Hero

Videos

Slideshows

Articles

Podcasts

Poll

“Sleep problems are understudied,” Ellen Lee, MD, told attendees at the 2021 American Psychiatric Association (APA) Annual Meeting. “They’re underdiagnosed and undertreated in people with mental illness.” Thus, Lee encouraged clinicians to screen for sleep problems, because sleep “is a modifiable and important target for intervention.” Lee, along with other colleagues, shared insights and preliminary research results on how sleep may impact mental health and psychiatric disorders.

Sleep problems affect between 30 and 80% of individuals with schizophrenia and are associated with lower quality of life and poorer cognitive and frontal lobe functioning, explained Lee, assistant professor in residence in the Department of Psychiatry at the University of California at 

 In as-yet unpublished research, Lee found that sleep apnea is associated with increased inflammation, while higher subjective reports of sleep quality are associated with lower levels of inflammation. Since inflammation is also associated with 

 treating sleep problems could also improve the symptoms of mental illnesses.

Beyond schizophrenia, sleep issues also appear in mood disorders like depression. Stephen Smagula, PhD, presented research on possible links between morning activation deficits and depression among family members caring for patients with dementia.

Older individuals with depression often report difficulty getting up and active in the 

 Morning activation deficits are sometimes thought to be immutable (some individuals are just not morning people), but in functional magnetic resonance imaging readings, dementia caregivers with depression showed higher resting-state amygdala-PCC connectivity, which is associated with stress, fear, and 

 “Although this is speculative,” Smagula cautioned, “it seems plausible that the non-morning type caregivers are doing behaviorally disengaged, emotion-focused coping. So put another way, some caregivers might wake up, feel overwhelmed, say ‘Expletive! I’m going back to bed.’”

This raises the possibility, according to Smagula, who is assistant professor of psychiatry and epidemiology at the University of Pittsburg, that “instead of treating the depression and hoping the morning activation deficit goes away, we could be targeting the morning activation deficit to treat the depression.” Clinicians could consider treatments such as activity scheduling, which would get the caregivers up and moving, increase their light exposure, decrease fragmented sleep, and limit the time they spend ruminating—all of which could improve their depressive symptoms.

Sleep also affects cognition, especially in older adults. Ruth O’Hara, PhD, presented initial data on the impacts of delta activity at sleep onset (DASO). Study participants with DASO demonstrated better affective function overall and over time, which led O’Hara to conclude that testing DASO or other variables may help clinicians predict patients’ cognitive futures. “We think that characterizing sleep dysregulation in older adults may in fact identify valuable biomarkers,” explained O’Hara, who is the Josephine Q. Berry Professor of Psychiatry and Behavioral Sciences at Stanford University. They could “help us predict cognitive decline and onset of dementia, as well as predicting affective dysfunction.”

1. Cohrs S. Sleep disturbances in patients with schizophrenia: impact and effect of antipsychotics. 

2. Keshavan MS, Montrose DM, Miewald JM, Jindal RD. Sleep correlates of cognition in early course psychotic disorders. 

3. Bromundt V, Köster M, Georgiev-Kill A, et al. Sleep-wake cycles and cognitive functioning in schizophrenia. 

4. Lee EE, Ancoli-Israel S, Eyler LT, et al. Sleep disturbances and inflammatory biomarkers in schizophrenia: focus on sex differences. 

5. Smagula SF, Capps CS, Krafty RT. Evaluating the timing of differences in activity related to depression symptoms across adulthood in the United States. 

6. Smagula SF, Karim HT, Ibrahim TS, et al. Resting-state function connectivity associated with being a "morning-type" dementia caregiver and having lower depression symptom severity. 

Sleep problems are understudied, underdiagnosed, and undertreated. 

Dreaming of New Treatments

Susan J. Noonan, MD, MPH, discusses the difficulties of allowing a patient or loved one their independence, even if it means making mistakes. 

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 

Caregivers may want to shield their loved one with a mental illness. How can they impart advice while also allowing their loved one their independence? 

Making Their Own Mistakes

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

. Hogarth Press; 1915. Volume 14:159-204.

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

Susan J. Noonan, MD, MPH, reccommends the following steps when dealing with a patient's anger: identify the emotion, convey understanding, and allow for a response. Remain neutral, calm, and empathetic. 

Helping a patient and their family with anger about a mood disorder can be difficult...

Anger and Its Causes

. 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? 

Share comments with your colleagues by emailing 

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

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?

Susan J. Noonan, MD, MPH, discusses how important it is to see a patient in their social setting, specifically their family. 

Mood disorders can be genetic and deeply affect surrounding people...

Mood Disorders: A Family Illness

Psychiatry may be lagging behind other branches of medicine in an important way.

“In the rest of medicine, as you increase the acuity you increase the number of treatments,” Nolan Williams, MD, told the attendees of the 2021 American Psychiatric Association (APA) Annual Meeting, but in psychiatry, “as we increase acuity we actually lose treatment options.”

Williams and his fellow presenters at a panel on rapidly acting medications

 all had the same question: How can psychiatrists design treatments to respond to sudden-onset conditions?

Williams, assistant professor of psychiatry and behavioral sciences at Stanford University Medical Center, described the situation as “emergency room purgatory.” Because of slow-acting treatments and limited hospital capacity, “the whole process of going through the inpatient unit can take several months,” he said. “The only treatment that we have available for these folks is ECT [electroconvulsive therapy.” But ECT is available in only 10% of US hospitals.

However, psychiatrists might have other options for fast-acting treatments. He shared 

showing that accelerated theta burst repetitive transcranial magnetic stimulation (r-TMS) had positive results for mood disorders, including MDD.

 R-TMS treatment works by stimulating the left dorsolateral prefrontal cortex (DLPFC). In MDD, the DLPFC may be failing to inhibit the subgenual cingulate, and the result of this network failure is cognitive impairment and inwardly directed negative thoughts,” Nolan explained. “By stimulating DLPFC, r-TMS corrects the mood imbalance and restores mood regulation.”

In initial numbers from his study of patients with a treatment-resistant mood disorder (TRD), Nolan found that after 5 days of sessions (10 hourly sessions at 1800 theta-burst pulses per hour), participants improved. On the Montgomery Asberg Depression Rating Scale (MADRS), he found an 80% average reduction of participants MADRS scores.

Another options for fast-acting treatment is ketamine. Charles DeBattista, MD, professor of psychiatry and behavioral sciences at Stanford University, presented evidence for its efficacy for TRD. He noted that ketamine is an anesthetic agent, a μ-opioid agonist, and while its effects on TRD are rapid, making it potentially helpful in psychiatric emergencies. “Often within a couple of hours to a day, patients experience a significant improvement, and the effects were sustained for a week or so,” he said. These effects did decrease after a week, but there is also evidence that repeated injections may lead to 

DeBattista also presented the option of esketamine, which has been fast tracked by the US Food and Drug Administration for treating TRD and acute suicidality in MDD. Multiple studies have found that it rapidly 

New mothers represent another population that might benefit from fast-acting medications. “Maternal mental health is something that’s been an enormous problem forever,” said Samantha Meltzer-Brody, MD, MPH. “Those of us that have the privilege of working with perinatal women are always struck by how debilitating PPD [postpartum depression] can be.” Rapidly acting medications could reduce mortality and morbidity, she said, and allow for more positive interactions between mothers and their newborns.

Although many selective serotonin reuptake inhibitors are approved to treat PPD, she pointed out that their initial effects may not be felt for weeks or even months, and many women’s symptoms do not respond to them. Meltzer-Brody, the Assad Meymandi Distinguished Professor and Chair in the University of North Carolina Department of Psychiatry, also considers an alternative to these medications: neurosteroids like brexanolone.

In a 2018 paper, Meltzer-Brody and her coauthors found brexanolone to be effective for

 Using the HDRS for measurement, the researchers found an average 8- to 10-point reduction in 12 hours, and around an 18-point reduction at 60 hours, the study’s primary endpoint. At day 30, participants average reduction remained, on average, 16 points down from baseline. The paper hypothesized that brexanolone works by increasing γ-aminobutyric acid (GABA) function, which appears to be inhibited during PPD.

With these new options, it seems psychiatry may not lag behind other branches of medicine for long. 

1. Williams N. Developing rapidly acting antidepressants: neurosteroids, dissociative agents (Ketamine Analogues and Psilocybin), and Accelerated Theta Burst r-TMS. Paper presented at: American Psychiatric Association Annual Meeting; May 1-3, 2021; virtual.

2. Nettekoven C, Volz LJ, Kutscha M, et al. Dose-dependent effects of theta burst rTMS on cortical excitability and resting-state connectivity of the human motor system. 

3. Li CT, Chen MH, Juan CH, et al. Efficacy of prefrontal theta-burst stimulation in refractory depression: a randomized sham-controlled study. 

4. Yip AG, George MS, Tendler A, et al. 61% of unmedicated treatment resistant depression patients who did not respond to acute TMS treatment responded after four weeks of twice weekly deep TMS in the Brainsway pivotal trial. 

5. Murrough JW, Perez AM, Pillemer S, et al. Rapid and longer-term antidepressant effects of repeated ketamine infusions in treatment-resistant major depression. 

6. Canuso CM, Singh JB, Fedgchin M, et al. Efficacy and safety of intranasal esketamine for the rapid reduction of symptoms of depression and suicidality in patients at imminent risk for suicide: results of a double-blind, randomized, placebo-controlled study. 

7. Fu DJ, Ionescu DF, Li X, et al. Esketamine nasal spray for rapid reduction of major depressive disorder symptoms in patients who have active suicidal ideation with intent: double-blind, randomized study (ASPIRE I). 

8. Meltzer-Brody S, Colquhoun H, Riesenberg R, et al. Brexanolone injection in post-partum depression: two multicentre, double-blind, randomised, placebo-controlled, phase 3 trials. 

What treatments could handle both psychiatric emergencies and long-standings mental health conditions—in a hurry?  

Fast-Acting Options for Mood Disorders and Psychiatric Emergencies

Susan J. Noonan, MD, MPH, talks about the way mood disorders can disrupt a patient's life, as they are chronic and often do not respond readily to treatment. 

What can be done when a mood disorder upends a patient's life?

A Life Interrupted: Impact of Mood Disorders

2021 American Psychiatric Association Virtual Meeting

, Richard C. Shelton, MD, the Charles B. Ireland Professor in the Department of Psychiatry and Behavioral Neurobiology at the University of Alabama at Birmingham, and the Director of the UAB Depression and Suicide Center, discussed the functions and concerns of ketamine.

“This is not a simple treatment or a treatment to take lightly,” Shelton said during the Q+A portion of his presentation. “On the other hand, we’ve seen remarkable results.”

Shelton began with a discussion of ketamine’s functions in the brain, and how it restores the regulatory processes for patients with mood disorders, using a 

“Stressful experiences cause a reduction or retraction of spines and synapses. The brain is less able to control or regulate the emotional state,” Shelton explained.

With ketamine administration, there is an almost immediate increase in formation of critical spine and synaptic proteins.

“When you add ketamine to the system, you produce a rapid return and restoration of those spines and synapses. We see an effect within 24 hours,” Shelton continued. “Ketamine has the ability to restore the regulatory control to the brain and helps to theoretically normalize mood.”

Shelton shared data from 8 studies regarding ketamine, and how it produced a rapid, robust effect for patients with severe, resistant mood disorders,

 and further studies on how ketamine functioned for patients with suicidal ideation.

“The good news: ketamine really seemed to work in these highly treatment-resistant patients,” Shelton said. 

Shelton also addressed key concerns regarding ketamine, especially how it may be a challenge to prescribe. First, the US Food and Drug Administration requires a “somewhat cumbersome” risk evaluation and mitigation strategy program, in which the clinic, provider, and patient must all be registered in the program. There are prior authorization hurdles, as well as reimbursement issues. Nonetheless, Shelton finds ketamine more than worth it.

“When I treated my first patient with IV ketamine in 2012, it was just amazing to see the effect occur within 24 hours,” Shelton said.

1. Li N, Liu RJ, Dwyer JM, et al. Glutamate N-methyl-D-aspartate receptor antagonists rapidly reverse behavioral and synaptic deficits caused by chronic stress exposure. 

2. Berman RM, Narasimhan M, Sanacora G, et al. A randomized clinical trial of repetitive transcranial magnetic stimulation in the treatment of major depression. 

3. Zarate CA, Singh JB, Carlson PJ, et al. A randomized trial of an N-methyl-D-aspartate antagonist in treatment-resistant major depression. 

4. Singh JB, Fedgchin M, Daly EJ, et al. A double-blind, randomized, placebo-controlled, dose-frequency study of intravenous ketamine in patients with treatment-resistant depression. 

5. Daly EJ, Singh JB. Adjunctive intranasal esketamine in treatment-resistant depression-reply. 

6. Fedgchin M, Trivedi M, Daly EJ, et al. Efficacy and safety of fixed-dose esketamine nasal spray combined with a new oral antidepressant in treatment-resistant depression: results of a randomized, double-blind, active-controlled study (TRANSFORM-1). 

7. Popova V, Daly EJ, Trivedi M, et al. Efficacy and safety of flexibly dosed esketamine nasal spray combined with a newly initiated oral antidepressant in treatment-resistant depression: A randomized double-blind active-controlled study. 

8. Daly EJ, Trivedi M, Janik A, et al. Efficacy of esketamine nasal spray plus oral antidepressant treatment for relapse prevention in patients with treatment-resistant depression: A randomized clinical trial. 

9. Wajs E, Aluisio L, Holder R, et al. Esketamine nasal spray plus oral antidepressant in patients with treatment-resistant depression: assessment of long-term safety in a phase 3, open-label study (SUSTAIN-2). 

10. Wilkinson ST, Ballard ED, Bloch MH, et al. The effect of a single dose of intravenous ketamine on suicidal ideation: A systematic review and individual participant data meta-analysis. 

11. Canuso CM, Singh JB, Fedgchin M, et al. Efficacy and safety of intranasal esketamine for the rapid reduction of symptoms of depression and suicidality in patients at imminent risk for suicide: results of a double-blind, randomized, placebo-controlled study. 

12. Fu DJ, Ionescu DF, Li X, et al. Esketamine nasal spray for rapid reduction of major depressive disorder symptoms in patients who have active suicidal ideation with intent: double-blind, randomized study (ASPIRE I). 

13. Ionescu DF, Fu DJ, Qiu X, et al. Esketamine nasal spray for rapid reduction of depressive symptoms in patients with major depressive disorder who have active suicide ideation with intent: Results of a phase 3, double-blind, randomized study (ASPIRE II). 

One doctor at the APA Virtual meeting explains how ketamine can rebuild spine and synaptic proteins in the brain, but may be difficult to actually prescribe to patients. 

Ketamine: Not A Simple Treatment, But a Worthy One

Susan J. Noonan, MD, MPH, talks about the need for both patients and family to understand symptoms of mood disorders. 

Teach both the patient and the patient's family are important steps to treating a mood disorder.

Mood Disorders