Current Psychiatry

I love Dr. Nasrallah’s editorials, but none more so than his commentary in the June issue, “A skeptical view of ‘progress’ in psychiatry” (From the Editor, Current Psychiatry, June 2011, p. 18-19), in which he deftly highlights factors hindering the advancement of our profession. Clearly, his arguments come from the heart and speak directly to many psychiatrists’ concerns about what is happening in clinical settings.

I believe managed care has contributed to the proliferation of irrational polypharmacy. This is a consequence of clinicians who find themselves under unrealistic time pressures and cost constraints to come up with an expedient, “magical” treatment for acute hospitalized patients.

In reference to the comments about the phrase “behavioral health,” I have always objected to the pejorative term “providers” to refer to physicians. The designation “behavioral health providers” lumps psychiatrists and all other workers in the mental health field under the same umbrella, blurring the roles and identities of the different professions. Insurance companies further dismiss our psychiatric follow-ups as “medication management,” which ignores the broader, more specialized nature of our work with patients for the purpose of slashing fees. We often take these terms for granted, accepting them as nothing more than semantics or corporate jargon, but they are not so innocuous. We all should be aware of how these labels limit psychiatric practice and allow us to be subjugated by parties with financial motives.

On behalf of all of us who see the insidious side of the so-called progress being made in psychiatry, thank you for this insightful, well organized, and well written editorial.

Radwan F. Haykal, MD
Clinical Professor of Psychiatry
University of Tennessee Health Science Center
Memphis, TN

I love Dr. Nasrallah’s editorials, but none more so than his commentary in the June issue, “A skeptical view of ‘progress’ in psychiatry” (From the Editor, Current Psychiatry, June 2011, p. 18-19), in which he deftly highlights factors hindering the advancement of our profession. Clearly, his arguments come from the heart and speak directly to many psychiatrists’ concerns about what is happening in clinical settings.

I believe managed care has contributed to the proliferation of irrational polypharmacy. This is a consequence of clinicians who find themselves under unrealistic time pressures and cost constraints to come up with an expedient, “magical” treatment for acute hospitalized patients.

In reference to the comments about the phrase “behavioral health,” I have always objected to the pejorative term “providers” to refer to physicians. The designation “behavioral health providers” lumps psychiatrists and all other workers in the mental health field under the same umbrella, blurring the roles and identities of the different professions. Insurance companies further dismiss our psychiatric follow-ups as “medication management,” which ignores the broader, more specialized nature of our work with patients for the purpose of slashing fees. We often take these terms for granted, accepting them as nothing more than semantics or corporate jargon, but they are not so innocuous. We all should be aware of how these labels limit psychiatric practice and allow us to be subjugated by parties with financial motives.

On behalf of all of us who see the insidious side of the so-called progress being made in psychiatry, thank you for this insightful, well organized, and well written editorial.

Radwan F. Haykal, MD
Clinical Professor of Psychiatry
University of Tennessee Health Science Center
Memphis, TN

I love Dr. Nasrallah’s editorials, but none more so than his commentary in the June issue, “A skeptical view of ‘progress’ in psychiatry” (From the Editor, Current Psychiatry, June 2011, p. 18-19), in which he deftly highlights factors hindering the advancement of our profession. Clearly, his arguments come from the heart and speak directly to many psychiatrists’ concerns about what is happening in clinical settings.

I believe managed care has contributed to the proliferation of irrational polypharmacy. This is a consequence of clinicians who find themselves under unrealistic time pressures and cost constraints to come up with an expedient, “magical” treatment for acute hospitalized patients.

In reference to the comments about the phrase “behavioral health,” I have always objected to the pejorative term “providers” to refer to physicians. The designation “behavioral health providers” lumps psychiatrists and all other workers in the mental health field under the same umbrella, blurring the roles and identities of the different professions. Insurance companies further dismiss our psychiatric follow-ups as “medication management,” which ignores the broader, more specialized nature of our work with patients for the purpose of slashing fees. We often take these terms for granted, accepting them as nothing more than semantics or corporate jargon, but they are not so innocuous. We all should be aware of how these labels limit psychiatric practice and allow us to be subjugated by parties with financial motives.

On behalf of all of us who see the insidious side of the so-called progress being made in psychiatry, thank you for this insightful, well organized, and well written editorial.

Radwan F. Haykal, MD
Clinical Professor of Psychiatry
University of Tennessee Health Science Center
Memphis, TN

Regarding Dr. Nasrallah’s insightful editorial (“A skeptical view of ‘progress’ in psychiatry,” From the Editor, Current Psychiatry, June 2011, p. 18-19): Since the late 1980s and early 1990s, the Employment Retirement Income Security Act, has enabled managed “care” to exist, with failed attempts to repeal or limit the act. Managed “care” has worked hard to change our language, such as “primary care physician” instead of physician or doctor and “behavioral health” instead of psychiatric or mental health care. These changes minimize our importance, influence, and reimbursements as well as the medications and treatments we use. When it was obvious what was happening, we abdicated our responsibility and control to the kind of people Dr. Nasrallah described.

There will be more cuts on reimbursements and limits on us unless we say “no.” We are not allowed to organize, physicians in Congress have not helped, and our elected professional organization leaders have little influence. We can give in and accept the “inevitable,” but the Hippocratic Oath seems to preclude such irresponsibility. We can refuse to treat anyone, except in emergencies, unless we choose to do so in good conscience. We need to change and the law has to change. The people who control our health care are evil, immoral, and venal; why should they be dictating care?

Gerald A. Shubs, MD
Butler Behavioral Health Services
Hamilton, OH

Dr. Nasrallah responds

Thanks to all my colleagues who took the time to read and express their views, to agree or to challenge the tenets in my editorial that lamented the lack of progress in certain practice aspects of psychiatry. Current Psychiatry is a marketplace of updates, ideas, suggestions, critiques, and rebuttals. It is interesting psychiatrists who have worked for a long time with seriously mentally ill patients in hospitals or the community seem to feel the pain of the lack of steady progress and/or the slippage in some areas, while those who identify with the managed care model of care see things differently— ie, managed care is, in fact, progress.

We psychiatrists evaluate and treat patients in very diverse settings and perceive things through different prisms, which is why we have disparate views. No one has a monopoly on the truth, but we all have important common ground: we all share an intense loyalty to our suffering patients, and we all share pride in our noble profession regardless of its ups or downs. We know in our hearts psychiatry remains indispensable for the well-being of all citizens. Pass it on…

Henry A. Nasrallah, MD
Editor-in-Chief

Regarding Dr. Nasrallah’s insightful editorial (“A skeptical view of ‘progress’ in psychiatry,” From the Editor, Current Psychiatry, June 2011, p. 18-19): Since the late 1980s and early 1990s, the Employment Retirement Income Security Act, has enabled managed “care” to exist, with failed attempts to repeal or limit the act. Managed “care” has worked hard to change our language, such as “primary care physician” instead of physician or doctor and “behavioral health” instead of psychiatric or mental health care. These changes minimize our importance, influence, and reimbursements as well as the medications and treatments we use. When it was obvious what was happening, we abdicated our responsibility and control to the kind of people Dr. Nasrallah described.

There will be more cuts on reimbursements and limits on us unless we say “no.” We are not allowed to organize, physicians in Congress have not helped, and our elected professional organization leaders have little influence. We can give in and accept the “inevitable,” but the Hippocratic Oath seems to preclude such irresponsibility. We can refuse to treat anyone, except in emergencies, unless we choose to do so in good conscience. We need to change and the law has to change. The people who control our health care are evil, immoral, and venal; why should they be dictating care?

Gerald A. Shubs, MD
Butler Behavioral Health Services
Hamilton, OH

Dr. Nasrallah responds

Thanks to all my colleagues who took the time to read and express their views, to agree or to challenge the tenets in my editorial that lamented the lack of progress in certain practice aspects of psychiatry. Current Psychiatry is a marketplace of updates, ideas, suggestions, critiques, and rebuttals. It is interesting psychiatrists who have worked for a long time with seriously mentally ill patients in hospitals or the community seem to feel the pain of the lack of steady progress and/or the slippage in some areas, while those who identify with the managed care model of care see things differently— ie, managed care is, in fact, progress.

We psychiatrists evaluate and treat patients in very diverse settings and perceive things through different prisms, which is why we have disparate views. No one has a monopoly on the truth, but we all have important common ground: we all share an intense loyalty to our suffering patients, and we all share pride in our noble profession regardless of its ups or downs. We know in our hearts psychiatry remains indispensable for the well-being of all citizens. Pass it on…

Henry A. Nasrallah, MD
Editor-in-Chief

Regarding Dr. Nasrallah’s insightful editorial (“A skeptical view of ‘progress’ in psychiatry,” From the Editor, Current Psychiatry, June 2011, p. 18-19): Since the late 1980s and early 1990s, the Employment Retirement Income Security Act, has enabled managed “care” to exist, with failed attempts to repeal or limit the act. Managed “care” has worked hard to change our language, such as “primary care physician” instead of physician or doctor and “behavioral health” instead of psychiatric or mental health care. These changes minimize our importance, influence, and reimbursements as well as the medications and treatments we use. When it was obvious what was happening, we abdicated our responsibility and control to the kind of people Dr. Nasrallah described.

There will be more cuts on reimbursements and limits on us unless we say “no.” We are not allowed to organize, physicians in Congress have not helped, and our elected professional organization leaders have little influence. We can give in and accept the “inevitable,” but the Hippocratic Oath seems to preclude such irresponsibility. We can refuse to treat anyone, except in emergencies, unless we choose to do so in good conscience. We need to change and the law has to change. The people who control our health care are evil, immoral, and venal; why should they be dictating care?

Gerald A. Shubs, MD
Butler Behavioral Health Services
Hamilton, OH

Dr. Nasrallah responds

Thanks to all my colleagues who took the time to read and express their views, to agree or to challenge the tenets in my editorial that lamented the lack of progress in certain practice aspects of psychiatry. Current Psychiatry is a marketplace of updates, ideas, suggestions, critiques, and rebuttals. It is interesting psychiatrists who have worked for a long time with seriously mentally ill patients in hospitals or the community seem to feel the pain of the lack of steady progress and/or the slippage in some areas, while those who identify with the managed care model of care see things differently— ie, managed care is, in fact, progress.

We psychiatrists evaluate and treat patients in very diverse settings and perceive things through different prisms, which is why we have disparate views. No one has a monopoly on the truth, but we all have important common ground: we all share an intense loyalty to our suffering patients, and we all share pride in our noble profession regardless of its ups or downs. We know in our hearts psychiatry remains indispensable for the well-being of all citizens. Pass it on…

Henry A. Nasrallah, MD
Editor-in-Chief

Dr. Nasrallah’s editorial (“A skeptical view of ‘progress’ in psychiatry,” From the Editor, Current Psychiatry, June 2011, p. 18-19) is intriguing because it summarized concerns I have seen frequently expressed in publications catering to psychiatrists. Since the advent of managed care, these kinds of “poor psychiatry” articles have appeared regularly.

Instead of bemoaning the lack of “progress” in psychiatry, perhaps Dr. Nasrallah would have been better served by focusing on change and its inevitability. I found it ridiculous he contrasted the “asylum era” with current practices in order to focus on length of stay. At that time, the mentally ill were—except for well-intentioned attempts at “cure” via “milieu therapy”—warehoused for years, if not lifetimes, under filthy conditions.

Dr. Nasrallah then segues into the expected attacks upon insurance companies, lack of parity, and drastically shortened lengths of stay. It is obvious 3 to 4 days of acute care generally is not sufficient for serious psychiatric conditions. As an experienced managed care and independent reviewer, I can assure Dr. Nasrallah such strict criteria sets are the minority. What about psychiatrists who keep patients until their insurance runs out or let relatively benign patients languish because they did not call attention to themselves and kept a bed filled? Contrary to Dr. Nasrallah’s assertion, judges and lawyers do not tell us how to practice medicine; they are part of a necessary system of checks and balances that, in a highly imperfect world, help prevent inappropriate or abusive practices by incompetent, uninvested, or morally deficient physicians, of which there are plenty.

Dr. Nasrallah should be aware terms such as “behavioral health” are largely the result of efforts to destigmatize mental illness, leading society to coin more politically correct and palatable terms for just about everything.

At no point does Dr. Nasrallah even hint at offering solutions. For example, psychiatrists have done next to nothing to educate the public about their profession. Meanwhile, a substantial number of prominent psychiatrists are more than happy to accept steak dinners and honoraria from drug companies, along with going out and speaking at free CME events, in order to oh-so-subtly hawk a medication that just happens to be manufactured by the company paying for the “free lunch.”

Forget about judges and lawyers “telling us how to practice.” What about “Big Pharma” manipulating us and advertising on television, urging viewers to “talk to their doctor” about medication X? Dr. Nasrallah is preaching to the choir here. What we need is less breast-beating and more constructive action.

Edward W. Darell, MD
Psychiatrist, Private Practice
New York, NY

Dr. Nasrallah’s editorial (“A skeptical view of ‘progress’ in psychiatry,” From the Editor, Current Psychiatry, June 2011, p. 18-19) is intriguing because it summarized concerns I have seen frequently expressed in publications catering to psychiatrists. Since the advent of managed care, these kinds of “poor psychiatry” articles have appeared regularly.

Instead of bemoaning the lack of “progress” in psychiatry, perhaps Dr. Nasrallah would have been better served by focusing on change and its inevitability. I found it ridiculous he contrasted the “asylum era” with current practices in order to focus on length of stay. At that time, the mentally ill were—except for well-intentioned attempts at “cure” via “milieu therapy”—warehoused for years, if not lifetimes, under filthy conditions.

Dr. Nasrallah then segues into the expected attacks upon insurance companies, lack of parity, and drastically shortened lengths of stay. It is obvious 3 to 4 days of acute care generally is not sufficient for serious psychiatric conditions. As an experienced managed care and independent reviewer, I can assure Dr. Nasrallah such strict criteria sets are the minority. What about psychiatrists who keep patients until their insurance runs out or let relatively benign patients languish because they did not call attention to themselves and kept a bed filled? Contrary to Dr. Nasrallah’s assertion, judges and lawyers do not tell us how to practice medicine; they are part of a necessary system of checks and balances that, in a highly imperfect world, help prevent inappropriate or abusive practices by incompetent, uninvested, or morally deficient physicians, of which there are plenty.

Dr. Nasrallah should be aware terms such as “behavioral health” are largely the result of efforts to destigmatize mental illness, leading society to coin more politically correct and palatable terms for just about everything.

At no point does Dr. Nasrallah even hint at offering solutions. For example, psychiatrists have done next to nothing to educate the public about their profession. Meanwhile, a substantial number of prominent psychiatrists are more than happy to accept steak dinners and honoraria from drug companies, along with going out and speaking at free CME events, in order to oh-so-subtly hawk a medication that just happens to be manufactured by the company paying for the “free lunch.”

Forget about judges and lawyers “telling us how to practice.” What about “Big Pharma” manipulating us and advertising on television, urging viewers to “talk to their doctor” about medication X? Dr. Nasrallah is preaching to the choir here. What we need is less breast-beating and more constructive action.

Edward W. Darell, MD
Psychiatrist, Private Practice
New York, NY

Dr. Nasrallah’s editorial (“A skeptical view of ‘progress’ in psychiatry,” From the Editor, Current Psychiatry, June 2011, p. 18-19) is intriguing because it summarized concerns I have seen frequently expressed in publications catering to psychiatrists. Since the advent of managed care, these kinds of “poor psychiatry” articles have appeared regularly.

Instead of bemoaning the lack of “progress” in psychiatry, perhaps Dr. Nasrallah would have been better served by focusing on change and its inevitability. I found it ridiculous he contrasted the “asylum era” with current practices in order to focus on length of stay. At that time, the mentally ill were—except for well-intentioned attempts at “cure” via “milieu therapy”—warehoused for years, if not lifetimes, under filthy conditions.

Dr. Nasrallah then segues into the expected attacks upon insurance companies, lack of parity, and drastically shortened lengths of stay. It is obvious 3 to 4 days of acute care generally is not sufficient for serious psychiatric conditions. As an experienced managed care and independent reviewer, I can assure Dr. Nasrallah such strict criteria sets are the minority. What about psychiatrists who keep patients until their insurance runs out or let relatively benign patients languish because they did not call attention to themselves and kept a bed filled? Contrary to Dr. Nasrallah’s assertion, judges and lawyers do not tell us how to practice medicine; they are part of a necessary system of checks and balances that, in a highly imperfect world, help prevent inappropriate or abusive practices by incompetent, uninvested, or morally deficient physicians, of which there are plenty.

Dr. Nasrallah should be aware terms such as “behavioral health” are largely the result of efforts to destigmatize mental illness, leading society to coin more politically correct and palatable terms for just about everything.

At no point does Dr. Nasrallah even hint at offering solutions. For example, psychiatrists have done next to nothing to educate the public about their profession. Meanwhile, a substantial number of prominent psychiatrists are more than happy to accept steak dinners and honoraria from drug companies, along with going out and speaking at free CME events, in order to oh-so-subtly hawk a medication that just happens to be manufactured by the company paying for the “free lunch.”

Forget about judges and lawyers “telling us how to practice.” What about “Big Pharma” manipulating us and advertising on television, urging viewers to “talk to their doctor” about medication X? Dr. Nasrallah is preaching to the choir here. What we need is less breast-beating and more constructive action.

Edward W. Darell, MD
Psychiatrist, Private Practice
New York, NY

I, too, am concerned with the lack of recent progress in psychiatry. Nevertheless, Dr. Nasrallah is missing some of the progress he downplays (“A skeptical view of ‘progress’ in psychiatry,” From the Editor, Current Psychiatry, June 2011, p. 18-19). For instance, the discovery of chlorpromazine brought about concomitant serious side effects and homelessness, but many patients gained a life in society, which allowed some to become peer specialists, helping others with mental illness. Sure, insurance hassles for state hospitalization did not exist and hospitalization stays today often are much too short, but 40 years ago, state mental hospitals were so-called “snake pits” of overcrowding with excrement on the floor, and precious little treatment. Yes, in psychiatry we have more legal constraints, but in part this is a reflection of past coercive and unneeded hospitalizations.

I agree funding reductions have broken public mental health systems, but psychiatrists generally have preferred private practice with mentally healthier patients and sat quietly while other disciplines took over psychotherapies. I also don’t like the term “behavioral health,” but behavior can be measured, and we have precious few ways to measure progress and outcomes in psychiatry. Maybe pharmaceutical companies are abandoning drug development because they have been unsuccessful in developing novel medications in the last few decades, instead benefitting from serendipitous discoveries such as chlorpromazine. We may need new approaches to biologic treatments to progress any further, but this should not be surprising, given how difficult it is to access and study the brain

Steven Moffic, MD
Professor of Psychiatry
Medical College of Wisconsin
Milwaukee, WI

I, too, am concerned with the lack of recent progress in psychiatry. Nevertheless, Dr. Nasrallah is missing some of the progress he downplays (“A skeptical view of ‘progress’ in psychiatry,” From the Editor, Current Psychiatry, June 2011, p. 18-19). For instance, the discovery of chlorpromazine brought about concomitant serious side effects and homelessness, but many patients gained a life in society, which allowed some to become peer specialists, helping others with mental illness. Sure, insurance hassles for state hospitalization did not exist and hospitalization stays today often are much too short, but 40 years ago, state mental hospitals were so-called “snake pits” of overcrowding with excrement on the floor, and precious little treatment. Yes, in psychiatry we have more legal constraints, but in part this is a reflection of past coercive and unneeded hospitalizations.

I agree funding reductions have broken public mental health systems, but psychiatrists generally have preferred private practice with mentally healthier patients and sat quietly while other disciplines took over psychotherapies. I also don’t like the term “behavioral health,” but behavior can be measured, and we have precious few ways to measure progress and outcomes in psychiatry. Maybe pharmaceutical companies are abandoning drug development because they have been unsuccessful in developing novel medications in the last few decades, instead benefitting from serendipitous discoveries such as chlorpromazine. We may need new approaches to biologic treatments to progress any further, but this should not be surprising, given how difficult it is to access and study the brain

Steven Moffic, MD
Professor of Psychiatry
Medical College of Wisconsin
Milwaukee, WI

I, too, am concerned with the lack of recent progress in psychiatry. Nevertheless, Dr. Nasrallah is missing some of the progress he downplays (“A skeptical view of ‘progress’ in psychiatry,” From the Editor, Current Psychiatry, June 2011, p. 18-19). For instance, the discovery of chlorpromazine brought about concomitant serious side effects and homelessness, but many patients gained a life in society, which allowed some to become peer specialists, helping others with mental illness. Sure, insurance hassles for state hospitalization did not exist and hospitalization stays today often are much too short, but 40 years ago, state mental hospitals were so-called “snake pits” of overcrowding with excrement on the floor, and precious little treatment. Yes, in psychiatry we have more legal constraints, but in part this is a reflection of past coercive and unneeded hospitalizations.

I agree funding reductions have broken public mental health systems, but psychiatrists generally have preferred private practice with mentally healthier patients and sat quietly while other disciplines took over psychotherapies. I also don’t like the term “behavioral health,” but behavior can be measured, and we have precious few ways to measure progress and outcomes in psychiatry. Maybe pharmaceutical companies are abandoning drug development because they have been unsuccessful in developing novel medications in the last few decades, instead benefitting from serendipitous discoveries such as chlorpromazine. We may need new approaches to biologic treatments to progress any further, but this should not be surprising, given how difficult it is to access and study the brain

Steven Moffic, MD
Professor of Psychiatry
Medical College of Wisconsin
Milwaukee, WI

I have practiced community mental health in Fayetteville, NC for 12 years and have observed every point Dr. Nasrallah made in “A skeptical view of ‘progress’ in psychiatry” (From the Editor, Current Psychiatry, June 2011, p. 18-19). As psychiatrists, we share a great deal of the blame. We handed over leadership of community mental health centers to social workers and allowed ourselves to be “carved out” of community hospitals. State hospitals are dysfunctional at best.

Dr. Nasrallah is correct in asking who is the “genius” behind these decisions. Many new psychiatric practices are based on family practice models of herding 60 to 80 patients per day. I’m not sure I will even recognize the practice of psychiatry in 10 to 20 years. Perhaps with obstinate rigor we can restore what we’ve lost.

Mark Chandler, MD
Medical Director
Cumberland County Mental Health Center
Fayetteville, NC

I have practiced community mental health in Fayetteville, NC for 12 years and have observed every point Dr. Nasrallah made in “A skeptical view of ‘progress’ in psychiatry” (From the Editor, Current Psychiatry, June 2011, p. 18-19). As psychiatrists, we share a great deal of the blame. We handed over leadership of community mental health centers to social workers and allowed ourselves to be “carved out” of community hospitals. State hospitals are dysfunctional at best.

Dr. Nasrallah is correct in asking who is the “genius” behind these decisions. Many new psychiatric practices are based on family practice models of herding 60 to 80 patients per day. I’m not sure I will even recognize the practice of psychiatry in 10 to 20 years. Perhaps with obstinate rigor we can restore what we’ve lost.

Mark Chandler, MD
Medical Director
Cumberland County Mental Health Center
Fayetteville, NC

I have practiced community mental health in Fayetteville, NC for 12 years and have observed every point Dr. Nasrallah made in “A skeptical view of ‘progress’ in psychiatry” (From the Editor, Current Psychiatry, June 2011, p. 18-19). As psychiatrists, we share a great deal of the blame. We handed over leadership of community mental health centers to social workers and allowed ourselves to be “carved out” of community hospitals. State hospitals are dysfunctional at best.

Dr. Nasrallah is correct in asking who is the “genius” behind these decisions. Many new psychiatric practices are based on family practice models of herding 60 to 80 patients per day. I’m not sure I will even recognize the practice of psychiatry in 10 to 20 years. Perhaps with obstinate rigor we can restore what we’ve lost.

Mark Chandler, MD
Medical Director
Cumberland County Mental Health Center
Fayetteville, NC

Discuss this article at www.facebook.com/CurrentPsychiatry

‘Progress’ in psychiatry

I have practiced community mental health in Fayetteville, NC for 12 years and have observed every point Dr. Nasrallah made in “A skeptical view of ‘progress’ in psychiatry” (From the Editor, Current Psychiatry, June 2011, p. 18-19). As psychiatrists, we share a great deal of the blame. We handed over leadership of community mental health centers to social workers and allowed ourselves to be “carved out” of community hospitals. State hospitals are dysfunctional at best.

Dr. Nasrallah is correct in asking who is the “genius” behind these decisions. Many new psychiatric practices are based on family practice models of herding 60 to 80 patients per day. I’m not sure I will even recognize the practice of psychiatry in 10 to 20 years. Perhaps with obstinate rigor we can restore what we’ve lost.

Mark Chandler, MD
Medical Director
Cumberland County Mental Health Center
Fayetteville, NC

Missed progress

I, too, am concerned with the lack of recent progress in psychiatry. Nevertheless, Dr. Nasrallah is missing some of the progress he downplays (“A skeptical view of ‘progress’ in psychiatry,” From the Editor, Current Psychiatry, June 2011, p. 18-19). For instance, the discovery of chlorpromazine brought about concomitant serious side effects and homelessness, but many patients gained a life in society, which allowed some to become peer specialists, helping others with mental illness. Sure, insurance hassles for state hospitalization did not exist and hospitalization stays today often are much too short, but 40 years ago, state mental hospitals were so-called “snake pits” of overcrowding with excrement on the floor, and precious little treatment. Yes, in psychiatry we have more legal constraints, but in part this is a reflection of past coercive and unneeded hospitalizations.

I agree funding reductions have broken public mental health systems, but psychiatrists generally have preferred private practice with mentally healthier patients and sat quietly while other disciplines took over psychotherapies. I also don’t like the term “behavioral health,” but behavior can be measured, and we have precious few ways to measure progress and outcomes in psychiatry. Maybe pharmaceutical companies are abandoning drug development because they have been unsuccessful in developing novel medications in the last few decades, instead benefitting from serendipitous discoveries such as chlorpromazine. We may need new approaches to biologic treatments to progress any further, but this should not be surprising, given how difficult it is to access and study the brain

Steven Moffic, MD
Professor of Psychiatry
Medical College of Wisconsin
Milwaukee, WI

Focus on change

Dr. Nasrallah’s editorial (“A skeptical view of ‘progress’ in psychiatry,” From the Editor, Current Psychiatry, June 2011, p. 18-19) is intriguing because it summarized concerns I have seen frequently expressed in publications catering to psychiatrists. Since the advent of managed care, these kinds of “poor psychiatry” articles have appeared regularly.

Instead of bemoaning the lack of “progress” in psychiatry, perhaps Dr. Nasrallah would have been better served by focusing on change and its inevitability. I found it ridiculous he contrasted the “asylum era” with current practices in order to focus on length of stay. At that time, the mentally ill were—except for well-intentioned attempts at “cure” via “milieu therapy”—warehoused for years, if not lifetimes, under filthy conditions.

Dr. Nasrallah then segues into the expected attacks upon insurance companies, lack of parity, and drastically shortened lengths of stay. It is obvious 3 to 4 days of acute care generally is not sufficient for serious psychiatric conditions. As an experienced managed care and independent reviewer, I can assure Dr. Nasrallah such strict criteria sets are the minority. What about psychiatrists who keep patients until their insurance runs out or let relatively benign patients languish because they did not call attention to themselves and kept a bed filled? Contrary to Dr. Nasrallah’s assertion, judges and lawyers do not tell us how to practice medicine; they are part of a necessary system of checks and balances that, in a highly imperfect world, help prevent inappropriate or abusive practices by incompetent, uninvested, or morally deficient physicians, of which there are plenty.

Dr. Nasrallah should be aware terms such as “behavioral health” are largely the result of efforts to destigmatize mental illness, leading society to coin more politically correct and palatable terms for just about everything.

At no point does Dr. Nasrallah even hint at offering solutions. For example, psychiatrists have done next to nothing to educate the public about their profession. Meanwhile, a substantial number of prominent psychiatrists are more than happy to accept steak dinners and honoraria from drug companies, along with going out and speaking at free CME events, in order to oh-so-subtly hawk a medication that just happens to be manufactured by the company paying for the “free lunch.”

Forget about judges and lawyers “telling us how to practice.” What about “Big Pharma” manipulating us and advertising on television, urging viewers to “talk to their doctor” about medication X? Dr. Nasrallah is preaching to the choir here. What we need is less breast-beating and more constructive action.

Edward W. Darell, MD
Psychiatrist, Private Practice
New York, NY

Managed care woes

Regarding Dr. Nasrallah’s insightful editorial (“A skeptical view of ‘progress’ in psychiatry,” From the Editor, Current Psychiatry, June 2011, p. 18-19): Since the late 1980s and early 1990s, the Employment Retirement Income Security Act, has enabled managed “care” to exist, with failed attempts to repeal or limit the act. Managed “care” has worked hard to change our language, such as “primary care physician” instead of physician or doctor and “behavioral health” instead of psychiatric or mental health care. These changes minimize our importance, influence, and reimbursements as well as the medications and treatments we use. When it was obvious what was happening, we abdicated our responsibility and control to the kind of people Dr. Nasrallah described.

There will be more cuts on reimbursements and limits on us unless we say “no.” We are not allowed to organize, physicians in Congress have not helped, and our elected professional organization leaders have little influence. We can give in and accept the “inevitable,” but the Hippocratic Oath seems to preclude such irresponsibility. We can refuse to treat anyone, except in emergencies, unless we choose to do so in good conscience. We need to change and the law has to change. The people who control our health care are evil, immoral, and venal; why should they be dictating care?

Gerald A. Shubs, MD
Butler Behavioral Health Services
Hamilton, OH

Insidious progress

I love Dr. Nasrallah’s editorials, but none more so than his commentary in the June issue, “A skeptical view of ‘progress’ in psychiatry” (From the Editor, Current Psychiatry, June 2011, p. 18-19), in which he deftly highlights factors hindering the advancement of our profession. Clearly, his arguments come from the heart and speak directly to many psychiatrists’ concerns about what is happening in clinical settings.

I believe managed care has contributed to the proliferation of irrational polypharmacy. This is a consequence of clinicians who find themselves under unrealistic time pressures and cost constraints to come up with an expedient, “magical” treatment for acute hospitalized patients.

In reference to the comments about the phrase “behavioral health,” I have always objected to the pejorative term “providers” to refer to physicians. The designation “behavioral health providers” lumps psychiatrists and all other workers in the mental health field under the same umbrella, blurring the roles and identities of the different professions. Insurance companies further dismiss our psychiatric follow-ups as “medication management,” which ignores the broader, more specialized nature of our work with patients for the purpose of slashing fees. We often take these terms for granted, accepting them as nothing more than semantics or corporate jargon, but they are not so innocuous. We all should be aware of how these labels limit psychiatric practice and allow us to be subjugated by parties with financial motives.

On behalf of all of us who see the insidious side of the so-called progress being made in psychiatry, thank you for this insightful, well organized, and well written editorial.

Radwan F. Haykal, MD
Clinical Professor of Psychiatry
University of Tennessee Health Science Center
Memphis, TN

To tell the truth

I loved Dr. Nasrallah’s editorial in the June 2011 issue (“A skeptical view of ‘progress’ in psychiatry,” Current Psychiatry, June 2011, p. 18-19). It’s calling a spade a spade. This should be published as an op-ed piece in the New York Times or another national newspaper so the public can see the reality of the situation.

Royal Kiehl, MD
Psychiatrist, Private Practice
Anchorage, AK

Dr. Nasrallah responds

Thanks to all my colleagues who took the time to read and express their views, to agree or to challenge the tenets in my editorial that lamented the lack of progress in certain practice aspects of psychiatry. Current Psychiatry is a marketplace of updates, ideas, suggestions, critiques, and rebuttals. It is interesting psychiatrists who have worked for a long time with seriously mentally ill patients in hospitals or the community seem to feel the pain of the lack of steady progress and/or the slippage in some areas, while those who identify with the managed care model of care see things differently— ie, managed care is, in fact, progress.

We psychiatrists evaluate and treat patients in very diverse settings and perceive things through different prisms, which is why we have disparate views. No one has a monopoly on the truth, but we all have important common ground: we all share an intense loyalty to our suffering patients, and we all share pride in our noble profession regardless of its ups or downs. We know in our hearts psychiatry remains indispensable for the well-being of all citizens. Pass it on…

Henry A. Nasrallah, MD
Editor-in-Chief

Discuss this article at www.facebook.com/CurrentPsychiatry

‘Progress’ in psychiatry

I have practiced community mental health in Fayetteville, NC for 12 years and have observed every point Dr. Nasrallah made in “A skeptical view of ‘progress’ in psychiatry” (From the Editor, Current Psychiatry, June 2011, p. 18-19). As psychiatrists, we share a great deal of the blame. We handed over leadership of community mental health centers to social workers and allowed ourselves to be “carved out” of community hospitals. State hospitals are dysfunctional at best.

Dr. Nasrallah is correct in asking who is the “genius” behind these decisions. Many new psychiatric practices are based on family practice models of herding 60 to 80 patients per day. I’m not sure I will even recognize the practice of psychiatry in 10 to 20 years. Perhaps with obstinate rigor we can restore what we’ve lost.

Mark Chandler, MD
Medical Director
Cumberland County Mental Health Center
Fayetteville, NC

Missed progress

I, too, am concerned with the lack of recent progress in psychiatry. Nevertheless, Dr. Nasrallah is missing some of the progress he downplays (“A skeptical view of ‘progress’ in psychiatry,” From the Editor, Current Psychiatry, June 2011, p. 18-19). For instance, the discovery of chlorpromazine brought about concomitant serious side effects and homelessness, but many patients gained a life in society, which allowed some to become peer specialists, helping others with mental illness. Sure, insurance hassles for state hospitalization did not exist and hospitalization stays today often are much too short, but 40 years ago, state mental hospitals were so-called “snake pits” of overcrowding with excrement on the floor, and precious little treatment. Yes, in psychiatry we have more legal constraints, but in part this is a reflection of past coercive and unneeded hospitalizations.

I agree funding reductions have broken public mental health systems, but psychiatrists generally have preferred private practice with mentally healthier patients and sat quietly while other disciplines took over psychotherapies. I also don’t like the term “behavioral health,” but behavior can be measured, and we have precious few ways to measure progress and outcomes in psychiatry. Maybe pharmaceutical companies are abandoning drug development because they have been unsuccessful in developing novel medications in the last few decades, instead benefitting from serendipitous discoveries such as chlorpromazine. We may need new approaches to biologic treatments to progress any further, but this should not be surprising, given how difficult it is to access and study the brain

Steven Moffic, MD
Professor of Psychiatry
Medical College of Wisconsin
Milwaukee, WI

Focus on change

Dr. Nasrallah’s editorial (“A skeptical view of ‘progress’ in psychiatry,” From the Editor, Current Psychiatry, June 2011, p. 18-19) is intriguing because it summarized concerns I have seen frequently expressed in publications catering to psychiatrists. Since the advent of managed care, these kinds of “poor psychiatry” articles have appeared regularly.

Instead of bemoaning the lack of “progress” in psychiatry, perhaps Dr. Nasrallah would have been better served by focusing on change and its inevitability. I found it ridiculous he contrasted the “asylum era” with current practices in order to focus on length of stay. At that time, the mentally ill were—except for well-intentioned attempts at “cure” via “milieu therapy”—warehoused for years, if not lifetimes, under filthy conditions.

Dr. Nasrallah then segues into the expected attacks upon insurance companies, lack of parity, and drastically shortened lengths of stay. It is obvious 3 to 4 days of acute care generally is not sufficient for serious psychiatric conditions. As an experienced managed care and independent reviewer, I can assure Dr. Nasrallah such strict criteria sets are the minority. What about psychiatrists who keep patients until their insurance runs out or let relatively benign patients languish because they did not call attention to themselves and kept a bed filled? Contrary to Dr. Nasrallah’s assertion, judges and lawyers do not tell us how to practice medicine; they are part of a necessary system of checks and balances that, in a highly imperfect world, help prevent inappropriate or abusive practices by incompetent, uninvested, or morally deficient physicians, of which there are plenty.

Dr. Nasrallah should be aware terms such as “behavioral health” are largely the result of efforts to destigmatize mental illness, leading society to coin more politically correct and palatable terms for just about everything.

At no point does Dr. Nasrallah even hint at offering solutions. For example, psychiatrists have done next to nothing to educate the public about their profession. Meanwhile, a substantial number of prominent psychiatrists are more than happy to accept steak dinners and honoraria from drug companies, along with going out and speaking at free CME events, in order to oh-so-subtly hawk a medication that just happens to be manufactured by the company paying for the “free lunch.”

Forget about judges and lawyers “telling us how to practice.” What about “Big Pharma” manipulating us and advertising on television, urging viewers to “talk to their doctor” about medication X? Dr. Nasrallah is preaching to the choir here. What we need is less breast-beating and more constructive action.

Edward W. Darell, MD
Psychiatrist, Private Practice
New York, NY

Managed care woes

Regarding Dr. Nasrallah’s insightful editorial (“A skeptical view of ‘progress’ in psychiatry,” From the Editor, Current Psychiatry, June 2011, p. 18-19): Since the late 1980s and early 1990s, the Employment Retirement Income Security Act, has enabled managed “care” to exist, with failed attempts to repeal or limit the act. Managed “care” has worked hard to change our language, such as “primary care physician” instead of physician or doctor and “behavioral health” instead of psychiatric or mental health care. These changes minimize our importance, influence, and reimbursements as well as the medications and treatments we use. When it was obvious what was happening, we abdicated our responsibility and control to the kind of people Dr. Nasrallah described.

There will be more cuts on reimbursements and limits on us unless we say “no.” We are not allowed to organize, physicians in Congress have not helped, and our elected professional organization leaders have little influence. We can give in and accept the “inevitable,” but the Hippocratic Oath seems to preclude such irresponsibility. We can refuse to treat anyone, except in emergencies, unless we choose to do so in good conscience. We need to change and the law has to change. The people who control our health care are evil, immoral, and venal; why should they be dictating care?

Gerald A. Shubs, MD
Butler Behavioral Health Services
Hamilton, OH

Insidious progress

I love Dr. Nasrallah’s editorials, but none more so than his commentary in the June issue, “A skeptical view of ‘progress’ in psychiatry” (From the Editor, Current Psychiatry, June 2011, p. 18-19), in which he deftly highlights factors hindering the advancement of our profession. Clearly, his arguments come from the heart and speak directly to many psychiatrists’ concerns about what is happening in clinical settings.

I believe managed care has contributed to the proliferation of irrational polypharmacy. This is a consequence of clinicians who find themselves under unrealistic time pressures and cost constraints to come up with an expedient, “magical” treatment for acute hospitalized patients.

In reference to the comments about the phrase “behavioral health,” I have always objected to the pejorative term “providers” to refer to physicians. The designation “behavioral health providers” lumps psychiatrists and all other workers in the mental health field under the same umbrella, blurring the roles and identities of the different professions. Insurance companies further dismiss our psychiatric follow-ups as “medication management,” which ignores the broader, more specialized nature of our work with patients for the purpose of slashing fees. We often take these terms for granted, accepting them as nothing more than semantics or corporate jargon, but they are not so innocuous. We all should be aware of how these labels limit psychiatric practice and allow us to be subjugated by parties with financial motives.

On behalf of all of us who see the insidious side of the so-called progress being made in psychiatry, thank you for this insightful, well organized, and well written editorial.

Radwan F. Haykal, MD
Clinical Professor of Psychiatry
University of Tennessee Health Science Center
Memphis, TN

To tell the truth

I loved Dr. Nasrallah’s editorial in the June 2011 issue (“A skeptical view of ‘progress’ in psychiatry,” Current Psychiatry, June 2011, p. 18-19). It’s calling a spade a spade. This should be published as an op-ed piece in the New York Times or another national newspaper so the public can see the reality of the situation.

Royal Kiehl, MD
Psychiatrist, Private Practice
Anchorage, AK

Dr. Nasrallah responds

Thanks to all my colleagues who took the time to read and express their views, to agree or to challenge the tenets in my editorial that lamented the lack of progress in certain practice aspects of psychiatry. Current Psychiatry is a marketplace of updates, ideas, suggestions, critiques, and rebuttals. It is interesting psychiatrists who have worked for a long time with seriously mentally ill patients in hospitals or the community seem to feel the pain of the lack of steady progress and/or the slippage in some areas, while those who identify with the managed care model of care see things differently— ie, managed care is, in fact, progress.

We psychiatrists evaluate and treat patients in very diverse settings and perceive things through different prisms, which is why we have disparate views. No one has a monopoly on the truth, but we all have important common ground: we all share an intense loyalty to our suffering patients, and we all share pride in our noble profession regardless of its ups or downs. We know in our hearts psychiatry remains indispensable for the well-being of all citizens. Pass it on…

Henry A. Nasrallah, MD
Editor-in-Chief

Discuss this article at www.facebook.com/CurrentPsychiatry

‘Progress’ in psychiatry

I have practiced community mental health in Fayetteville, NC for 12 years and have observed every point Dr. Nasrallah made in “A skeptical view of ‘progress’ in psychiatry” (From the Editor, Current Psychiatry, June 2011, p. 18-19). As psychiatrists, we share a great deal of the blame. We handed over leadership of community mental health centers to social workers and allowed ourselves to be “carved out” of community hospitals. State hospitals are dysfunctional at best.

Dr. Nasrallah is correct in asking who is the “genius” behind these decisions. Many new psychiatric practices are based on family practice models of herding 60 to 80 patients per day. I’m not sure I will even recognize the practice of psychiatry in 10 to 20 years. Perhaps with obstinate rigor we can restore what we’ve lost.

Mark Chandler, MD
Medical Director
Cumberland County Mental Health Center
Fayetteville, NC

Missed progress

I, too, am concerned with the lack of recent progress in psychiatry. Nevertheless, Dr. Nasrallah is missing some of the progress he downplays (“A skeptical view of ‘progress’ in psychiatry,” From the Editor, Current Psychiatry, June 2011, p. 18-19). For instance, the discovery of chlorpromazine brought about concomitant serious side effects and homelessness, but many patients gained a life in society, which allowed some to become peer specialists, helping others with mental illness. Sure, insurance hassles for state hospitalization did not exist and hospitalization stays today often are much too short, but 40 years ago, state mental hospitals were so-called “snake pits” of overcrowding with excrement on the floor, and precious little treatment. Yes, in psychiatry we have more legal constraints, but in part this is a reflection of past coercive and unneeded hospitalizations.

I agree funding reductions have broken public mental health systems, but psychiatrists generally have preferred private practice with mentally healthier patients and sat quietly while other disciplines took over psychotherapies. I also don’t like the term “behavioral health,” but behavior can be measured, and we have precious few ways to measure progress and outcomes in psychiatry. Maybe pharmaceutical companies are abandoning drug development because they have been unsuccessful in developing novel medications in the last few decades, instead benefitting from serendipitous discoveries such as chlorpromazine. We may need new approaches to biologic treatments to progress any further, but this should not be surprising, given how difficult it is to access and study the brain

Steven Moffic, MD
Professor of Psychiatry
Medical College of Wisconsin
Milwaukee, WI

Focus on change

Dr. Nasrallah’s editorial (“A skeptical view of ‘progress’ in psychiatry,” From the Editor, Current Psychiatry, June 2011, p. 18-19) is intriguing because it summarized concerns I have seen frequently expressed in publications catering to psychiatrists. Since the advent of managed care, these kinds of “poor psychiatry” articles have appeared regularly.

Instead of bemoaning the lack of “progress” in psychiatry, perhaps Dr. Nasrallah would have been better served by focusing on change and its inevitability. I found it ridiculous he contrasted the “asylum era” with current practices in order to focus on length of stay. At that time, the mentally ill were—except for well-intentioned attempts at “cure” via “milieu therapy”—warehoused for years, if not lifetimes, under filthy conditions.

Dr. Nasrallah then segues into the expected attacks upon insurance companies, lack of parity, and drastically shortened lengths of stay. It is obvious 3 to 4 days of acute care generally is not sufficient for serious psychiatric conditions. As an experienced managed care and independent reviewer, I can assure Dr. Nasrallah such strict criteria sets are the minority. What about psychiatrists who keep patients until their insurance runs out or let relatively benign patients languish because they did not call attention to themselves and kept a bed filled? Contrary to Dr. Nasrallah’s assertion, judges and lawyers do not tell us how to practice medicine; they are part of a necessary system of checks and balances that, in a highly imperfect world, help prevent inappropriate or abusive practices by incompetent, uninvested, or morally deficient physicians, of which there are plenty.

Dr. Nasrallah should be aware terms such as “behavioral health” are largely the result of efforts to destigmatize mental illness, leading society to coin more politically correct and palatable terms for just about everything.

At no point does Dr. Nasrallah even hint at offering solutions. For example, psychiatrists have done next to nothing to educate the public about their profession. Meanwhile, a substantial number of prominent psychiatrists are more than happy to accept steak dinners and honoraria from drug companies, along with going out and speaking at free CME events, in order to oh-so-subtly hawk a medication that just happens to be manufactured by the company paying for the “free lunch.”

Forget about judges and lawyers “telling us how to practice.” What about “Big Pharma” manipulating us and advertising on television, urging viewers to “talk to their doctor” about medication X? Dr. Nasrallah is preaching to the choir here. What we need is less breast-beating and more constructive action.

Edward W. Darell, MD
Psychiatrist, Private Practice
New York, NY

Managed care woes

Regarding Dr. Nasrallah’s insightful editorial (“A skeptical view of ‘progress’ in psychiatry,” From the Editor, Current Psychiatry, June 2011, p. 18-19): Since the late 1980s and early 1990s, the Employment Retirement Income Security Act, has enabled managed “care” to exist, with failed attempts to repeal or limit the act. Managed “care” has worked hard to change our language, such as “primary care physician” instead of physician or doctor and “behavioral health” instead of psychiatric or mental health care. These changes minimize our importance, influence, and reimbursements as well as the medications and treatments we use. When it was obvious what was happening, we abdicated our responsibility and control to the kind of people Dr. Nasrallah described.

There will be more cuts on reimbursements and limits on us unless we say “no.” We are not allowed to organize, physicians in Congress have not helped, and our elected professional organization leaders have little influence. We can give in and accept the “inevitable,” but the Hippocratic Oath seems to preclude such irresponsibility. We can refuse to treat anyone, except in emergencies, unless we choose to do so in good conscience. We need to change and the law has to change. The people who control our health care are evil, immoral, and venal; why should they be dictating care?

Gerald A. Shubs, MD
Butler Behavioral Health Services
Hamilton, OH

Insidious progress

I love Dr. Nasrallah’s editorials, but none more so than his commentary in the June issue, “A skeptical view of ‘progress’ in psychiatry” (From the Editor, Current Psychiatry, June 2011, p. 18-19), in which he deftly highlights factors hindering the advancement of our profession. Clearly, his arguments come from the heart and speak directly to many psychiatrists’ concerns about what is happening in clinical settings.

I believe managed care has contributed to the proliferation of irrational polypharmacy. This is a consequence of clinicians who find themselves under unrealistic time pressures and cost constraints to come up with an expedient, “magical” treatment for acute hospitalized patients.

In reference to the comments about the phrase “behavioral health,” I have always objected to the pejorative term “providers” to refer to physicians. The designation “behavioral health providers” lumps psychiatrists and all other workers in the mental health field under the same umbrella, blurring the roles and identities of the different professions. Insurance companies further dismiss our psychiatric follow-ups as “medication management,” which ignores the broader, more specialized nature of our work with patients for the purpose of slashing fees. We often take these terms for granted, accepting them as nothing more than semantics or corporate jargon, but they are not so innocuous. We all should be aware of how these labels limit psychiatric practice and allow us to be subjugated by parties with financial motives.

On behalf of all of us who see the insidious side of the so-called progress being made in psychiatry, thank you for this insightful, well organized, and well written editorial.

Radwan F. Haykal, MD
Clinical Professor of Psychiatry
University of Tennessee Health Science Center
Memphis, TN

To tell the truth

I loved Dr. Nasrallah’s editorial in the June 2011 issue (“A skeptical view of ‘progress’ in psychiatry,” Current Psychiatry, June 2011, p. 18-19). It’s calling a spade a spade. This should be published as an op-ed piece in the New York Times or another national newspaper so the public can see the reality of the situation.

Royal Kiehl, MD
Psychiatrist, Private Practice
Anchorage, AK

Dr. Nasrallah responds

Thanks to all my colleagues who took the time to read and express their views, to agree or to challenge the tenets in my editorial that lamented the lack of progress in certain practice aspects of psychiatry. Current Psychiatry is a marketplace of updates, ideas, suggestions, critiques, and rebuttals. It is interesting psychiatrists who have worked for a long time with seriously mentally ill patients in hospitals or the community seem to feel the pain of the lack of steady progress and/or the slippage in some areas, while those who identify with the managed care model of care see things differently— ie, managed care is, in fact, progress.

We psychiatrists evaluate and treat patients in very diverse settings and perceive things through different prisms, which is why we have disparate views. No one has a monopoly on the truth, but we all have important common ground: we all share an intense loyalty to our suffering patients, and we all share pride in our noble profession regardless of its ups or downs. We know in our hearts psychiatry remains indispensable for the well-being of all citizens. Pass it on…

Henry A. Nasrallah, MD
Editor-in-Chief

Discuss this article at www.facebook.com/CurrentPsychiatry

Vasovagal syncope—also called neurocardiogenic syncope—is a brief loss of consciousness caused by a sudden drop in heart rate and blood pressure usually diagnosed and treated by a cardiologist. Psychiatrists rarely are consulted in such cases, but evidence suggests these patients often have comorbid psychiatric disorders.¹ Psychiatrists can aid cardiologists in treating patients troubled by recurring episodes of vasovagal syncope.

Similar to panic disorder, vasovagal syncope can occur following a trigger or without any warning. After an initial event, vasovagal syncope episodes may never occur again, may occur occasionally, or may be frequent. Cardiologists use Holter monitoring, echocardiography, laboratory testing, stress testing, tilt table monitoring, and other methods to rule out cardiac causes of syncope. For patients whom a cardiac or neurologic cause cannot be determined, there is no recommended treatment, although beta blockers commonly are used.²

I suggest a protocol that includes psychiatric evaluation, pharmacotherapy, cognitive-behavioral therapy (CBT), and patient education.

Psychiatric evaluation. Because psychiatric disorders often accompany vasovagal syncope, patients should undergo a thorough psychiatric evaluation, and any comorbid psychiatric disorders should be addressed according to current treatment guidelines.

Pharmacotherapy. Because serotonin (5-HT) may play a key role in blood pressure regulation and vasovagal syncope,² a selective serotonin reuptake inhibitor (SSRI) may be an option. Evidence suggests paroxetine and sertraline may help prevent vasovagal syncope, and other SSRIs may share this benefit.³ In 1 nonrandomized trial of 74 patients with a history of vasovagal syncope, amitriptyline prevented recurrent episodes.⁴ In a small trial, sublingual lorazepam, 2 to 4 mg, prevented vasovagal attacks in patients undergoing a procedure that previously triggered syncope.⁵

CBT can help patients identify and modify thoughts that trigger syncope. In a small case series, CBT led to significant reductions in syncopal episodes.⁶ Educate patients about environmental triggers of vasovagal events they can avoid, such as dehydration, hot rooms, long periods of standing, and emotional events. Patients who have known triggers that usually cannot be avoided, such as the sight of blood and other conditioned responses, may be helped by behavioral therapies such as systematic desensitization. Patients with known body triggers may be able to take prophylactic medication—for example, patients who are known to faint when nauseous may be able to take prochlorperazine to prevent a syncopal episode.

Patient education. Patients who experience presyncopal symptoms such as lightheadedness, visual dimming, nausea, and weakness should be instructed to lie down on the floor with their legs up at the first sign of an impending episode. If sitting, they can put their head between their knees. Progressive relaxation should be avoided. Patients might be able to block an episode by crossing their legs and tensing their muscles.⁷

Disclosure

Dr. LaFerney reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Discuss this article at www.facebook.com/CurrentPsychiatry

Vasovagal syncope—also called neurocardiogenic syncope—is a brief loss of consciousness caused by a sudden drop in heart rate and blood pressure usually diagnosed and treated by a cardiologist. Psychiatrists rarely are consulted in such cases, but evidence suggests these patients often have comorbid psychiatric disorders.¹ Psychiatrists can aid cardiologists in treating patients troubled by recurring episodes of vasovagal syncope.

Similar to panic disorder, vasovagal syncope can occur following a trigger or without any warning. After an initial event, vasovagal syncope episodes may never occur again, may occur occasionally, or may be frequent. Cardiologists use Holter monitoring, echocardiography, laboratory testing, stress testing, tilt table monitoring, and other methods to rule out cardiac causes of syncope. For patients whom a cardiac or neurologic cause cannot be determined, there is no recommended treatment, although beta blockers commonly are used.²

I suggest a protocol that includes psychiatric evaluation, pharmacotherapy, cognitive-behavioral therapy (CBT), and patient education.

Psychiatric evaluation. Because psychiatric disorders often accompany vasovagal syncope, patients should undergo a thorough psychiatric evaluation, and any comorbid psychiatric disorders should be addressed according to current treatment guidelines.

Pharmacotherapy. Because serotonin (5-HT) may play a key role in blood pressure regulation and vasovagal syncope,² a selective serotonin reuptake inhibitor (SSRI) may be an option. Evidence suggests paroxetine and sertraline may help prevent vasovagal syncope, and other SSRIs may share this benefit.³ In 1 nonrandomized trial of 74 patients with a history of vasovagal syncope, amitriptyline prevented recurrent episodes.⁴ In a small trial, sublingual lorazepam, 2 to 4 mg, prevented vasovagal attacks in patients undergoing a procedure that previously triggered syncope.⁵

CBT can help patients identify and modify thoughts that trigger syncope. In a small case series, CBT led to significant reductions in syncopal episodes.⁶ Educate patients about environmental triggers of vasovagal events they can avoid, such as dehydration, hot rooms, long periods of standing, and emotional events. Patients who have known triggers that usually cannot be avoided, such as the sight of blood and other conditioned responses, may be helped by behavioral therapies such as systematic desensitization. Patients with known body triggers may be able to take prophylactic medication—for example, patients who are known to faint when nauseous may be able to take prochlorperazine to prevent a syncopal episode.

Patient education. Patients who experience presyncopal symptoms such as lightheadedness, visual dimming, nausea, and weakness should be instructed to lie down on the floor with their legs up at the first sign of an impending episode. If sitting, they can put their head between their knees. Progressive relaxation should be avoided. Patients might be able to block an episode by crossing their legs and tensing their muscles.⁷

Disclosure

Dr. LaFerney reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Discuss this article at www.facebook.com/CurrentPsychiatry

Vasovagal syncope—also called neurocardiogenic syncope—is a brief loss of consciousness caused by a sudden drop in heart rate and blood pressure usually diagnosed and treated by a cardiologist. Psychiatrists rarely are consulted in such cases, but evidence suggests these patients often have comorbid psychiatric disorders.¹ Psychiatrists can aid cardiologists in treating patients troubled by recurring episodes of vasovagal syncope.

Similar to panic disorder, vasovagal syncope can occur following a trigger or without any warning. After an initial event, vasovagal syncope episodes may never occur again, may occur occasionally, or may be frequent. Cardiologists use Holter monitoring, echocardiography, laboratory testing, stress testing, tilt table monitoring, and other methods to rule out cardiac causes of syncope. For patients whom a cardiac or neurologic cause cannot be determined, there is no recommended treatment, although beta blockers commonly are used.²

I suggest a protocol that includes psychiatric evaluation, pharmacotherapy, cognitive-behavioral therapy (CBT), and patient education.

Psychiatric evaluation. Because psychiatric disorders often accompany vasovagal syncope, patients should undergo a thorough psychiatric evaluation, and any comorbid psychiatric disorders should be addressed according to current treatment guidelines.

Pharmacotherapy. Because serotonin (5-HT) may play a key role in blood pressure regulation and vasovagal syncope,² a selective serotonin reuptake inhibitor (SSRI) may be an option. Evidence suggests paroxetine and sertraline may help prevent vasovagal syncope, and other SSRIs may share this benefit.³ In 1 nonrandomized trial of 74 patients with a history of vasovagal syncope, amitriptyline prevented recurrent episodes.⁴ In a small trial, sublingual lorazepam, 2 to 4 mg, prevented vasovagal attacks in patients undergoing a procedure that previously triggered syncope.⁵

CBT can help patients identify and modify thoughts that trigger syncope. In a small case series, CBT led to significant reductions in syncopal episodes.⁶ Educate patients about environmental triggers of vasovagal events they can avoid, such as dehydration, hot rooms, long periods of standing, and emotional events. Patients who have known triggers that usually cannot be avoided, such as the sight of blood and other conditioned responses, may be helped by behavioral therapies such as systematic desensitization. Patients with known body triggers may be able to take prophylactic medication—for example, patients who are known to faint when nauseous may be able to take prochlorperazine to prevent a syncopal episode.

Patient education. Patients who experience presyncopal symptoms such as lightheadedness, visual dimming, nausea, and weakness should be instructed to lie down on the floor with their legs up at the first sign of an impending episode. If sitting, they can put their head between their knees. Progressive relaxation should be avoided. Patients might be able to block an episode by crossing their legs and tensing their muscles.⁷

Disclosure

Dr. LaFerney reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Discuss this article at www.facebook.com/CurrentPsychiatry

Psychiatrists—especially residents—often prefer to reside close to the hospitals in which they train and work. Training programs in urban settings may offer their residents housing either attached to the hospital or immediately adjacent to it.

Psychiatry residents often discover their most ill patients also prefer to live close to the hospital. They become acquainted with their neighbors on the streets and in the emergency room. As a consequence, new residents must learn how to maintain appropriate boundaries in these situations.

Patients as neighbors

Chronic psychiatric patients are likely to utilize the services of the closest hospital. Individuals with severe mental illness seem especially prone to move to and live in areas near a hospital. For example, a study of VA patients with schizophrenia, bipolar disorder, and depression found those with schizophrenia and bipolar disorder were more likely to move closer to their health care providers.¹ Also, many hospitals and training programs are located in inner-city areas, where individuals with severe mental illness are known to cluster.^2-4

Managing boundaries

When encountering their chronically mentally ill patients on the street, psychiatric residents could have a host of reactions—ranging from becoming over-involved in their patients’ lives to completely avoiding them—that could cause them and their patients significant distress. The literature on boundary management in these situations is immense, and conclusions often are nebulous. Most authors suggest if a psychiatrist encounters a patient outside of the office, he or she should follow the patient’s lead while trying to avoid discussing the patient’s problems in public.⁵

It is important for residency training programs to educate residents on how to manage these professional boundaries. Residents should seek out support from their training department when they encounter these difficult situations.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Discuss this article at www.facebook.com/CurrentPsychiatry

Psychiatrists—especially residents—often prefer to reside close to the hospitals in which they train and work. Training programs in urban settings may offer their residents housing either attached to the hospital or immediately adjacent to it.

Psychiatry residents often discover their most ill patients also prefer to live close to the hospital. They become acquainted with their neighbors on the streets and in the emergency room. As a consequence, new residents must learn how to maintain appropriate boundaries in these situations.

Patients as neighbors

Chronic psychiatric patients are likely to utilize the services of the closest hospital. Individuals with severe mental illness seem especially prone to move to and live in areas near a hospital. For example, a study of VA patients with schizophrenia, bipolar disorder, and depression found those with schizophrenia and bipolar disorder were more likely to move closer to their health care providers.¹ Also, many hospitals and training programs are located in inner-city areas, where individuals with severe mental illness are known to cluster.^2-4

Managing boundaries

When encountering their chronically mentally ill patients on the street, psychiatric residents could have a host of reactions—ranging from becoming over-involved in their patients’ lives to completely avoiding them—that could cause them and their patients significant distress. The literature on boundary management in these situations is immense, and conclusions often are nebulous. Most authors suggest if a psychiatrist encounters a patient outside of the office, he or she should follow the patient’s lead while trying to avoid discussing the patient’s problems in public.⁵

It is important for residency training programs to educate residents on how to manage these professional boundaries. Residents should seek out support from their training department when they encounter these difficult situations.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

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Psychiatrists—especially residents—often prefer to reside close to the hospitals in which they train and work. Training programs in urban settings may offer their residents housing either attached to the hospital or immediately adjacent to it.

Psychiatry residents often discover their most ill patients also prefer to live close to the hospital. They become acquainted with their neighbors on the streets and in the emergency room. As a consequence, new residents must learn how to maintain appropriate boundaries in these situations.

Patients as neighbors

Chronic psychiatric patients are likely to utilize the services of the closest hospital. Individuals with severe mental illness seem especially prone to move to and live in areas near a hospital. For example, a study of VA patients with schizophrenia, bipolar disorder, and depression found those with schizophrenia and bipolar disorder were more likely to move closer to their health care providers.¹ Also, many hospitals and training programs are located in inner-city areas, where individuals with severe mental illness are known to cluster.^2-4

Managing boundaries

When encountering their chronically mentally ill patients on the street, psychiatric residents could have a host of reactions—ranging from becoming over-involved in their patients’ lives to completely avoiding them—that could cause them and their patients significant distress. The literature on boundary management in these situations is immense, and conclusions often are nebulous. Most authors suggest if a psychiatrist encounters a patient outside of the office, he or she should follow the patient’s lead while trying to avoid discussing the patient’s problems in public.⁵

It is important for residency training programs to educate residents on how to manage these professional boundaries. Residents should seek out support from their training department when they encounter these difficult situations.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

The placebo effect—when a patient’s symptoms improve with an inert pill—is widely recognized in medicine. Placebo has an especially important role in psychiatry, especially given the fact that a substantial proportion of patients with mood, anxiety, or psychotic disorders improve and experience some side effects with placebo in double-blind studies conducted by drug manufacturers as part of FDA registration trials.

On the other hand, non-psychiatric medical disorders such as pneumonia and diabetes are unlikely to improve with placebo. Thus, psychiatric brain disorders appear to be particularly susceptible to the placebo effect, which implies it could be harnessed in psychiatric care. A component of every medication prescribed in psychiatry is a variable placebo effect in addition to the actual pharmacodynamic effects.

Some physicians (including non-psychiatrists) openly admit to using placebo—which is sold as Obecalp capsules—to treat patients with vague aches, pains, insomnia, or low energy. Some published studies have shown patients respond to inert pills even when the physician tells them in advance they will be receiving a placebo!¹ This reflects the power of the placebo effect programmed in the human brain, which may have an evolutionary advantage of instilling hope and sustaining faith things will get better despite serious physical or psychological adversity.

What health care professionals often overlook is that the placebo effect transcends the pill itself. The most powerful placebo is the psychiatrist or nurse practitioner who prescribes the pill. In fact, the placebo effect of a clinician occurs even without prescribing any medication.

The shape and color of a placebo pill may endow it with a greater effect (eg, a red and blue striped placebo caplet looks more impressive and may project an aura of being more effective than a plain white tablet). Similarly, a patient is influenced positively or negatively by a range of attributes that characterize his or her psychiatrist, and the totality of the impressions (positive or negative) the psychiatrist “projects” may enhance or detract from whatever treatment is administered, including medication or psychotherapy. This is why different prescribers may achieve disparate results when prescribing the same psychotropic.

Many subtle and not-so-subtle verbal and nonverbal aspects of a clinician can project an “aura” of competence and trust for the patient, which will contribute to a better treatment outcome because of the patient’s stronger unconscious expectation of improvement. These include the psychiatrist’s grooming and clothing, his facial expression and demeanor, the neatness of his desk, the décor of his office, the cleanliness of the waiting room, even the appearance of the neighborhood where his clinic is located. Wearing a white coat instead of street clothes can evoke the image of a physician/healer, which is a strong positive placebo effect that can be exploited for many patients. Direct eye contact an open body posture, a firm, reassuring voice, and a handshake or caring pat on the back at the end of the session when appropriate all contribute to patient improvement even before he or she ingests any pills. A psychiatrist can enhance the response and tolerability of a drug by expressing confidence in the medication and assuring the patient if taken as prescribed the medication will help and will be tolerable according to published studies. Even slight uncertainty by the psychiatrist about the potential usefulness of a medication—even if realistic—may compromise the patient’s response.

Take the following extreme illustration of a psychiatrist whose image projects a powerful negative placebo effect that could undermine therapeutic outcome and even patient adherence: Dr. X works in a dilapidated building in a downtrodden neighborhood. Several furniture pieces in his waiting room are torn or broken. The carpet is worn and features several stains. His office is poorly lit and reeks of mildew and stale cigarette butts. He barely looks at the patient but types on a laptop as the patient speaks. Dr. X is dressed in a casual sports shirt and blue jeans. His hair is disheveled. The floor of his office is littered with piles of journals and books. Dr. X speaks in a hurried, impatient tone and often interrupts the patient to ask a barrage of questions unrelated to what the patient was talking about. Occasionally, Dr. X stops typing, leans back in his worn creaky chair, crosses his arms, and just stares at the patient. He then abruptly ends the session because “there are many other patients waiting.” He scribbles a prescription, slides it over the desk to the patient, and says “Here, take this until next visit and we’ll see if it works for you.” The psychiatrist never leaves his chair and keeps typing as the patient dejectedly leaves the office.

Dr. X clearly has squandered the valuable placebo effect inherent in his role that not only can enhance the medication efficacy but also usually bolsters the therapeutic alliance. The many negative aspects of his demeanor, behavior, relatedness, and office probably will decrease the likelihood of a good outcome in his patient

Every clinician can achieve better treatment results by creating a set of positive personal and environmental cues to reinforce that powerful and intangible force that expedites the relief of psychiatric symptoms. It would be folly to squander the remarkable placebo inherent in us “healers.”

The placebo effect—when a patient’s symptoms improve with an inert pill—is widely recognized in medicine. Placebo has an especially important role in psychiatry, especially given the fact that a substantial proportion of patients with mood, anxiety, or psychotic disorders improve and experience some side effects with placebo in double-blind studies conducted by drug manufacturers as part of FDA registration trials.

On the other hand, non-psychiatric medical disorders such as pneumonia and diabetes are unlikely to improve with placebo. Thus, psychiatric brain disorders appear to be particularly susceptible to the placebo effect, which implies it could be harnessed in psychiatric care. A component of every medication prescribed in psychiatry is a variable placebo effect in addition to the actual pharmacodynamic effects.

Some physicians (including non-psychiatrists) openly admit to using placebo—which is sold as Obecalp capsules—to treat patients with vague aches, pains, insomnia, or low energy. Some published studies have shown patients respond to inert pills even when the physician tells them in advance they will be receiving a placebo!¹ This reflects the power of the placebo effect programmed in the human brain, which may have an evolutionary advantage of instilling hope and sustaining faith things will get better despite serious physical or psychological adversity.

What health care professionals often overlook is that the placebo effect transcends the pill itself. The most powerful placebo is the psychiatrist or nurse practitioner who prescribes the pill. In fact, the placebo effect of a clinician occurs even without prescribing any medication.

The shape and color of a placebo pill may endow it with a greater effect (eg, a red and blue striped placebo caplet looks more impressive and may project an aura of being more effective than a plain white tablet). Similarly, a patient is influenced positively or negatively by a range of attributes that characterize his or her psychiatrist, and the totality of the impressions (positive or negative) the psychiatrist “projects” may enhance or detract from whatever treatment is administered, including medication or psychotherapy. This is why different prescribers may achieve disparate results when prescribing the same psychotropic.

Many subtle and not-so-subtle verbal and nonverbal aspects of a clinician can project an “aura” of competence and trust for the patient, which will contribute to a better treatment outcome because of the patient’s stronger unconscious expectation of improvement. These include the psychiatrist’s grooming and clothing, his facial expression and demeanor, the neatness of his desk, the décor of his office, the cleanliness of the waiting room, even the appearance of the neighborhood where his clinic is located. Wearing a white coat instead of street clothes can evoke the image of a physician/healer, which is a strong positive placebo effect that can be exploited for many patients. Direct eye contact an open body posture, a firm, reassuring voice, and a handshake or caring pat on the back at the end of the session when appropriate all contribute to patient improvement even before he or she ingests any pills. A psychiatrist can enhance the response and tolerability of a drug by expressing confidence in the medication and assuring the patient if taken as prescribed the medication will help and will be tolerable according to published studies. Even slight uncertainty by the psychiatrist about the potential usefulness of a medication—even if realistic—may compromise the patient’s response.

Take the following extreme illustration of a psychiatrist whose image projects a powerful negative placebo effect that could undermine therapeutic outcome and even patient adherence: Dr. X works in a dilapidated building in a downtrodden neighborhood. Several furniture pieces in his waiting room are torn or broken. The carpet is worn and features several stains. His office is poorly lit and reeks of mildew and stale cigarette butts. He barely looks at the patient but types on a laptop as the patient speaks. Dr. X is dressed in a casual sports shirt and blue jeans. His hair is disheveled. The floor of his office is littered with piles of journals and books. Dr. X speaks in a hurried, impatient tone and often interrupts the patient to ask a barrage of questions unrelated to what the patient was talking about. Occasionally, Dr. X stops typing, leans back in his worn creaky chair, crosses his arms, and just stares at the patient. He then abruptly ends the session because “there are many other patients waiting.” He scribbles a prescription, slides it over the desk to the patient, and says “Here, take this until next visit and we’ll see if it works for you.” The psychiatrist never leaves his chair and keeps typing as the patient dejectedly leaves the office.

Dr. X clearly has squandered the valuable placebo effect inherent in his role that not only can enhance the medication efficacy but also usually bolsters the therapeutic alliance. The many negative aspects of his demeanor, behavior, relatedness, and office probably will decrease the likelihood of a good outcome in his patient

Every clinician can achieve better treatment results by creating a set of positive personal and environmental cues to reinforce that powerful and intangible force that expedites the relief of psychiatric symptoms. It would be folly to squander the remarkable placebo inherent in us “healers.”

The placebo effect—when a patient’s symptoms improve with an inert pill—is widely recognized in medicine. Placebo has an especially important role in psychiatry, especially given the fact that a substantial proportion of patients with mood, anxiety, or psychotic disorders improve and experience some side effects with placebo in double-blind studies conducted by drug manufacturers as part of FDA registration trials.

On the other hand, non-psychiatric medical disorders such as pneumonia and diabetes are unlikely to improve with placebo. Thus, psychiatric brain disorders appear to be particularly susceptible to the placebo effect, which implies it could be harnessed in psychiatric care. A component of every medication prescribed in psychiatry is a variable placebo effect in addition to the actual pharmacodynamic effects.

Some physicians (including non-psychiatrists) openly admit to using placebo—which is sold as Obecalp capsules—to treat patients with vague aches, pains, insomnia, or low energy. Some published studies have shown patients respond to inert pills even when the physician tells them in advance they will be receiving a placebo!¹ This reflects the power of the placebo effect programmed in the human brain, which may have an evolutionary advantage of instilling hope and sustaining faith things will get better despite serious physical or psychological adversity.

What health care professionals often overlook is that the placebo effect transcends the pill itself. The most powerful placebo is the psychiatrist or nurse practitioner who prescribes the pill. In fact, the placebo effect of a clinician occurs even without prescribing any medication.

The shape and color of a placebo pill may endow it with a greater effect (eg, a red and blue striped placebo caplet looks more impressive and may project an aura of being more effective than a plain white tablet). Similarly, a patient is influenced positively or negatively by a range of attributes that characterize his or her psychiatrist, and the totality of the impressions (positive or negative) the psychiatrist “projects” may enhance or detract from whatever treatment is administered, including medication or psychotherapy. This is why different prescribers may achieve disparate results when prescribing the same psychotropic.

Many subtle and not-so-subtle verbal and nonverbal aspects of a clinician can project an “aura” of competence and trust for the patient, which will contribute to a better treatment outcome because of the patient’s stronger unconscious expectation of improvement. These include the psychiatrist’s grooming and clothing, his facial expression and demeanor, the neatness of his desk, the décor of his office, the cleanliness of the waiting room, even the appearance of the neighborhood where his clinic is located. Wearing a white coat instead of street clothes can evoke the image of a physician/healer, which is a strong positive placebo effect that can be exploited for many patients. Direct eye contact an open body posture, a firm, reassuring voice, and a handshake or caring pat on the back at the end of the session when appropriate all contribute to patient improvement even before he or she ingests any pills. A psychiatrist can enhance the response and tolerability of a drug by expressing confidence in the medication and assuring the patient if taken as prescribed the medication will help and will be tolerable according to published studies. Even slight uncertainty by the psychiatrist about the potential usefulness of a medication—even if realistic—may compromise the patient’s response.

Take the following extreme illustration of a psychiatrist whose image projects a powerful negative placebo effect that could undermine therapeutic outcome and even patient adherence: Dr. X works in a dilapidated building in a downtrodden neighborhood. Several furniture pieces in his waiting room are torn or broken. The carpet is worn and features several stains. His office is poorly lit and reeks of mildew and stale cigarette butts. He barely looks at the patient but types on a laptop as the patient speaks. Dr. X is dressed in a casual sports shirt and blue jeans. His hair is disheveled. The floor of his office is littered with piles of journals and books. Dr. X speaks in a hurried, impatient tone and often interrupts the patient to ask a barrage of questions unrelated to what the patient was talking about. Occasionally, Dr. X stops typing, leans back in his worn creaky chair, crosses his arms, and just stares at the patient. He then abruptly ends the session because “there are many other patients waiting.” He scribbles a prescription, slides it over the desk to the patient, and says “Here, take this until next visit and we’ll see if it works for you.” The psychiatrist never leaves his chair and keeps typing as the patient dejectedly leaves the office.

Dr. X clearly has squandered the valuable placebo effect inherent in his role that not only can enhance the medication efficacy but also usually bolsters the therapeutic alliance. The many negative aspects of his demeanor, behavior, relatedness, and office probably will decrease the likelihood of a good outcome in his patient

Every clinician can achieve better treatment results by creating a set of positive personal and environmental cues to reinforce that powerful and intangible force that expedites the relief of psychiatric symptoms. It would be folly to squander the remarkable placebo inherent in us “healers.”