

 Speaking of the long view, in a 2013 editorial for 

, on the 100th anniversary of Karl Jaspers, MD’s 

; Mario Maj, MD, PhD, commented on the analogies between Jaspers’ historical context and our own. 

The most striking analogy is that nowadays, exactly like one century ago, the enthusiasm brought about by a period of exceptional progress of research in neurosciences is being followed by some disillusionment, due to the limited relevance of that progress to the elucidation of the pathophysiology of mental disorders.

 I do think that eventually we will learn a lot more about the organization and the functioning of the brain: how it works, not just at the genetic or the cellular level but also at the circuitry level, such that we would begin to link the activity of the brain circuits with certain states of mind. We can already do that to some degree already, but we will be able to do it better, with more precision and explanatory power.

That is not to say that everything can be or should be explained by neurobiology. You know, again, one of the implications of my psychedelic experience for me has been that it is hard to think about these issues with our current limited understanding of the mind-body problem.

A difference between where we are now and where we were a hundred years ago is that the late 19th century, early 20th century was kind of the end of that neuroscience period. 

, was born in 1856, the same year as Freud. The neuropathological work that the generation of Alzheimer and Kraepelin were doing peaked in the late 19th century and early 20th century in terms of its effects on psychiatry. The discovery of plaques and tangles in dementia, or the work arounds tertiary syphilis, for example. Neuroscience obviously continued on in the next decades, but its impact on psychiatry was very limited. In contrast, I think we are in a period now where the current wave of neuroscientific research is still offering more and more fertile hypotheses and lines of inquiry. For example, all the research going on around immunological and inflammatory processes in psychiatric disorders. It may turn out to be right or wrong, we do not know, but my timeframe to think about these things is more like 50 years, not 10 or 20 years.

 Any message for psychiatric trainees and early career psychiatrists?

 First of all, I think we are in a fabulous time for psychiatry. The number of US medical school graduates going into psychiatry has nearly doubled over the last 7 years. No other major specialty has seen such a large growth of new recruits. The field has enormous flexibility, richness, and breadth of interests. The stigma around mental disorders is going down and there is greater public discussion about mental health. One only has to look at the discussions related to mental health around the COVID-19 pandemic. This emphasis on mental health is really quite unprecedented.

We never know how our lives and careers are going to work out for us as individuals. If somebody had told me when I was a first-year resident in psychiatry at Harvard that I would become the president of the American Psychiatric Association, I would have laughed. I expect that our trainees will accomplish even greater things. Not only psychiatry trainees should have confidence in the field and in themselves, but their mentors should also have confidence in them. There is a great episode of 

 that I quoted in my presidential address.

President Bartlet is played by Martin Sheen and his communications aide, Sam Seaborn by Rob Lowe. They are playing chess while at the same time Bartlet is navigating a complex China-Taiwan diplomatic crisis. Sam is amazed and asks him how he does it. Bartlet answers, “You have a lot of help. You listen to everybody and then you call the play. [Rises to his feet] Sam, you’re gonna run for President one day. Don’t be scared. You can do it. I believe in you. [Looks at the board] That’s checkmate.”

So, that is kind of what I am saying to you, and to trainees who are younger than you: I believe in you, and I think that you can do amazing things. Not that I know about anybody’s individual future, but I can see that our trainees and younger psychiatrists such as yourself are going to have an impact on the field and the world around them. And that is a great thing, and you should feel confident that you have the ability to make a difference, and to do that in a way that is respectful of others, even those who are critical of the field.

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of 

is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of Psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the

Dr Aftab and Dr Summergrad have no relevant financial disclosures or conflicts of interest.

The Standard Edition of the Complete Psychological Works of Sigmund Freud

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2. Stengel E. Classification of mental disorders. 

3. Kendell RE, Cooper JE, Gourlay AJ, et al. Diagnostic criteria of American and British psychiatrists. 

4. Aftab A, Summergrad P. Paul Summergrad, MD, on the state of psychiatry. 

The Medical Model in Theory and Practice: Ahmed Samei Huda

September 4, 2020. Accessed May 18, 2021. 

On the Method of Theoretical Physics. The Herbert Spencer Lecture, delivered at Oxford, 10 June 1933

. Trans. Nicola Luckhurst. Penguin Classics, 2004.

9. Maj M. Mental disorders as "brain diseases" and Jaspers' legacy. 

In this conversation, a former APA president discusses mystical and meditative experiences, reconciling psychoanalysis and neuroscience, and tensions surrounding the medical model. 

Psychiatry and the Long View: Paul Summergrad, MD

Psychiatrists are called on to help patients with an array of stubborn mental health illnesses. Some of the most challenging to treat are also the deadliest: eating disorders. Characterized by a persistent disturbance of eating that impairs health and psychosocial functioning, these disorders include anorexia nervosa, avoidant/restrictive food intake disorder, binge eating disorder, bulimia nervosa, pica, and rumination disorder. Too often, their outcomes are tragic. Anorexia nervosa is associated with the highest mortality rate of all psychiatric disorders, with fatal outcomes observed in approximately 10% of cases, primarily from 

Recently I watched the 2017 Netflix film 

, a semi-autobiographical story about a 20-year-old named Ellen and her journey to recovery from anorexia nervosa. It is based on the experiences of Marti Noxon, the film’s director, and Lily Collins, the actress who plays Ellen. The film starts with a written warning of triggers, a warning that should be taken seriously by anyone likely to be upset or encouraged by the behavior.

In the film, Ellen is a cynical, artistic young woman whose anorexia has made her life unmanageable. Forced to see a new doctor by her nervous stepmother, she ends up in an inpatient rehab unlike any other she has been in before: A house with 7 young individuals supervised by a blunt house manager and an unconventional clinician—Dr Beckman, played by Keanu Reeves. The young patients are diverse, both demographically and in terms of their eating disorders. The housemates include a Black female with binge eating disorder, a White female with bulimia nervosa, a British white male with anorexia, and a pregnant White female with anorexia (who has a miscarriage). The movie’s diverse cast reflects the epidemiology of eating disorders, which affect individuals of various ages, sizes, socioeconomic statuses, gender identities, races, and cultural and ethnic backgrounds.

When we meet Ellen, her weight has fallen dangerously low; she exercises excessively, shows obsessive attention to counting calories, and hints at a preoccupation with thoughts of food, consistent with the diagnosis of anorexia nervosa. Another character with anorexia nervosa also feels distressed when she learns the number of calories that she has received through a feeding tube. Ellen wears loose clothing, which is a warning sign for anorexia, since loose outfits hide weight loss and can help the wearer 

 She reassures her sister and herself that she has it all under control, a common belief among patients with eating disorders.

Another character, Anna, has bulimia nervosa. She engages in the purging behavior of vomiting, uses laxatives, and exercises secretly. Anna’s experience of binge eating is not shown, despite binging being a core component of bulimia. Often, individuals with binge eating disorder are not given significant attention, even though this is the most common eating disorder in the 

The movie also shows the exasperation of the patients’ families. Ellen’s stepmother and stepsister exemplify the fallacies that so many individuals have about eating disorders. “Why don’t you just eat?” Ellen’s sister asks in exasperation, while her stepmom gibes: “Do you think this is beautiful?” The pathogenesis of eating disorders is complex and attributable to a combination of genetic, environmental, and biological factors, including dysregulation of homeostatic drive and the 

 Like most mental illnesses, childhood adversity plays an important role. Ellen’s mother came out as gay when Ellen was 13 years old and now lives in Phoenix, running a horse therapy farm with her partner. We do not see the father; he seems to be physically and emotionally absent. The child with the eating disorder is often expressing dysfunction within the family system through her behaviors and symptoms, as Ellen exemplifies.

Ellen and her peers are shown in a residential group home in which they have a lot of say in their treatment. This may not be a realistic portrayal. Treatment of eating disorders generally involves an interdisciplinary team; this team includes a mental health clinician, dietitian, and a general medical clinician. Although Beckham conducts individual and family sessions, the treatment approach overall does not match with commonly used, well-established therapy plans like cognitive behavioral therapy, psychodynamic psychotherapy, or the Maudsley model of 

Beckham has a tough tone: He calls Ellen’s attitude “childish and cowardly” and tells her, “You know how [to recover].” He makes statements such as, “Stop waiting for life to be easy. Stop hoping for somebody to save you....Face some hard facts and you could have an incredible life.” These ideas suggest that Ellen needs to simply use her willpower and decide to get better, which is not a realistic vision for recovery. For Ellen, it was not about eating, it was about deciding to choose life. To achieve long-term recovery, the focus needs to be redirected to the underlying emotional, cultural, psychological, and spiritual issues.

Several noteworthy scenes have stayed with me: The emotional scene when Ellen asks her mother to feed her like a baby; the thousands of emotions that trace across her face every time she steps on the scale to be weighed; and the way she constantly circles her upper arm with her middle finger and thumb (a practice known as body checking). At the end of her family therapy, Ellen states, “I’m sorry that I’m not a person anymore; that I’m a problem.” This is touching, because medical professionals and family can lose sight of the fact that their patients are individuals with feelings, not just diagnoses.

Noxon’s film does an incredible job of portraying the nuances of this complicated character living with an even more convoluted illness while also developing the world around her. 

 finds the humor in its material, the absurdity of real-life mixed in with real dangers. Collins, who has been honest about her own experiences with eating disorders, channels that struggle into a fine performance.

In 1983, when Karen Carpenter died of anorexia, the general public expressed shock that someone could starve themselves to death. In the 1990s, unfortunately, skinny was the overwhelming female beauty standard. Now some websites glamorize anorexia, advising readers on how to avoid eating, and some show so-called 

 pictures on Instagram. The more we talk about eating disorders as a serious mental illness, the more we can break down the walls of stigma that keep individuals from seeking the early intervention that improves prognosis.

is chief resident physician of psychiatry at the University of Missouri–Columbia.

1. Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. 

. National Eating Disorders Association. Accessed April 21, 2021. 

. National Eating Disorders Association. Accessed April 21, 2021. 

4. Treasure J, Claudino AM, Zucker N. Eating disorders. 

5. Zipfel S, Giel KE, Bulik CM, et al. Anorexia nervosa: aetiology, assessment, and treatment. 

A television drama looks at eating disorders from the patient, physician, and family perspectives. What does it get right—and wrong?

Breaking the Skinny Standard: Anorexia on Screen 

. In this Mental Health Minute, Adel B. Korkor, MD, discusses the science behind exercise’s efficacy, his own struggles with anxiety , and how it all inspired him to start a 

 devoted to achieving mental wellbeing through physical activity.

 is a retired physician and founder of the nonprofit Five Fifty Five Run/Walk.

Has exercise helped either you or your patients achieve better mental health? 

Running, walking, and other forms of exercise create some specific chemical changes in the body—which may end up benefitting the mind. 

Why Would Physical Activity Improve Mental Health?

Obsessive-compulsive disorder and related conditions like 

, hording disorder, and trichotillomania are all common mental health issues. They all impair psychosocial functioning and quality of life, sometimes to a dangerous degree. Fortunately, well-known, first-line treatments are often effective. But for tough cases, clinicians may need other options.

In this Mental Health Minute, Katharine Phillips, MD, previews an upcoming panel at the American Psychiatric Association’s annual meeting: “

Treatment of Severe Obsessive-Compulsive and Related Disorders: What Do You Do If First-Line Treatments Don’t Work

?” Phillips and the panelists will discuss the latest research and treatment developments.

is currently professor of psychiatry, DeWitt Wallace Senior Scholar, and Residency Research Director for the Department of Psychiatry at Weill Cornell Medicine. She is also an attending psychiatrist at New York-Presbyterian Hospital and adjunct professor of Psychiatry and Human Behavior at the Alpert Medical School of Brown University.

Have your patients had unrealistic ideas about their bodies or appearances? 

Obsessive-compulsive disorder and related conditions do not always respond to first-line treatments. Fortunately, new options are on the horizon. 

What To Do When First-Line Treatments Don’t Succeed

Kathleen Flaherty, JD, is a lawyer and currently serves as the Executive Director of Connecticut 

, a statewide non-profit agency that provides legal services to low-income individuals with mental health conditions on matters related to their treatment, recovery, and civil rights. She is a graduate of Wellesley College (’88) and Harvard Law School (’94) and has devoted her legal career to advocating for the rights of individuals with psychiatric disabilities. She is the recipient of many awards for her advocacy and legal work, including the 2021 Charles J. Parker Legal Services Award, recognizing excellence in career-long dedication to the delivery of legal services to the disadvantaged in Connecticut, and the 2017 Board of Directors Award by National Alliance on Mental Illness, CT.

Given her personal experience of receiving mental health services as a patient/service user and long career as a lawyer providing services to disadvantaged individuals with mental illness, Ms Flaherty is well-placed to recognize the deficiencies in our current psychiatric and legal systems, particularly when it comes to involuntary psychiatric care and treatment. Debates regarding social justice, disability and human rights, involuntary detention and treatment, expectations regarding safety and risk, and the carceral nature of inpatient psychiatric care are increasingly entering public consciousness. This exchange with Ms Flaherty delves into some of these intricate issues.

 Your experience in providing legal representation to low-income individuals with mental health conditions in matters concerning their civil rights, including involuntary commitment and involuntary treatments, offers you a unique perspective on the challenges facing individuals with mental illness that may not be readily apparent to psychiatrists. What sort of systemic difficulties and obstacles have you observed in this regard? What issues do you think are being overlooked by the current systems of mental health care, especially by psychiatrists?

 Thanks for inviting me to have this dialogue with you. As the Executive Director of Connecticut Legal Rights Project (CLRP), I lead a team that represents clients who are eligible for mental health services from the 

State of Connecticut Department of Mental Health and Addiction Services

. Many of the challenges faced by our clients are the same challenges faced by others in Connecticut and around the country: a lack of decent, safe, affordable, and accessible housing; insufficient voluntary services and supports because of chronic underfunding of the community-based system of care; and unequal opportunity when it comes to education and employment. You have asked about systemic issues I have observed in my legal work, and there is a long list.

The systemic difficulties and obstacles experienced by our clients subjected to the state actions of involuntary treatment and involuntary civil commitment are longstanding and pervasive. Systemic inequity and poverty are layered over discrimination that stems from disability.

Many police departments reflect the larger prejudices of their communities and use infractions and laws to criminalize disability, instead of providing accommodations and diversion into health care and meeting basic needs. Systemic problems within the state judicial action of involuntary commitment include ineffective assistance of counsel, lack of adequate due process, lack of access to independent expert witnesses, and treating judicial hearings like treatment team meetings in how they look at behavior and outcomes.

The judicial system does not have a realistic and accurate understanding of mental health conditions, which results in almost complete deference to proffered diagnosis and risk assessments, both of which lack a robust foundation in empirical science. The judicial system has limited awareness of the complicated efficacy (to the extent that it exists) of psychiatric treatment and medication, especially for the cohort of patients subjected to commitment. Once committed, the problems include unsafe conditions of confinement, police presence at hospitals, inadequate system response to allegations of patient abuse and neglect, and forced psychiatric treatment. The system often fails to provide adequate information about the risks and benefits of psychiatric medication so that patients can give truly informed consent. Finally, discharge planning is inadequate; patients’ rights to be discharged into the most integrated setting as soon as they are stable and ready for discharge is routinely violated.

A lawyer discusses how the legal system treats (and mistreats) those with mental illnesses. 

Anxiety & Stress Disorders