James Randolph Hillard, MD

The University of Cincinnati has received a once-in-a-lifetime opportunity to do something great for psychiatry, and we invite you to share our dream.

We have received a $30 million donation to build the Craig and Frances Lindner Center of HOPE, a state-of-the-science psychiatric treatment center, on a 100-acre site north of Cincinnati. The center—with adult and adolescent inpatient beds and integrated outpatient services—will be operated by the Health Alliance of Greater Cincinnati. Current Psychiatry Deputy Editor Paul E. Keck, Jr., MD, professor and vice chairman for research at the university’s department of psychiatry, has been named psychiatrist-in-chief.

Whom do we consult for the most practical, creative ideas to design the center? Current Psychiatry readers, of course!

Have you complained about programs or facilities you inherited and dreamed of things you might do differently if you could start from scratch? If so, please send us:

• suggestions for innovative programs we might implement
• ideas to make our center clinically and financially successful
• ways to improve the “usual” hospital and outpatient programs.

Please e-mail your ideas to [email protected]. We will award $1,000 for the best suggestion received by Dec. 1, 2005. Dr. Keck and I will determine the winner, with deputy editor Lois E. Krahn, MD, casting a tie-breaking vote if necessary. We will post all useful or thought-provoking suggestions on www.currentpsychiatry.com.

The University of Cincinnati has received a once-in-a-lifetime opportunity to do something great for psychiatry, and we invite you to share our dream.

We have received a $30 million donation to build the Craig and Frances Lindner Center of HOPE, a state-of-the-science psychiatric treatment center, on a 100-acre site north of Cincinnati. The center—with adult and adolescent inpatient beds and integrated outpatient services—will be operated by the Health Alliance of Greater Cincinnati. Current Psychiatry Deputy Editor Paul E. Keck, Jr., MD, professor and vice chairman for research at the university’s department of psychiatry, has been named psychiatrist-in-chief.

Whom do we consult for the most practical, creative ideas to design the center? Current Psychiatry readers, of course!

Have you complained about programs or facilities you inherited and dreamed of things you might do differently if you could start from scratch? If so, please send us:

• suggestions for innovative programs we might implement
• ideas to make our center clinically and financially successful
• ways to improve the “usual” hospital and outpatient programs.

Please e-mail your ideas to [email protected]. We will award $1,000 for the best suggestion received by Dec. 1, 2005. Dr. Keck and I will determine the winner, with deputy editor Lois E. Krahn, MD, casting a tie-breaking vote if necessary. We will post all useful or thought-provoking suggestions on www.currentpsychiatry.com.

The University of Cincinnati has received a once-in-a-lifetime opportunity to do something great for psychiatry, and we invite you to share our dream.

We have received a $30 million donation to build the Craig and Frances Lindner Center of HOPE, a state-of-the-science psychiatric treatment center, on a 100-acre site north of Cincinnati. The center—with adult and adolescent inpatient beds and integrated outpatient services—will be operated by the Health Alliance of Greater Cincinnati. Current Psychiatry Deputy Editor Paul E. Keck, Jr., MD, professor and vice chairman for research at the university’s department of psychiatry, has been named psychiatrist-in-chief.

Whom do we consult for the most practical, creative ideas to design the center? Current Psychiatry readers, of course!

Have you complained about programs or facilities you inherited and dreamed of things you might do differently if you could start from scratch? If so, please send us:

• suggestions for innovative programs we might implement
• ideas to make our center clinically and financially successful
• ways to improve the “usual” hospital and outpatient programs.

Please e-mail your ideas to [email protected]. We will award $1,000 for the best suggestion received by Dec. 1, 2005. Dr. Keck and I will determine the winner, with deputy editor Lois E. Krahn, MD, casting a tie-breaking vote if necessary. We will post all useful or thought-provoking suggestions on www.currentpsychiatry.com.

We all watched with horror the news reports of Hurricane Katrina submerging New Orleans and devastating the Gulf Coast. As individuals and as a profession, we want to help—but what can we do?

Many of us have worked with victims of mass disasters at some point in our careers, and we all have worked with victims of individual disasters, such as fires, auto accidents, and domestic violence. If you are like me, you have sometimes felt helpless in the face of disaster and wondered whether what we do makes a difference.

Fortunately, our training equips us for disasters, whether mass or individual. Two articles in this month’s issue address psychiatric responses to trauma:

• Drs. Patricia Gerbarg and Richard Brown examine data on why yoga breathing practices may rapidly reduce posttraumatic stress, anxiety, and depression in survivors of natural and man-made disasters, including Hurricane Katrina, the 9/11 World Trade Center terrorist attacks, and many others.
• Drs. Charles Gillespie and Charles Nemeroff document the association between early life stress (particularly child abuse or neglect) and what appears to be a neurobiologically unique form of depression in adults.

Together, these articles suggest strategies to help disaster victims in the short run and patients with chronic depressive symptoms in the long run.

Of course, we need more research to refine our approaches to patients battered by storms or cruelty, but at least we have some guidance. Under the circumstances, we do the best we can.

We all watched with horror the news reports of Hurricane Katrina submerging New Orleans and devastating the Gulf Coast. As individuals and as a profession, we want to help—but what can we do?

Many of us have worked with victims of mass disasters at some point in our careers, and we all have worked with victims of individual disasters, such as fires, auto accidents, and domestic violence. If you are like me, you have sometimes felt helpless in the face of disaster and wondered whether what we do makes a difference.

Fortunately, our training equips us for disasters, whether mass or individual. Two articles in this month’s issue address psychiatric responses to trauma:

• Drs. Patricia Gerbarg and Richard Brown examine data on why yoga breathing practices may rapidly reduce posttraumatic stress, anxiety, and depression in survivors of natural and man-made disasters, including Hurricane Katrina, the 9/11 World Trade Center terrorist attacks, and many others.
• Drs. Charles Gillespie and Charles Nemeroff document the association between early life stress (particularly child abuse or neglect) and what appears to be a neurobiologically unique form of depression in adults.

Together, these articles suggest strategies to help disaster victims in the short run and patients with chronic depressive symptoms in the long run.

Of course, we need more research to refine our approaches to patients battered by storms or cruelty, but at least we have some guidance. Under the circumstances, we do the best we can.

We all watched with horror the news reports of Hurricane Katrina submerging New Orleans and devastating the Gulf Coast. As individuals and as a profession, we want to help—but what can we do?

Many of us have worked with victims of mass disasters at some point in our careers, and we all have worked with victims of individual disasters, such as fires, auto accidents, and domestic violence. If you are like me, you have sometimes felt helpless in the face of disaster and wondered whether what we do makes a difference.

Fortunately, our training equips us for disasters, whether mass or individual. Two articles in this month’s issue address psychiatric responses to trauma:

• Drs. Patricia Gerbarg and Richard Brown examine data on why yoga breathing practices may rapidly reduce posttraumatic stress, anxiety, and depression in survivors of natural and man-made disasters, including Hurricane Katrina, the 9/11 World Trade Center terrorist attacks, and many others.
• Drs. Charles Gillespie and Charles Nemeroff document the association between early life stress (particularly child abuse or neglect) and what appears to be a neurobiologically unique form of depression in adults.

Together, these articles suggest strategies to help disaster victims in the short run and patients with chronic depressive symptoms in the long run.

Of course, we need more research to refine our approaches to patients battered by storms or cruelty, but at least we have some guidance. Under the circumstances, we do the best we can.

Complete recovery must be our goal for each patient we treat. Richard Van Rhoads and Alan Gelenberg make this point in their article on treating major depressive illness to remission. Other Current Psychiatry authors who have emphasized recovery from psychiatric illness as a primary goal include:

• Pamela Wiegartz and Sonya Rasminsky on obsessive-compulsive disorder (April 2005)
• Lee Altman and Christopher Schneck on rapid-cycling bipolar disorder (November 2004)
• Willem Martens on schizophrenia (July 2004).

For years, psychiatry’s goal was symptom reduction, not recovery. The severely mentally ill were neglected at worst or warehoused in long-term institutional or custodial care. Treatment was limited to keeping patients from being an imminent risk to themselves or others.

Our options expanded gradually as safer medications were developed, effective psychotherapies were validated, and outpatient care brought a new focus on lifelong case management. Now we have tools to achieve much more-ambitious treatment goals.

Rather than being content with partial symptom remission, we need to vigorously promote recovery. Of course, some patients will still have residual symptoms and dysfunction, but let’s never give up too soon.

Complete recovery must be our goal for each patient we treat. Richard Van Rhoads and Alan Gelenberg make this point in their article on treating major depressive illness to remission. Other Current Psychiatry authors who have emphasized recovery from psychiatric illness as a primary goal include:

• Pamela Wiegartz and Sonya Rasminsky on obsessive-compulsive disorder (April 2005)
• Lee Altman and Christopher Schneck on rapid-cycling bipolar disorder (November 2004)
• Willem Martens on schizophrenia (July 2004).

For years, psychiatry’s goal was symptom reduction, not recovery. The severely mentally ill were neglected at worst or warehoused in long-term institutional or custodial care. Treatment was limited to keeping patients from being an imminent risk to themselves or others.

Our options expanded gradually as safer medications were developed, effective psychotherapies were validated, and outpatient care brought a new focus on lifelong case management. Now we have tools to achieve much more-ambitious treatment goals.

Rather than being content with partial symptom remission, we need to vigorously promote recovery. Of course, some patients will still have residual symptoms and dysfunction, but let’s never give up too soon.

Complete recovery must be our goal for each patient we treat. Richard Van Rhoads and Alan Gelenberg make this point in their article on treating major depressive illness to remission. Other Current Psychiatry authors who have emphasized recovery from psychiatric illness as a primary goal include:

• Pamela Wiegartz and Sonya Rasminsky on obsessive-compulsive disorder (April 2005)
• Lee Altman and Christopher Schneck on rapid-cycling bipolar disorder (November 2004)
• Willem Martens on schizophrenia (July 2004).

For years, psychiatry’s goal was symptom reduction, not recovery. The severely mentally ill were neglected at worst or warehoused in long-term institutional or custodial care. Treatment was limited to keeping patients from being an imminent risk to themselves or others.

Our options expanded gradually as safer medications were developed, effective psychotherapies were validated, and outpatient care brought a new focus on lifelong case management. Now we have tools to achieve much more-ambitious treatment goals.

Rather than being content with partial symptom remission, we need to vigorously promote recovery. Of course, some patients will still have residual symptoms and dysfunction, but let’s never give up too soon.

A persistent myth about psychiatrists is that we all take vacations in August:

• Judith Rossner wrote August, a successful novel based on the premise that all the psychiatrists left town that month, leaving their patients to their own devices.
• Bill Murray and Richard Dreyfuss starred in the film What About Bob?, in which a patient was so distressed to be left alone that he followed his psychiatrist on his August vacation.
• John Katzenbach wrote The Analyst, in which a patient plots to kill his psychiatrist/analyst for going on vacation in August.

This August vacation theme seems “anti-psychiatry” to me. It suggests we belong to some cult (Freud took August vacations, so the rest of us do, too), or that we do not care about our patients (or at least fail to provide adequate cross-coverage).

One can test the hypothesis that psychiatrists—compared with the general population—are more likely to take August vacations. Using vacation data from my university department in Cincinnati, I find no evidence that psychiatrists take August vacations more than other physicians do. This small study awaits confirmation by larger-scale epidemiologic studies.

If you’re reading this issue of Current Psychiatry in August, you are probably not on vacation. If it’s any consolation, most of your colleagues (at least here in Cincinnati) are not on vacation, either.

A persistent myth about psychiatrists is that we all take vacations in August:

• Judith Rossner wrote August, a successful novel based on the premise that all the psychiatrists left town that month, leaving their patients to their own devices.
• Bill Murray and Richard Dreyfuss starred in the film What About Bob?, in which a patient was so distressed to be left alone that he followed his psychiatrist on his August vacation.
• John Katzenbach wrote The Analyst, in which a patient plots to kill his psychiatrist/analyst for going on vacation in August.

This August vacation theme seems “anti-psychiatry” to me. It suggests we belong to some cult (Freud took August vacations, so the rest of us do, too), or that we do not care about our patients (or at least fail to provide adequate cross-coverage).

One can test the hypothesis that psychiatrists—compared with the general population—are more likely to take August vacations. Using vacation data from my university department in Cincinnati, I find no evidence that psychiatrists take August vacations more than other physicians do. This small study awaits confirmation by larger-scale epidemiologic studies.

If you’re reading this issue of Current Psychiatry in August, you are probably not on vacation. If it’s any consolation, most of your colleagues (at least here in Cincinnati) are not on vacation, either.

A persistent myth about psychiatrists is that we all take vacations in August:

• Judith Rossner wrote August, a successful novel based on the premise that all the psychiatrists left town that month, leaving their patients to their own devices.
• Bill Murray and Richard Dreyfuss starred in the film What About Bob?, in which a patient was so distressed to be left alone that he followed his psychiatrist on his August vacation.
• John Katzenbach wrote The Analyst, in which a patient plots to kill his psychiatrist/analyst for going on vacation in August.

This August vacation theme seems “anti-psychiatry” to me. It suggests we belong to some cult (Freud took August vacations, so the rest of us do, too), or that we do not care about our patients (or at least fail to provide adequate cross-coverage).

One can test the hypothesis that psychiatrists—compared with the general population—are more likely to take August vacations. Using vacation data from my university department in Cincinnati, I find no evidence that psychiatrists take August vacations more than other physicians do. This small study awaits confirmation by larger-scale epidemiologic studies.

If you’re reading this issue of Current Psychiatry in August, you are probably not on vacation. If it’s any consolation, most of your colleagues (at least here in Cincinnati) are not on vacation, either.

Is the FDA being overly zealous with its “black box” warnings? The latest advisory—associating atypical antipsychotics with increased mortality among patients with dementia—joins another black box linking these drugs to potentially fatal diabetes. And, as of October, black boxes warn of “clinical worsening” and “suicidality” associated with using SSRI antidepressants in children and adolescents.

An FDA analysis of 5,111 demented patients in 16 trials found about a 1.6-fold increase in mortality among those receiving atypical antipsychotics. According to the Alzheimer’s Association, the risk of death is “real but small;” 1.5% to 2% of the patients receiving antipsychotics died, compared with 1% of those receiving placebo.

Atypical antipsychotics are useful—at times life-saving—for many agitated elderly patients, and this new labeling should not be used as the basis to withhold these drugs from patients who might benefit from them.

Of course, black boxes are not unique to psychotropics. The COX-2 inhibitor arthritis drugs and others recently have joined more than 200 drugs with these warning labels. What leads the FDA to dichotomize drugs into “black-boxed” or “not black-boxed?” And why do black boxes seem to be proliferating?

I think the reason is that the FDA has been criticized for not doing more to prevent adverse drug events and is feeling the pressure. If someone has an adverse event after taking a black-boxed drug, the FDA can now say something like, “I told you so.” This is, as far as I can tell, the same reason for the Department of Homeland Security’s color-coded terrorism threat levels. One could argue that the much-maligned five-level terror rating system (from green to red) is more rational than the FDA’s two-level system, black or not black.

Congress has been debating whether the terrorism threat system is useful or is unnecessarily alarming the public and making us less safe. We should be asking the same questions about the FDA’s black box system.

Is the FDA being overly zealous with its “black box” warnings? The latest advisory—associating atypical antipsychotics with increased mortality among patients with dementia—joins another black box linking these drugs to potentially fatal diabetes. And, as of October, black boxes warn of “clinical worsening” and “suicidality” associated with using SSRI antidepressants in children and adolescents.

An FDA analysis of 5,111 demented patients in 16 trials found about a 1.6-fold increase in mortality among those receiving atypical antipsychotics. According to the Alzheimer’s Association, the risk of death is “real but small;” 1.5% to 2% of the patients receiving antipsychotics died, compared with 1% of those receiving placebo.

Atypical antipsychotics are useful—at times life-saving—for many agitated elderly patients, and this new labeling should not be used as the basis to withhold these drugs from patients who might benefit from them.

Of course, black boxes are not unique to psychotropics. The COX-2 inhibitor arthritis drugs and others recently have joined more than 200 drugs with these warning labels. What leads the FDA to dichotomize drugs into “black-boxed” or “not black-boxed?” And why do black boxes seem to be proliferating?

I think the reason is that the FDA has been criticized for not doing more to prevent adverse drug events and is feeling the pressure. If someone has an adverse event after taking a black-boxed drug, the FDA can now say something like, “I told you so.” This is, as far as I can tell, the same reason for the Department of Homeland Security’s color-coded terrorism threat levels. One could argue that the much-maligned five-level terror rating system (from green to red) is more rational than the FDA’s two-level system, black or not black.

Congress has been debating whether the terrorism threat system is useful or is unnecessarily alarming the public and making us less safe. We should be asking the same questions about the FDA’s black box system.

Is the FDA being overly zealous with its “black box” warnings? The latest advisory—associating atypical antipsychotics with increased mortality among patients with dementia—joins another black box linking these drugs to potentially fatal diabetes. And, as of October, black boxes warn of “clinical worsening” and “suicidality” associated with using SSRI antidepressants in children and adolescents.

An FDA analysis of 5,111 demented patients in 16 trials found about a 1.6-fold increase in mortality among those receiving atypical antipsychotics. According to the Alzheimer’s Association, the risk of death is “real but small;” 1.5% to 2% of the patients receiving antipsychotics died, compared with 1% of those receiving placebo.

Atypical antipsychotics are useful—at times life-saving—for many agitated elderly patients, and this new labeling should not be used as the basis to withhold these drugs from patients who might benefit from them.

Of course, black boxes are not unique to psychotropics. The COX-2 inhibitor arthritis drugs and others recently have joined more than 200 drugs with these warning labels. What leads the FDA to dichotomize drugs into “black-boxed” or “not black-boxed?” And why do black boxes seem to be proliferating?

I think the reason is that the FDA has been criticized for not doing more to prevent adverse drug events and is feeling the pressure. If someone has an adverse event after taking a black-boxed drug, the FDA can now say something like, “I told you so.” This is, as far as I can tell, the same reason for the Department of Homeland Security’s color-coded terrorism threat levels. One could argue that the much-maligned five-level terror rating system (from green to red) is more rational than the FDA’s two-level system, black or not black.

Congress has been debating whether the terrorism threat system is useful or is unnecessarily alarming the public and making us less safe. We should be asking the same questions about the FDA’s black box system.

The American Psychiatric Association, National Alliance for the Mentally Ill, and National Mental Health Association recently warned against relying on “effectiveness research.”

How can anyone warn against effectiveness research? Isn’t that like warning against mom or apple pie? (Well, I guess psychiatrists and nutritionists have warned us about mom and apple pie.) But shouldn’t we aspire to practice evidence-based medicine?

These organizations, of course, are warning against a trend to rely solely on “evidence-based” research. Appropriate research should inform our therapy choices, but an approach that lacks double-blind, placebo-controlled studies is not necessarily ineffective. Parachutes are not considered ineffective, though no properly controlled trials have compared outcomes of users versus nonusers jumping from planes (see “Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomized controlled trials.” British Medical Journal 2003;327:1459-61).

Concerned that some insurers are paying for only the cheapest medications unless “evidence-based” proof shows a more-expensive treatment to be significantly better, the APA/NAMI/NMHA stated: “True evidence-based approaches marry all available and appropriate scientific research with clinical experience to ensure treatments lead to the best possible outcomes. Implementing public policies based solely on one of these elements without the other is not an evidence-based approach.”

We at Current Psychiatry agree. The marriage of clinical data with clinical experience is what this journal is all about.

The American Psychiatric Association, National Alliance for the Mentally Ill, and National Mental Health Association recently warned against relying on “effectiveness research.”

How can anyone warn against effectiveness research? Isn’t that like warning against mom or apple pie? (Well, I guess psychiatrists and nutritionists have warned us about mom and apple pie.) But shouldn’t we aspire to practice evidence-based medicine?

These organizations, of course, are warning against a trend to rely solely on “evidence-based” research. Appropriate research should inform our therapy choices, but an approach that lacks double-blind, placebo-controlled studies is not necessarily ineffective. Parachutes are not considered ineffective, though no properly controlled trials have compared outcomes of users versus nonusers jumping from planes (see “Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomized controlled trials.” British Medical Journal 2003;327:1459-61).

Concerned that some insurers are paying for only the cheapest medications unless “evidence-based” proof shows a more-expensive treatment to be significantly better, the APA/NAMI/NMHA stated: “True evidence-based approaches marry all available and appropriate scientific research with clinical experience to ensure treatments lead to the best possible outcomes. Implementing public policies based solely on one of these elements without the other is not an evidence-based approach.”

We at Current Psychiatry agree. The marriage of clinical data with clinical experience is what this journal is all about.

The American Psychiatric Association, National Alliance for the Mentally Ill, and National Mental Health Association recently warned against relying on “effectiveness research.”

How can anyone warn against effectiveness research? Isn’t that like warning against mom or apple pie? (Well, I guess psychiatrists and nutritionists have warned us about mom and apple pie.) But shouldn’t we aspire to practice evidence-based medicine?

These organizations, of course, are warning against a trend to rely solely on “evidence-based” research. Appropriate research should inform our therapy choices, but an approach that lacks double-blind, placebo-controlled studies is not necessarily ineffective. Parachutes are not considered ineffective, though no properly controlled trials have compared outcomes of users versus nonusers jumping from planes (see “Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomized controlled trials.” British Medical Journal 2003;327:1459-61).

Concerned that some insurers are paying for only the cheapest medications unless “evidence-based” proof shows a more-expensive treatment to be significantly better, the APA/NAMI/NMHA stated: “True evidence-based approaches marry all available and appropriate scientific research with clinical experience to ensure treatments lead to the best possible outcomes. Implementing public policies based solely on one of these elements without the other is not an evidence-based approach.”

We at Current Psychiatry agree. The marriage of clinical data with clinical experience is what this journal is all about.

Pressed for time? Then discover the time-saving resources available at www.currentpsychiatry.com. Our Web site now has full-text HTML and PDF versions of any article we have ever published. You can search by title, subject, or author; read Web-only content such as Dr. John Luo’s “Psyber Psychiatry;” earn CME credits online, and much more.

I have used currentpsychiatry.com twice recently to solve real clinical problems:

• One weekend, an 80-year-old patient was concerned about medication interactions. I got the information I needed on cytochrome P-450 isoenzymes without having to search the whole Internet or evaluate a hundred different sites’ reliability. Even more important, I didn’t have to make a special trip to my office or the library.
• Another time, a patient asked me what I knew about omega-3 fatty acids and ADHD. She and I visited the site and discussed the data on the spot.

Having this information online makes it difficult to justify keeping old journals for years. I found my March 2005 editorial on this topic in seconds by entering “hoarding” in the site’s search field. I never would have found that issue in my messy office. It also makes it difficult to justify using books as reference sources because they quickly become outdated, whereas our Web site remains forever current.

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Pressed for time? Then discover the time-saving resources available at www.currentpsychiatry.com. Our Web site now has full-text HTML and PDF versions of any article we have ever published. You can search by title, subject, or author; read Web-only content such as Dr. John Luo’s “Psyber Psychiatry;” earn CME credits online, and much more.

I have used currentpsychiatry.com twice recently to solve real clinical problems:

• One weekend, an 80-year-old patient was concerned about medication interactions. I got the information I needed on cytochrome P-450 isoenzymes without having to search the whole Internet or evaluate a hundred different sites’ reliability. Even more important, I didn’t have to make a special trip to my office or the library.
• Another time, a patient asked me what I knew about omega-3 fatty acids and ADHD. She and I visited the site and discussed the data on the spot.

Having this information online makes it difficult to justify keeping old journals for years. I found my March 2005 editorial on this topic in seconds by entering “hoarding” in the site’s search field. I never would have found that issue in my messy office. It also makes it difficult to justify using books as reference sources because they quickly become outdated, whereas our Web site remains forever current.

f

Pressed for time? Then discover the time-saving resources available at www.currentpsychiatry.com. Our Web site now has full-text HTML and PDF versions of any article we have ever published. You can search by title, subject, or author; read Web-only content such as Dr. John Luo’s “Psyber Psychiatry;” earn CME credits online, and much more.

I have used currentpsychiatry.com twice recently to solve real clinical problems:

• One weekend, an 80-year-old patient was concerned about medication interactions. I got the information I needed on cytochrome P-450 isoenzymes without having to search the whole Internet or evaluate a hundred different sites’ reliability. Even more important, I didn’t have to make a special trip to my office or the library.
• Another time, a patient asked me what I knew about omega-3 fatty acids and ADHD. She and I visited the site and discussed the data on the spot.

Having this information online makes it difficult to justify keeping old journals for years. I found my March 2005 editorial on this topic in seconds by entering “hoarding” in the site’s search field. I never would have found that issue in my messy office. It also makes it difficult to justify using books as reference sources because they quickly become outdated, whereas our Web site remains forever current.

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Notice anything different about my picture this month? Yes, my beard is gone after 28 years. I grew it between medical school and psychiatry residency to look older. Recently, I reached what author Malcolm Gladwell coined a “tipping point” and got rid of it to look younger.

I also grew my beard (a goatee, actually) to project my vision of a psychiatrist—a nonconformist, an intellectual. Sigmund Freud had a beard, of course, and I suspect that because of him the percentage of hirsute faces is much higher in psychiatry than in other medical specialties.

I went to college in the ‘60s and early ‘70s, so the beard helped me resist feeling that I had “gone establishment” when I became a doctor. But now I am more secure in my psychiatric identity and have come to terms with being part of established medicine. I am president of my university’s multispecialty practice group, and without the beard I look more like my clean-shaven colleagues from other departments. Maybe shaving will help secure my identity as a “real” doctor, despite decades of not doing physical exams.

Are beards becoming less common among psychiatrists? My impression is yes, but my only evidence comes from counting beards in the University of Cincinnati psychiatry department’s annual photos. In 1990, 27% of men on the faculty sported facial hair, and the percentage fell to 8.8% by 2001.

As psychiatry becomes more mainstream, maybe our appearances are becoming more mainstream, too. Or maybe I am indulging in that psychiatric temptation to over-generalize from a single case report.

Notice anything different about my picture this month? Yes, my beard is gone after 28 years. I grew it between medical school and psychiatry residency to look older. Recently, I reached what author Malcolm Gladwell coined a “tipping point” and got rid of it to look younger.

I also grew my beard (a goatee, actually) to project my vision of a psychiatrist—a nonconformist, an intellectual. Sigmund Freud had a beard, of course, and I suspect that because of him the percentage of hirsute faces is much higher in psychiatry than in other medical specialties.

I went to college in the ‘60s and early ‘70s, so the beard helped me resist feeling that I had “gone establishment” when I became a doctor. But now I am more secure in my psychiatric identity and have come to terms with being part of established medicine. I am president of my university’s multispecialty practice group, and without the beard I look more like my clean-shaven colleagues from other departments. Maybe shaving will help secure my identity as a “real” doctor, despite decades of not doing physical exams.

Are beards becoming less common among psychiatrists? My impression is yes, but my only evidence comes from counting beards in the University of Cincinnati psychiatry department’s annual photos. In 1990, 27% of men on the faculty sported facial hair, and the percentage fell to 8.8% by 2001.

As psychiatry becomes more mainstream, maybe our appearances are becoming more mainstream, too. Or maybe I am indulging in that psychiatric temptation to over-generalize from a single case report.

Notice anything different about my picture this month? Yes, my beard is gone after 28 years. I grew it between medical school and psychiatry residency to look older. Recently, I reached what author Malcolm Gladwell coined a “tipping point” and got rid of it to look younger.

I also grew my beard (a goatee, actually) to project my vision of a psychiatrist—a nonconformist, an intellectual. Sigmund Freud had a beard, of course, and I suspect that because of him the percentage of hirsute faces is much higher in psychiatry than in other medical specialties.

I went to college in the ‘60s and early ‘70s, so the beard helped me resist feeling that I had “gone establishment” when I became a doctor. But now I am more secure in my psychiatric identity and have come to terms with being part of established medicine. I am president of my university’s multispecialty practice group, and without the beard I look more like my clean-shaven colleagues from other departments. Maybe shaving will help secure my identity as a “real” doctor, despite decades of not doing physical exams.

Are beards becoming less common among psychiatrists? My impression is yes, but my only evidence comes from counting beards in the University of Cincinnati psychiatry department’s annual photos. In 1990, 27% of men on the faculty sported facial hair, and the percentage fell to 8.8% by 2001.

As psychiatry becomes more mainstream, maybe our appearances are becoming more mainstream, too. Or maybe I am indulging in that psychiatric temptation to over-generalize from a single case report.

Compulsive hoarders collect useless things—most often newspapers, magazines, old clothing, bags, books, mail, notes, and lists, according to this month’s article by Jamie Feusner, MD, and Sanjaya Saxena, MD, of the UCLA Neuropsychiatric Institute.

Initially I thought I didn’t save all of those items since I don’t save old clothes and bags. Then I remembered the closetful of clothes that don’t fit me. I lost weight last year, but—playing the odds—these clothes may fit me again someday and I hesitate to discard them. I also remembered all those APA-logo scientific meeting tote bags I haven’t thrown away.

These may be small obsessive-compulsive signs compared with my hoarding of medical journals. To my amazement, I have more than 2,000 journals in my office. I haven’t looked at more than a handful and probably didn’t read most when I received them. Why do I keep them? Could I have “problems with information processing, obsessional anxiety, and avoiding decisions” that Drs. Feusner and Saxena suggest as targets for psychotherapeutic intervention?

Maybe it’s rational to keep these journals in case I want to look something up, but then why save Current Psychiatry? Its full text is available online.

My best explanation is that old journals are an interior design element. William Morris, the 19th century designer and proponent of the arts and crafts movement, counseled: “Have nothing in your homes that you do not know to be useful or believe to be beautiful.”

Old journals may be visual clutter, but they are beautiful to me because they remind me that psychiatric treatments are backed by decades of study and research. When I wonder if I know anything at all (you have those moments, don’t you?), glancing at my shelves of journals reassures me and gives me courage to continue the perpetually astonishing unknown that is clinical practice.

Compulsive hoarders collect useless things—most often newspapers, magazines, old clothing, bags, books, mail, notes, and lists, according to this month’s article by Jamie Feusner, MD, and Sanjaya Saxena, MD, of the UCLA Neuropsychiatric Institute.

Initially I thought I didn’t save all of those items since I don’t save old clothes and bags. Then I remembered the closetful of clothes that don’t fit me. I lost weight last year, but—playing the odds—these clothes may fit me again someday and I hesitate to discard them. I also remembered all those APA-logo scientific meeting tote bags I haven’t thrown away.

These may be small obsessive-compulsive signs compared with my hoarding of medical journals. To my amazement, I have more than 2,000 journals in my office. I haven’t looked at more than a handful and probably didn’t read most when I received them. Why do I keep them? Could I have “problems with information processing, obsessional anxiety, and avoiding decisions” that Drs. Feusner and Saxena suggest as targets for psychotherapeutic intervention?

Maybe it’s rational to keep these journals in case I want to look something up, but then why save Current Psychiatry? Its full text is available online.

My best explanation is that old journals are an interior design element. William Morris, the 19th century designer and proponent of the arts and crafts movement, counseled: “Have nothing in your homes that you do not know to be useful or believe to be beautiful.”

Old journals may be visual clutter, but they are beautiful to me because they remind me that psychiatric treatments are backed by decades of study and research. When I wonder if I know anything at all (you have those moments, don’t you?), glancing at my shelves of journals reassures me and gives me courage to continue the perpetually astonishing unknown that is clinical practice.

Compulsive hoarders collect useless things—most often newspapers, magazines, old clothing, bags, books, mail, notes, and lists, according to this month’s article by Jamie Feusner, MD, and Sanjaya Saxena, MD, of the UCLA Neuropsychiatric Institute.

Initially I thought I didn’t save all of those items since I don’t save old clothes and bags. Then I remembered the closetful of clothes that don’t fit me. I lost weight last year, but—playing the odds—these clothes may fit me again someday and I hesitate to discard them. I also remembered all those APA-logo scientific meeting tote bags I haven’t thrown away.

These may be small obsessive-compulsive signs compared with my hoarding of medical journals. To my amazement, I have more than 2,000 journals in my office. I haven’t looked at more than a handful and probably didn’t read most when I received them. Why do I keep them? Could I have “problems with information processing, obsessional anxiety, and avoiding decisions” that Drs. Feusner and Saxena suggest as targets for psychotherapeutic intervention?

Maybe it’s rational to keep these journals in case I want to look something up, but then why save Current Psychiatry? Its full text is available online.

My best explanation is that old journals are an interior design element. William Morris, the 19th century designer and proponent of the arts and crafts movement, counseled: “Have nothing in your homes that you do not know to be useful or believe to be beautiful.”

Old journals may be visual clutter, but they are beautiful to me because they remind me that psychiatric treatments are backed by decades of study and research. When I wonder if I know anything at all (you have those moments, don’t you?), glancing at my shelves of journals reassures me and gives me courage to continue the perpetually astonishing unknown that is clinical practice.

For some years, I have been considering giving up traditional psychotherapy and concentrating on “rationalization therapy.” Patients will tell me what they want to do, and I will help them rationalize it.

Much of what passes for psychotherapy is, in fact, rationalization therapy in disguise. What’s different about my idea is that accurately labeling this new therapy will make the transaction more honest. We will abandon any talk about “making patients well” and concentrate on making them feel good about getting what they want.

Rationalization therapy can also rescue us from time-based billing. One reason surgeons make more money than we do is that they can bill on codes related to a procedure’s difficulty. We, on the other hand, are trapped into billing for the minutes we spend with a patient, regardless of how difficult our psychotherapeutic goals may be.

For rationalization therapy, I propose that we bill on how difficult it is to rationalize the patient’s wish, regardless of how long it takes us to help him or her rationalize it. For example, rationalizing taking an extra sick day from work when not really sick would be a Level-1 code with low reimbursement. Rationalizing murder would be a Level-3 code, resulting in much higher reimbursement.

For rationalizing murder, we also would be entitled to a higher relative value unit (RVU) reimbursement. This RVU would take into account not just our “physicians work” component but also a cost-of-practice component for higher professional liability costs we might incur.

Rationalization therapy thus would be win-win for us and our patients. My only hesitation in making this practice change has to do with another idea I’m considering, called “procrastination therapy.” But I’ll get to that another day.

For some years, I have been considering giving up traditional psychotherapy and concentrating on “rationalization therapy.” Patients will tell me what they want to do, and I will help them rationalize it.

Much of what passes for psychotherapy is, in fact, rationalization therapy in disguise. What’s different about my idea is that accurately labeling this new therapy will make the transaction more honest. We will abandon any talk about “making patients well” and concentrate on making them feel good about getting what they want.

Rationalization therapy can also rescue us from time-based billing. One reason surgeons make more money than we do is that they can bill on codes related to a procedure’s difficulty. We, on the other hand, are trapped into billing for the minutes we spend with a patient, regardless of how difficult our psychotherapeutic goals may be.

For rationalization therapy, I propose that we bill on how difficult it is to rationalize the patient’s wish, regardless of how long it takes us to help him or her rationalize it. For example, rationalizing taking an extra sick day from work when not really sick would be a Level-1 code with low reimbursement. Rationalizing murder would be a Level-3 code, resulting in much higher reimbursement.

For rationalizing murder, we also would be entitled to a higher relative value unit (RVU) reimbursement. This RVU would take into account not just our “physicians work” component but also a cost-of-practice component for higher professional liability costs we might incur.

Rationalization therapy thus would be win-win for us and our patients. My only hesitation in making this practice change has to do with another idea I’m considering, called “procrastination therapy.” But I’ll get to that another day.

For some years, I have been considering giving up traditional psychotherapy and concentrating on “rationalization therapy.” Patients will tell me what they want to do, and I will help them rationalize it.

Much of what passes for psychotherapy is, in fact, rationalization therapy in disguise. What’s different about my idea is that accurately labeling this new therapy will make the transaction more honest. We will abandon any talk about “making patients well” and concentrate on making them feel good about getting what they want.

Rationalization therapy can also rescue us from time-based billing. One reason surgeons make more money than we do is that they can bill on codes related to a procedure’s difficulty. We, on the other hand, are trapped into billing for the minutes we spend with a patient, regardless of how difficult our psychotherapeutic goals may be.

For rationalization therapy, I propose that we bill on how difficult it is to rationalize the patient’s wish, regardless of how long it takes us to help him or her rationalize it. For example, rationalizing taking an extra sick day from work when not really sick would be a Level-1 code with low reimbursement. Rationalizing murder would be a Level-3 code, resulting in much higher reimbursement.

For rationalizing murder, we also would be entitled to a higher relative value unit (RVU) reimbursement. This RVU would take into account not just our “physicians work” component but also a cost-of-practice component for higher professional liability costs we might incur.

Rationalization therapy thus would be win-win for us and our patients. My only hesitation in making this practice change has to do with another idea I’m considering, called “procrastination therapy.” But I’ll get to that another day.