Hero

Videos

Slideshows

Articles

Podcasts

Poll

by Devon Price, PhD; New York: Atria Books, 2021.

Editor's Note: As clinicians who treat mental illness, we have undoubtedly seen individuals who are labeled “lazy.” Some of our patients who are suffering the most may be those who have labeled themselves lazy. Fortunately, for those of us who chastise ourselves for taking even a moment away from work to focus on ourselves, and for our patients who cudgel themselves too, 

. Dr Price, a social psychologist and professor at Loyola University of Chicago’s School of Continuing and Professional Studies, recently sat for an interview, conducted via Zoom, on the topic of laziness. The interview will hopefully whet the appetite to read and recommend this truly helpful book.

Q: When I heard that you had written a book about the concept of laziness, the first question that came into my mind was: have you ever been called lazy?

A. I have only ever called myself lazy. I think I have absolutely been a workaholic in the way that I think a lot of academics are trained to be. You get this idea that you need to have a full course load, you need to be doing service to the university, you need to be doing research. And you need to be a self-starter if you want to have even a prayer of a career. They kind of drill that into you even as an undergrad. I think I have always had that bug in the back of my brain telling me that I was not doing enough. Many of us feel pressure to be a self-made individual and to be very individualistic and successful. So I am someone who has not been called lazy too often, because I have been able to check off a lot of society’s little boxes that make you look like a good little worker bee.

Q: I have always thought that when someone comes to me and tells me “my spouse is lazy” or “my employee is lazy,” they are using a lazy word, because it does not really give a useful description of what is going on. Why do you think the word lazy is used so frequently in our society?

A: The word has always had an air of moral condemnation to it. Its root words mean both feeble or weak willed and morally corrupt. A lot of times it is easier to write someone off as lacking essential qualities, lacking some drive or willpower that you need to succeed, than it is to ask what can be done to help. Does this individual have needs that are not getting met? What struggles is this individual facing that are not being taken seriously? What structural problems are getting in their way? When somebody looks lazy, maybe they just see no reason why they should be doing a task. So that is also an important question to ask. Have we failed to motivate them and empower them?

Q: Those are much more difficult questions to ask.

A: It is hard to ask those questions. It is even harder to solve those problems once the questions have been asked. It is much easier to say, “Oh, I give up on this individual. They lack that essential quality that they need for success.”

Q: Your answers make it impossible to ignore the uneven playing field that so many individuals face when trying to succeed in life, and particularly in science and academia. Do you have any thoughts on how inequities affect perceptions of laziness?

A: It is a thorny problem. When you are teaching and mentoring, it is important (as much as possible) to be flexible when you can. At the same time, I think giving honest feedback is essential. “Listen, I understand that you have things going against you. I know that this is not a reflection of some flaw or failure in you. But we do need to get you to a certain level, and I really am invested in seeing you reach that level. So, what can I do to help support you?” There is a lot of social psychology research suggesting that instructors, especially white instructors, are uncomfortable giving critical feedback to black students. Even black students who are doing really well! They are afraid of being perceived as racist, so they overcorrect, and this is true of sexism and other biases as well. If you can, try to level with them: tell them where they need to grow and give them the same critical feedback that you would give anyone else. Also be there to support them through hardships that are not their fault. I think that can really make a big difference. But it is a steep uphill battle.

A: There are so many areas of life where individuals are made to feel like they are not enough. We have already talked about racism, sexism, and things like that. But workaholism pervades almost everything in American culture and life. That affects individuals’ self-image, their depression levels, their anxiety levels, and how much they put on their plate. We know that those things are huge risk factors for all kinds of psychiatric and psychological issues. If you are doing too much, that looks a lot like an anxiety disorder, or anxiety profile, even if maybe you otherwise would not be in that situation.

is an attending psychiatrist at Montefiore Medical Center. He is the Book Review editor at 

Patients and care providers often call themselves lazy. But what are the clinical consequences and cultural meanings of this term? 

Laziness Does Not Exist

Well done, Dr Ronald Pies. Your article “

Psychiatry and the Dark Night of the Soul

” reminds us of the human condition’s complexity, which should never be separated from our clinical work. We may distinguish clinical problems from existential and religious issues, but we must use great caution before we separate attributes that are inextricably linked.

is a family physician in High Point, North Carolina.

” long before I trained as a therapist. Recently I came across 2 cases of ladies in their mid-30s. Each of them presented with profound feelings of existential anxiety. My hypothesis and diagnosis was that they were going through the first stage of the dark night of the soul (ie, purgation). I feel that my assessment is validated by your article.

 is a psychotherapist at the Independent Medico-Legal Unit (IMLU) in Kiambu, Kenya. He holds a B.Psy. in counseling from the University of Nairobi.

What did you think of Dr Pies’ article, “

Share comments with your colleagues by emailing 

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

Although existential and religious issues may be distinguished in clinical care, the human condition’s complexity and the Dark Night of the Soul cannot.

Can Existential Issues Really Be Divorced From Clinical Practice? From Our Readers

No scientific studies support the claim that Blue Monday, the third Monday of January, is the saddest day of the year. Where did this myth come from?

In 2005, Cliff Arnal, a Welsh psychologist, came up with a 

 for the most depressing day of the year to use for a holiday travel company, Sky Travel. Factors included weather conditions, debt levels, time passed since Christmas, low motivation levels, and failing New Year’s resolutions. However, this seemingly harmless marketing tactic meant to sell summer vacations grew far beyond its original purpose. Unfortunately, it became, as Arnal dubbed it, “a self-fulfilling prophecy.”

Now, Dr Arnal has changed his tune drastically, apologizing for his formula, and even calling himself an “Activist to #StopBlueMonday” in his 

“These types of formulae, if anything, probably serve to oversimplify the complexities of real-life experience,” an anonymous spokesperson related to NBC News.

While it may not be scientifically proven, Dr Arnal’s idea of a gloomy post-holiday low point may carry some weight. Shorter days and cold temperatures can negatively affect mood and lead to 

 In the UK, up to a third of the population experiences SAD.

 Wintertime body changes can affect hormones, sleeping habits, eating habits, and mood.

Blue Monday may have caused an extra sense of dread to hang around January, especially for patients with depression and anxiety. They may feel pressure to overcome this particular sad holiday.

 To combat this pressure, AXA PPP Health came up with 7 ways to help boost morale and motivation.

-Identify the reason behind any lack of motivation

These simple strategies may help you or your patients stay positive not just on Blue Monday, but for all of the winter months.

1. Cohut M. The truth about ‘Blue Monday.’ 

. January 21, 2019. Accessed January 18, 2021. 

https://www.medicalnewstoday.com/articles/324236

2. Carlile J. Jan. 24 called worst day of the year. 

. January 21, 2005. Accessed January 18, 2021. 

https://www.nbcnews.com/id/wbna6847012#.XEW54M_7SqA

3. Katz D. Blue Monday isn’t real but winter’s impact on your mood can be. 

. Updated January 20, 2020. Accessed January 18, 2021. 

https://www.wbir.com/article/news/health/blue-monday-isnt-real-but-winters-impact-on-your-mood-can-be/51-5351a7e7-50fc-4987-a004-73ddb3d27a7c

4. What does Blue Monday mean for our mental health? 

. January 6, 2021. Accessed January 18, 2021. 

https://www.mentalhealth.org.uk/blog/what-does-blue-monday-mean-our-mental-health

5. Dorsey K. Seven ways fed-up workers can beat Blue Monday. 

. January 12, 2018. Accessed January 18, 2021. 

https://www.insider.co.uk/news/blue-monday-2018-january-15-11840132

Is the purported “saddest day of the year” evidence-based?

The Myth of Blue Monday

 with Awais Aftab, MD, I have received a good deal of feedback on my positions, both pro and con. Upon further reflection, I would like to clarify my position regarding the following comments I made in the interview:

And, yes—we often hear anecdotes concerning patients who tell their current clinician some version of, ‘My psychiatrist said I have a chemical imbalance . . .’ But where is the evidence that this is what patients were actually told? Who has contacted the patient’s psychiatrist, or reviewed his/her case notes, to see if that was really what the patient was told? To my knowledge, there has never been a study examining the other side of the story—and, to be clear: patients are not infallible recorders of what their doctors tell them.

I regret that I did not state my point more clearly. In particular, I inadvertently implied that the psychiatrist’s recollections or case notes are, in some sense, always dispositive regarding what patients were actually or really told, as if psychiatrists were infallible recorders of what was said in a session. This was not my intention, nor is it my belief. Just as patients may sometimes misperceive or misunderstand a point or statement made by the psychiatrist, so, too, psychiatrists may err in what they recall or in what they write in their notes. And, yes: some clinicians may consciously or unconsciously misstate what they told the patient, for various reasons. (I have had personal experience with my own physicians writing comments in their session notes that did not correspond to what I recalled from the meeting!)

My point in the interview was that any valid claim or report regarding what patients have been told about so-called “chemical imbalances” must take into account not only the patient’s recollection, but also: what psychiatrists themselves recall saying; what they intended to convey; and in what context the term 

For example, did the psychiatrist say something like, “Your illness is definitely caused by a chemical imbalance”? Or was it more like, “We don’t know the precise causes of depression, but chemical changes in the brain may play some role, along with psychological, social, and environmental factors”? There is nothing fundamentally wrong or misleading, of course, with the second type of explanation.

In addition, the therapeutic alliance is built on trust. Accordingly, our patients’ reports should always be considered prima facie credible, absent extraordinarily compelling evidence to the contrary (eg, obvious delusions, documented malingering, and so on). But credible—ie, worthy of belief or confidence—does not necessarily mean factually correct in all aspects and details. The same may be said, of course, of claims made by clinicians. 

To put these matters in a broader context: a recent study evaluated the prevalence of etiological beliefs about depression in a sample of acutely distressed psychiatric patients in an intensive hospital treatment program. The study found that the most commonly endorsed explanation for depression was not one invoking the chemical imbalance notion; rather, psychosocial explanations of depression were the most commonly endorsed etiology, with the chemical imbalance belief coming in second. The authors noted that popular beliefs about what causes depression “may be adopted from a variety of external sources, including television advertisements, anti-stigma campaigns promoting biogenetic explanations, and 

Beliefs may also evolve from patients’ individual experience with treatment; for example, “participants who cannot explain the cause of their depression or pinpoint a triggering event may eventually attribute their depression to hidden, unknown biological mechanisms. Or if psychological therapies had failed in the past, participants may come to believe depression must be due to biological causes.”

All of this is simply to note that popularization of the chemical imbalance canard is almost certainly an over-determined effect, in which the role of psychiatrists (or other clinicians) is but 1 possible causal factor.

I believe that in the near decade since I described the chemical imbalance notion as 

 psychiatry has matured and deepened in its mode of explanation to patients—though research on that point is sorely needed. For now, the best explanation we have is that clinically significant depression is the outcome of biological, psychosocial, environmental, and even 

 The relative contribution of any single component almost certainly varies from patient to patient, and case to case. I believe that well-informed psychiatrists have known and embraced that holistic view for decades. The remaining challenge lies in communicating it clearly and consistently to our patients—and on that score, we can all do better.

I am aware that the American Psychiatric Association once had a statement posted on their public education website that referred to "imbalances in brain chemistry." I am happy to report that, in response to my conferring with the APA, the old statement has been 

"While the precise mechanism of action of psychiatric medications is not fully understood, they may beneficially modulate chemical signaling and communication within the brain, which may reduce some symptoms of psychiatric disorders

is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and editor in chief emeritus of

Thanks to Awais Aftab, MD, for his collegial and trenchant interview and to Joe Pierre, MD, for referring me to the Schroder et al1 study.

1. Schroder HS, Duda JM, Christensen K, et al. Stressors and chemical imbalances: Beliefs about the causes of depression in an acute psychiatric treatment sample. 

2. Pies R. Psychiatry’s new brain-mind and the legend of the “chemical imbalance.” 

. July 11, 2011. Accessed January 5, 2021.

https://www.psychiatrictimes.com/view/psychiatrys-new-brain-mind-and-legend-chemical-imbalance

3. Pies R. Psychiatry and the dark night of the soul. 

TM. Dec. 14, 2020. Accessed January 5, 2021. 

https://www.psychiatrictimes.com/view/psychiatry-dark-night-soul

Is there a way to find balance in discussing the chemical imbalance theory of depression?

What We Tell Patients about Depression, and What They Say They Have Been Told

Susan J. Noonan, MD, MPH, discusses how schedules can be vital for patients who struggle with day-to-day tasks. Her top tip is to keep to their set schedule, even when they do not feel like it.

is a physician consultant and Certified Peer Specialist in the Department of Psychiatry at McLean Hospital and the Massachusetts General Hospital. She is the author of four books and a blog on managing depression, most recently 

Helping Others With Depression: Words to Say, Things to Do (December 2020)

. Dr Noonan offers peer counseling to fellow patients, including physicians and other professionals, and can be confidentially reached through her website at 

Creating a schedule and keeping it can be a huge help to patients with anxiety or depression. 

The Importance of Routine

An article in the December 2020 issue, “

The Intertwining Effect of Mood Disorders and Infertility

,” made many important points. I would like to raise to a few additional issues that seem to be often overlooked.

Women taking serotonin uptake inhibitors (SSRIs) to help them cope with infertility are actually increasing their serum prolactin to an unhealthy level. This hyperprolactinemia, in turn, 

 Unknowingly, they are hindering their changes of conception. This is the biology underlying the common folk wisdom that one cannot usually become pregnant while lactating/breastfeeding. This is when prolactin levels are very high.

I urge all women with fertility issues, especially those on SSRIs, to get a simple blood test measuring their serum prolactin level. An elevated serum prolactin level can be corrected with oral dopamine agonists (dopamine-stimulating) medications.

Certain antipsychotic meds, whether typical or atypical, can also elevate serum prolactin levels. Risperidone in particular can cause hyperprolactinemia in female and males, which causes lactation (galactorrhea) from their breasts. A third, less common cause of hyperprolactinemia is a tumor of the anterior pituitary gland, known as an anterior pituitary adenoma. This can be detected by an MRI of the brain.

Once identified, hyperprolactinemia can be readily corrected by dopamine agonists such as 

 Once the prolactin level has come back down to the normal rage, ovulation can occur. The patient can then discuss with her psychiatrist whether or not to continue the psychotropic medications at the current doses or lower, depending on the severity of her particular symptoms and stressors.

In conclusion, women struggling to conceive who are on SSRIs and/or antipsychotic medication should request that their serum prolactin levels be checked. This cause of infertility can be readily corrected. Therefore, it should be checked, especially before moving on to more invasive and uncomfortable fertility tests, such as a hysterosalpingogram, and certainly before beginning the injections to prepare for IVF.

is a psychiatrist at the Manhattan Psychiatric Center, in the Outpatient Department on 125th St., NYC. She is the author of 

, forthcoming from Amazon, and played Dr Zalutsky on “The Sopranos.”

1. Torre DL, Falorni A. Pharmacological causes of hyperprolactinemia. 

2. Matsuzaki T, Azuma K, Irahara M, et al. Mechanism of anovulation in hyperprolactinemic amenorrhea determined by pulsatile gonadotropin-releasing hormone injection combined with human chorionic gonadotropin. 

3. Schlechte JA. Long-term management of prolactinomas. 

In addressing mood disorders associated with infertility, sometimes the cure may be worse than the disease. 

Do SSRIs Decrease Fertility?

In honor of the New Year, I reviewed a list of 

10 novel agents in the pharmaceutical pipeline

 that demonstrate an array of mechanisms that may eventually join our clinical pharmacopeia (see cover story). Several of these agents hold promise as treatments to improve efficacy as well as tolerability for significant subpopulations of our patients. Amidt the excitement and hope of 

, it is important to place our expectations and curative fantasies in the appropriate context. As of today, based on what we know, the human brain remains the most complex organ in the universe. The average adult brain weighs only 3 lbs and is constructed with 80 billion neurons. Each neuron connects to other neurons with up to 10,000 synapses. These synapses are in a constant state of neuroplasticity, strengthening connections here and reducing connections there based on the ever-changing demands of our environment—both internal and external.

Remarkably, each human brain has approximately 1 quadrillion synapses/connections that define our moment-to-moment changing connectome, which is the foundation of our uniqueness and identity. One quadrillion equals 1000 trillion, which is the number 1 followed by 15 zeroes: wrap your mind around that—pun intended. We continue to discover novel receptors, subreceptors, genetic polymorphisms, epigenetic modifications, enzymes, neurotransmitters, synergistic/ antagonistic interneuronal connections, and more with each passing day. This list is limited to physical elements of the brain that create our current primitive understanding of the nature of consciousness.

Additionally, we are relatively clueless as to the variables that weave together to create a personality, determine how much resilience a person has, or contribute to the opposing qualities of compassion and unapologetic violence toward others. Nonetheless it is truly remarkable how much we have learned about our brains during the past century. From sequencing the entire human genome, to mapping out neural microcircuits that cross through divergent brain structures, to the windows into brain function that MRI, 

, and single-photon emission computed tomography scans have opened, our basic science knowledge of the brain continues to explode beyond what science fiction of the past predicted.

During the last 100 years, serendipity and creative genius have produced psychiatric drugs that have truly advanced our understanding of the brain and significantly lessened the tremendous burden of suffering from major mental illnesses such as schizophrenia, major depressive disorder, bipolar disorder, anxiety disorders, and substance use disorders. In 1955, shortly after chlorpromazine was introduced in the United States as our first antipsychotic medication, 558,922 individuals were hospitalized in state and county psychiatric hospitals. By 1990, that number of hospitalized individuals dropped to 115,000 while the total US population increased.

 to the United States in 1989, our first antipsychotic FDA approved for treatment-resistant schizophrenia, led to a second wave of deinstitutionalization. In my state of New Hampshire, the number of psychiatric patients hospitalized at New Hampshire State Hospital dropped from 2700 in 1963 to 120 in 2013, according to Jay Couture, CEO of Seacoast Mental Health Center, Portsmouth, New Hampshire. Let me be clear, this dramatic decrease in national and NH state hospital admissions is not entirely based on newer or better medications, nor is it necessarily something of pride.

On October 31, 1963, President John F. Kennedy signed the Community Mental Health Act into law. He optimistically stated: “The time has come for a bold new approach … If we apply our medical knowledge and social insights fully, all but a small portion of the mentally ill can eventually achieve a wholesome and constructive social adjustment.” Although the intent was good, the ensuing deinstitutionalization of patients with psychiatric disorders across the country was rapidly enacted before the necessary outpatient and supported residential structures were in place. Additionally, the naivety in 1963 included an overinflated belief that antipsychotic medication alone would adequately treat the deinstitutionalized.

Today more individuals with schizophrenia are institutionalized in correctional facilities than in psychiatric hospitals, and the homeless population includes a large number of individuals with serious mental illnesses. An 

, Recovery After an Initial Schizophrenia Episode (RAISE),

 began in 2009, and compared the outcomes of 404 individuals with a diagnosis o first-episode psychosis who were randomized to 2 different treatment interventions and followed for 2 or more years. Remarkably, the 

 of untreated psychosis in this population was 74 weeks.

 RAISE concluded that the treatment group receiving a comprehensive intervention, in contrast with community treatment as usual, demonstrated a greater improvement in psychiatric symptoms, quality of life, and participation in work and school, and remained in treatment longer. Comprehensive intervention included aggressive antipsychotic medication, cognitive behavioral therapy, family education and support, and educational and vocational rehabilitation. The shorter the duration of untreated psychosis was predictive of a significantly greater improvement of quality of life and total score on the Positive and Negative Syndrome Scale (PANSS).

 Hence, we continue to learn the importance of a broad treatment intervention that affects many elements of day-to-day life.

Here at the beginning of 2021, 30 years after George Bush’s “decade of the brain,” we continue to struggle to achieve adequate response and less commonly full remission in all the major psychiatric disorders. As I see it, we are right where we should be. Progress is always incremental, with an occasional paradigm shift. In psychiatry we have learned that optimal treatment of our patients includes far more than medications, including the drugs in the pipeline. The same can be said about all medical disorders. Despite huge advances in medicine and surgery, illness is a familiar part of most of our lives.

We will likely never attain a complete understanding of the human mind, body, and soul. Knowledge is limited by the biases and tools of inquiry that we bring to our exploration of what is not known—which certainly greatly exceeds that which we know. Yet a fascinating quality of us humans is that we act and pretend like we know everything in contrast to the generation that preceded us. In psychiatry we sometimes speak with amusement, condescendence, or disgust when we teach students about the cutting-edge treatments of the mid-1900s. Insulin shock therapy was used routinely during the 1940s and 1950s for the treatment of schizophrenia. Frontal lobotomies were performed during this same time period for a variety of psychiatric disorders; this involved inserting an instrument into the prefrontal cortex and severing neuronal connections, which commonly resulted in a dramatic loss of the individual’s prior personality and intellect. You can be sure that we will be equally judged in 100 years for our current state-of-the-art treatments.

The good news is that this is how science and the advancement of knowledge works. In 1675, Isaac Newton wrote in a letter to Robert Hooke: “If I have seen further it is by standing on the shoulders of Giants.”

 Ultimately, no single person discovers or invents any one thing. Rather, insights organically arise when the necessary foundation has been established by the hypothesis and theories of predecessors, along with an infinite number of unknowable factors that converge to enlighten that moment in time.

Ultimately, we deserve to revel in every scientific breakthrough, no matter how large or small. However, we must remain mindful that today’s treatments will eventually become outdated and replaced by the discoveries of tomorrow, and this is what good science is all about. We must humble ourselves as modeled by one of science’s greatest minds—

I do not know what I may appear to the world, but to myself I seem to have been only like a boy playing on the seashore, and diverting myself in now and then finding a smoother pebble or a prettier shell than ordinary, whilst the great ocean of truth lay all undiscovered before me.

It would be naïve to anticipate that one day we will understand that great ocean of truth, but we should never cease in our curiosity, exploration, and discovery of yet another pebble or seashell.

 is medical director, Brain Health, Exeter, New Hampshire; editor in chief, 

; staff psychiatrist, Seacoast Mental Health Center, Exeter; consulting psychiatrist, Exeter Hospital, Exeter; consulting psychiatrist, Insight Meditation Society, Barre, MA.

1. McKenzie JF, Pinger RR, Kotecki JE. An introduction to community health. Jones and Bartlett Publishers; 2008.

Evidence-based treatments for first episode psychosis: components of coordinated specialty care

3. Kane JM, Robinson DG, Schooler NR, et al. 

Comprehensive versus usual community care for first-episode psychosis: 2-year outcomes from the NIMH RAISE early treatment program

4. Chen C. On the shoulders of giants. . Springer; 2003. 

https://doi.org/10.1007/978-1-4471-0051-5_5

5. Isaac Newton - Playing on the seashore did Newton really say it? Accessed December 6, 2020. 

https://todayinsci.com/N/Newton_Isaac/NewtonIsaac-PlayingOnTheSeashore.htm

Our basic science knowledge of the brain continues to explode beyond what science fiction of the past has predicted.

Seashells, Not an Ocean

In this Mental Health Minute, Michael F. Myers, MD, addresses the issue of depression among medical students and doctors. He outlines the reasons why it can be hard for medical professionals to seek treatment and offers practical advice for clinicians who want to help their colleagues.

Myers is speaking from personal experience, having treated many medical professionals over the course of his long career. He discusses physician depression and many other topics in his new memoir, 

is professor of Clinical Psychiatry and recent past Vice-Chair of Education and Director of Training in the Department of Psychiatry & Behavioral Sciences at SUNY-Downstate Medical Center in Brooklyn, NY.

Michael F. Myers, MD, discusses depression among physicians, a theme from his new memoir, Becoming a Doctors’ Doctor. 

“We’re Like Everybody Else: We Are Prone to Depression.”

Susan J. Noonan, MD, MPH, talks how withdrawing risks prolonging depression, how all alone time is not the same, and how patients can push themselves in small steps to socialize. 

Solitude is not the same as isolation. Is a patient isolating themselves and what can be done to help?

Avoiding Isolation

Susan Noonan, MD, MPH, talks how small, broken down tasks and a system will help patients maintain their mental health. 

Daily routine and structure will decrease a patient's stress and give them a sense of accomplishment. 

Depression