Major Depressive Disorder

A commonly held belief that classic psychedelic therapy can trigger suicidal thoughts, actions, or other types of self-harm is not supported by research, and, in fact, the opposite may be true.

Results from a meta-analysis of individual patient data showed that psychedelic therapy was associated with large, acute, and sustained decreases in suicidality across a range of clinical patient populations.

“This is the first analysis to synthesize suicidality outcome data from recent clinical trials with psychedelics. It gives us a better understanding of the effects of psychedelics on suicidality in the context of clinical trials,” study investigator Cory Weissman, MD, department of psychiatry, University of Toronto, told this news organization.

The evidence suggests psychedelic therapy “may reduce suicidal ideation when administered in the appropriate setting and offered to carefully screened patients,” Dr. Weissman said.

The findings were published online Jan. 18 in The Journal of Clinical Psychiatry.
 

More research needed

The analysis included seven psychedelic therapy clinical trials that had data on suicidality. Five of the trials used psilocybin plus psychotherapy and two used ayahuasca plus psychotherapy. All seven trials had a “low” risk of bias.

Patients included in the trials had treatment-resistant major depressive disorder (MDD), recurrent MDD, AIDS-related demoralization, and distress related to life-threatening cancer.

The meta-analytic results showed significant decreases in suicidality at all acute time points (80 to 240 minutes post administration) and at most post-acute time points (1 day to 4 months post administration).

Effect sizes for reductions in suicidality were “large” at all acute time points, with standardized mean differences (SMD) ranging from -1.48 to -1.72, and remained large from 1 day to 3-4 months after therapy (SMD range, -1.50 to -2.36).

At 6 months, the effect size for reductions in suicidality with psychedelic therapy was “medium” (SMD, -0.65).

Large effect sizes for reductions in suicidality occurred across the different patient populations represented in the trial, the investigators note.

No study reported any suicide-related adverse events because of administration of a psychedelic. There were also “very few” acute (6.5%) or postacute (3.0%) elevations in suicidality, “providing support for the safety of psychedelic therapy within controlled contexts,” the researchers write.

They caution, however, that large controlled trials that specifically evaluate the effect of psychedelic therapy on suicidality are needed.
 

Promising avenue

In an accompanying editorial, Daniel Grossman, BS, and Peter Hendricks, PhD, department of health behavior, University of Alabama at Birmingham, note that results of this review warrant “optimism” for use of psychedelics for treatment of suicidality.

Based on this study and others, classic psychedelic therapy for suicidality appears to be a “promising avenue” for further investigation, they write.

However, research and anecdotes about increased suicidality and other self-harm attributed to psychedelic therapy, “though evidently rare, remain a critical concern” for further research to address, Dr. Grossman and Dr. Hendricks add.

The hope is that future research “clarifies who is most subject to these risks, what factors best identify them, and how best to navigate their treatment safely,” they write.

The meta-analysis had no funding. Dr. Weissman receives funding from the Brain and Behavior Research Foundation and serves on the advisory board of GoodCap Pharmaceuticals. Dr. Hendricks is on the scientific advisory board of Bright Minds Biosciences, Eleusis Benefit Corporation, and Rest Pharmaceuticals.

A version of this article first appeared on Medscape.com.

A commonly held belief that classic psychedelic therapy can trigger suicidal thoughts, actions, or other types of self-harm is not supported by research, and, in fact, the opposite may be true.

Results from a meta-analysis of individual patient data showed that psychedelic therapy was associated with large, acute, and sustained decreases in suicidality across a range of clinical patient populations.

“This is the first analysis to synthesize suicidality outcome data from recent clinical trials with psychedelics. It gives us a better understanding of the effects of psychedelics on suicidality in the context of clinical trials,” study investigator Cory Weissman, MD, department of psychiatry, University of Toronto, told this news organization.

The evidence suggests psychedelic therapy “may reduce suicidal ideation when administered in the appropriate setting and offered to carefully screened patients,” Dr. Weissman said.

The findings were published online Jan. 18 in The Journal of Clinical Psychiatry.
 

More research needed

The analysis included seven psychedelic therapy clinical trials that had data on suicidality. Five of the trials used psilocybin plus psychotherapy and two used ayahuasca plus psychotherapy. All seven trials had a “low” risk of bias.

Patients included in the trials had treatment-resistant major depressive disorder (MDD), recurrent MDD, AIDS-related demoralization, and distress related to life-threatening cancer.

The meta-analytic results showed significant decreases in suicidality at all acute time points (80 to 240 minutes post administration) and at most post-acute time points (1 day to 4 months post administration).

Effect sizes for reductions in suicidality were “large” at all acute time points, with standardized mean differences (SMD) ranging from -1.48 to -1.72, and remained large from 1 day to 3-4 months after therapy (SMD range, -1.50 to -2.36).

At 6 months, the effect size for reductions in suicidality with psychedelic therapy was “medium” (SMD, -0.65).

Large effect sizes for reductions in suicidality occurred across the different patient populations represented in the trial, the investigators note.

No study reported any suicide-related adverse events because of administration of a psychedelic. There were also “very few” acute (6.5%) or postacute (3.0%) elevations in suicidality, “providing support for the safety of psychedelic therapy within controlled contexts,” the researchers write.

They caution, however, that large controlled trials that specifically evaluate the effect of psychedelic therapy on suicidality are needed.
 

Promising avenue

In an accompanying editorial, Daniel Grossman, BS, and Peter Hendricks, PhD, department of health behavior, University of Alabama at Birmingham, note that results of this review warrant “optimism” for use of psychedelics for treatment of suicidality.

Based on this study and others, classic psychedelic therapy for suicidality appears to be a “promising avenue” for further investigation, they write.

However, research and anecdotes about increased suicidality and other self-harm attributed to psychedelic therapy, “though evidently rare, remain a critical concern” for further research to address, Dr. Grossman and Dr. Hendricks add.

The hope is that future research “clarifies who is most subject to these risks, what factors best identify them, and how best to navigate their treatment safely,” they write.

The meta-analysis had no funding. Dr. Weissman receives funding from the Brain and Behavior Research Foundation and serves on the advisory board of GoodCap Pharmaceuticals. Dr. Hendricks is on the scientific advisory board of Bright Minds Biosciences, Eleusis Benefit Corporation, and Rest Pharmaceuticals.

A version of this article first appeared on Medscape.com.

A commonly held belief that classic psychedelic therapy can trigger suicidal thoughts, actions, or other types of self-harm is not supported by research, and, in fact, the opposite may be true.

Results from a meta-analysis of individual patient data showed that psychedelic therapy was associated with large, acute, and sustained decreases in suicidality across a range of clinical patient populations.

“This is the first analysis to synthesize suicidality outcome data from recent clinical trials with psychedelics. It gives us a better understanding of the effects of psychedelics on suicidality in the context of clinical trials,” study investigator Cory Weissman, MD, department of psychiatry, University of Toronto, told this news organization.

The evidence suggests psychedelic therapy “may reduce suicidal ideation when administered in the appropriate setting and offered to carefully screened patients,” Dr. Weissman said.

The findings were published online Jan. 18 in The Journal of Clinical Psychiatry.
 

More research needed

The analysis included seven psychedelic therapy clinical trials that had data on suicidality. Five of the trials used psilocybin plus psychotherapy and two used ayahuasca plus psychotherapy. All seven trials had a “low” risk of bias.

Patients included in the trials had treatment-resistant major depressive disorder (MDD), recurrent MDD, AIDS-related demoralization, and distress related to life-threatening cancer.

The meta-analytic results showed significant decreases in suicidality at all acute time points (80 to 240 minutes post administration) and at most post-acute time points (1 day to 4 months post administration).

Effect sizes for reductions in suicidality were “large” at all acute time points, with standardized mean differences (SMD) ranging from -1.48 to -1.72, and remained large from 1 day to 3-4 months after therapy (SMD range, -1.50 to -2.36).

At 6 months, the effect size for reductions in suicidality with psychedelic therapy was “medium” (SMD, -0.65).

Large effect sizes for reductions in suicidality occurred across the different patient populations represented in the trial, the investigators note.

No study reported any suicide-related adverse events because of administration of a psychedelic. There were also “very few” acute (6.5%) or postacute (3.0%) elevations in suicidality, “providing support for the safety of psychedelic therapy within controlled contexts,” the researchers write.

They caution, however, that large controlled trials that specifically evaluate the effect of psychedelic therapy on suicidality are needed.
 

Promising avenue

In an accompanying editorial, Daniel Grossman, BS, and Peter Hendricks, PhD, department of health behavior, University of Alabama at Birmingham, note that results of this review warrant “optimism” for use of psychedelics for treatment of suicidality.

Based on this study and others, classic psychedelic therapy for suicidality appears to be a “promising avenue” for further investigation, they write.

However, research and anecdotes about increased suicidality and other self-harm attributed to psychedelic therapy, “though evidently rare, remain a critical concern” for further research to address, Dr. Grossman and Dr. Hendricks add.

The hope is that future research “clarifies who is most subject to these risks, what factors best identify them, and how best to navigate their treatment safely,” they write.

The meta-analysis had no funding. Dr. Weissman receives funding from the Brain and Behavior Research Foundation and serves on the advisory board of GoodCap Pharmaceuticals. Dr. Hendricks is on the scientific advisory board of Bright Minds Biosciences, Eleusis Benefit Corporation, and Rest Pharmaceuticals.

A version of this article first appeared on Medscape.com.

Intravenous ketamine is effective for treating depression but is inferior to electroconvulsive therapy (ECT), new research suggests.

In the first head-to-head trial, ECT was more effective than intravenous ketamine in hospitalized patients with severe depression, with higher remission rates and a greater reduction in symptoms.

However, ketamine led to remission in nearly half of participants and is a “valuable” option for treating severe depression, particularly in younger patients, the investigators noted.

The high rate of remission for ketamine infusion “indicates that it definitely can be used in a clinical setting, but it is more probable that a patient will achieve remission with ECT compared to ketamine,” principal investigator Pouya Movahed Rad, MD, PhD (pharmacology), senior consultant and researcher in psychiatry, Lund (Sweden) University, said in an interview.

Results of the KetECT study were recently published online in the International Journal of Neuropsychopharmacology.
 

Primary focus on remission

The parallel, open-label, noninferiority study included 186 patients aged 18-85 years who were hospitalized with severe unipolar depression and had a score of at least 20 on the Montgomery-Åsberg Depression Rating Scale (MADRS).

Participants were randomly allocated (1:1) to thrice-weekly infusions of racemic ketamine (0.5 mg/kg over 40 minutes) or ECT. All patients continued to take their antidepressant medication during the study. The primary outcome was remission, defined as a MADRS score of 10 or less.  

Results showed the remission rate was significantly higher in the ECT group than in the ketamine group (63% vs. 46%, respectively; P = .026). The 95% confidence interval of the difference in remission rates was estimated between 2% and 30%. 

Both ketamine and ECT required a median of six treatment sessions to induce remission.

Post-hoc analysis indicated that age was a factor in the findings. In the ECT group, remission was significantly more likely in older patients (51-85 years), compared with younger patients (18-50 years), with remission rates of 77% and 50%, respectively.

But the opposite was true in the ketamine group, with significantly higher remission rates in younger versus older patients (61% vs. 37%).

The study results also support the safety and efficacy of ketamine in patients with psychotic depression, which was present in 15% of patients in the ECT group and 18% of those in the ketamine group.

In this subgroup, half of patients with psychotic depression remitted after ketamine, with no indications of adverse reactions particular for these patients. The remission rate with ECT was 79%.

During the 12-month follow-up period, rate of relapse among remitters was similar at 64% in the ECT group and 70% in the ketamine group (log rank P = .44).
 

Let the patient decide

As expected, ECT and ketamine had distinct side effect profiles. Subjectively reported prolonged amnesia was more common with ECT and reports of dissociative side effects, anxiety, blurred vision, euphoria, vertigo, and diplopia (double vision) were more common with ketamine. 

“Dissociative symptoms were, as expected, observed during treatment with ketamine, but they were brief and in the majority of cases mild and tolerable,” Dr. Movahed Rad said.

The investigators noted that participating study sites all had long-time experience with ECT but no experience administering ketamine.

“Staffs, and some patients, were familiar with side effects common to ECT but were less prepared for the adverse psychological effects of ketamine. This, and knowing ECT was available after the study, probably contributed to the higher dropout rate in the ketamine group,” they wrote.

If both ECT and ketamine are available, “the patient’s preference should, of course, be taken in account when choosing treatment,” said Dr. Movahed Rad.

“Ketamine should be offered if ECT is not available, or cannot be given due to excessive risks with anesthesia or other somatic risk factor. Patients who have not responded to ECT or have had unacceptable side effects should be offered ketamine infusion and vice versa,” he added.

A good alternative

Commenting on the findings, Roger McIntyre, MD, professor of psychiatry and pharmacology, University of Toronto, said the data confirm ECT is highly effective for treatment-resistant depression and show that “newcomer” intravenous ketamine also performs “exceptionally well.”

“This is an extremely important study that really establishes the efficacy of ketamine in a very difficult to treat population,” added Dr. McIntyre, who was not involved in the research.

He added that this “rigorous, well-designed study addresses a critical question” about the comparative efficacy of ECT and intravenous ketamine. It also makes “quite a strong statement about the efficacy of ketamine in younger people.”

He cautioned, however, that this study represents the “first data point and, of course, is not the final word on the topic. There are other studies currently still ongoing that are also comparing ECT to IV ketamine and we’ll look forward to seeing the results.”

The fact that 15%-20% of the study patients had psychotic depression is also noteworthy, said Dr. McIntyre.

“We’ve been hesitant to use ketamine in these patients, I think for obvious reasons, but we recently published a paper showing that it is safe and very effective in these patients,” he said.

Having ketamine as a treatment option is important because the majority of patients who could benefit from ECT decline it, often because of the stigma associated with the procedure, which is often portrayed negatively in films and other media.

“I have been recommending ECT almost every day of my professional life and 98 times out of 100 people say: ‘Thanks but no thanks.’ That’s a problem because ECT is so effective,” Dr. McIntyre said.

The study was funded by the Swedish Research Council, Crafoord Foundation, Skåne Regional Council, Königska Foundation, Lions Forskningsfond Skåne, and the OM Perssons donation foundation. Dr. Movahed Rad has received lecturer honoraria from Lundbeck. Dr. McIntyre has received research grant support from the Canadian Institutes of Health Research/Global Alliance for Chronic Diseases/Chinese National Natural Research Foundation and speaker/consultation fees from Lundbeck, Janssen, and other companies. McIntyre is also CEO of AltMed.

A version of this article first appeared on Medscape.com.

Intravenous ketamine is effective for treating depression but is inferior to electroconvulsive therapy (ECT), new research suggests.

In the first head-to-head trial, ECT was more effective than intravenous ketamine in hospitalized patients with severe depression, with higher remission rates and a greater reduction in symptoms.

However, ketamine led to remission in nearly half of participants and is a “valuable” option for treating severe depression, particularly in younger patients, the investigators noted.

The high rate of remission for ketamine infusion “indicates that it definitely can be used in a clinical setting, but it is more probable that a patient will achieve remission with ECT compared to ketamine,” principal investigator Pouya Movahed Rad, MD, PhD (pharmacology), senior consultant and researcher in psychiatry, Lund (Sweden) University, said in an interview.

Results of the KetECT study were recently published online in the International Journal of Neuropsychopharmacology.
 

Primary focus on remission

The parallel, open-label, noninferiority study included 186 patients aged 18-85 years who were hospitalized with severe unipolar depression and had a score of at least 20 on the Montgomery-Åsberg Depression Rating Scale (MADRS).

Participants were randomly allocated (1:1) to thrice-weekly infusions of racemic ketamine (0.5 mg/kg over 40 minutes) or ECT. All patients continued to take their antidepressant medication during the study. The primary outcome was remission, defined as a MADRS score of 10 or less.  

Results showed the remission rate was significantly higher in the ECT group than in the ketamine group (63% vs. 46%, respectively; P = .026). The 95% confidence interval of the difference in remission rates was estimated between 2% and 30%. 

Both ketamine and ECT required a median of six treatment sessions to induce remission.

Post-hoc analysis indicated that age was a factor in the findings. In the ECT group, remission was significantly more likely in older patients (51-85 years), compared with younger patients (18-50 years), with remission rates of 77% and 50%, respectively.

But the opposite was true in the ketamine group, with significantly higher remission rates in younger versus older patients (61% vs. 37%).

The study results also support the safety and efficacy of ketamine in patients with psychotic depression, which was present in 15% of patients in the ECT group and 18% of those in the ketamine group.

In this subgroup, half of patients with psychotic depression remitted after ketamine, with no indications of adverse reactions particular for these patients. The remission rate with ECT was 79%.

During the 12-month follow-up period, rate of relapse among remitters was similar at 64% in the ECT group and 70% in the ketamine group (log rank P = .44).
 

Let the patient decide

As expected, ECT and ketamine had distinct side effect profiles. Subjectively reported prolonged amnesia was more common with ECT and reports of dissociative side effects, anxiety, blurred vision, euphoria, vertigo, and diplopia (double vision) were more common with ketamine. 

“Dissociative symptoms were, as expected, observed during treatment with ketamine, but they were brief and in the majority of cases mild and tolerable,” Dr. Movahed Rad said.

The investigators noted that participating study sites all had long-time experience with ECT but no experience administering ketamine.

“Staffs, and some patients, were familiar with side effects common to ECT but were less prepared for the adverse psychological effects of ketamine. This, and knowing ECT was available after the study, probably contributed to the higher dropout rate in the ketamine group,” they wrote.

If both ECT and ketamine are available, “the patient’s preference should, of course, be taken in account when choosing treatment,” said Dr. Movahed Rad.

“Ketamine should be offered if ECT is not available, or cannot be given due to excessive risks with anesthesia or other somatic risk factor. Patients who have not responded to ECT or have had unacceptable side effects should be offered ketamine infusion and vice versa,” he added.

A good alternative

Commenting on the findings, Roger McIntyre, MD, professor of psychiatry and pharmacology, University of Toronto, said the data confirm ECT is highly effective for treatment-resistant depression and show that “newcomer” intravenous ketamine also performs “exceptionally well.”

“This is an extremely important study that really establishes the efficacy of ketamine in a very difficult to treat population,” added Dr. McIntyre, who was not involved in the research.

He added that this “rigorous, well-designed study addresses a critical question” about the comparative efficacy of ECT and intravenous ketamine. It also makes “quite a strong statement about the efficacy of ketamine in younger people.”

He cautioned, however, that this study represents the “first data point and, of course, is not the final word on the topic. There are other studies currently still ongoing that are also comparing ECT to IV ketamine and we’ll look forward to seeing the results.”

The fact that 15%-20% of the study patients had psychotic depression is also noteworthy, said Dr. McIntyre.

“We’ve been hesitant to use ketamine in these patients, I think for obvious reasons, but we recently published a paper showing that it is safe and very effective in these patients,” he said.

Having ketamine as a treatment option is important because the majority of patients who could benefit from ECT decline it, often because of the stigma associated with the procedure, which is often portrayed negatively in films and other media.

“I have been recommending ECT almost every day of my professional life and 98 times out of 100 people say: ‘Thanks but no thanks.’ That’s a problem because ECT is so effective,” Dr. McIntyre said.

The study was funded by the Swedish Research Council, Crafoord Foundation, Skåne Regional Council, Königska Foundation, Lions Forskningsfond Skåne, and the OM Perssons donation foundation. Dr. Movahed Rad has received lecturer honoraria from Lundbeck. Dr. McIntyre has received research grant support from the Canadian Institutes of Health Research/Global Alliance for Chronic Diseases/Chinese National Natural Research Foundation and speaker/consultation fees from Lundbeck, Janssen, and other companies. McIntyre is also CEO of AltMed.

A version of this article first appeared on Medscape.com.

Intravenous ketamine is effective for treating depression but is inferior to electroconvulsive therapy (ECT), new research suggests.

In the first head-to-head trial, ECT was more effective than intravenous ketamine in hospitalized patients with severe depression, with higher remission rates and a greater reduction in symptoms.

However, ketamine led to remission in nearly half of participants and is a “valuable” option for treating severe depression, particularly in younger patients, the investigators noted.

The high rate of remission for ketamine infusion “indicates that it definitely can be used in a clinical setting, but it is more probable that a patient will achieve remission with ECT compared to ketamine,” principal investigator Pouya Movahed Rad, MD, PhD (pharmacology), senior consultant and researcher in psychiatry, Lund (Sweden) University, said in an interview.

Results of the KetECT study were recently published online in the International Journal of Neuropsychopharmacology.
 

Primary focus on remission

The parallel, open-label, noninferiority study included 186 patients aged 18-85 years who were hospitalized with severe unipolar depression and had a score of at least 20 on the Montgomery-Åsberg Depression Rating Scale (MADRS).

Participants were randomly allocated (1:1) to thrice-weekly infusions of racemic ketamine (0.5 mg/kg over 40 minutes) or ECT. All patients continued to take their antidepressant medication during the study. The primary outcome was remission, defined as a MADRS score of 10 or less.  

Results showed the remission rate was significantly higher in the ECT group than in the ketamine group (63% vs. 46%, respectively; P = .026). The 95% confidence interval of the difference in remission rates was estimated between 2% and 30%. 

Both ketamine and ECT required a median of six treatment sessions to induce remission.

Post-hoc analysis indicated that age was a factor in the findings. In the ECT group, remission was significantly more likely in older patients (51-85 years), compared with younger patients (18-50 years), with remission rates of 77% and 50%, respectively.

But the opposite was true in the ketamine group, with significantly higher remission rates in younger versus older patients (61% vs. 37%).

The study results also support the safety and efficacy of ketamine in patients with psychotic depression, which was present in 15% of patients in the ECT group and 18% of those in the ketamine group.

In this subgroup, half of patients with psychotic depression remitted after ketamine, with no indications of adverse reactions particular for these patients. The remission rate with ECT was 79%.

During the 12-month follow-up period, rate of relapse among remitters was similar at 64% in the ECT group and 70% in the ketamine group (log rank P = .44).
 

Let the patient decide

As expected, ECT and ketamine had distinct side effect profiles. Subjectively reported prolonged amnesia was more common with ECT and reports of dissociative side effects, anxiety, blurred vision, euphoria, vertigo, and diplopia (double vision) were more common with ketamine. 

“Dissociative symptoms were, as expected, observed during treatment with ketamine, but they were brief and in the majority of cases mild and tolerable,” Dr. Movahed Rad said.

The investigators noted that participating study sites all had long-time experience with ECT but no experience administering ketamine.

“Staffs, and some patients, were familiar with side effects common to ECT but were less prepared for the adverse psychological effects of ketamine. This, and knowing ECT was available after the study, probably contributed to the higher dropout rate in the ketamine group,” they wrote.

If both ECT and ketamine are available, “the patient’s preference should, of course, be taken in account when choosing treatment,” said Dr. Movahed Rad.

“Ketamine should be offered if ECT is not available, or cannot be given due to excessive risks with anesthesia or other somatic risk factor. Patients who have not responded to ECT or have had unacceptable side effects should be offered ketamine infusion and vice versa,” he added.

A good alternative

Commenting on the findings, Roger McIntyre, MD, professor of psychiatry and pharmacology, University of Toronto, said the data confirm ECT is highly effective for treatment-resistant depression and show that “newcomer” intravenous ketamine also performs “exceptionally well.”

“This is an extremely important study that really establishes the efficacy of ketamine in a very difficult to treat population,” added Dr. McIntyre, who was not involved in the research.

He added that this “rigorous, well-designed study addresses a critical question” about the comparative efficacy of ECT and intravenous ketamine. It also makes “quite a strong statement about the efficacy of ketamine in younger people.”

He cautioned, however, that this study represents the “first data point and, of course, is not the final word on the topic. There are other studies currently still ongoing that are also comparing ECT to IV ketamine and we’ll look forward to seeing the results.”

The fact that 15%-20% of the study patients had psychotic depression is also noteworthy, said Dr. McIntyre.

“We’ve been hesitant to use ketamine in these patients, I think for obvious reasons, but we recently published a paper showing that it is safe and very effective in these patients,” he said.

Having ketamine as a treatment option is important because the majority of patients who could benefit from ECT decline it, often because of the stigma associated with the procedure, which is often portrayed negatively in films and other media.

“I have been recommending ECT almost every day of my professional life and 98 times out of 100 people say: ‘Thanks but no thanks.’ That’s a problem because ECT is so effective,” Dr. McIntyre said.

The study was funded by the Swedish Research Council, Crafoord Foundation, Skåne Regional Council, Königska Foundation, Lions Forskningsfond Skåne, and the OM Perssons donation foundation. Dr. Movahed Rad has received lecturer honoraria from Lundbeck. Dr. McIntyre has received research grant support from the Canadian Institutes of Health Research/Global Alliance for Chronic Diseases/Chinese National Natural Research Foundation and speaker/consultation fees from Lundbeck, Janssen, and other companies. McIntyre is also CEO of AltMed.

A version of this article first appeared on Medscape.com.

Electrical brain stimulation may have the potential to improve verbal memory, results of a small study of patients with epilepsy suggest.

Investigators observed improvements in patients implanted with a responsive neurostimulation system (RNS) to control seizures, in that the patients had improved word recall when the system was activated.

Beyond epilepsy, “we suspect that our results would be broadly applicable regardless of the underlying condition, for example, memory loss with Alzheimer’s disease or traumatic brain injury,” Zulfi Haneef, MBBS, MD, associate professor of neurology, Baylor College of Medicine, Houston, said in an interview.

“Mental health conditions such as depression or psychosis could also benefit from targeted electrical stimulation. While we focused on enhancing a preferred brain function [such as memory], parallel areas of research may target enhancing function [such as weakness following stroke] or suppressing function [to manage conditions such as chronic pain,]” Dr. Haneef added.

The study was published online Jan. 17, 2022, in Neurosurgery.

As reported by this news organization, the RNS system (NeuroPace) is approved by the Food and Drug Administration to treat medically refractory focal seizures in adults. Following implantation of the system, patients attend the clinic for adjustments about every 8-12 weeks.

The investigators studied 17 patients with epilepsy and RNS implants who attended the clinic for routine appointments. A clinical neuropsychologist administered the Hopkins Verbal Learning Test–Revised (HVLT-R), a well-validated list-learning measure of memory and verbal learning.

Patients were read a list of 12 semantically related words and asked to recall the list after three different learning trials. Active or sham stimulation was performed for every third word presented for immediate recall. 

The investigators found that the HVLT-R delayed recall raw score was higher for the stimulation condition, compared with the nonstimulation condition (paired t-test, P = .04; effect size, d = 0.627).

“The patients were not aware of when the RNS system was being activated. We alternated when patients were undergoing stimulation versus no stimulation, and still found that when patients’ RNS systems were activated, their memory recall score was greater than when there was no stimulation,” Dr. Haneef said in a release.

This suggests the “human memory can be potentially improved by direct electrical brain stimulation at extremely low currents,” Dr. Haneef said in an interview.

Most patients in the study had stimulation of the hippocampus, the brain’s memory center.

“Moving forward we would want to look at how different patterns or standardized stimulation patterns affect memory. Ultimately, the underlying brain rhythms responsible for these changes in brain function need to be understood so that a more targeted and precise application of electrical stimulation can be achieved,” Dr. Haneef said.

The researchers also caution that, for this preliminary study, no follow-up testing was conducted to determine whether the memory improvement was transient and settled back to baseline after a specified period.

However, they note, this study lays the groundwork for larger-scale and extensive studies examining the nuanced effects of brain stimulation on human cognition and memory.

The study was funded by the Mike Hogg Foundation. Dr. Haneef and two coauthors received coverage for travel expenses but no honorarium for a NeuroPace advisory meeting.

A version of this article first appeared on Medscape.com.

Electrical brain stimulation may have the potential to improve verbal memory, results of a small study of patients with epilepsy suggest.

Investigators observed improvements in patients implanted with a responsive neurostimulation system (RNS) to control seizures, in that the patients had improved word recall when the system was activated.

Beyond epilepsy, “we suspect that our results would be broadly applicable regardless of the underlying condition, for example, memory loss with Alzheimer’s disease or traumatic brain injury,” Zulfi Haneef, MBBS, MD, associate professor of neurology, Baylor College of Medicine, Houston, said in an interview.

“Mental health conditions such as depression or psychosis could also benefit from targeted electrical stimulation. While we focused on enhancing a preferred brain function [such as memory], parallel areas of research may target enhancing function [such as weakness following stroke] or suppressing function [to manage conditions such as chronic pain,]” Dr. Haneef added.

The study was published online Jan. 17, 2022, in Neurosurgery.

As reported by this news organization, the RNS system (NeuroPace) is approved by the Food and Drug Administration to treat medically refractory focal seizures in adults. Following implantation of the system, patients attend the clinic for adjustments about every 8-12 weeks.

The investigators studied 17 patients with epilepsy and RNS implants who attended the clinic for routine appointments. A clinical neuropsychologist administered the Hopkins Verbal Learning Test–Revised (HVLT-R), a well-validated list-learning measure of memory and verbal learning.

Patients were read a list of 12 semantically related words and asked to recall the list after three different learning trials. Active or sham stimulation was performed for every third word presented for immediate recall. 

The investigators found that the HVLT-R delayed recall raw score was higher for the stimulation condition, compared with the nonstimulation condition (paired t-test, P = .04; effect size, d = 0.627).

“The patients were not aware of when the RNS system was being activated. We alternated when patients were undergoing stimulation versus no stimulation, and still found that when patients’ RNS systems were activated, their memory recall score was greater than when there was no stimulation,” Dr. Haneef said in a release.

This suggests the “human memory can be potentially improved by direct electrical brain stimulation at extremely low currents,” Dr. Haneef said in an interview.

Most patients in the study had stimulation of the hippocampus, the brain’s memory center.

“Moving forward we would want to look at how different patterns or standardized stimulation patterns affect memory. Ultimately, the underlying brain rhythms responsible for these changes in brain function need to be understood so that a more targeted and precise application of electrical stimulation can be achieved,” Dr. Haneef said.

The researchers also caution that, for this preliminary study, no follow-up testing was conducted to determine whether the memory improvement was transient and settled back to baseline after a specified period.

However, they note, this study lays the groundwork for larger-scale and extensive studies examining the nuanced effects of brain stimulation on human cognition and memory.

The study was funded by the Mike Hogg Foundation. Dr. Haneef and two coauthors received coverage for travel expenses but no honorarium for a NeuroPace advisory meeting.

A version of this article first appeared on Medscape.com.

Electrical brain stimulation may have the potential to improve verbal memory, results of a small study of patients with epilepsy suggest.

Investigators observed improvements in patients implanted with a responsive neurostimulation system (RNS) to control seizures, in that the patients had improved word recall when the system was activated.

Beyond epilepsy, “we suspect that our results would be broadly applicable regardless of the underlying condition, for example, memory loss with Alzheimer’s disease or traumatic brain injury,” Zulfi Haneef, MBBS, MD, associate professor of neurology, Baylor College of Medicine, Houston, said in an interview.

“Mental health conditions such as depression or psychosis could also benefit from targeted electrical stimulation. While we focused on enhancing a preferred brain function [such as memory], parallel areas of research may target enhancing function [such as weakness following stroke] or suppressing function [to manage conditions such as chronic pain,]” Dr. Haneef added.

The study was published online Jan. 17, 2022, in Neurosurgery.

As reported by this news organization, the RNS system (NeuroPace) is approved by the Food and Drug Administration to treat medically refractory focal seizures in adults. Following implantation of the system, patients attend the clinic for adjustments about every 8-12 weeks.

The investigators studied 17 patients with epilepsy and RNS implants who attended the clinic for routine appointments. A clinical neuropsychologist administered the Hopkins Verbal Learning Test–Revised (HVLT-R), a well-validated list-learning measure of memory and verbal learning.

Patients were read a list of 12 semantically related words and asked to recall the list after three different learning trials. Active or sham stimulation was performed for every third word presented for immediate recall. 

The investigators found that the HVLT-R delayed recall raw score was higher for the stimulation condition, compared with the nonstimulation condition (paired t-test, P = .04; effect size, d = 0.627).

“The patients were not aware of when the RNS system was being activated. We alternated when patients were undergoing stimulation versus no stimulation, and still found that when patients’ RNS systems were activated, their memory recall score was greater than when there was no stimulation,” Dr. Haneef said in a release.

This suggests the “human memory can be potentially improved by direct electrical brain stimulation at extremely low currents,” Dr. Haneef said in an interview.

Most patients in the study had stimulation of the hippocampus, the brain’s memory center.

“Moving forward we would want to look at how different patterns or standardized stimulation patterns affect memory. Ultimately, the underlying brain rhythms responsible for these changes in brain function need to be understood so that a more targeted and precise application of electrical stimulation can be achieved,” Dr. Haneef said.

The researchers also caution that, for this preliminary study, no follow-up testing was conducted to determine whether the memory improvement was transient and settled back to baseline after a specified period.

However, they note, this study lays the groundwork for larger-scale and extensive studies examining the nuanced effects of brain stimulation on human cognition and memory.

The study was funded by the Mike Hogg Foundation. Dr. Haneef and two coauthors received coverage for travel expenses but no honorarium for a NeuroPace advisory meeting.

A version of this article first appeared on Medscape.com.

Three weekly infusions of the dissociative anesthetic ketamine coupled with mindfulness-based relapse prevention therapy may help adults with alcohol use disorder (AUD) maintain abstinence, new research suggests.

Preliminary results from a phase 2, double-blind, placebo-controlled trial show ketamine was well tolerated and, compared with placebo, associated with more days of abstinence from alcohol at 6 months.

The results suggest ketamine plus psychological therapy may be a “new, relatively brief treatment that has long lasting effects in AUD,” Celia Morgan, PhD, professor of psychopharmacology, University of Exeter, United Kingdom, told this news organization.

The study was published online Jan. 11 in the American Journal of Psychiatry.
 

Target depression

Depressive symptoms are common in patients under treatment for AUD and increase relapse risk.

“Ketamine may support alcohol abstinence by temporarily alleviating depressive symptoms during the high-risk relapse period in the weeks after detoxification,” the investigators note.

Ketamine may also provide a “temporary boost to synaptogenesis and neurogenesis, which may allow psychological therapies and new strategies for managing addiction to embed more readily,” they add.

To test these theories, the researchers recruited 96 adults (mean age, 44 years, 35 women) with severe AUD to participate in the trial.

All participants had to abstain from alcohol for at least 24 hours before the trial started and have a reading of 0.0 on a breath alcohol test at the baseline visit.

Participants were randomly allocated to one of four groups:

1. three weekly ketamine infusions of 0.8 mg/kg IV over 40 minutes plus psychological therapy

2. three saline infusions plus psychological therapy

3. three ketamine infusions plus alcohol education

4. three saline infusions plus alcohol education

The primary outcome was self-reported percentage of days abstinent, as well as confirmed alcohol relapse at 6-month follow-up.

At 6-month follow-up, ketamine was associated with a significantly greater number of days abstinent from alcohol (mean difference, 10.1%; 95% confidence interval, 1.1-19.0), “although confidence intervals were wide, consistent with a proof-of-concept study,” the authors note.

The greatest reduction in total days off alcohol occurred in the ketamine plus relapse-prevention therapy group compared with the saline plus alcohol education group (mean difference, 15.9%; 95% CI, 3.8-28.1).

There was no significant difference in relapse rate between the ketamine and placebo groups. No serious adverse effects were reported in any participant.
 

Growing evidence

These findings support some other studies that have also suggested a benefit of ketamine in AUD.

As reported by this news organization, one recent study found a single infusion of ketamine combined with counseling may help alcohol-dependent patients curb their drinking.

A separate study showed that a single dose of ketamine plus therapy that focused on reactivating drinking-related “maladaptive reward memories” reduced drinking urges and alcohol intake more than just ketamine or a placebo infusion alone.

“That ketamine can reduce both alcohol use and depression in AUD is encouraging therapeutically,” the researchers write.

“While a clear link between depression and AUD is acknowledged, alcohol and mental health services still struggle to meet the needs of dual-diagnosis patients, so ketamine may represent a solution to this long-standing comorbidity,” they add.

Dr. Morgan said in an interview that adjunctive ketamine with relapse-prevention therapy is “currently being delivered in Awakn Clinics in the U.K. and Norway, but we need to conduct the phase 3 trial in order to make the treatment more widely accessible.”
 

An ‘Intriguing new therapy’

Reached for comment, Timothy Brennan, MD, MPH, chief of clinical services, Addiction Institute of Mount Sinai, New York, said ketamine “continues to be an intriguing new therapy for a variety of mental health conditions.”

“Unfortunately, the study did not show any difference in rates of relapse to alcohol, though an improvement in days of abstinence is certainly noteworthy,” Dr. Brennan said in an interview.

“Because this was just a proof-of-concept study and did not compare ketamine to any FDA-approved pharmacotherapy for alcohol, it remains too early to recommend ketamine infusions to those suffering from alcohol use disorder,” he cautioned.

The study was supported by the Medical Research Council. Dr. Morgan has received royalties for KARE (Ketamine for Reduction of Alcoholic Relapse) therapy license distribution. KARE therapy is licensed from University of Exeter to Awakn Life Sciences. Dr. Morgan has received research funding from Awakn Life Sciences and has served as a consultant for Janssen Pharmaceuticals. Other coauthors have disclosed relationships with industry; the full list can be found with the original article. Dr. Brennan has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Three weekly infusions of the dissociative anesthetic ketamine coupled with mindfulness-based relapse prevention therapy may help adults with alcohol use disorder (AUD) maintain abstinence, new research suggests.

Preliminary results from a phase 2, double-blind, placebo-controlled trial show ketamine was well tolerated and, compared with placebo, associated with more days of abstinence from alcohol at 6 months.

The results suggest ketamine plus psychological therapy may be a “new, relatively brief treatment that has long lasting effects in AUD,” Celia Morgan, PhD, professor of psychopharmacology, University of Exeter, United Kingdom, told this news organization.

The study was published online Jan. 11 in the American Journal of Psychiatry.
 

Target depression

Depressive symptoms are common in patients under treatment for AUD and increase relapse risk.

“Ketamine may support alcohol abstinence by temporarily alleviating depressive symptoms during the high-risk relapse period in the weeks after detoxification,” the investigators note.

Ketamine may also provide a “temporary boost to synaptogenesis and neurogenesis, which may allow psychological therapies and new strategies for managing addiction to embed more readily,” they add.

To test these theories, the researchers recruited 96 adults (mean age, 44 years, 35 women) with severe AUD to participate in the trial.

All participants had to abstain from alcohol for at least 24 hours before the trial started and have a reading of 0.0 on a breath alcohol test at the baseline visit.

Participants were randomly allocated to one of four groups:

1. three weekly ketamine infusions of 0.8 mg/kg IV over 40 minutes plus psychological therapy

2. three saline infusions plus psychological therapy

3. three ketamine infusions plus alcohol education

4. three saline infusions plus alcohol education

The primary outcome was self-reported percentage of days abstinent, as well as confirmed alcohol relapse at 6-month follow-up.

At 6-month follow-up, ketamine was associated with a significantly greater number of days abstinent from alcohol (mean difference, 10.1%; 95% confidence interval, 1.1-19.0), “although confidence intervals were wide, consistent with a proof-of-concept study,” the authors note.

The greatest reduction in total days off alcohol occurred in the ketamine plus relapse-prevention therapy group compared with the saline plus alcohol education group (mean difference, 15.9%; 95% CI, 3.8-28.1).

There was no significant difference in relapse rate between the ketamine and placebo groups. No serious adverse effects were reported in any participant.
 

Growing evidence

These findings support some other studies that have also suggested a benefit of ketamine in AUD.

As reported by this news organization, one recent study found a single infusion of ketamine combined with counseling may help alcohol-dependent patients curb their drinking.

A separate study showed that a single dose of ketamine plus therapy that focused on reactivating drinking-related “maladaptive reward memories” reduced drinking urges and alcohol intake more than just ketamine or a placebo infusion alone.

“That ketamine can reduce both alcohol use and depression in AUD is encouraging therapeutically,” the researchers write.

“While a clear link between depression and AUD is acknowledged, alcohol and mental health services still struggle to meet the needs of dual-diagnosis patients, so ketamine may represent a solution to this long-standing comorbidity,” they add.

Dr. Morgan said in an interview that adjunctive ketamine with relapse-prevention therapy is “currently being delivered in Awakn Clinics in the U.K. and Norway, but we need to conduct the phase 3 trial in order to make the treatment more widely accessible.”
 

An ‘Intriguing new therapy’

Reached for comment, Timothy Brennan, MD, MPH, chief of clinical services, Addiction Institute of Mount Sinai, New York, said ketamine “continues to be an intriguing new therapy for a variety of mental health conditions.”

“Unfortunately, the study did not show any difference in rates of relapse to alcohol, though an improvement in days of abstinence is certainly noteworthy,” Dr. Brennan said in an interview.

“Because this was just a proof-of-concept study and did not compare ketamine to any FDA-approved pharmacotherapy for alcohol, it remains too early to recommend ketamine infusions to those suffering from alcohol use disorder,” he cautioned.

The study was supported by the Medical Research Council. Dr. Morgan has received royalties for KARE (Ketamine for Reduction of Alcoholic Relapse) therapy license distribution. KARE therapy is licensed from University of Exeter to Awakn Life Sciences. Dr. Morgan has received research funding from Awakn Life Sciences and has served as a consultant for Janssen Pharmaceuticals. Other coauthors have disclosed relationships with industry; the full list can be found with the original article. Dr. Brennan has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Three weekly infusions of the dissociative anesthetic ketamine coupled with mindfulness-based relapse prevention therapy may help adults with alcohol use disorder (AUD) maintain abstinence, new research suggests.

Preliminary results from a phase 2, double-blind, placebo-controlled trial show ketamine was well tolerated and, compared with placebo, associated with more days of abstinence from alcohol at 6 months.

The results suggest ketamine plus psychological therapy may be a “new, relatively brief treatment that has long lasting effects in AUD,” Celia Morgan, PhD, professor of psychopharmacology, University of Exeter, United Kingdom, told this news organization.

The study was published online Jan. 11 in the American Journal of Psychiatry.
 

Target depression

Depressive symptoms are common in patients under treatment for AUD and increase relapse risk.

“Ketamine may support alcohol abstinence by temporarily alleviating depressive symptoms during the high-risk relapse period in the weeks after detoxification,” the investigators note.

Ketamine may also provide a “temporary boost to synaptogenesis and neurogenesis, which may allow psychological therapies and new strategies for managing addiction to embed more readily,” they add.

To test these theories, the researchers recruited 96 adults (mean age, 44 years, 35 women) with severe AUD to participate in the trial.

All participants had to abstain from alcohol for at least 24 hours before the trial started and have a reading of 0.0 on a breath alcohol test at the baseline visit.

Participants were randomly allocated to one of four groups:

1. three weekly ketamine infusions of 0.8 mg/kg IV over 40 minutes plus psychological therapy

2. three saline infusions plus psychological therapy

3. three ketamine infusions plus alcohol education

4. three saline infusions plus alcohol education

The primary outcome was self-reported percentage of days abstinent, as well as confirmed alcohol relapse at 6-month follow-up.

At 6-month follow-up, ketamine was associated with a significantly greater number of days abstinent from alcohol (mean difference, 10.1%; 95% confidence interval, 1.1-19.0), “although confidence intervals were wide, consistent with a proof-of-concept study,” the authors note.

The greatest reduction in total days off alcohol occurred in the ketamine plus relapse-prevention therapy group compared with the saline plus alcohol education group (mean difference, 15.9%; 95% CI, 3.8-28.1).

There was no significant difference in relapse rate between the ketamine and placebo groups. No serious adverse effects were reported in any participant.
 

Growing evidence

These findings support some other studies that have also suggested a benefit of ketamine in AUD.

As reported by this news organization, one recent study found a single infusion of ketamine combined with counseling may help alcohol-dependent patients curb their drinking.

A separate study showed that a single dose of ketamine plus therapy that focused on reactivating drinking-related “maladaptive reward memories” reduced drinking urges and alcohol intake more than just ketamine or a placebo infusion alone.

“That ketamine can reduce both alcohol use and depression in AUD is encouraging therapeutically,” the researchers write.

“While a clear link between depression and AUD is acknowledged, alcohol and mental health services still struggle to meet the needs of dual-diagnosis patients, so ketamine may represent a solution to this long-standing comorbidity,” they add.

Dr. Morgan said in an interview that adjunctive ketamine with relapse-prevention therapy is “currently being delivered in Awakn Clinics in the U.K. and Norway, but we need to conduct the phase 3 trial in order to make the treatment more widely accessible.”
 

An ‘Intriguing new therapy’

Reached for comment, Timothy Brennan, MD, MPH, chief of clinical services, Addiction Institute of Mount Sinai, New York, said ketamine “continues to be an intriguing new therapy for a variety of mental health conditions.”

“Unfortunately, the study did not show any difference in rates of relapse to alcohol, though an improvement in days of abstinence is certainly noteworthy,” Dr. Brennan said in an interview.

“Because this was just a proof-of-concept study and did not compare ketamine to any FDA-approved pharmacotherapy for alcohol, it remains too early to recommend ketamine infusions to those suffering from alcohol use disorder,” he cautioned.

The study was supported by the Medical Research Council. Dr. Morgan has received royalties for KARE (Ketamine for Reduction of Alcoholic Relapse) therapy license distribution. KARE therapy is licensed from University of Exeter to Awakn Life Sciences. Dr. Morgan has received research funding from Awakn Life Sciences and has served as a consultant for Janssen Pharmaceuticals. Other coauthors have disclosed relationships with industry; the full list can be found with the original article. Dr. Brennan has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Violence against women remains a global dilemma in need of attention. Physical violence in particular, is the most prevalent type of violence across all genders, races, and nationalities.

The Centers for Disease Control and Prevention says more than 43 million women and 38 million men report experiencing psychological aggression by an intimate partner in their lifetime. Meanwhile, 11 million women and 5 million men report enduring sexual or physical violence and intimate partner violence (IPV), and/or stalking by an intimate partner during their lifetimes, according to the CDC.1

COVID pandemic’s influence

Isolation tied to the COVID-19 pandemic has been linked to increased IPV. A study conducted by researchers at the University of California, Davis, suggested that extra stress experienced during the COVID-19 pandemic caused by income loss, and the inability to pay for housing and food exacerbated the prevalence of IPV early during the pandemic.⁶

That study, where researchers collected in surveys of nearly 400 adults in the beginning in April 2020 for 10 weeks, showed that more services and communication are needed so that frontline health care and food bank workers, for example, in addition to social workers, doctors, and therapists, can spot the signs and ask clients questions about potential IPV. They could then link survivors to pertinent assistance and resources.

Furthermore, multiple factors probably have played a pivotal role in increasing the prevalence of IPV during the COVID-19 pandemic. For instance, disruption to usual health and social services as well as diminished access to support systems, such as shelters, and charity helplines negatively affected the reporting of domestic violence.

Long before the pandemic, over the past decade, international and national bodies have played a crucial role in terms of improving the awareness and response to domestic violence.^7,8 In addition, several policies have been introduced in countries around the globe emphasizing the need to inquire routinely about domestic violence. Nevertheless, mental health services often fail to adequately address domestic violence in clinical encounters. A systematic review of domestic violence assessment screening performed in a variety of health care settings found that evidence was insufficient to conclude that routine inquiry improved morbidity and mortality among victims of IPV.⁹ So the question becomes: How can we get our patients to tell us about these experiences so we can intervene?
 

Gender differences in perpetuating IPV

Several studies have found that abuse can result in various mental illnesses, such as depression, PTSD, anxiety, and suicidal ideation. Again, men have a disproportionately higher rate of perpetrating IPV, compared with women. This theory has been a source of debate in the academic community for years, but recent research has confirmed that women do perpetuate violence against their partners to some extent.^10,11

Some members of the LGBTQ+ community also report experiencing violence from partners, so as clinicians, we also need to raise our awareness about the existence of violence among same-sex couples. In fact, a team of Italian researchers report more than 50% of gay men and almost 75% of lesbian women reported that they had been psychologically abused by a partner.¹² More research into this area is needed.
 

Our role as health care professionals

The U.S. Preventive Services Task Force advises that all clinic visits include regular IPV screening.¹³ But these screenings are all too rare. In fact, a meta-analysis of 19 trials of more than 1,600 participants showed only 9%-40% of doctors routinely test for IPV.¹⁴ That research clearly shows how important it is for all clinicians to execute IPV screening. However, numerous challenges toward screening exist, including personal discomfort, limited time during appointments, insufficient resources, and inadequate training.

One ongoing debate revolves around which clinician should screen for IPV. Should the psychiatrist carry out this role – or perhaps the primary care physician, nurse, or social worker? These issues become even more fraught when clinicians worry about offending the patient – especially if the clinician is a male.¹⁵

The bottom line is that physicians should inquire about intimate partner violence, because research indicates that women are more likely to reveal abuse when prompted. In addition, during physician appointments, they can use the physician-patient therapeutic connection to conduct a domestic violence evaluation, give resources to victims, and provide ongoing care. Patients who exhibit treatment resistance, persistent pain, depression, sleeplessness, and headaches should prompt psychiatrists to conduct additional investigations into the likelihood of intimate partner violence and domestic abuse.

W also should be attentive when counseling patients about domestic violence when suggesting life-changing events such as pregnancy, employment loss, separation, or divorce. Similar to the recommendations of the USPSTF that all women and men should be screened for IPV, it is suggested that physicians be conscious of facilitating a conversation and not being overtly judgmental while observing body cues. Using the statements such as “we have been hearing a lot of violence in our community lately” could be a segue to introduce the subject.

Asking the question of whether you are being hit rather than being abused has allowed more women to open up more about domestic violence. While physicians are aware that most victims might recant and often go back to their abusers, victims need to be counseled that the abuse might intensify and lead to death.

For women who perpetuate IPV and survivors of IPV, safety is the priority. Physicians should provide safety options and be the facilitators. Studies have shown that fewer victims get the referral to the supporting agencies when IPV is indicated, which puts their safety at risk. In women who commit IPV, clinicians should assess the role of the individual in an IPV disclosure. There are various treatment modalities, whether the violence is performed through self-defense, bidirectionally, or because of aggression.

With the advancement of technology, web-based training on how to ask for IPV, documentation, acknowledgment, and structured referral increase physicians’ confidence when faced with an IPV disclosure than none.¹⁶ Treatment modalities should include medication reconciliation and cognitive-behavioral therapy – focusing on emotion regulation.

Using instruments such as the danger assessment tool can help physicians intervene early, reducing the risk of domestic violence and IPV recurrence instead of using clinical assessment alone.¹⁷ Physicians should convey empathy, validate victims, and help, especially when abuse is reported.

Also, it is important to evaluate survivors’ safety. Counseling can help people rebuild their self-esteem. Structured referrals for psychiatric help and support services are needed to help survivors on the long road to recovery.

Training all physicians, regardless of specialty, is essential to improve prompt IPV identification and bring awareness to resources available to survivors when IPV is disclosed. Although we described an association between IPV victims becoming possible perpetrators of IPV, more long-term studies are required to show the various processes that influence IPV perpetration rates, especially by survivors.

We would also like international and national regulatory bodies to increase the awareness of IPV and adequately address IPV with special emphasis on how mental health services should assess, identify, and respond to services for people who are survivors and perpetrators of IPV.

Dr. Kumari, Dr. Otite, Dr. Afzal, Dr. Alcera, and Dr. Doumas are affiliated with Hackensack Meridian Health at Ocean Medical Center, Brick, N.J. They have no conflicts of interest.

References

1. Centers for Disease Control and Prevention. Preventing intimate partner violence. 2020 Oct 9.

2. Yu R et al. PLOS Med. 16(12):e1002995. doi: 10.1371/journal.pmed.1002995.

3. Oram S et al. Epidemiol Psychiatr Sci. 2014 Dec;23(4):361-76.

4. Munro OE and Sellbom M. Pers Ment Health. 2020 Mar 11. doi: 10.1002/pmh.1480.

5. Sahraian A et al. Asian J Psychiatry. 2020 Jun. doi: 10.1016/j.ajp.2020.102062.

6. Nikos-Rose K. “COVID-19 Isolation Linked to Increased Domestic Violence, Researchers Suggest.” 2021 Feb 24. University of California, Davis.

7. World Health Organization. “Responding to intimate partner violence and sexual violence against women.” WHO clinical policy guidelines. 2013.

8. National Institute for Health and Care Excellence. “Domestic violence and abuse: Multi-agency working.” PH50. 2014 Feb 26.

9. Feder GS et al. Arch Intern Med. 2006;166(1):22-37.

10. Gondolf EW. Violence Against Women. 2014 Dec;20(12)1539-46.

11. Hamberger LK and Larsen SE. J Fam Violence. 2015;30(6):699-717.

12. Rollè L et al. Front Psychol. 21 Aug 2018. doi: 10.3389/fpsyg.2018.01506.

13. Paterno MT and Draughon JE. J Midwif Women Health. 2016;61(31):370-5.

14. Kalra N et al. Cochrane Database Syst Rev. 2021 May 31;5(5)CD012423.

15. Larsen SE and Hamberger LK. J Fam Viol. 2015;30:1007-30.

16. Kalra N et al. Cochrane Database Syst Rev. 2017 Feb;2017(2):CD012423.

17. Campbell JC et al. J Interpers Violence. 2009;24(4):653-74.

Violence against women remains a global dilemma in need of attention. Physical violence in particular, is the most prevalent type of violence across all genders, races, and nationalities.

The Centers for Disease Control and Prevention says more than 43 million women and 38 million men report experiencing psychological aggression by an intimate partner in their lifetime. Meanwhile, 11 million women and 5 million men report enduring sexual or physical violence and intimate partner violence (IPV), and/or stalking by an intimate partner during their lifetimes, according to the CDC.1

COVID pandemic’s influence

Isolation tied to the COVID-19 pandemic has been linked to increased IPV. A study conducted by researchers at the University of California, Davis, suggested that extra stress experienced during the COVID-19 pandemic caused by income loss, and the inability to pay for housing and food exacerbated the prevalence of IPV early during the pandemic.⁶

That study, where researchers collected in surveys of nearly 400 adults in the beginning in April 2020 for 10 weeks, showed that more services and communication are needed so that frontline health care and food bank workers, for example, in addition to social workers, doctors, and therapists, can spot the signs and ask clients questions about potential IPV. They could then link survivors to pertinent assistance and resources.

Furthermore, multiple factors probably have played a pivotal role in increasing the prevalence of IPV during the COVID-19 pandemic. For instance, disruption to usual health and social services as well as diminished access to support systems, such as shelters, and charity helplines negatively affected the reporting of domestic violence.

Long before the pandemic, over the past decade, international and national bodies have played a crucial role in terms of improving the awareness and response to domestic violence.^7,8 In addition, several policies have been introduced in countries around the globe emphasizing the need to inquire routinely about domestic violence. Nevertheless, mental health services often fail to adequately address domestic violence in clinical encounters. A systematic review of domestic violence assessment screening performed in a variety of health care settings found that evidence was insufficient to conclude that routine inquiry improved morbidity and mortality among victims of IPV.⁹ So the question becomes: How can we get our patients to tell us about these experiences so we can intervene?
 

Gender differences in perpetuating IPV

Several studies have found that abuse can result in various mental illnesses, such as depression, PTSD, anxiety, and suicidal ideation. Again, men have a disproportionately higher rate of perpetrating IPV, compared with women. This theory has been a source of debate in the academic community for years, but recent research has confirmed that women do perpetuate violence against their partners to some extent.^10,11

Some members of the LGBTQ+ community also report experiencing violence from partners, so as clinicians, we also need to raise our awareness about the existence of violence among same-sex couples. In fact, a team of Italian researchers report more than 50% of gay men and almost 75% of lesbian women reported that they had been psychologically abused by a partner.¹² More research into this area is needed.
 

Our role as health care professionals

The U.S. Preventive Services Task Force advises that all clinic visits include regular IPV screening.¹³ But these screenings are all too rare. In fact, a meta-analysis of 19 trials of more than 1,600 participants showed only 9%-40% of doctors routinely test for IPV.¹⁴ That research clearly shows how important it is for all clinicians to execute IPV screening. However, numerous challenges toward screening exist, including personal discomfort, limited time during appointments, insufficient resources, and inadequate training.

One ongoing debate revolves around which clinician should screen for IPV. Should the psychiatrist carry out this role – or perhaps the primary care physician, nurse, or social worker? These issues become even more fraught when clinicians worry about offending the patient – especially if the clinician is a male.¹⁵

The bottom line is that physicians should inquire about intimate partner violence, because research indicates that women are more likely to reveal abuse when prompted. In addition, during physician appointments, they can use the physician-patient therapeutic connection to conduct a domestic violence evaluation, give resources to victims, and provide ongoing care. Patients who exhibit treatment resistance, persistent pain, depression, sleeplessness, and headaches should prompt psychiatrists to conduct additional investigations into the likelihood of intimate partner violence and domestic abuse.

W also should be attentive when counseling patients about domestic violence when suggesting life-changing events such as pregnancy, employment loss, separation, or divorce. Similar to the recommendations of the USPSTF that all women and men should be screened for IPV, it is suggested that physicians be conscious of facilitating a conversation and not being overtly judgmental while observing body cues. Using the statements such as “we have been hearing a lot of violence in our community lately” could be a segue to introduce the subject.

Asking the question of whether you are being hit rather than being abused has allowed more women to open up more about domestic violence. While physicians are aware that most victims might recant and often go back to their abusers, victims need to be counseled that the abuse might intensify and lead to death.

For women who perpetuate IPV and survivors of IPV, safety is the priority. Physicians should provide safety options and be the facilitators. Studies have shown that fewer victims get the referral to the supporting agencies when IPV is indicated, which puts their safety at risk. In women who commit IPV, clinicians should assess the role of the individual in an IPV disclosure. There are various treatment modalities, whether the violence is performed through self-defense, bidirectionally, or because of aggression.

With the advancement of technology, web-based training on how to ask for IPV, documentation, acknowledgment, and structured referral increase physicians’ confidence when faced with an IPV disclosure than none.¹⁶ Treatment modalities should include medication reconciliation and cognitive-behavioral therapy – focusing on emotion regulation.

Using instruments such as the danger assessment tool can help physicians intervene early, reducing the risk of domestic violence and IPV recurrence instead of using clinical assessment alone.¹⁷ Physicians should convey empathy, validate victims, and help, especially when abuse is reported.

Also, it is important to evaluate survivors’ safety. Counseling can help people rebuild their self-esteem. Structured referrals for psychiatric help and support services are needed to help survivors on the long road to recovery.

Training all physicians, regardless of specialty, is essential to improve prompt IPV identification and bring awareness to resources available to survivors when IPV is disclosed. Although we described an association between IPV victims becoming possible perpetrators of IPV, more long-term studies are required to show the various processes that influence IPV perpetration rates, especially by survivors.

We would also like international and national regulatory bodies to increase the awareness of IPV and adequately address IPV with special emphasis on how mental health services should assess, identify, and respond to services for people who are survivors and perpetrators of IPV.

Dr. Kumari, Dr. Otite, Dr. Afzal, Dr. Alcera, and Dr. Doumas are affiliated with Hackensack Meridian Health at Ocean Medical Center, Brick, N.J. They have no conflicts of interest.

References

1. Centers for Disease Control and Prevention. Preventing intimate partner violence. 2020 Oct 9.

2. Yu R et al. PLOS Med. 16(12):e1002995. doi: 10.1371/journal.pmed.1002995.

3. Oram S et al. Epidemiol Psychiatr Sci. 2014 Dec;23(4):361-76.

4. Munro OE and Sellbom M. Pers Ment Health. 2020 Mar 11. doi: 10.1002/pmh.1480.

5. Sahraian A et al. Asian J Psychiatry. 2020 Jun. doi: 10.1016/j.ajp.2020.102062.

6. Nikos-Rose K. “COVID-19 Isolation Linked to Increased Domestic Violence, Researchers Suggest.” 2021 Feb 24. University of California, Davis.

7. World Health Organization. “Responding to intimate partner violence and sexual violence against women.” WHO clinical policy guidelines. 2013.

8. National Institute for Health and Care Excellence. “Domestic violence and abuse: Multi-agency working.” PH50. 2014 Feb 26.

9. Feder GS et al. Arch Intern Med. 2006;166(1):22-37.

10. Gondolf EW. Violence Against Women. 2014 Dec;20(12)1539-46.

11. Hamberger LK and Larsen SE. J Fam Violence. 2015;30(6):699-717.

12. Rollè L et al. Front Psychol. 21 Aug 2018. doi: 10.3389/fpsyg.2018.01506.

13. Paterno MT and Draughon JE. J Midwif Women Health. 2016;61(31):370-5.

14. Kalra N et al. Cochrane Database Syst Rev. 2021 May 31;5(5)CD012423.

15. Larsen SE and Hamberger LK. J Fam Viol. 2015;30:1007-30.

16. Kalra N et al. Cochrane Database Syst Rev. 2017 Feb;2017(2):CD012423.

17. Campbell JC et al. J Interpers Violence. 2009;24(4):653-74.

Violence against women remains a global dilemma in need of attention. Physical violence in particular, is the most prevalent type of violence across all genders, races, and nationalities.

The Centers for Disease Control and Prevention says more than 43 million women and 38 million men report experiencing psychological aggression by an intimate partner in their lifetime. Meanwhile, 11 million women and 5 million men report enduring sexual or physical violence and intimate partner violence (IPV), and/or stalking by an intimate partner during their lifetimes, according to the CDC.1

COVID pandemic’s influence

Isolation tied to the COVID-19 pandemic has been linked to increased IPV. A study conducted by researchers at the University of California, Davis, suggested that extra stress experienced during the COVID-19 pandemic caused by income loss, and the inability to pay for housing and food exacerbated the prevalence of IPV early during the pandemic.⁶

That study, where researchers collected in surveys of nearly 400 adults in the beginning in April 2020 for 10 weeks, showed that more services and communication are needed so that frontline health care and food bank workers, for example, in addition to social workers, doctors, and therapists, can spot the signs and ask clients questions about potential IPV. They could then link survivors to pertinent assistance and resources.

Furthermore, multiple factors probably have played a pivotal role in increasing the prevalence of IPV during the COVID-19 pandemic. For instance, disruption to usual health and social services as well as diminished access to support systems, such as shelters, and charity helplines negatively affected the reporting of domestic violence.

Long before the pandemic, over the past decade, international and national bodies have played a crucial role in terms of improving the awareness and response to domestic violence.^7,8 In addition, several policies have been introduced in countries around the globe emphasizing the need to inquire routinely about domestic violence. Nevertheless, mental health services often fail to adequately address domestic violence in clinical encounters. A systematic review of domestic violence assessment screening performed in a variety of health care settings found that evidence was insufficient to conclude that routine inquiry improved morbidity and mortality among victims of IPV.⁹ So the question becomes: How can we get our patients to tell us about these experiences so we can intervene?
 

Gender differences in perpetuating IPV

Several studies have found that abuse can result in various mental illnesses, such as depression, PTSD, anxiety, and suicidal ideation. Again, men have a disproportionately higher rate of perpetrating IPV, compared with women. This theory has been a source of debate in the academic community for years, but recent research has confirmed that women do perpetuate violence against their partners to some extent.^10,11

Some members of the LGBTQ+ community also report experiencing violence from partners, so as clinicians, we also need to raise our awareness about the existence of violence among same-sex couples. In fact, a team of Italian researchers report more than 50% of gay men and almost 75% of lesbian women reported that they had been psychologically abused by a partner.¹² More research into this area is needed.
 

Our role as health care professionals

The U.S. Preventive Services Task Force advises that all clinic visits include regular IPV screening.¹³ But these screenings are all too rare. In fact, a meta-analysis of 19 trials of more than 1,600 participants showed only 9%-40% of doctors routinely test for IPV.¹⁴ That research clearly shows how important it is for all clinicians to execute IPV screening. However, numerous challenges toward screening exist, including personal discomfort, limited time during appointments, insufficient resources, and inadequate training.

One ongoing debate revolves around which clinician should screen for IPV. Should the psychiatrist carry out this role – or perhaps the primary care physician, nurse, or social worker? These issues become even more fraught when clinicians worry about offending the patient – especially if the clinician is a male.¹⁵

The bottom line is that physicians should inquire about intimate partner violence, because research indicates that women are more likely to reveal abuse when prompted. In addition, during physician appointments, they can use the physician-patient therapeutic connection to conduct a domestic violence evaluation, give resources to victims, and provide ongoing care. Patients who exhibit treatment resistance, persistent pain, depression, sleeplessness, and headaches should prompt psychiatrists to conduct additional investigations into the likelihood of intimate partner violence and domestic abuse.

W also should be attentive when counseling patients about domestic violence when suggesting life-changing events such as pregnancy, employment loss, separation, or divorce. Similar to the recommendations of the USPSTF that all women and men should be screened for IPV, it is suggested that physicians be conscious of facilitating a conversation and not being overtly judgmental while observing body cues. Using the statements such as “we have been hearing a lot of violence in our community lately” could be a segue to introduce the subject.

Asking the question of whether you are being hit rather than being abused has allowed more women to open up more about domestic violence. While physicians are aware that most victims might recant and often go back to their abusers, victims need to be counseled that the abuse might intensify and lead to death.

For women who perpetuate IPV and survivors of IPV, safety is the priority. Physicians should provide safety options and be the facilitators. Studies have shown that fewer victims get the referral to the supporting agencies when IPV is indicated, which puts their safety at risk. In women who commit IPV, clinicians should assess the role of the individual in an IPV disclosure. There are various treatment modalities, whether the violence is performed through self-defense, bidirectionally, or because of aggression.

With the advancement of technology, web-based training on how to ask for IPV, documentation, acknowledgment, and structured referral increase physicians’ confidence when faced with an IPV disclosure than none.¹⁶ Treatment modalities should include medication reconciliation and cognitive-behavioral therapy – focusing on emotion regulation.

Using instruments such as the danger assessment tool can help physicians intervene early, reducing the risk of domestic violence and IPV recurrence instead of using clinical assessment alone.¹⁷ Physicians should convey empathy, validate victims, and help, especially when abuse is reported.

Also, it is important to evaluate survivors’ safety. Counseling can help people rebuild their self-esteem. Structured referrals for psychiatric help and support services are needed to help survivors on the long road to recovery.

Training all physicians, regardless of specialty, is essential to improve prompt IPV identification and bring awareness to resources available to survivors when IPV is disclosed. Although we described an association between IPV victims becoming possible perpetrators of IPV, more long-term studies are required to show the various processes that influence IPV perpetration rates, especially by survivors.

We would also like international and national regulatory bodies to increase the awareness of IPV and adequately address IPV with special emphasis on how mental health services should assess, identify, and respond to services for people who are survivors and perpetrators of IPV.

Dr. Kumari, Dr. Otite, Dr. Afzal, Dr. Alcera, and Dr. Doumas are affiliated with Hackensack Meridian Health at Ocean Medical Center, Brick, N.J. They have no conflicts of interest.

References

1. Centers for Disease Control and Prevention. Preventing intimate partner violence. 2020 Oct 9.

2. Yu R et al. PLOS Med. 16(12):e1002995. doi: 10.1371/journal.pmed.1002995.

3. Oram S et al. Epidemiol Psychiatr Sci. 2014 Dec;23(4):361-76.

4. Munro OE and Sellbom M. Pers Ment Health. 2020 Mar 11. doi: 10.1002/pmh.1480.

5. Sahraian A et al. Asian J Psychiatry. 2020 Jun. doi: 10.1016/j.ajp.2020.102062.

6. Nikos-Rose K. “COVID-19 Isolation Linked to Increased Domestic Violence, Researchers Suggest.” 2021 Feb 24. University of California, Davis.

7. World Health Organization. “Responding to intimate partner violence and sexual violence against women.” WHO clinical policy guidelines. 2013.

8. National Institute for Health and Care Excellence. “Domestic violence and abuse: Multi-agency working.” PH50. 2014 Feb 26.

9. Feder GS et al. Arch Intern Med. 2006;166(1):22-37.

10. Gondolf EW. Violence Against Women. 2014 Dec;20(12)1539-46.

11. Hamberger LK and Larsen SE. J Fam Violence. 2015;30(6):699-717.

12. Rollè L et al. Front Psychol. 21 Aug 2018. doi: 10.3389/fpsyg.2018.01506.

13. Paterno MT and Draughon JE. J Midwif Women Health. 2016;61(31):370-5.

14. Kalra N et al. Cochrane Database Syst Rev. 2021 May 31;5(5)CD012423.

15. Larsen SE and Hamberger LK. J Fam Viol. 2015;30:1007-30.

16. Kalra N et al. Cochrane Database Syst Rev. 2017 Feb;2017(2):CD012423.

17. Campbell JC et al. J Interpers Violence. 2009;24(4):653-74.

Depending on the data you’re looking at, 40%-60% of physicians are burned out.

Research studies and the eye test reveal the painfully obvious: Colleagues are tired, winded, spent, and at times way past burned out. People aren’t asking me if they’re burned out. They know they’re burned out; heck, they can even recite the Maslach burnout inventory, forward and backward, in a mask, or while completing a COVID quarantine. A fair share of people know the key steps to prevent burnout and promote recovery.

What I’m starting to see more of is, “Why should I even bother to recover from this? Why pick myself up again just to get another occupational stress injury (burnout, demoralization, moral injury, etc.)?” In other words, it’s not just simply about negating burnout; it’s about supporting and facilitating the motivation to work.

We’ve been through so much with COVID that it might be challenging to remember when you saw a truly engaged work environment. No doubt, we have outstanding professionals across medicine who answer the bell every day. However, if you’ve been looking closely, many teams/units have lost a bit of the zip and pep. The synergy and trust aren’t as smooth, and at noon, everyone counts the hours to the end of the shift.

You may be thinking, Well, of course, they are; we’re still amid a pandemic, and people have been through hell. Your observation would be correct, except I’ve personally seen some teams weather the pandemic storm and still remain engaged (some even more involved).

The No. 1 consult result for the GW Resiliency and Well-Being Center, where I work, has been on lectures for burnout. The R&WC has given so many of these lectures that my dreams take the form of a PowerPoint presentation. Overall the talks have gone very well. We’ve added skills sections on practices of whole-person care. We’ve blitzed the daylights out of restorative sleep, yet I know we are still searching for the correct narrative.

Motivated staff, faculty, and students will genuinely take in the information and follow the recommendations; however, they still struggle to find that drive and zest for work. Yes, moving from burnout to neutral is reasonable but likely won’t move the needle of your professional or personal life. We need to have the emotional energy and the clear desire to utilize that energy for a meaningful purpose.

Talking about burnout in specific ways is straightforward and, in my opinion, much easier than talking about engagement. Part of the challenge when trying to discuss engagement is that people can feel invalidated or that you’re telling them to be stoic. Or worse yet, that the problem of burnout primarily lies with them. It’s essential to recognize the role of an organizational factor in burnout (approximately 80%, depending on the study); still, even if you address burnout, people may not be miserable, but it doesn’t mean they will stay at their current job (please cue intro music for the Great Resignation).

Engagement models have existed for some time and certainly have gained much more attention in health care settings over the past 2 decades. Engagement can be described as having three components: dedication, vigor, and absorption. When a person is filling all three of these components over time, presto – you get the much-sought-after state of the supremely engaged professional.

These models definitely give us excellent starting points to approach engagement from a pre-COVID era. In COVID and beyond, I’m not sure how these models will stand up in a hybrid work environment, where autonomy and flexibility could be more valued than ever. Personally, COVID revealed some things I was missing in my work pre-COVID:

• Time to think and process. This was one of the great things about being a consultation-liaison psychiatrist; it was literally feast or famine.
• Doing what I’m talented at and really enjoy.
• Time is short, and I want to be more present in the life of my family.
• Growth and curiosity are vitally important to me. These have to be part of my daily ritual and practice.

The list above isn’t exhaustive, but I’ve found them to be my own personal recipe for being engaged. Over the next series of articles, I’m going to focus on engagement and factors related to key resilience. These articles will be informed by a front-line view from my colleagues, and hopefully start to separate the myth from reality on the subject of health professional engagement and resilience.

Everyone be safe and well!

A version of this article first appeared on Medscape.com.

Depending on the data you’re looking at, 40%-60% of physicians are burned out.

Research studies and the eye test reveal the painfully obvious: Colleagues are tired, winded, spent, and at times way past burned out. People aren’t asking me if they’re burned out. They know they’re burned out; heck, they can even recite the Maslach burnout inventory, forward and backward, in a mask, or while completing a COVID quarantine. A fair share of people know the key steps to prevent burnout and promote recovery.

What I’m starting to see more of is, “Why should I even bother to recover from this? Why pick myself up again just to get another occupational stress injury (burnout, demoralization, moral injury, etc.)?” In other words, it’s not just simply about negating burnout; it’s about supporting and facilitating the motivation to work.

We’ve been through so much with COVID that it might be challenging to remember when you saw a truly engaged work environment. No doubt, we have outstanding professionals across medicine who answer the bell every day. However, if you’ve been looking closely, many teams/units have lost a bit of the zip and pep. The synergy and trust aren’t as smooth, and at noon, everyone counts the hours to the end of the shift.

You may be thinking, Well, of course, they are; we’re still amid a pandemic, and people have been through hell. Your observation would be correct, except I’ve personally seen some teams weather the pandemic storm and still remain engaged (some even more involved).

The No. 1 consult result for the GW Resiliency and Well-Being Center, where I work, has been on lectures for burnout. The R&WC has given so many of these lectures that my dreams take the form of a PowerPoint presentation. Overall the talks have gone very well. We’ve added skills sections on practices of whole-person care. We’ve blitzed the daylights out of restorative sleep, yet I know we are still searching for the correct narrative.

Motivated staff, faculty, and students will genuinely take in the information and follow the recommendations; however, they still struggle to find that drive and zest for work. Yes, moving from burnout to neutral is reasonable but likely won’t move the needle of your professional or personal life. We need to have the emotional energy and the clear desire to utilize that energy for a meaningful purpose.

Talking about burnout in specific ways is straightforward and, in my opinion, much easier than talking about engagement. Part of the challenge when trying to discuss engagement is that people can feel invalidated or that you’re telling them to be stoic. Or worse yet, that the problem of burnout primarily lies with them. It’s essential to recognize the role of an organizational factor in burnout (approximately 80%, depending on the study); still, even if you address burnout, people may not be miserable, but it doesn’t mean they will stay at their current job (please cue intro music for the Great Resignation).

Engagement models have existed for some time and certainly have gained much more attention in health care settings over the past 2 decades. Engagement can be described as having three components: dedication, vigor, and absorption. When a person is filling all three of these components over time, presto – you get the much-sought-after state of the supremely engaged professional.

These models definitely give us excellent starting points to approach engagement from a pre-COVID era. In COVID and beyond, I’m not sure how these models will stand up in a hybrid work environment, where autonomy and flexibility could be more valued than ever. Personally, COVID revealed some things I was missing in my work pre-COVID:

• Time to think and process. This was one of the great things about being a consultation-liaison psychiatrist; it was literally feast or famine.
• Doing what I’m talented at and really enjoy.
• Time is short, and I want to be more present in the life of my family.
• Growth and curiosity are vitally important to me. These have to be part of my daily ritual and practice.

The list above isn’t exhaustive, but I’ve found them to be my own personal recipe for being engaged. Over the next series of articles, I’m going to focus on engagement and factors related to key resilience. These articles will be informed by a front-line view from my colleagues, and hopefully start to separate the myth from reality on the subject of health professional engagement and resilience.

Everyone be safe and well!

A version of this article first appeared on Medscape.com.

Depending on the data you’re looking at, 40%-60% of physicians are burned out.

Research studies and the eye test reveal the painfully obvious: Colleagues are tired, winded, spent, and at times way past burned out. People aren’t asking me if they’re burned out. They know they’re burned out; heck, they can even recite the Maslach burnout inventory, forward and backward, in a mask, or while completing a COVID quarantine. A fair share of people know the key steps to prevent burnout and promote recovery.

What I’m starting to see more of is, “Why should I even bother to recover from this? Why pick myself up again just to get another occupational stress injury (burnout, demoralization, moral injury, etc.)?” In other words, it’s not just simply about negating burnout; it’s about supporting and facilitating the motivation to work.

We’ve been through so much with COVID that it might be challenging to remember when you saw a truly engaged work environment. No doubt, we have outstanding professionals across medicine who answer the bell every day. However, if you’ve been looking closely, many teams/units have lost a bit of the zip and pep. The synergy and trust aren’t as smooth, and at noon, everyone counts the hours to the end of the shift.

You may be thinking, Well, of course, they are; we’re still amid a pandemic, and people have been through hell. Your observation would be correct, except I’ve personally seen some teams weather the pandemic storm and still remain engaged (some even more involved).

The No. 1 consult result for the GW Resiliency and Well-Being Center, where I work, has been on lectures for burnout. The R&WC has given so many of these lectures that my dreams take the form of a PowerPoint presentation. Overall the talks have gone very well. We’ve added skills sections on practices of whole-person care. We’ve blitzed the daylights out of restorative sleep, yet I know we are still searching for the correct narrative.

Motivated staff, faculty, and students will genuinely take in the information and follow the recommendations; however, they still struggle to find that drive and zest for work. Yes, moving from burnout to neutral is reasonable but likely won’t move the needle of your professional or personal life. We need to have the emotional energy and the clear desire to utilize that energy for a meaningful purpose.

Talking about burnout in specific ways is straightforward and, in my opinion, much easier than talking about engagement. Part of the challenge when trying to discuss engagement is that people can feel invalidated or that you’re telling them to be stoic. Or worse yet, that the problem of burnout primarily lies with them. It’s essential to recognize the role of an organizational factor in burnout (approximately 80%, depending on the study); still, even if you address burnout, people may not be miserable, but it doesn’t mean they will stay at their current job (please cue intro music for the Great Resignation).

Engagement models have existed for some time and certainly have gained much more attention in health care settings over the past 2 decades. Engagement can be described as having three components: dedication, vigor, and absorption. When a person is filling all three of these components over time, presto – you get the much-sought-after state of the supremely engaged professional.

These models definitely give us excellent starting points to approach engagement from a pre-COVID era. In COVID and beyond, I’m not sure how these models will stand up in a hybrid work environment, where autonomy and flexibility could be more valued than ever. Personally, COVID revealed some things I was missing in my work pre-COVID:

• Time to think and process. This was one of the great things about being a consultation-liaison psychiatrist; it was literally feast or famine.
• Doing what I’m talented at and really enjoy.
• Time is short, and I want to be more present in the life of my family.
• Growth and curiosity are vitally important to me. These have to be part of my daily ritual and practice.

The list above isn’t exhaustive, but I’ve found them to be my own personal recipe for being engaged. Over the next series of articles, I’m going to focus on engagement and factors related to key resilience. These articles will be informed by a front-line view from my colleagues, and hopefully start to separate the myth from reality on the subject of health professional engagement and resilience.

Everyone be safe and well!

A version of this article first appeared on Medscape.com.

Almost 4 years had passed since Pearl Harbor forced the United States into the Second World War when three military and government services members went to the American Psychiatric Association with a plea: They needed soldiers who could pass the military’s mental and emotional health screening.

The military had rejected or discharged more than 2.5 million servicemen and volunteers on mental health grounds, and frustrated psychiatrists in the service didn’t know where else to turn but to their century-old professional psychiatric organization.

But the APA had grown so large and unwieldy by then that its size, bureaucracy, and singular focus on research left few resources for helping solve an urgent national mental health problem, no matter how worthy it was.

“At the time, the APA was kind of the face of organized psychiatry, but it was organized in a way that did not lend itself to addressing the needs of the military,” said Jack W. Bonner III, MD, professor emeritus of psychiatry at the University of South Carolina, Greenville. “It was considered sort of a stodgy organization that really wasn’t nimble enough to reorganize to look at those needs at that point in time.”

And that, the military psychiatrists decided, would not do. Desperate to solve the problem, they took matters into their own hands.

Nearly 2 years later, 15 psychiatrists, mostly military or ex-military, gathered in the hotel room of the U.S. Army Medical Corps chief of neuropsychiatry the night before the annual APA conference. It was 1946, and America had won the war – but with a huge toll on mental health, both in and out of the military. Aside from veterans’ “shell shock” and the specter of inadequate troops for potential future conflicts, huge social shifts had occurred during the war, and public mental health hospitals and community resources had deteriorated just as demand for psychiatrists and mental health personnel well outstripped supply.

If the APA wasn’t going to tackle these problems head on, the 15 psychiatrists decided, they would force it to, and they enshrined that goal in the name they gave themselves: the Group for the Advancement of Psychiatry. Two days later, three of them challenged incumbent APA officers in elections and won. The infiltration of these “Young Turks,” as they thought of themselves, had begun. From that point forward, GAP members have frequently held APA leadership positions, and APA leaders have often gone on to join GAP. Gradually, the smaller upstart organization nudged the behemoth toward more involvement with social issues, but GAP remains more nimble given its size.

“The APA is a pretty leviathan organization and can’t deal with issues in the same way a smaller organization can, and GAP can fulfill that role of being much more responsive to contemporary issues,” said Dr. Bonner, who is a member of GAP’s planning, marketing, and communications committee.
 

The think tank of psychiatry

If it seems strange today that such progressivism arose from military medical officers, equally striking is how that nascent group has improbably grown from its modest, pragmatic beginnings into a psychiatry “think tank” today. Now in its 75th year, GAP can boast of its influence at the locus of nearly every intersection of society and psychiatry, from mental health care in prisons to use of controversial treatments such as shock therapy, from racial tensions to gender inequality, from medical school curricula to mental institution standards, from LBGTQ rights to climate change.

“We’re not here to do the latest double-blind, placebo-controlled research on things,” said Lawrence S. Gross, MD, president of GAP, professor of clinical psychiatry and the behavioral sciences at the University of Southern California, Los Angeles, and a member of the committee on psychopharmacology. “It’s more for leaders to think about issues in different areas that affect the field of psychiatry and how they interface with society.”

Or, more simply, “GAP is a group that predominantly exists for one major purpose, and that is to add to the body of knowledge in the field,” said Sy Saeed, MD, MS, chair of the department of psychiatry at East Carolina University, Greenville, N.C., and chair of the group’s administration and leadership committee.

And the organization doesn’t shy from controversial topics, either, such as examining direct-to-consumer marketing and when patients should stop antidepressant therapy.

“We’re very good at getting marketed to on when to start medications, but how good are we at actually timing when to cut back on them? How long is long enough to treat?” Dr. Gross asked. The organization continues to have “an undercurrent of recognizing and fostering change and making people aware of things that may be controversial at times but also further the field by looking at these different areas of psychiatry.”

Despite the group’s relatively small size of about 200 members, its impact touches nearly everyone in the profession, whether they realize it or not. And though the group certainly has its weaknesses – such as steep membership fees that may deter some from joining and its need to improve membership diversity – GAP actively seeks ways to address these internal challenges just as it does external ones.

“It’s probably one of the best-kept secrets in psychiatry,” Dr. Gross said. But it’s a secret the members want out. That’s one reason members consider the organization’s crown jewel to be its fellowship program. In fact, Steven S. Sharfstein, MD, MPA, a former GAP president, clinical professor of psychiatry at the University of Maryland, Baltimore, and chair of the planning, marketing, and communications committee, did not formally join GAP until the 1980s. But he first became involved with the group as a resident in the fellowship program in 1969.

In its current incarnation, 12 fellows spend 2 years as working members of GAP, assigned to one of its committees to put in work just like every other member is expected to do, but they reap the wisdom and mentorship of its members at the same time.

One thing that makes GAP so special to its members is the ability “to mentor young psychiatrists, going from generation to generation trying to identify leaders and facilitate their growth,” Dr. Gross said. And that process, through not only the fellowship program but also through the members’ diversity of ages and career stages, sustains the organization’s vigor.

“Its strength is that you create this continuum where senior people get to mentor people who are early in their career, and this way, the knowledge continues,” Dr. Saaed said.
 

Creation, not death, by committee

In the early years, GAP’s longevity was in question. Once it had successfully steered the APA toward taking more action to address social problems, did it still have a role to play? A majority of members decided that it did. “New problems arose as old ones were solved,” wrote the late Albert Deutsch in an early history of GAP, and “some steps which were confidently expected to repair an ill or defect did not turn out to be completely effective.” In its first decade, GAP members led the APA to establish new medical director and director of information positions, to improve professional standards and facilitate improvement of mental health facilities, and to expand training.

But where GAP really excelled was in developing projects, something the APA wasn’t well-suited to do, explained Carol C. Nadelson, MD, professor of psychiatry at Harvard Medical School, Boston, a member of the gender and mental health committee, and a past president of GAP. And the breadth of those projects has “expanded as the field has changed and evolved,” said Dr. Nadelson, the first woman president of the APA.

Those projects, the beating heart of GAP’s work, come from its specialized working committees, groups of 6-12 members who spend a couple years focused on a single question or problem in psychiatry that the committee has decided needs attention. The number of committees has grown from 9 at its founding to 32 today, shrinking and expanding as society’s needs demand. Each committee looks for an area it thinks is important and needs attention or updating and then decides how to proceed in addressing it. This structure as a confederation of committees differs greatly from other medical organizations.

“Committees really function in an autonomous, almost independent manner,” Dr. Bonner said. “They control their work, what they do, and how they do it, and the executive structure of the organization has very little impact on those individual committees.”

It’s only when a committee produces whatever project it’s working on that it’s disseminated to the rest of the organization for review.

“The fact that it’s such a federated organization is both a strength and a weakness,” said Roberto Lewis-Fernández, MD, professor of clinical psychiatry at Columbia University, New York, and chair of the cultural psychiatry committee. The tension between becoming too siloed within a committee and needing some sense of greater unity and the cross-pollination that provides is always present, but it’s perhaps also part of the organization’s vibrancy as it constantly seeks the right balance.

It also sometimes allows for fruitful collaborations, such as a recent publication produced by both the religion committee and the LGBTQ+ committee on helping LGBTQ+ teenagers and communities of faith, pointed out Jack Drescher, MD, a GAP past president who serves as clinical professor of psychiatry at Columbia University, and a member of the LGBTQ and media committees.

GAP is also unique in expecting every member to actively put in work toward its mission.

“If you join the APA, you can do absolutely nothing, or you can go to a conference once a year and learn from other people, but you don’t have to be active,” said Gail Robinson, MD, professor of psychiatry and ob.gyn. at the University of Toronto and chair of GAP’s gender and mental health committee. But if you’re a GAP member who isn’t contributing, expect to hear from someone asking how they can help you figure out how you can contribute.

Expecting that much work from members means meeting more often than most medical societies. Except during the pandemic, GAP members have always met twice a year for a long weekend in White Plains, N.Y., to focus almost exclusively on the committees’ current projects. Each meeting allows members “to immerse themselves in thinking about topics that the various committees find of interest and think might be of interest to the rest of the world,” said David Adler, MD, a professor of psychiatry and medicine at Tufts Medical Center in Boston, and chair of the GAP publication board. Whereas APA meetings are massive, frenetic events focused primarily on new research and continuing education for tens of thousands of attendees, GAP meetings are more intimidate and meditative, “a time in which the leaders can exchange ideas in a more private setting,” Dr. Adler said.

What makes GAP’s meetings so special is that they provide a temporary refuge with the explicit goal of encouraging unhurried discussion and deliberation about big ideas that matter, Dr. Robinson said.

“One of the enjoyable parts of GAP is that you have time to think,” Dr. Robinson said. “In your regular life, you’re seeing patients, you’re doing research or organizing things, but in GAP, you can sit with a group of like-minded, interested people and toss some ideas around about what’s important right now. What should we be looking at? What is the field not paying enough attention to? And then the ideas bubble up. In a lot of other organizations, you’re doing specific work, some of it political, some in terms of the organization, but to just sort of sit and think about what’s important in your field and what people should know more about is a different kind of feeling.”
 

A force for change

The work GAP produces has had a substantial impact on the field of psychiatry and society in general over the past 7 and a half decades. Consider this list of just a handful of GAP contributions in its first decade.

• Guidance regarding electroconvulsive therapy in 1947, followed by an update, in response to reaction to the first document, in 1950.
• A guide to school integration after Brown v. Board of Education that considered the psychiatric challenges of integration.
• A report for employers on workers with epilepsy for occupational health and safety.
• Publications that raised mental hospital standards in the 1950s.
• A range of action documents used by medical schools, psychology and social work departments and agencies, governmental bodies, courts, industry, public schools, and community health and welfare agencies.

Over the years, GAP’s influence has sometimes been overt – such as publishing the only diagnostic and statistical manual for child psychiatry for years before that material was incorporated into the official DSM. Sometimes it’s just ahead of the curve, such as the women’s mental health committee publishing a paper that reviewed the evidence on “abortion trauma syndrome” and concluding that it doesn’t exist shortly before the American Psychological Association and the U.K.’s Royal College of Psychiatrists published reviews with similar conclusions. In a few instances, GAP has caused shifts in how the APA operates, such as encouraging the larger organization to publish books on mental health, said Dr. Sharfstein, a past president of the APA.

Much of the organization’s impact occurs through its effects on education, which affects clinical psychiatry at large.“Some reports are very much designed to have an impact on psychiatry education, residency training and curriculum development, which would have a big impact on practice,” Dr. Sharfstein said. An example is the committee on disasters, which examines the best ways for mental health professionals to respond to and mitigate the mental health fallout from the consequences of natural and manmade disasters.

Most often, though, GAP’s influence is akin to strategically planting very carefully cultivated seeds throughout the academic and clinical media ecosystems and letting them bloom how they will. For example, Dr. Lewis-Fernández described a project the cultural committee published in 2013: a checklist for how a psychiatry research article should address topics related to race, ethnicity, and culture. After reviewing articles in the field and their methodologies, the group developed a checklist of best practices and tested them with articles in the field to see how the checklist held up before publishing it.

“Initially, some people read it, some people didn’t, but over time, it’s gotten picked up, and it’s now about to be used in a journal on psychiatric services as a guide to authors and reviews on the appropriate use of these concepts,” Dr. Lewis-Fernández said.

GAP’s influence also blooms through the cross-pollination that occurs at meetings, where leaders in psychiatry from all across the country come together, discuss ideas, and then take new ideas back to their universities, where they teach them to their residents. Perhaps the best example of this influence in recent years has been a increasing shift in teaching about LGBTQ+ issues.

“There’s an underrepresentation of teaching about LGBTQ+ issues in many psychiatric training programs in many medical schools,” Dr. Drescher said. The organization has worked to raise awareness about these gaps in the education of medical students and mental health professionals and then address it, such as designing an online module curriculum in the early 2000s for how to teach residents about LGBTQ+ mental health issues and then updating it as needed.

Perhaps GAP’s greatest lifetime achievement is forcing the field of psychiatry to confront the fact that it – and its patients – do not stand apart from the society in which they exist.

“People aren’t just psychiatric disorders. They live in society, and society has an impact on them, and that affects how people cope,” Dr. Robinson said. That was once a radical concept, but now “psychiatry as a whole has moved to be more broadly expansive” just as GAP itself has broadened its scope, as evidenced by the wide range of committees, more than triple what the organization had at its founding. “GAP was really at the vanguard of that expansion into the recognizing the need to consider the interaction between the individual and the environment they live in socially.”

That’s never been more true than during the COVID-19 pandemic, contributing to perhaps the greatest mental health crisis in the nation’s history since World War II. But the pandemic hasn’t slowed down GAP’s work. In fact, in some ways, the pandemic has facilitated the group’s ability to meet more often virtually and focus on acute issues the pandemic itself has caused. The psychopathology committee published one paper on the impact of telehealth on treating the chronic mentally ill during COVID, and another delved into rethinking where things stand with institutional racism within psychiatry. The women’s mental health committee published articles on the impact of COVID on pregnant and postpartum women, and the impact of COVID on minority women.
 

Confronting challenges within, too

For all its positive influence, GAP has its weaknesses as well. Two of the biggest barriers to membership, for example, are the steep dues and travel to the twice annual meetings, Dr. Lewis-Fernández said.

The membership dues are not needlessly high: The organization relies on philanthropy and dues for all of its activities, most recently, secured endowments from institutional and individual donors to fund all of the GAP fellows, Dr. Gross said.

“With a low number of members, the cost is larger per member,” Dr. Bonner explained. In fact, GAP has only recently overcome a period of financial uncertainty, now finally on solid ground in terms of fundings.

While the dues can be onerous, Dr. Lewis-Fernández said the organization has been actively thinking about ways to reduce it, particularly for those who may need help if traveling from farther away or younger-career individuals, such as those without tenure or with young families.

It can also be difficult for the organization to attract diverse members from different racial and ethnic groups when leaders in psychiatry from those backgrounds are courted by many other groups, or just to attract younger members in general, but GAP continues to seek ways to overcome those challenges.

“The majority of people in GAP have some kind of academic interest, and the nature of being an early career psychiatrist in academia is that you have to publish to get promoted,” Dr. Bonner said. GAP’s historical practice of producing publications by committee without individual attribution was a disincentive to those early-career folks. “More recently, we’ve changed that so that now individuals can put their names on their product, which has eliminated that particular barriers for young people.”

As the organization continues to seek ways to address those issues, it also faces the same challenges as every other scientific group: Staying relevant in the new, and constantly changing, media landscape.

“It’s an interesting evolution because it started off with books and monographs for many, many years,” Dr. Robinson said, “and then it kind of moved away from that to more articles.” More recently, some committees have returned to writing books while others explore other forms of media to keep up with the times. Long gone are the days when a committee might spend 2-10 years producing one monograph.

“In today’s world, you can’t be relevant operating that way,” said Dr. Bonner, noting that some committees have produced videos or podcasts.

But the sheer amount of information out there is intimidating as well. “Nowadays, a lot of people get their information off the Internet, and how do you actually sift through that?” Dr. Saeed said. “How you find signal in this noise is a whole different thing now, so how GAP produces its information is at that trajectory right now. Should we be producing more electronic books? What should be our peer-review process? How do we make sure the information is current? If we are about sharing information and generating new knowledge, what’s the best way of disseminating that?”

A testament to the organization’s willingness to confront that challenge, however, is its exploration of every possible platform – even those well outside the traditional ones. The climate committee, for example, recently set about addressing climate anxiety in children, but they didn’t produce a report or develop a teaching module or even develop a series of podcasts. Instead, the committee collaborated with Jeremy D. Wortzel, MPhil, an MD and MPH candidate at the University of Pennsylvania, Philadelphia, and Lena K. Champlin, a doctoral candidate in environmental science at Drexel University, Philadelpha, to write a children’s book. “Coco’s Fire: Changing Climate Anxiety into Climate Action” was published in October 2021.
 

GAP continues to leave its mark

For all the work that members put into the organization, members say they reap substantial benefits as well. Dr. Saaed recalls feeling flattered when invited to join the organization because of how influential it is and the opportunity to work with so many leaders in psychiatry. “When you come to GAP committee meetings, you would run into people whose book or research you might have read and who are very prominent in the field,” he said.

Dr. Drescher credited GAP with helping him develop his voice and polish his editing skills, which later aided him when he became editor of the Journal of Gay and Lesbian Mental Health. When the LGBTQ+ committee shifted from reports to writing op-eds, members learned how to write opinion pieces and then teach members of other committees those skills, resulting in GAP-produced op-eds in consumer and trade publications. And then there are the intangible rewards that leave a profound impact on members.

Some members see GAP as central to their professional lives and perhaps legacies.

“Outside of the medical center, this has probably been the most important professional organization of my career, and I think there are a lot of people who feel that way,” Dr. Adler said. “It’s a very unique experience, and the goal is to examine today’s critical issues and say something about them in a way in which maybe the world will take notice.”

Almost 4 years had passed since Pearl Harbor forced the United States into the Second World War when three military and government services members went to the American Psychiatric Association with a plea: They needed soldiers who could pass the military’s mental and emotional health screening.

The military had rejected or discharged more than 2.5 million servicemen and volunteers on mental health grounds, and frustrated psychiatrists in the service didn’t know where else to turn but to their century-old professional psychiatric organization.

But the APA had grown so large and unwieldy by then that its size, bureaucracy, and singular focus on research left few resources for helping solve an urgent national mental health problem, no matter how worthy it was.

“At the time, the APA was kind of the face of organized psychiatry, but it was organized in a way that did not lend itself to addressing the needs of the military,” said Jack W. Bonner III, MD, professor emeritus of psychiatry at the University of South Carolina, Greenville. “It was considered sort of a stodgy organization that really wasn’t nimble enough to reorganize to look at those needs at that point in time.”

And that, the military psychiatrists decided, would not do. Desperate to solve the problem, they took matters into their own hands.

Nearly 2 years later, 15 psychiatrists, mostly military or ex-military, gathered in the hotel room of the U.S. Army Medical Corps chief of neuropsychiatry the night before the annual APA conference. It was 1946, and America had won the war – but with a huge toll on mental health, both in and out of the military. Aside from veterans’ “shell shock” and the specter of inadequate troops for potential future conflicts, huge social shifts had occurred during the war, and public mental health hospitals and community resources had deteriorated just as demand for psychiatrists and mental health personnel well outstripped supply.

If the APA wasn’t going to tackle these problems head on, the 15 psychiatrists decided, they would force it to, and they enshrined that goal in the name they gave themselves: the Group for the Advancement of Psychiatry. Two days later, three of them challenged incumbent APA officers in elections and won. The infiltration of these “Young Turks,” as they thought of themselves, had begun. From that point forward, GAP members have frequently held APA leadership positions, and APA leaders have often gone on to join GAP. Gradually, the smaller upstart organization nudged the behemoth toward more involvement with social issues, but GAP remains more nimble given its size.

“The APA is a pretty leviathan organization and can’t deal with issues in the same way a smaller organization can, and GAP can fulfill that role of being much more responsive to contemporary issues,” said Dr. Bonner, who is a member of GAP’s planning, marketing, and communications committee.
 

The think tank of psychiatry

If it seems strange today that such progressivism arose from military medical officers, equally striking is how that nascent group has improbably grown from its modest, pragmatic beginnings into a psychiatry “think tank” today. Now in its 75th year, GAP can boast of its influence at the locus of nearly every intersection of society and psychiatry, from mental health care in prisons to use of controversial treatments such as shock therapy, from racial tensions to gender inequality, from medical school curricula to mental institution standards, from LBGTQ rights to climate change.

“We’re not here to do the latest double-blind, placebo-controlled research on things,” said Lawrence S. Gross, MD, president of GAP, professor of clinical psychiatry and the behavioral sciences at the University of Southern California, Los Angeles, and a member of the committee on psychopharmacology. “It’s more for leaders to think about issues in different areas that affect the field of psychiatry and how they interface with society.”

Or, more simply, “GAP is a group that predominantly exists for one major purpose, and that is to add to the body of knowledge in the field,” said Sy Saeed, MD, MS, chair of the department of psychiatry at East Carolina University, Greenville, N.C., and chair of the group’s administration and leadership committee.

And the organization doesn’t shy from controversial topics, either, such as examining direct-to-consumer marketing and when patients should stop antidepressant therapy.

“We’re very good at getting marketed to on when to start medications, but how good are we at actually timing when to cut back on them? How long is long enough to treat?” Dr. Gross asked. The organization continues to have “an undercurrent of recognizing and fostering change and making people aware of things that may be controversial at times but also further the field by looking at these different areas of psychiatry.”

Despite the group’s relatively small size of about 200 members, its impact touches nearly everyone in the profession, whether they realize it or not. And though the group certainly has its weaknesses – such as steep membership fees that may deter some from joining and its need to improve membership diversity – GAP actively seeks ways to address these internal challenges just as it does external ones.

“It’s probably one of the best-kept secrets in psychiatry,” Dr. Gross said. But it’s a secret the members want out. That’s one reason members consider the organization’s crown jewel to be its fellowship program. In fact, Steven S. Sharfstein, MD, MPA, a former GAP president, clinical professor of psychiatry at the University of Maryland, Baltimore, and chair of the planning, marketing, and communications committee, did not formally join GAP until the 1980s. But he first became involved with the group as a resident in the fellowship program in 1969.

In its current incarnation, 12 fellows spend 2 years as working members of GAP, assigned to one of its committees to put in work just like every other member is expected to do, but they reap the wisdom and mentorship of its members at the same time.

One thing that makes GAP so special to its members is the ability “to mentor young psychiatrists, going from generation to generation trying to identify leaders and facilitate their growth,” Dr. Gross said. And that process, through not only the fellowship program but also through the members’ diversity of ages and career stages, sustains the organization’s vigor.

“Its strength is that you create this continuum where senior people get to mentor people who are early in their career, and this way, the knowledge continues,” Dr. Saaed said.
 

Creation, not death, by committee

In the early years, GAP’s longevity was in question. Once it had successfully steered the APA toward taking more action to address social problems, did it still have a role to play? A majority of members decided that it did. “New problems arose as old ones were solved,” wrote the late Albert Deutsch in an early history of GAP, and “some steps which were confidently expected to repair an ill or defect did not turn out to be completely effective.” In its first decade, GAP members led the APA to establish new medical director and director of information positions, to improve professional standards and facilitate improvement of mental health facilities, and to expand training.

But where GAP really excelled was in developing projects, something the APA wasn’t well-suited to do, explained Carol C. Nadelson, MD, professor of psychiatry at Harvard Medical School, Boston, a member of the gender and mental health committee, and a past president of GAP. And the breadth of those projects has “expanded as the field has changed and evolved,” said Dr. Nadelson, the first woman president of the APA.

Those projects, the beating heart of GAP’s work, come from its specialized working committees, groups of 6-12 members who spend a couple years focused on a single question or problem in psychiatry that the committee has decided needs attention. The number of committees has grown from 9 at its founding to 32 today, shrinking and expanding as society’s needs demand. Each committee looks for an area it thinks is important and needs attention or updating and then decides how to proceed in addressing it. This structure as a confederation of committees differs greatly from other medical organizations.

“Committees really function in an autonomous, almost independent manner,” Dr. Bonner said. “They control their work, what they do, and how they do it, and the executive structure of the organization has very little impact on those individual committees.”

It’s only when a committee produces whatever project it’s working on that it’s disseminated to the rest of the organization for review.

“The fact that it’s such a federated organization is both a strength and a weakness,” said Roberto Lewis-Fernández, MD, professor of clinical psychiatry at Columbia University, New York, and chair of the cultural psychiatry committee. The tension between becoming too siloed within a committee and needing some sense of greater unity and the cross-pollination that provides is always present, but it’s perhaps also part of the organization’s vibrancy as it constantly seeks the right balance.

It also sometimes allows for fruitful collaborations, such as a recent publication produced by both the religion committee and the LGBTQ+ committee on helping LGBTQ+ teenagers and communities of faith, pointed out Jack Drescher, MD, a GAP past president who serves as clinical professor of psychiatry at Columbia University, and a member of the LGBTQ and media committees.

GAP is also unique in expecting every member to actively put in work toward its mission.

“If you join the APA, you can do absolutely nothing, or you can go to a conference once a year and learn from other people, but you don’t have to be active,” said Gail Robinson, MD, professor of psychiatry and ob.gyn. at the University of Toronto and chair of GAP’s gender and mental health committee. But if you’re a GAP member who isn’t contributing, expect to hear from someone asking how they can help you figure out how you can contribute.

Expecting that much work from members means meeting more often than most medical societies. Except during the pandemic, GAP members have always met twice a year for a long weekend in White Plains, N.Y., to focus almost exclusively on the committees’ current projects. Each meeting allows members “to immerse themselves in thinking about topics that the various committees find of interest and think might be of interest to the rest of the world,” said David Adler, MD, a professor of psychiatry and medicine at Tufts Medical Center in Boston, and chair of the GAP publication board. Whereas APA meetings are massive, frenetic events focused primarily on new research and continuing education for tens of thousands of attendees, GAP meetings are more intimidate and meditative, “a time in which the leaders can exchange ideas in a more private setting,” Dr. Adler said.

What makes GAP’s meetings so special is that they provide a temporary refuge with the explicit goal of encouraging unhurried discussion and deliberation about big ideas that matter, Dr. Robinson said.

“One of the enjoyable parts of GAP is that you have time to think,” Dr. Robinson said. “In your regular life, you’re seeing patients, you’re doing research or organizing things, but in GAP, you can sit with a group of like-minded, interested people and toss some ideas around about what’s important right now. What should we be looking at? What is the field not paying enough attention to? And then the ideas bubble up. In a lot of other organizations, you’re doing specific work, some of it political, some in terms of the organization, but to just sort of sit and think about what’s important in your field and what people should know more about is a different kind of feeling.”
 

A force for change

The work GAP produces has had a substantial impact on the field of psychiatry and society in general over the past 7 and a half decades. Consider this list of just a handful of GAP contributions in its first decade.

• Guidance regarding electroconvulsive therapy in 1947, followed by an update, in response to reaction to the first document, in 1950.
• A guide to school integration after Brown v. Board of Education that considered the psychiatric challenges of integration.
• A report for employers on workers with epilepsy for occupational health and safety.
• Publications that raised mental hospital standards in the 1950s.
• A range of action documents used by medical schools, psychology and social work departments and agencies, governmental bodies, courts, industry, public schools, and community health and welfare agencies.

Over the years, GAP’s influence has sometimes been overt – such as publishing the only diagnostic and statistical manual for child psychiatry for years before that material was incorporated into the official DSM. Sometimes it’s just ahead of the curve, such as the women’s mental health committee publishing a paper that reviewed the evidence on “abortion trauma syndrome” and concluding that it doesn’t exist shortly before the American Psychological Association and the U.K.’s Royal College of Psychiatrists published reviews with similar conclusions. In a few instances, GAP has caused shifts in how the APA operates, such as encouraging the larger organization to publish books on mental health, said Dr. Sharfstein, a past president of the APA.

Much of the organization’s impact occurs through its effects on education, which affects clinical psychiatry at large.“Some reports are very much designed to have an impact on psychiatry education, residency training and curriculum development, which would have a big impact on practice,” Dr. Sharfstein said. An example is the committee on disasters, which examines the best ways for mental health professionals to respond to and mitigate the mental health fallout from the consequences of natural and manmade disasters.

Most often, though, GAP’s influence is akin to strategically planting very carefully cultivated seeds throughout the academic and clinical media ecosystems and letting them bloom how they will. For example, Dr. Lewis-Fernández described a project the cultural committee published in 2013: a checklist for how a psychiatry research article should address topics related to race, ethnicity, and culture. After reviewing articles in the field and their methodologies, the group developed a checklist of best practices and tested them with articles in the field to see how the checklist held up before publishing it.

“Initially, some people read it, some people didn’t, but over time, it’s gotten picked up, and it’s now about to be used in a journal on psychiatric services as a guide to authors and reviews on the appropriate use of these concepts,” Dr. Lewis-Fernández said.

GAP’s influence also blooms through the cross-pollination that occurs at meetings, where leaders in psychiatry from all across the country come together, discuss ideas, and then take new ideas back to their universities, where they teach them to their residents. Perhaps the best example of this influence in recent years has been a increasing shift in teaching about LGBTQ+ issues.

“There’s an underrepresentation of teaching about LGBTQ+ issues in many psychiatric training programs in many medical schools,” Dr. Drescher said. The organization has worked to raise awareness about these gaps in the education of medical students and mental health professionals and then address it, such as designing an online module curriculum in the early 2000s for how to teach residents about LGBTQ+ mental health issues and then updating it as needed.

Perhaps GAP’s greatest lifetime achievement is forcing the field of psychiatry to confront the fact that it – and its patients – do not stand apart from the society in which they exist.

“People aren’t just psychiatric disorders. They live in society, and society has an impact on them, and that affects how people cope,” Dr. Robinson said. That was once a radical concept, but now “psychiatry as a whole has moved to be more broadly expansive” just as GAP itself has broadened its scope, as evidenced by the wide range of committees, more than triple what the organization had at its founding. “GAP was really at the vanguard of that expansion into the recognizing the need to consider the interaction between the individual and the environment they live in socially.”

That’s never been more true than during the COVID-19 pandemic, contributing to perhaps the greatest mental health crisis in the nation’s history since World War II. But the pandemic hasn’t slowed down GAP’s work. In fact, in some ways, the pandemic has facilitated the group’s ability to meet more often virtually and focus on acute issues the pandemic itself has caused. The psychopathology committee published one paper on the impact of telehealth on treating the chronic mentally ill during COVID, and another delved into rethinking where things stand with institutional racism within psychiatry. The women’s mental health committee published articles on the impact of COVID on pregnant and postpartum women, and the impact of COVID on minority women.
 

Confronting challenges within, too

For all its positive influence, GAP has its weaknesses as well. Two of the biggest barriers to membership, for example, are the steep dues and travel to the twice annual meetings, Dr. Lewis-Fernández said.

The membership dues are not needlessly high: The organization relies on philanthropy and dues for all of its activities, most recently, secured endowments from institutional and individual donors to fund all of the GAP fellows, Dr. Gross said.

“With a low number of members, the cost is larger per member,” Dr. Bonner explained. In fact, GAP has only recently overcome a period of financial uncertainty, now finally on solid ground in terms of fundings.

While the dues can be onerous, Dr. Lewis-Fernández said the organization has been actively thinking about ways to reduce it, particularly for those who may need help if traveling from farther away or younger-career individuals, such as those without tenure or with young families.

It can also be difficult for the organization to attract diverse members from different racial and ethnic groups when leaders in psychiatry from those backgrounds are courted by many other groups, or just to attract younger members in general, but GAP continues to seek ways to overcome those challenges.

“The majority of people in GAP have some kind of academic interest, and the nature of being an early career psychiatrist in academia is that you have to publish to get promoted,” Dr. Bonner said. GAP’s historical practice of producing publications by committee without individual attribution was a disincentive to those early-career folks. “More recently, we’ve changed that so that now individuals can put their names on their product, which has eliminated that particular barriers for young people.”

As the organization continues to seek ways to address those issues, it also faces the same challenges as every other scientific group: Staying relevant in the new, and constantly changing, media landscape.

“It’s an interesting evolution because it started off with books and monographs for many, many years,” Dr. Robinson said, “and then it kind of moved away from that to more articles.” More recently, some committees have returned to writing books while others explore other forms of media to keep up with the times. Long gone are the days when a committee might spend 2-10 years producing one monograph.

“In today’s world, you can’t be relevant operating that way,” said Dr. Bonner, noting that some committees have produced videos or podcasts.

But the sheer amount of information out there is intimidating as well. “Nowadays, a lot of people get their information off the Internet, and how do you actually sift through that?” Dr. Saeed said. “How you find signal in this noise is a whole different thing now, so how GAP produces its information is at that trajectory right now. Should we be producing more electronic books? What should be our peer-review process? How do we make sure the information is current? If we are about sharing information and generating new knowledge, what’s the best way of disseminating that?”

A testament to the organization’s willingness to confront that challenge, however, is its exploration of every possible platform – even those well outside the traditional ones. The climate committee, for example, recently set about addressing climate anxiety in children, but they didn’t produce a report or develop a teaching module or even develop a series of podcasts. Instead, the committee collaborated with Jeremy D. Wortzel, MPhil, an MD and MPH candidate at the University of Pennsylvania, Philadelphia, and Lena K. Champlin, a doctoral candidate in environmental science at Drexel University, Philadelpha, to write a children’s book. “Coco’s Fire: Changing Climate Anxiety into Climate Action” was published in October 2021.
 

GAP continues to leave its mark

For all the work that members put into the organization, members say they reap substantial benefits as well. Dr. Saaed recalls feeling flattered when invited to join the organization because of how influential it is and the opportunity to work with so many leaders in psychiatry. “When you come to GAP committee meetings, you would run into people whose book or research you might have read and who are very prominent in the field,” he said.

Dr. Drescher credited GAP with helping him develop his voice and polish his editing skills, which later aided him when he became editor of the Journal of Gay and Lesbian Mental Health. When the LGBTQ+ committee shifted from reports to writing op-eds, members learned how to write opinion pieces and then teach members of other committees those skills, resulting in GAP-produced op-eds in consumer and trade publications. And then there are the intangible rewards that leave a profound impact on members.

Some members see GAP as central to their professional lives and perhaps legacies.

“Outside of the medical center, this has probably been the most important professional organization of my career, and I think there are a lot of people who feel that way,” Dr. Adler said. “It’s a very unique experience, and the goal is to examine today’s critical issues and say something about them in a way in which maybe the world will take notice.”

Almost 4 years had passed since Pearl Harbor forced the United States into the Second World War when three military and government services members went to the American Psychiatric Association with a plea: They needed soldiers who could pass the military’s mental and emotional health screening.

The military had rejected or discharged more than 2.5 million servicemen and volunteers on mental health grounds, and frustrated psychiatrists in the service didn’t know where else to turn but to their century-old professional psychiatric organization.

But the APA had grown so large and unwieldy by then that its size, bureaucracy, and singular focus on research left few resources for helping solve an urgent national mental health problem, no matter how worthy it was.

“At the time, the APA was kind of the face of organized psychiatry, but it was organized in a way that did not lend itself to addressing the needs of the military,” said Jack W. Bonner III, MD, professor emeritus of psychiatry at the University of South Carolina, Greenville. “It was considered sort of a stodgy organization that really wasn’t nimble enough to reorganize to look at those needs at that point in time.”

And that, the military psychiatrists decided, would not do. Desperate to solve the problem, they took matters into their own hands.

Nearly 2 years later, 15 psychiatrists, mostly military or ex-military, gathered in the hotel room of the U.S. Army Medical Corps chief of neuropsychiatry the night before the annual APA conference. It was 1946, and America had won the war – but with a huge toll on mental health, both in and out of the military. Aside from veterans’ “shell shock” and the specter of inadequate troops for potential future conflicts, huge social shifts had occurred during the war, and public mental health hospitals and community resources had deteriorated just as demand for psychiatrists and mental health personnel well outstripped supply.

If the APA wasn’t going to tackle these problems head on, the 15 psychiatrists decided, they would force it to, and they enshrined that goal in the name they gave themselves: the Group for the Advancement of Psychiatry. Two days later, three of them challenged incumbent APA officers in elections and won. The infiltration of these “Young Turks,” as they thought of themselves, had begun. From that point forward, GAP members have frequently held APA leadership positions, and APA leaders have often gone on to join GAP. Gradually, the smaller upstart organization nudged the behemoth toward more involvement with social issues, but GAP remains more nimble given its size.

“The APA is a pretty leviathan organization and can’t deal with issues in the same way a smaller organization can, and GAP can fulfill that role of being much more responsive to contemporary issues,” said Dr. Bonner, who is a member of GAP’s planning, marketing, and communications committee.
 

The think tank of psychiatry

If it seems strange today that such progressivism arose from military medical officers, equally striking is how that nascent group has improbably grown from its modest, pragmatic beginnings into a psychiatry “think tank” today. Now in its 75th year, GAP can boast of its influence at the locus of nearly every intersection of society and psychiatry, from mental health care in prisons to use of controversial treatments such as shock therapy, from racial tensions to gender inequality, from medical school curricula to mental institution standards, from LBGTQ rights to climate change.

“We’re not here to do the latest double-blind, placebo-controlled research on things,” said Lawrence S. Gross, MD, president of GAP, professor of clinical psychiatry and the behavioral sciences at the University of Southern California, Los Angeles, and a member of the committee on psychopharmacology. “It’s more for leaders to think about issues in different areas that affect the field of psychiatry and how they interface with society.”

Or, more simply, “GAP is a group that predominantly exists for one major purpose, and that is to add to the body of knowledge in the field,” said Sy Saeed, MD, MS, chair of the department of psychiatry at East Carolina University, Greenville, N.C., and chair of the group’s administration and leadership committee.

And the organization doesn’t shy from controversial topics, either, such as examining direct-to-consumer marketing and when patients should stop antidepressant therapy.

“We’re very good at getting marketed to on when to start medications, but how good are we at actually timing when to cut back on them? How long is long enough to treat?” Dr. Gross asked. The organization continues to have “an undercurrent of recognizing and fostering change and making people aware of things that may be controversial at times but also further the field by looking at these different areas of psychiatry.”

Despite the group’s relatively small size of about 200 members, its impact touches nearly everyone in the profession, whether they realize it or not. And though the group certainly has its weaknesses – such as steep membership fees that may deter some from joining and its need to improve membership diversity – GAP actively seeks ways to address these internal challenges just as it does external ones.

“It’s probably one of the best-kept secrets in psychiatry,” Dr. Gross said. But it’s a secret the members want out. That’s one reason members consider the organization’s crown jewel to be its fellowship program. In fact, Steven S. Sharfstein, MD, MPA, a former GAP president, clinical professor of psychiatry at the University of Maryland, Baltimore, and chair of the planning, marketing, and communications committee, did not formally join GAP until the 1980s. But he first became involved with the group as a resident in the fellowship program in 1969.

In its current incarnation, 12 fellows spend 2 years as working members of GAP, assigned to one of its committees to put in work just like every other member is expected to do, but they reap the wisdom and mentorship of its members at the same time.

One thing that makes GAP so special to its members is the ability “to mentor young psychiatrists, going from generation to generation trying to identify leaders and facilitate their growth,” Dr. Gross said. And that process, through not only the fellowship program but also through the members’ diversity of ages and career stages, sustains the organization’s vigor.

“Its strength is that you create this continuum where senior people get to mentor people who are early in their career, and this way, the knowledge continues,” Dr. Saaed said.
 

Creation, not death, by committee

In the early years, GAP’s longevity was in question. Once it had successfully steered the APA toward taking more action to address social problems, did it still have a role to play? A majority of members decided that it did. “New problems arose as old ones were solved,” wrote the late Albert Deutsch in an early history of GAP, and “some steps which were confidently expected to repair an ill or defect did not turn out to be completely effective.” In its first decade, GAP members led the APA to establish new medical director and director of information positions, to improve professional standards and facilitate improvement of mental health facilities, and to expand training.

But where GAP really excelled was in developing projects, something the APA wasn’t well-suited to do, explained Carol C. Nadelson, MD, professor of psychiatry at Harvard Medical School, Boston, a member of the gender and mental health committee, and a past president of GAP. And the breadth of those projects has “expanded as the field has changed and evolved,” said Dr. Nadelson, the first woman president of the APA.

Those projects, the beating heart of GAP’s work, come from its specialized working committees, groups of 6-12 members who spend a couple years focused on a single question or problem in psychiatry that the committee has decided needs attention. The number of committees has grown from 9 at its founding to 32 today, shrinking and expanding as society’s needs demand. Each committee looks for an area it thinks is important and needs attention or updating and then decides how to proceed in addressing it. This structure as a confederation of committees differs greatly from other medical organizations.

“Committees really function in an autonomous, almost independent manner,” Dr. Bonner said. “They control their work, what they do, and how they do it, and the executive structure of the organization has very little impact on those individual committees.”

It’s only when a committee produces whatever project it’s working on that it’s disseminated to the rest of the organization for review.

“The fact that it’s such a federated organization is both a strength and a weakness,” said Roberto Lewis-Fernández, MD, professor of clinical psychiatry at Columbia University, New York, and chair of the cultural psychiatry committee. The tension between becoming too siloed within a committee and needing some sense of greater unity and the cross-pollination that provides is always present, but it’s perhaps also part of the organization’s vibrancy as it constantly seeks the right balance.

It also sometimes allows for fruitful collaborations, such as a recent publication produced by both the religion committee and the LGBTQ+ committee on helping LGBTQ+ teenagers and communities of faith, pointed out Jack Drescher, MD, a GAP past president who serves as clinical professor of psychiatry at Columbia University, and a member of the LGBTQ and media committees.

GAP is also unique in expecting every member to actively put in work toward its mission.

“If you join the APA, you can do absolutely nothing, or you can go to a conference once a year and learn from other people, but you don’t have to be active,” said Gail Robinson, MD, professor of psychiatry and ob.gyn. at the University of Toronto and chair of GAP’s gender and mental health committee. But if you’re a GAP member who isn’t contributing, expect to hear from someone asking how they can help you figure out how you can contribute.

Expecting that much work from members means meeting more often than most medical societies. Except during the pandemic, GAP members have always met twice a year for a long weekend in White Plains, N.Y., to focus almost exclusively on the committees’ current projects. Each meeting allows members “to immerse themselves in thinking about topics that the various committees find of interest and think might be of interest to the rest of the world,” said David Adler, MD, a professor of psychiatry and medicine at Tufts Medical Center in Boston, and chair of the GAP publication board. Whereas APA meetings are massive, frenetic events focused primarily on new research and continuing education for tens of thousands of attendees, GAP meetings are more intimidate and meditative, “a time in which the leaders can exchange ideas in a more private setting,” Dr. Adler said.

What makes GAP’s meetings so special is that they provide a temporary refuge with the explicit goal of encouraging unhurried discussion and deliberation about big ideas that matter, Dr. Robinson said.

“One of the enjoyable parts of GAP is that you have time to think,” Dr. Robinson said. “In your regular life, you’re seeing patients, you’re doing research or organizing things, but in GAP, you can sit with a group of like-minded, interested people and toss some ideas around about what’s important right now. What should we be looking at? What is the field not paying enough attention to? And then the ideas bubble up. In a lot of other organizations, you’re doing specific work, some of it political, some in terms of the organization, but to just sort of sit and think about what’s important in your field and what people should know more about is a different kind of feeling.”
 

A force for change

The work GAP produces has had a substantial impact on the field of psychiatry and society in general over the past 7 and a half decades. Consider this list of just a handful of GAP contributions in its first decade.

• Guidance regarding electroconvulsive therapy in 1947, followed by an update, in response to reaction to the first document, in 1950.
• A guide to school integration after Brown v. Board of Education that considered the psychiatric challenges of integration.
• A report for employers on workers with epilepsy for occupational health and safety.
• Publications that raised mental hospital standards in the 1950s.
• A range of action documents used by medical schools, psychology and social work departments and agencies, governmental bodies, courts, industry, public schools, and community health and welfare agencies.

Over the years, GAP’s influence has sometimes been overt – such as publishing the only diagnostic and statistical manual for child psychiatry for years before that material was incorporated into the official DSM. Sometimes it’s just ahead of the curve, such as the women’s mental health committee publishing a paper that reviewed the evidence on “abortion trauma syndrome” and concluding that it doesn’t exist shortly before the American Psychological Association and the U.K.’s Royal College of Psychiatrists published reviews with similar conclusions. In a few instances, GAP has caused shifts in how the APA operates, such as encouraging the larger organization to publish books on mental health, said Dr. Sharfstein, a past president of the APA.

Much of the organization’s impact occurs through its effects on education, which affects clinical psychiatry at large.“Some reports are very much designed to have an impact on psychiatry education, residency training and curriculum development, which would have a big impact on practice,” Dr. Sharfstein said. An example is the committee on disasters, which examines the best ways for mental health professionals to respond to and mitigate the mental health fallout from the consequences of natural and manmade disasters.

Most often, though, GAP’s influence is akin to strategically planting very carefully cultivated seeds throughout the academic and clinical media ecosystems and letting them bloom how they will. For example, Dr. Lewis-Fernández described a project the cultural committee published in 2013: a checklist for how a psychiatry research article should address topics related to race, ethnicity, and culture. After reviewing articles in the field and their methodologies, the group developed a checklist of best practices and tested them with articles in the field to see how the checklist held up before publishing it.

“Initially, some people read it, some people didn’t, but over time, it’s gotten picked up, and it’s now about to be used in a journal on psychiatric services as a guide to authors and reviews on the appropriate use of these concepts,” Dr. Lewis-Fernández said.

GAP’s influence also blooms through the cross-pollination that occurs at meetings, where leaders in psychiatry from all across the country come together, discuss ideas, and then take new ideas back to their universities, where they teach them to their residents. Perhaps the best example of this influence in recent years has been a increasing shift in teaching about LGBTQ+ issues.

“There’s an underrepresentation of teaching about LGBTQ+ issues in many psychiatric training programs in many medical schools,” Dr. Drescher said. The organization has worked to raise awareness about these gaps in the education of medical students and mental health professionals and then address it, such as designing an online module curriculum in the early 2000s for how to teach residents about LGBTQ+ mental health issues and then updating it as needed.

Perhaps GAP’s greatest lifetime achievement is forcing the field of psychiatry to confront the fact that it – and its patients – do not stand apart from the society in which they exist.

“People aren’t just psychiatric disorders. They live in society, and society has an impact on them, and that affects how people cope,” Dr. Robinson said. That was once a radical concept, but now “psychiatry as a whole has moved to be more broadly expansive” just as GAP itself has broadened its scope, as evidenced by the wide range of committees, more than triple what the organization had at its founding. “GAP was really at the vanguard of that expansion into the recognizing the need to consider the interaction between the individual and the environment they live in socially.”

That’s never been more true than during the COVID-19 pandemic, contributing to perhaps the greatest mental health crisis in the nation’s history since World War II. But the pandemic hasn’t slowed down GAP’s work. In fact, in some ways, the pandemic has facilitated the group’s ability to meet more often virtually and focus on acute issues the pandemic itself has caused. The psychopathology committee published one paper on the impact of telehealth on treating the chronic mentally ill during COVID, and another delved into rethinking where things stand with institutional racism within psychiatry. The women’s mental health committee published articles on the impact of COVID on pregnant and postpartum women, and the impact of COVID on minority women.
 

Confronting challenges within, too

For all its positive influence, GAP has its weaknesses as well. Two of the biggest barriers to membership, for example, are the steep dues and travel to the twice annual meetings, Dr. Lewis-Fernández said.

The membership dues are not needlessly high: The organization relies on philanthropy and dues for all of its activities, most recently, secured endowments from institutional and individual donors to fund all of the GAP fellows, Dr. Gross said.

“With a low number of members, the cost is larger per member,” Dr. Bonner explained. In fact, GAP has only recently overcome a period of financial uncertainty, now finally on solid ground in terms of fundings.

While the dues can be onerous, Dr. Lewis-Fernández said the organization has been actively thinking about ways to reduce it, particularly for those who may need help if traveling from farther away or younger-career individuals, such as those without tenure or with young families.

It can also be difficult for the organization to attract diverse members from different racial and ethnic groups when leaders in psychiatry from those backgrounds are courted by many other groups, or just to attract younger members in general, but GAP continues to seek ways to overcome those challenges.

“The majority of people in GAP have some kind of academic interest, and the nature of being an early career psychiatrist in academia is that you have to publish to get promoted,” Dr. Bonner said. GAP’s historical practice of producing publications by committee without individual attribution was a disincentive to those early-career folks. “More recently, we’ve changed that so that now individuals can put their names on their product, which has eliminated that particular barriers for young people.”

As the organization continues to seek ways to address those issues, it also faces the same challenges as every other scientific group: Staying relevant in the new, and constantly changing, media landscape.

“It’s an interesting evolution because it started off with books and monographs for many, many years,” Dr. Robinson said, “and then it kind of moved away from that to more articles.” More recently, some committees have returned to writing books while others explore other forms of media to keep up with the times. Long gone are the days when a committee might spend 2-10 years producing one monograph.

“In today’s world, you can’t be relevant operating that way,” said Dr. Bonner, noting that some committees have produced videos or podcasts.

But the sheer amount of information out there is intimidating as well. “Nowadays, a lot of people get their information off the Internet, and how do you actually sift through that?” Dr. Saeed said. “How you find signal in this noise is a whole different thing now, so how GAP produces its information is at that trajectory right now. Should we be producing more electronic books? What should be our peer-review process? How do we make sure the information is current? If we are about sharing information and generating new knowledge, what’s the best way of disseminating that?”

A testament to the organization’s willingness to confront that challenge, however, is its exploration of every possible platform – even those well outside the traditional ones. The climate committee, for example, recently set about addressing climate anxiety in children, but they didn’t produce a report or develop a teaching module or even develop a series of podcasts. Instead, the committee collaborated with Jeremy D. Wortzel, MPhil, an MD and MPH candidate at the University of Pennsylvania, Philadelphia, and Lena K. Champlin, a doctoral candidate in environmental science at Drexel University, Philadelpha, to write a children’s book. “Coco’s Fire: Changing Climate Anxiety into Climate Action” was published in October 2021.
 

GAP continues to leave its mark

For all the work that members put into the organization, members say they reap substantial benefits as well. Dr. Saaed recalls feeling flattered when invited to join the organization because of how influential it is and the opportunity to work with so many leaders in psychiatry. “When you come to GAP committee meetings, you would run into people whose book or research you might have read and who are very prominent in the field,” he said.

Dr. Drescher credited GAP with helping him develop his voice and polish his editing skills, which later aided him when he became editor of the Journal of Gay and Lesbian Mental Health. When the LGBTQ+ committee shifted from reports to writing op-eds, members learned how to write opinion pieces and then teach members of other committees those skills, resulting in GAP-produced op-eds in consumer and trade publications. And then there are the intangible rewards that leave a profound impact on members.

Some members see GAP as central to their professional lives and perhaps legacies.

“Outside of the medical center, this has probably been the most important professional organization of my career, and I think there are a lot of people who feel that way,” Dr. Adler said. “It’s a very unique experience, and the goal is to examine today’s critical issues and say something about them in a way in which maybe the world will take notice.”

First-year psychiatry resident Jake Goodman, MD, knew he was taking a chance when he opened up on his popular social media platforms about his personal mental health battle. He mulled over the decision for several weeks before deciding to take the plunge.

As he voiced recently on his TikTok page, his biggest social media fanbase, with 1.3 million followers, it felt freeing to get his personal struggle off his chest.

“I’m a doctor in training, and most doctors would advise me not to post this,” the 29-year-old from Miami said in the video last month, which garnered 1.2 million views on TikTok alone. “They would say it’s risky for my career. But I didn’t join the medical field to continue the toxic status quo. I’m part of a new generation of health care professionals that are not afraid to be vulnerable and talk about mental health.”

“Dr. Jake,” as he calls himself on social media, admitted he was a physician who treats mental illness and also takes medication for it. “It felt good to say that. And by the way, I’m proud of it,” he said in the TikTok post.

A champion of mental health throughout the pandemic, Dr. Goodman called attention to the illness in the medical field. In a message on Instagram, he stated, “Opening up about your mental health as a medical professional, especially as a doctor who treats mental illness, can be taboo ... So here’s me leading by example.”

He also cited statistics on the challenge: “1 in 2 people will be diagnosed with a mental health illness at some point in their life. Yet many of us will never take medication that can help correct the chemical imbalance in our brains due to medication stigma: the fear that taking medications for our mental health somehow makes us weak.”

Mental health remains an issue among residents. Nearly 70% of residents polled by Medscape in its 2021 Residents Lifestyle & Happiness Report said they strongly or somewhat agree there’s a stigma against seeking mental health help. And nearly half, or 47% of those polled, said they sometimes (36%) or always/most of the time (11%) were depressed. The latter category rose in the past year.

Dr. Goodman told this news organization that he became passionate about mental health when he lost a college friend to suicide. “It really exposed the stigma” of mental health, he said. “I always knew it was there, but it took me seeing someone lose his life and [asking] why didn’t he feel comfortable talking to us, and why didn’t I feel comfortable talking to him?”
 

Stress of medical training

The decision to pursue psychiatry as his specialty came after a rotation in a clinic for people struggling with substance use disorders. “I was enthralled to see people change their life ... just by mental health care.” It’s why he went into medicine, he tells this news organization. “I always wanted to be in a field to help people [before they hit] rock bottom, when no one else could be there for them.”

Dr. Goodman’s personal battle with mental health didn’t arise until he started residency. “I was not really myself.” He said he felt numb and burned out. “I was not getting as much enjoyment out of things.” A friend pointed out that he might be depressed, so he went to see a therapist and then a psychiatrist and started on medication. “It had a profound impact on how I felt.”

Still, it took a while before Dr. Goodman was comfortable sharing his story with the 1.6 million followers he had already built across his social media platforms.

“I started on social media in 2020 with the goal of advocating for mental health and inspiring future doctors.” He said the message seemed to resonate with people struggling during the early part of the pandemic. On his social media accounts, he also talks about medical school, residency, and being a health care provider. His fiancé is also a resident doctor, in internal medicine.

Dr. Goodman is also trying to create a more realistic image of doctors than the superheroes he believed they were growing up. He wants those who grow up wanting to be doctors and who look up to him to see him as a human being with vulnerabilities, such as mental health.

“You can be a doctor and have mental health issues. Seeking treatment for mental health makes you a better doctor, and for other health care workers suffering in the midst of the pandemic, I want to let them know they are not alone.”

He pointed to the statistic that doctors have one of the highest suicide rates of any professions. “It’s better to talk about that in the early stages of training.”

Students, residents, or attending physicians who have mental health challenges shouldn’t allow their symptoms to go untreated, Dr. Goodman added. “Holding in all the stress and anxiety and feelings in a very traumatic field may be dangerous. Opening up and seeking treatment, that’s the brave thing to do.”

One of his goals is to campaign for the removal of a question on state medical licensing forms requiring doctors to report any mental health diagnosis. It’s why doctors may be afraid to admit that they are struggling. “I’m still here. It didn’t ruin my career.”

Doctors who seek treatment for mental health are theoretically protected under the Americans With Disabilities Act from being refused a license on the basis of that diagnosis. Dr. Goodman hopes to advocate at the state level to reduce discrimination and increase accessibility for doctors to seek mental health care.

Still, Dr. Goodman concedes he was initially fearful of the repercussions. “I opened up about it because this post could save lives. I was doing what I believed in.”

So if he runs into barriers to receive his medical license because of his admission, “that’s a serious problem,” he said. “There is already a shortage of doctors. We’ll see what happens in a few years. I am not the only one who will answer ‘yes’ to having sought treatment for a mental illness. The questions do not really need to be there.”

A version of this article first appeared on Medscape.com.

First-year psychiatry resident Jake Goodman, MD, knew he was taking a chance when he opened up on his popular social media platforms about his personal mental health battle. He mulled over the decision for several weeks before deciding to take the plunge.

As he voiced recently on his TikTok page, his biggest social media fanbase, with 1.3 million followers, it felt freeing to get his personal struggle off his chest.

“I’m a doctor in training, and most doctors would advise me not to post this,” the 29-year-old from Miami said in the video last month, which garnered 1.2 million views on TikTok alone. “They would say it’s risky for my career. But I didn’t join the medical field to continue the toxic status quo. I’m part of a new generation of health care professionals that are not afraid to be vulnerable and talk about mental health.”

“Dr. Jake,” as he calls himself on social media, admitted he was a physician who treats mental illness and also takes medication for it. “It felt good to say that. And by the way, I’m proud of it,” he said in the TikTok post.

A champion of mental health throughout the pandemic, Dr. Goodman called attention to the illness in the medical field. In a message on Instagram, he stated, “Opening up about your mental health as a medical professional, especially as a doctor who treats mental illness, can be taboo ... So here’s me leading by example.”

He also cited statistics on the challenge: “1 in 2 people will be diagnosed with a mental health illness at some point in their life. Yet many of us will never take medication that can help correct the chemical imbalance in our brains due to medication stigma: the fear that taking medications for our mental health somehow makes us weak.”

Mental health remains an issue among residents. Nearly 70% of residents polled by Medscape in its 2021 Residents Lifestyle & Happiness Report said they strongly or somewhat agree there’s a stigma against seeking mental health help. And nearly half, or 47% of those polled, said they sometimes (36%) or always/most of the time (11%) were depressed. The latter category rose in the past year.

Dr. Goodman told this news organization that he became passionate about mental health when he lost a college friend to suicide. “It really exposed the stigma” of mental health, he said. “I always knew it was there, but it took me seeing someone lose his life and [asking] why didn’t he feel comfortable talking to us, and why didn’t I feel comfortable talking to him?”
 

Stress of medical training

The decision to pursue psychiatry as his specialty came after a rotation in a clinic for people struggling with substance use disorders. “I was enthralled to see people change their life ... just by mental health care.” It’s why he went into medicine, he tells this news organization. “I always wanted to be in a field to help people [before they hit] rock bottom, when no one else could be there for them.”

Dr. Goodman’s personal battle with mental health didn’t arise until he started residency. “I was not really myself.” He said he felt numb and burned out. “I was not getting as much enjoyment out of things.” A friend pointed out that he might be depressed, so he went to see a therapist and then a psychiatrist and started on medication. “It had a profound impact on how I felt.”

Still, it took a while before Dr. Goodman was comfortable sharing his story with the 1.6 million followers he had already built across his social media platforms.

“I started on social media in 2020 with the goal of advocating for mental health and inspiring future doctors.” He said the message seemed to resonate with people struggling during the early part of the pandemic. On his social media accounts, he also talks about medical school, residency, and being a health care provider. His fiancé is also a resident doctor, in internal medicine.

Dr. Goodman is also trying to create a more realistic image of doctors than the superheroes he believed they were growing up. He wants those who grow up wanting to be doctors and who look up to him to see him as a human being with vulnerabilities, such as mental health.

“You can be a doctor and have mental health issues. Seeking treatment for mental health makes you a better doctor, and for other health care workers suffering in the midst of the pandemic, I want to let them know they are not alone.”

He pointed to the statistic that doctors have one of the highest suicide rates of any professions. “It’s better to talk about that in the early stages of training.”

Students, residents, or attending physicians who have mental health challenges shouldn’t allow their symptoms to go untreated, Dr. Goodman added. “Holding in all the stress and anxiety and feelings in a very traumatic field may be dangerous. Opening up and seeking treatment, that’s the brave thing to do.”

One of his goals is to campaign for the removal of a question on state medical licensing forms requiring doctors to report any mental health diagnosis. It’s why doctors may be afraid to admit that they are struggling. “I’m still here. It didn’t ruin my career.”

Doctors who seek treatment for mental health are theoretically protected under the Americans With Disabilities Act from being refused a license on the basis of that diagnosis. Dr. Goodman hopes to advocate at the state level to reduce discrimination and increase accessibility for doctors to seek mental health care.

Still, Dr. Goodman concedes he was initially fearful of the repercussions. “I opened up about it because this post could save lives. I was doing what I believed in.”

So if he runs into barriers to receive his medical license because of his admission, “that’s a serious problem,” he said. “There is already a shortage of doctors. We’ll see what happens in a few years. I am not the only one who will answer ‘yes’ to having sought treatment for a mental illness. The questions do not really need to be there.”

A version of this article first appeared on Medscape.com.

First-year psychiatry resident Jake Goodman, MD, knew he was taking a chance when he opened up on his popular social media platforms about his personal mental health battle. He mulled over the decision for several weeks before deciding to take the plunge.

As he voiced recently on his TikTok page, his biggest social media fanbase, with 1.3 million followers, it felt freeing to get his personal struggle off his chest.

“I’m a doctor in training, and most doctors would advise me not to post this,” the 29-year-old from Miami said in the video last month, which garnered 1.2 million views on TikTok alone. “They would say it’s risky for my career. But I didn’t join the medical field to continue the toxic status quo. I’m part of a new generation of health care professionals that are not afraid to be vulnerable and talk about mental health.”

“Dr. Jake,” as he calls himself on social media, admitted he was a physician who treats mental illness and also takes medication for it. “It felt good to say that. And by the way, I’m proud of it,” he said in the TikTok post.

A champion of mental health throughout the pandemic, Dr. Goodman called attention to the illness in the medical field. In a message on Instagram, he stated, “Opening up about your mental health as a medical professional, especially as a doctor who treats mental illness, can be taboo ... So here’s me leading by example.”

He also cited statistics on the challenge: “1 in 2 people will be diagnosed with a mental health illness at some point in their life. Yet many of us will never take medication that can help correct the chemical imbalance in our brains due to medication stigma: the fear that taking medications for our mental health somehow makes us weak.”

Mental health remains an issue among residents. Nearly 70% of residents polled by Medscape in its 2021 Residents Lifestyle & Happiness Report said they strongly or somewhat agree there’s a stigma against seeking mental health help. And nearly half, or 47% of those polled, said they sometimes (36%) or always/most of the time (11%) were depressed. The latter category rose in the past year.

Dr. Goodman told this news organization that he became passionate about mental health when he lost a college friend to suicide. “It really exposed the stigma” of mental health, he said. “I always knew it was there, but it took me seeing someone lose his life and [asking] why didn’t he feel comfortable talking to us, and why didn’t I feel comfortable talking to him?”
 

Stress of medical training

The decision to pursue psychiatry as his specialty came after a rotation in a clinic for people struggling with substance use disorders. “I was enthralled to see people change their life ... just by mental health care.” It’s why he went into medicine, he tells this news organization. “I always wanted to be in a field to help people [before they hit] rock bottom, when no one else could be there for them.”

Dr. Goodman’s personal battle with mental health didn’t arise until he started residency. “I was not really myself.” He said he felt numb and burned out. “I was not getting as much enjoyment out of things.” A friend pointed out that he might be depressed, so he went to see a therapist and then a psychiatrist and started on medication. “It had a profound impact on how I felt.”

Still, it took a while before Dr. Goodman was comfortable sharing his story with the 1.6 million followers he had already built across his social media platforms.

“I started on social media in 2020 with the goal of advocating for mental health and inspiring future doctors.” He said the message seemed to resonate with people struggling during the early part of the pandemic. On his social media accounts, he also talks about medical school, residency, and being a health care provider. His fiancé is also a resident doctor, in internal medicine.

Dr. Goodman is also trying to create a more realistic image of doctors than the superheroes he believed they were growing up. He wants those who grow up wanting to be doctors and who look up to him to see him as a human being with vulnerabilities, such as mental health.

“You can be a doctor and have mental health issues. Seeking treatment for mental health makes you a better doctor, and for other health care workers suffering in the midst of the pandemic, I want to let them know they are not alone.”

He pointed to the statistic that doctors have one of the highest suicide rates of any professions. “It’s better to talk about that in the early stages of training.”

Students, residents, or attending physicians who have mental health challenges shouldn’t allow their symptoms to go untreated, Dr. Goodman added. “Holding in all the stress and anxiety and feelings in a very traumatic field may be dangerous. Opening up and seeking treatment, that’s the brave thing to do.”

One of his goals is to campaign for the removal of a question on state medical licensing forms requiring doctors to report any mental health diagnosis. It’s why doctors may be afraid to admit that they are struggling. “I’m still here. It didn’t ruin my career.”

Doctors who seek treatment for mental health are theoretically protected under the Americans With Disabilities Act from being refused a license on the basis of that diagnosis. Dr. Goodman hopes to advocate at the state level to reduce discrimination and increase accessibility for doctors to seek mental health care.

Still, Dr. Goodman concedes he was initially fearful of the repercussions. “I opened up about it because this post could save lives. I was doing what I believed in.”

So if he runs into barriers to receive his medical license because of his admission, “that’s a serious problem,” he said. “There is already a shortage of doctors. We’ll see what happens in a few years. I am not the only one who will answer ‘yes’ to having sought treatment for a mental illness. The questions do not really need to be there.”

A version of this article first appeared on Medscape.com.

The Group for the Advancement of Psychiatry’s Committee on the Family published an updated curriculum in October 2021 on family-oriented care. The first curriculum, published in 2006, was nominated as the American Association of Directors of Psychiatric Residency Training model curriculum for family-oriented care. The updated curriculum, produced by the GAP family committee and guests, is shorter and more focused.

The following is a summary of the introduction and the highlights.
 

Introduction

Use of family systems–based techniques in the diagnosis and care of patients is a key evidence-based tool for psychiatric disorders. However, it is not a current Accreditation Council for Graduate Medical Education Training training requirement, and it is possible to complete psychiatry residency without exposure to this key framework.

Here, we highlight the importance of considering patients through a “family systems” lens and the incorporation of multiple individuals from an individual patient’s identified system in their care.

Current medicine curricula emphasize patient autonomy, one of the core pillars of ethics. Autonomy is the cornerstone of the everyday practice within medicine of communicating all risks, benefits, and alternatives of a proposed treatment to a patient making decisions about desired paths forward. This prevents paternalistic care in which the doctor “knows best” and makes decisions for the patient. Unfortunately, the emphasis of this pillar has morphed over time into the idea that the individual patient is the only person to whom this information should be provided or from whom information should be obtained.

Extensive research proves conclusively that family support, education, and psychoeducation improve both patient and family functioning in medical and psychiatric illness. When clinicians focus solely on the identified patient, they miss the ability to obtain key information that might influence diagnosis and treatment as well as overlook the opportunity to use the structure and support system around a patient to strengthen their care and improve treatment outcomes.

The network and family dynamics around a patient can be critical to providing accurate information on medication adherence and symptoms, supporting recovery, and handling emergencies. Markedly improved patient outcomes occur when family members are seen as allies and offered support, assessment, and psychoeducation. In fact, the American Psychiatric Association’s Practice Guidelines on the treatment of schizophrenia (2020), major depressive disorder (2010), and bipolar disorder (2002) include the expectation that patients’ family members will be involved in the assessment and treatment of patients. Yet, training in how to incorporate these practices is often minimal or nonexistent during residency.

A family systems orientation is distinguished by its view of the family as a transactional system. Stressful events and problems of an individual member affect the whole family as a functional unit, with ripple effects for all members and their relationships. In turn, the family response – how the family handles problems – contributes significantly to positive adaptation or to individual and relational dysfunction. Thus, individual problems are assessed and addressed in the context of the family, with attention to socioeconomic and other environmental stressors.

A family systems approach is distinguished less by who is in the room and more by the clinician’s attention to relationship systems in assessment and treatment planning. We need to consider how family members may contribute to – and be affected by – problem situations. Most importantly, regardless of the source of difficulties, we involve key family members who can contribute to needed changes. Interventions are aimed at modifying dysfunctional patterns, tapping family resources, and strengthening both individual and family functioning.

A family systemic lens is useful for working with all types of families, for example: refugee families, thinking through child adoption processes, working with families with specific social disadvantages, etc. Incorporating issues of race, gender, and sexual orientation is important in this work, as is working with larger systems such as schools, workplaces, and health care settings.

As opposed to previous viewpoints that family therapy is the only “family” skill to be taught during residency, the GAP committee proposes that psychiatric residents should be trained in skills of family inclusion, support, and psychoeducation, and that these skills should be taught throughout the residency. Our goal is to have residents be able to consider any case through a family systems lens, to understand how patients’ illnesses and their family systems have bidirectional effects on each other, to perform a basic assessment of family system functioning, and to use this information in diagnostic and treatment planning.
 

Training goals

Systems-based thinking will enable trainees to:

1. Ally with family members to work with the patient to comply with goals of care (for example, taking medications, complying with lifestyle changes, and maintaining sobriety).

• Teachers focus on engagement, joining with families.

2. Help patients understand the influences of their families in their own lives, such as intergenerational transmission of trauma and resilience.

• Teachers focus on the creation of a genogram, and the location of the individual within their family system.

3. Understand that mental health includes the creation and maintenance of healthy relationships.

• Teachers focus on assessing a willingness to listen to others’ points of view and the cocreation of a shared reality and belief system: a belief that relationships can change over time and how to create new family narratives.

4. Understand the impact of illness on the family unit and the impact of the family unit on illness.

• Teachers focus on the concept of a family system, clarifying the roles within the family, including caregiving responsibilities.

5. Assess the family for strengths and weaknesses.

• Teachers focus on how families maintain a healthy emotional climate, allocate roles, decide on rules, problem-solving abilities, and so on.

6. Gather information from multiple informants in the same room.

• Teachers focus on using communication techniques to elicit, guide, and redirect information from multiple individuals of a system with varying perspectives in the same room. Teachers help students understand that there are multiple realities in families and learn how to maintain multidirectional partiality.

Knowledge, skills, and attitudes across all treatment settings

Knowledge: Beginning level

• Healthy family functioning at the various phases of the family life cycle. Systems concepts are applicable to families, multidisciplinary teams in clinical settings, and medical/government organizations. However, family systems are distinguished by deep attachment bonds, specific generational hierarchy, goals of emotional safety and, for many families, child rearing.
• Systemic thinking, unlike a linear cause and effect model, examines the feedback loops by which multiple persons or groups arrive at a specific way of functioning.
• Understanding boundaries, subsystems, and feedback loops is critical to understanding interpersonal connections. Understand how the family affects and is affected by psychiatric and medical illnesses. Impact of interpersonal stress on biological systems. The role of expressed emotion (EE) in psychiatric illness. EE describes the level of criticism, hostility, and emotional overinvolvement in families. It has been studied extensively across the health care spectrum, and cultural variance is significant.
• The components of family psychoeducation, and its associated research in improving patient and family outcomes.

Knowledge: Advanced level

• Principles of adaptive and maladaptive relational functioning in family life and family organization, communication, problem solving, and emotional regulation. Role of family strengths, resilience in reducing vulnerability.
• Couple and family development over the life cycle.
• Understanding multigenerational patterns.
• How age, gender, class, culture, and spirituality affect family life.
• The variety of family forms (for example, single parent, stepfamilies, same-sex parents).
• Special issues in couples and families, including loss, divorce and remarriage, immigration, illness, secrets, affairs, violence, alcohol and substance abuse, sexuality, including LGBTQi. Relationship of families to larger systems, for example, schools, work, health care systems, government agencies.

Skills

• Family-interviewing skills, especially managing high levels of emotion and making room for multiple points of view.
• Promoting resilience, hope, and strength.
• Basic psychoeducation techniques, which includes providing a therapeutic space for emotional processing, providing information about the illness, skills such as better communication, problem-solving, and relapse drill and support.
• Collaborative treatment planning with family members and other helping professionals. Treatment planning should include all members of the system: patient, family members, and members of the treatment team. Good planning establishes a role for family members, helps define criteria for managing emergencies, looks for areas of strength and resilience and provides clear and realistic goals for treatment.
• Knowledge of, and referral to, local and national resources, both in the community and online.

Attitudes

• Appreciate the multiple points of view in a family.
• Interest in family members as people with their own needs and history.
• Including family members as a resource in recovery.
• Understand caregiver burden and rewards and that stress extends to all family members.

Training techniques

Most learning takes place at the level of patient, supervisor, and resident. It is critical that the resident sees faculty members dealing with patients in observed or shared family sessions, and /or sees videos made by faculty or professionally made videos. Attitudes are best learned by modeling.

Areas of focus can include time management, addressing the fear that family sessions may get out of control, and the influence of the residents’ own life experiences and background including potential generational or cultural differences on their assessment and interactions with patient family dynamics. In skill development, our goal is efficient interviewing, history taking, and support in controlling sessions.

It is difficult to specify which techniques are most useful in didactic sessions as each presenter will have a different skill set for engaging the class. The techniques that work best are the ones most comfortable to the presenter. Any technique that gets emotions involved, such as role play, sculpting, discussing movie clips, bringing in family members to discuss their experiences, or self-exploration, will generate the most powerful learning. If time permits, exploration of the resident’s own family, including a genogram, is an exceptionally helpful technique, especially if accompanied by asking the residents to interview their own families.
 

Adult didactic curriculum

The curriculum represents basic concepts. We have vignettes by the authors, if needed, but it is best if the class, including the supervisor, uses vignettes from their own experiences. Material for use in class is in references, but the class is urged to draw on their own experiences as this supports strength-based teaching. The following are key topics and concepts for each of the training years.
 

Basic concepts for PGY1 and PGY2

1. Where are you in the family and individual life cycles? What are your experiences with psychiatric illness in family/friends? Open discussion about how individual and family life cycles interact. Draw genograms of s/o in the class or with the supervisor.

2. Healthy family functioning and family resilience. Recommend asking residents to talk to their parents/elders about their lives and family life cycle when they were your age. Open discussion about what makes a healthy resilient family.

3. How do I connect with the family rather than just one person? How do you learn to hold multiple perspectives? How do I try not to take sides/multidirectional partiality? How do I see each person in a positive way? How do I focus on family strengths, rather than focusing on someone behaving badly (which is really hard because it is overlearned in individual therapy).

4. What are the common factors used across all therapies, both individual and family? When is it best to use an individual relational approach versus a family systemic approach?

5. How do I decide if a family needs support or education or family therapy?

6. Psychoeducation: Research, current use and cultural adaptations.

7. Attachment styles and couples therapy.

8. What is the evidence base behind our work?

System practice for PGY 3 and 4

These seminars follow the basic seminars. The focus is on clarification of what systems thinking means. Systems thinking or relational thinking is to be differentiated from systems-based practice. These lectures require knowledge of systemic practice. If there are no local experts, residency programs can reach out to national experts at the Association of Family Psychiatrists, for help with virtual/remote or in-person teaching.

Here is a list of other topics that should be covered:

• Relational formulation, nested subsystems, boundaries, history of these concepts, contributions to the development of family therapy.
• How to define and identify common systems concepts, such as circular patterns, feedback loops, and triangulation. Teach circular questioning. Framing. This concept is the family systems equivalent of insight. How to intervene to effect communication change and behavior change?
• Working at interfaces: community, legal, government, agencies, and so on, and other treaters, consultation. Include systemic and individual racism.
• Understanding the complexity of intimacy.
• Emergency situations. When to report regarding abuse. Dealing with family trauma.
• Varieties of family therapy; assumptions and major concepts.

*The new curriculum was written by The GAP Committee on the Family: Ellen Berman, MD; John Rolland, MD, MPH; John Sargent, MD; and me, and with guests Chayanin Foongsathaporn, MD; Sarah Nguyen, MD, MPH; Neha Sharma, DO; and Jodi Zik, MD. For the full curriculum, which includes residency milestones, site-specific training goals, references, and case studies, please access the Association of Family Psychiatry’s website: www.familypsychiatrists.org.Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose. Contact Dr. Heru at [email protected].


 

The Group for the Advancement of Psychiatry’s Committee on the Family published an updated curriculum in October 2021 on family-oriented care. The first curriculum, published in 2006, was nominated as the American Association of Directors of Psychiatric Residency Training model curriculum for family-oriented care. The updated curriculum, produced by the GAP family committee and guests, is shorter and more focused.

The following is a summary of the introduction and the highlights.
 

Introduction

Use of family systems–based techniques in the diagnosis and care of patients is a key evidence-based tool for psychiatric disorders. However, it is not a current Accreditation Council for Graduate Medical Education Training training requirement, and it is possible to complete psychiatry residency without exposure to this key framework.

Here, we highlight the importance of considering patients through a “family systems” lens and the incorporation of multiple individuals from an individual patient’s identified system in their care.

Current medicine curricula emphasize patient autonomy, one of the core pillars of ethics. Autonomy is the cornerstone of the everyday practice within medicine of communicating all risks, benefits, and alternatives of a proposed treatment to a patient making decisions about desired paths forward. This prevents paternalistic care in which the doctor “knows best” and makes decisions for the patient. Unfortunately, the emphasis of this pillar has morphed over time into the idea that the individual patient is the only person to whom this information should be provided or from whom information should be obtained.

Extensive research proves conclusively that family support, education, and psychoeducation improve both patient and family functioning in medical and psychiatric illness. When clinicians focus solely on the identified patient, they miss the ability to obtain key information that might influence diagnosis and treatment as well as overlook the opportunity to use the structure and support system around a patient to strengthen their care and improve treatment outcomes.

The network and family dynamics around a patient can be critical to providing accurate information on medication adherence and symptoms, supporting recovery, and handling emergencies. Markedly improved patient outcomes occur when family members are seen as allies and offered support, assessment, and psychoeducation. In fact, the American Psychiatric Association’s Practice Guidelines on the treatment of schizophrenia (2020), major depressive disorder (2010), and bipolar disorder (2002) include the expectation that patients’ family members will be involved in the assessment and treatment of patients. Yet, training in how to incorporate these practices is often minimal or nonexistent during residency.

A family systems orientation is distinguished by its view of the family as a transactional system. Stressful events and problems of an individual member affect the whole family as a functional unit, with ripple effects for all members and their relationships. In turn, the family response – how the family handles problems – contributes significantly to positive adaptation or to individual and relational dysfunction. Thus, individual problems are assessed and addressed in the context of the family, with attention to socioeconomic and other environmental stressors.

A family systems approach is distinguished less by who is in the room and more by the clinician’s attention to relationship systems in assessment and treatment planning. We need to consider how family members may contribute to – and be affected by – problem situations. Most importantly, regardless of the source of difficulties, we involve key family members who can contribute to needed changes. Interventions are aimed at modifying dysfunctional patterns, tapping family resources, and strengthening both individual and family functioning.

A family systemic lens is useful for working with all types of families, for example: refugee families, thinking through child adoption processes, working with families with specific social disadvantages, etc. Incorporating issues of race, gender, and sexual orientation is important in this work, as is working with larger systems such as schools, workplaces, and health care settings.

As opposed to previous viewpoints that family therapy is the only “family” skill to be taught during residency, the GAP committee proposes that psychiatric residents should be trained in skills of family inclusion, support, and psychoeducation, and that these skills should be taught throughout the residency. Our goal is to have residents be able to consider any case through a family systems lens, to understand how patients’ illnesses and their family systems have bidirectional effects on each other, to perform a basic assessment of family system functioning, and to use this information in diagnostic and treatment planning.
 

Training goals

Systems-based thinking will enable trainees to:

1. Ally with family members to work with the patient to comply with goals of care (for example, taking medications, complying with lifestyle changes, and maintaining sobriety).

• Teachers focus on engagement, joining with families.

2. Help patients understand the influences of their families in their own lives, such as intergenerational transmission of trauma and resilience.

• Teachers focus on the creation of a genogram, and the location of the individual within their family system.

3. Understand that mental health includes the creation and maintenance of healthy relationships.

• Teachers focus on assessing a willingness to listen to others’ points of view and the cocreation of a shared reality and belief system: a belief that relationships can change over time and how to create new family narratives.

4. Understand the impact of illness on the family unit and the impact of the family unit on illness.

• Teachers focus on the concept of a family system, clarifying the roles within the family, including caregiving responsibilities.

5. Assess the family for strengths and weaknesses.

• Teachers focus on how families maintain a healthy emotional climate, allocate roles, decide on rules, problem-solving abilities, and so on.

6. Gather information from multiple informants in the same room.

• Teachers focus on using communication techniques to elicit, guide, and redirect information from multiple individuals of a system with varying perspectives in the same room. Teachers help students understand that there are multiple realities in families and learn how to maintain multidirectional partiality.

Knowledge, skills, and attitudes across all treatment settings

Knowledge: Beginning level

• Healthy family functioning at the various phases of the family life cycle. Systems concepts are applicable to families, multidisciplinary teams in clinical settings, and medical/government organizations. However, family systems are distinguished by deep attachment bonds, specific generational hierarchy, goals of emotional safety and, for many families, child rearing.
• Systemic thinking, unlike a linear cause and effect model, examines the feedback loops by which multiple persons or groups arrive at a specific way of functioning.
• Understanding boundaries, subsystems, and feedback loops is critical to understanding interpersonal connections. Understand how the family affects and is affected by psychiatric and medical illnesses. Impact of interpersonal stress on biological systems. The role of expressed emotion (EE) in psychiatric illness. EE describes the level of criticism, hostility, and emotional overinvolvement in families. It has been studied extensively across the health care spectrum, and cultural variance is significant.
• The components of family psychoeducation, and its associated research in improving patient and family outcomes.

Knowledge: Advanced level

• Principles of adaptive and maladaptive relational functioning in family life and family organization, communication, problem solving, and emotional regulation. Role of family strengths, resilience in reducing vulnerability.
• Couple and family development over the life cycle.
• Understanding multigenerational patterns.
• How age, gender, class, culture, and spirituality affect family life.
• The variety of family forms (for example, single parent, stepfamilies, same-sex parents).
• Special issues in couples and families, including loss, divorce and remarriage, immigration, illness, secrets, affairs, violence, alcohol and substance abuse, sexuality, including LGBTQi. Relationship of families to larger systems, for example, schools, work, health care systems, government agencies.

Skills

• Family-interviewing skills, especially managing high levels of emotion and making room for multiple points of view.
• Promoting resilience, hope, and strength.
• Basic psychoeducation techniques, which includes providing a therapeutic space for emotional processing, providing information about the illness, skills such as better communication, problem-solving, and relapse drill and support.
• Collaborative treatment planning with family members and other helping professionals. Treatment planning should include all members of the system: patient, family members, and members of the treatment team. Good planning establishes a role for family members, helps define criteria for managing emergencies, looks for areas of strength and resilience and provides clear and realistic goals for treatment.
• Knowledge of, and referral to, local and national resources, both in the community and online.

Attitudes

• Appreciate the multiple points of view in a family.
• Interest in family members as people with their own needs and history.
• Including family members as a resource in recovery.
• Understand caregiver burden and rewards and that stress extends to all family members.

Training techniques

Most learning takes place at the level of patient, supervisor, and resident. It is critical that the resident sees faculty members dealing with patients in observed or shared family sessions, and /or sees videos made by faculty or professionally made videos. Attitudes are best learned by modeling.

Areas of focus can include time management, addressing the fear that family sessions may get out of control, and the influence of the residents’ own life experiences and background including potential generational or cultural differences on their assessment and interactions with patient family dynamics. In skill development, our goal is efficient interviewing, history taking, and support in controlling sessions.

It is difficult to specify which techniques are most useful in didactic sessions as each presenter will have a different skill set for engaging the class. The techniques that work best are the ones most comfortable to the presenter. Any technique that gets emotions involved, such as role play, sculpting, discussing movie clips, bringing in family members to discuss their experiences, or self-exploration, will generate the most powerful learning. If time permits, exploration of the resident’s own family, including a genogram, is an exceptionally helpful technique, especially if accompanied by asking the residents to interview their own families.
 

Adult didactic curriculum

The curriculum represents basic concepts. We have vignettes by the authors, if needed, but it is best if the class, including the supervisor, uses vignettes from their own experiences. Material for use in class is in references, but the class is urged to draw on their own experiences as this supports strength-based teaching. The following are key topics and concepts for each of the training years.
 

Basic concepts for PGY1 and PGY2

1. Where are you in the family and individual life cycles? What are your experiences with psychiatric illness in family/friends? Open discussion about how individual and family life cycles interact. Draw genograms of s/o in the class or with the supervisor.

2. Healthy family functioning and family resilience. Recommend asking residents to talk to their parents/elders about their lives and family life cycle when they were your age. Open discussion about what makes a healthy resilient family.

3. How do I connect with the family rather than just one person? How do you learn to hold multiple perspectives? How do I try not to take sides/multidirectional partiality? How do I see each person in a positive way? How do I focus on family strengths, rather than focusing on someone behaving badly (which is really hard because it is overlearned in individual therapy).

4. What are the common factors used across all therapies, both individual and family? When is it best to use an individual relational approach versus a family systemic approach?

5. How do I decide if a family needs support or education or family therapy?

6. Psychoeducation: Research, current use and cultural adaptations.

7. Attachment styles and couples therapy.

8. What is the evidence base behind our work?

System practice for PGY 3 and 4

These seminars follow the basic seminars. The focus is on clarification of what systems thinking means. Systems thinking or relational thinking is to be differentiated from systems-based practice. These lectures require knowledge of systemic practice. If there are no local experts, residency programs can reach out to national experts at the Association of Family Psychiatrists, for help with virtual/remote or in-person teaching.

Here is a list of other topics that should be covered:

• Relational formulation, nested subsystems, boundaries, history of these concepts, contributions to the development of family therapy.
• How to define and identify common systems concepts, such as circular patterns, feedback loops, and triangulation. Teach circular questioning. Framing. This concept is the family systems equivalent of insight. How to intervene to effect communication change and behavior change?
• Working at interfaces: community, legal, government, agencies, and so on, and other treaters, consultation. Include systemic and individual racism.
• Understanding the complexity of intimacy.
• Emergency situations. When to report regarding abuse. Dealing with family trauma.
• Varieties of family therapy; assumptions and major concepts.

*The new curriculum was written by The GAP Committee on the Family: Ellen Berman, MD; John Rolland, MD, MPH; John Sargent, MD; and me, and with guests Chayanin Foongsathaporn, MD; Sarah Nguyen, MD, MPH; Neha Sharma, DO; and Jodi Zik, MD. For the full curriculum, which includes residency milestones, site-specific training goals, references, and case studies, please access the Association of Family Psychiatry’s website: www.familypsychiatrists.org.Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose. Contact Dr. Heru at [email protected].


 

The Group for the Advancement of Psychiatry’s Committee on the Family published an updated curriculum in October 2021 on family-oriented care. The first curriculum, published in 2006, was nominated as the American Association of Directors of Psychiatric Residency Training model curriculum for family-oriented care. The updated curriculum, produced by the GAP family committee and guests, is shorter and more focused.

The following is a summary of the introduction and the highlights.
 

Introduction

Use of family systems–based techniques in the diagnosis and care of patients is a key evidence-based tool for psychiatric disorders. However, it is not a current Accreditation Council for Graduate Medical Education Training training requirement, and it is possible to complete psychiatry residency without exposure to this key framework.

Here, we highlight the importance of considering patients through a “family systems” lens and the incorporation of multiple individuals from an individual patient’s identified system in their care.

Current medicine curricula emphasize patient autonomy, one of the core pillars of ethics. Autonomy is the cornerstone of the everyday practice within medicine of communicating all risks, benefits, and alternatives of a proposed treatment to a patient making decisions about desired paths forward. This prevents paternalistic care in which the doctor “knows best” and makes decisions for the patient. Unfortunately, the emphasis of this pillar has morphed over time into the idea that the individual patient is the only person to whom this information should be provided or from whom information should be obtained.

Extensive research proves conclusively that family support, education, and psychoeducation improve both patient and family functioning in medical and psychiatric illness. When clinicians focus solely on the identified patient, they miss the ability to obtain key information that might influence diagnosis and treatment as well as overlook the opportunity to use the structure and support system around a patient to strengthen their care and improve treatment outcomes.

The network and family dynamics around a patient can be critical to providing accurate information on medication adherence and symptoms, supporting recovery, and handling emergencies. Markedly improved patient outcomes occur when family members are seen as allies and offered support, assessment, and psychoeducation. In fact, the American Psychiatric Association’s Practice Guidelines on the treatment of schizophrenia (2020), major depressive disorder (2010), and bipolar disorder (2002) include the expectation that patients’ family members will be involved in the assessment and treatment of patients. Yet, training in how to incorporate these practices is often minimal or nonexistent during residency.

A family systems orientation is distinguished by its view of the family as a transactional system. Stressful events and problems of an individual member affect the whole family as a functional unit, with ripple effects for all members and their relationships. In turn, the family response – how the family handles problems – contributes significantly to positive adaptation or to individual and relational dysfunction. Thus, individual problems are assessed and addressed in the context of the family, with attention to socioeconomic and other environmental stressors.

A family systems approach is distinguished less by who is in the room and more by the clinician’s attention to relationship systems in assessment and treatment planning. We need to consider how family members may contribute to – and be affected by – problem situations. Most importantly, regardless of the source of difficulties, we involve key family members who can contribute to needed changes. Interventions are aimed at modifying dysfunctional patterns, tapping family resources, and strengthening both individual and family functioning.

A family systemic lens is useful for working with all types of families, for example: refugee families, thinking through child adoption processes, working with families with specific social disadvantages, etc. Incorporating issues of race, gender, and sexual orientation is important in this work, as is working with larger systems such as schools, workplaces, and health care settings.

As opposed to previous viewpoints that family therapy is the only “family” skill to be taught during residency, the GAP committee proposes that psychiatric residents should be trained in skills of family inclusion, support, and psychoeducation, and that these skills should be taught throughout the residency. Our goal is to have residents be able to consider any case through a family systems lens, to understand how patients’ illnesses and their family systems have bidirectional effects on each other, to perform a basic assessment of family system functioning, and to use this information in diagnostic and treatment planning.
 

Training goals

Systems-based thinking will enable trainees to:

1. Ally with family members to work with the patient to comply with goals of care (for example, taking medications, complying with lifestyle changes, and maintaining sobriety).

• Teachers focus on engagement, joining with families.

2. Help patients understand the influences of their families in their own lives, such as intergenerational transmission of trauma and resilience.

• Teachers focus on the creation of a genogram, and the location of the individual within their family system.

3. Understand that mental health includes the creation and maintenance of healthy relationships.

• Teachers focus on assessing a willingness to listen to others’ points of view and the cocreation of a shared reality and belief system: a belief that relationships can change over time and how to create new family narratives.

4. Understand the impact of illness on the family unit and the impact of the family unit on illness.

• Teachers focus on the concept of a family system, clarifying the roles within the family, including caregiving responsibilities.

5. Assess the family for strengths and weaknesses.

• Teachers focus on how families maintain a healthy emotional climate, allocate roles, decide on rules, problem-solving abilities, and so on.

6. Gather information from multiple informants in the same room.

• Teachers focus on using communication techniques to elicit, guide, and redirect information from multiple individuals of a system with varying perspectives in the same room. Teachers help students understand that there are multiple realities in families and learn how to maintain multidirectional partiality.

Knowledge, skills, and attitudes across all treatment settings

Knowledge: Beginning level

• Healthy family functioning at the various phases of the family life cycle. Systems concepts are applicable to families, multidisciplinary teams in clinical settings, and medical/government organizations. However, family systems are distinguished by deep attachment bonds, specific generational hierarchy, goals of emotional safety and, for many families, child rearing.
• Systemic thinking, unlike a linear cause and effect model, examines the feedback loops by which multiple persons or groups arrive at a specific way of functioning.
• Understanding boundaries, subsystems, and feedback loops is critical to understanding interpersonal connections. Understand how the family affects and is affected by psychiatric and medical illnesses. Impact of interpersonal stress on biological systems. The role of expressed emotion (EE) in psychiatric illness. EE describes the level of criticism, hostility, and emotional overinvolvement in families. It has been studied extensively across the health care spectrum, and cultural variance is significant.
• The components of family psychoeducation, and its associated research in improving patient and family outcomes.

Knowledge: Advanced level

• Principles of adaptive and maladaptive relational functioning in family life and family organization, communication, problem solving, and emotional regulation. Role of family strengths, resilience in reducing vulnerability.
• Couple and family development over the life cycle.
• Understanding multigenerational patterns.
• How age, gender, class, culture, and spirituality affect family life.
• The variety of family forms (for example, single parent, stepfamilies, same-sex parents).
• Special issues in couples and families, including loss, divorce and remarriage, immigration, illness, secrets, affairs, violence, alcohol and substance abuse, sexuality, including LGBTQi. Relationship of families to larger systems, for example, schools, work, health care systems, government agencies.

Skills

• Family-interviewing skills, especially managing high levels of emotion and making room for multiple points of view.
• Promoting resilience, hope, and strength.
• Basic psychoeducation techniques, which includes providing a therapeutic space for emotional processing, providing information about the illness, skills such as better communication, problem-solving, and relapse drill and support.
• Collaborative treatment planning with family members and other helping professionals. Treatment planning should include all members of the system: patient, family members, and members of the treatment team. Good planning establishes a role for family members, helps define criteria for managing emergencies, looks for areas of strength and resilience and provides clear and realistic goals for treatment.
• Knowledge of, and referral to, local and national resources, both in the community and online.

Attitudes

• Appreciate the multiple points of view in a family.
• Interest in family members as people with their own needs and history.
• Including family members as a resource in recovery.
• Understand caregiver burden and rewards and that stress extends to all family members.

Training techniques

Most learning takes place at the level of patient, supervisor, and resident. It is critical that the resident sees faculty members dealing with patients in observed or shared family sessions, and /or sees videos made by faculty or professionally made videos. Attitudes are best learned by modeling.

Areas of focus can include time management, addressing the fear that family sessions may get out of control, and the influence of the residents’ own life experiences and background including potential generational or cultural differences on their assessment and interactions with patient family dynamics. In skill development, our goal is efficient interviewing, history taking, and support in controlling sessions.

It is difficult to specify which techniques are most useful in didactic sessions as each presenter will have a different skill set for engaging the class. The techniques that work best are the ones most comfortable to the presenter. Any technique that gets emotions involved, such as role play, sculpting, discussing movie clips, bringing in family members to discuss their experiences, or self-exploration, will generate the most powerful learning. If time permits, exploration of the resident’s own family, including a genogram, is an exceptionally helpful technique, especially if accompanied by asking the residents to interview their own families.
 

Adult didactic curriculum

The curriculum represents basic concepts. We have vignettes by the authors, if needed, but it is best if the class, including the supervisor, uses vignettes from their own experiences. Material for use in class is in references, but the class is urged to draw on their own experiences as this supports strength-based teaching. The following are key topics and concepts for each of the training years.
 

Basic concepts for PGY1 and PGY2

1. Where are you in the family and individual life cycles? What are your experiences with psychiatric illness in family/friends? Open discussion about how individual and family life cycles interact. Draw genograms of s/o in the class or with the supervisor.

2. Healthy family functioning and family resilience. Recommend asking residents to talk to their parents/elders about their lives and family life cycle when they were your age. Open discussion about what makes a healthy resilient family.

3. How do I connect with the family rather than just one person? How do you learn to hold multiple perspectives? How do I try not to take sides/multidirectional partiality? How do I see each person in a positive way? How do I focus on family strengths, rather than focusing on someone behaving badly (which is really hard because it is overlearned in individual therapy).

4. What are the common factors used across all therapies, both individual and family? When is it best to use an individual relational approach versus a family systemic approach?

5. How do I decide if a family needs support or education or family therapy?

6. Psychoeducation: Research, current use and cultural adaptations.

7. Attachment styles and couples therapy.

8. What is the evidence base behind our work?

System practice for PGY 3 and 4

These seminars follow the basic seminars. The focus is on clarification of what systems thinking means. Systems thinking or relational thinking is to be differentiated from systems-based practice. These lectures require knowledge of systemic practice. If there are no local experts, residency programs can reach out to national experts at the Association of Family Psychiatrists, for help with virtual/remote or in-person teaching.

Here is a list of other topics that should be covered:

• Relational formulation, nested subsystems, boundaries, history of these concepts, contributions to the development of family therapy.
• How to define and identify common systems concepts, such as circular patterns, feedback loops, and triangulation. Teach circular questioning. Framing. This concept is the family systems equivalent of insight. How to intervene to effect communication change and behavior change?
• Working at interfaces: community, legal, government, agencies, and so on, and other treaters, consultation. Include systemic and individual racism.
• Understanding the complexity of intimacy.
• Emergency situations. When to report regarding abuse. Dealing with family trauma.
• Varieties of family therapy; assumptions and major concepts.

*The new curriculum was written by The GAP Committee on the Family: Ellen Berman, MD; John Rolland, MD, MPH; John Sargent, MD; and me, and with guests Chayanin Foongsathaporn, MD; Sarah Nguyen, MD, MPH; Neha Sharma, DO; and Jodi Zik, MD. For the full curriculum, which includes residency milestones, site-specific training goals, references, and case studies, please access the Association of Family Psychiatry’s website: www.familypsychiatrists.org.Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose. Contact Dr. Heru at [email protected].


 

A social worker called with a plea in April 2020, when the hospital was filled with COVID-19 patients, some so sick they were on ventilators. “I need your help with a family. Mom is in the ICU, intubated; her son died here 2 weeks ago of COVID and her daughters are overwhelmed, unable to visit because of restrictions. The staff anticipates extubating Elvira imminently, but she will be fragile and alone. When is the right time to tell Elvira that Tony died?”

That happened at the beginning of the COVID pandemic. I handled the case remotely with heroic help from overburdened nurses and doctors who were acting as medical staff, social workers, and substitute family to an isolated patient in the hospital. Such was the confusion with the new virus before vaccines and treatments.
 

The impact of pandemics: A historical perspective

Beginning in antiquity, there were pandemics that decimated populations. Before antibiotics, vaccines or awareness of microorganisms, people feared contagion and sought isolation from the sick. People also thought that those who recovered were less likely to fall ill again, and if they did get sick, the illness would be milder.

There is abundant documentation of bubonic plague outbreaks, such as the “Black Death” in the Middle Ages. The Spanish flu of 1918 struck down robust young Americans and spread worldwide. Although the bubonic plague was at the center of major infectious outbreaks, including the pandemic of the Justinian era (500s) and the Great Plague of London (1665-1666), other infectious diseases, untreatable at the time, prevailed simultaneously. Wars, world trade, unsanitary conditions, and urban crowding enhanced the spread. Pandemics shaped history. Some historians attribute the fall of the Roman Empire to unrelenting infectious disease carried in migratory battles.

Even in the earliest outbreaks, the poor populace died more readily than the well off, who had means to escape and seclude themselves from congested areas. Samuel Pepys, a diarist of the London Plague, was a famed businessman and government official; he wrote of seeing the suffering in his city, but he escaped to live with his wife in their country home. What Samuel Pepys wrote of London during the Plague can apply to the early period of the COVID pandemic: “How few people I see, and those looking like people that had taken leave of the world.”

There are lurid descriptions of the chaos of pandemics, especially of the Black Death and the Plague of London. First published in 1722, Daniel Defoe’s “A Journal of the Plague Year” describes the suffering of the sick that included people abandoning the afflicted and others running rampant with delirium in the streets, screaming in pain. City officials took cruel measures that they considered necessary, such as locking away families in their homes, sick and well together, when an individual member showed symptoms. The Middle Ages saw deadly anti-Semitism. During the Black Death, fanatics murdered Jews in the belief that they brought on the pestilence. Ignorance created panic.

As happens in tragedy, there was also bravery. Some stayed to tend to the sick; charities provided food for poor people during the London Plague.
 

Back to the 21st century

After 3 weeks on the ventilator, Elvira got extubated. A team including her doctor, nurse, and Connie, one of her daughters, told Elvira that her 28-year-old son had died of COVID. I began telepsychiatry with Elvira and her two daughters. Treatment continued after Elvira returned home. In telephone sessions, we discussed bereavement and how to cope with the emotional and physical challenges in recovery.

Before he contracted COVID, Tony, Elvira’s son, had compromised health. He was on dialysis awaiting a kidney transplant. His mother prepared his meals and often accompanied Tony to doctor appointments. Still, Elvira said, “I wasn’t there to hold his hand.” At age 71, Elvira was also at high risk. She suffered from diabetes, high blood pressure, hyperlipidemia, and had coronary stents. Elvira was compliant with medications for her conditions.
 

What we know; where we are

“Infectious diseases are not static conditions but depend upon a constantly changing relationship between parasite and invaded species which is bound to result in modifications of both clinical and epidemiological manifestations.”

Hans Zinsser, Rats, Lice and History

We need to be informed by history and grateful to the geniuses who brought us into the modern age of medicine. We can prevent diseases with public health measures, and by understanding and treating crises. Edward Jenner, who recognized the protective effect of cowpox against smallpox, developed inoculations beginning in 1796; he ushered in immunology and saved the lives of millions. Smallpox is now eradicated. A succession of microbe hunters, including Louis Pasteur and Robert Koch, benefited from the development of the microscope by Antonie van Leeuwenhoek. With the advent and use of penicillin in the early 1940s, Alexander Fleming welcomed antibiotics; by the 1960s this modality became widespread. In the mid-20th century, immunologists recognized that bacteria and viruses change and adapt to the environment.

The planet has seen ravaging pandemics that then dissipated and, although untreatable at the time, disappeared into a reservoir, such as rats or lice. People also developed herd immunity from exposure to the offending microorganisms within the population. Less toxic, these agents no longer kill those who get infected but they can be transmissible and endemic to humans.

The mental health consequences of pandemics are reminiscent of other severe illnesses. The seriously ill develop cognitive aberrations and can become delirious. The population at risk and those who get sick can experience depression, PTSD, and anxiety – including panic.
 

Update on Elvira

Elvira continues to improve. She also participates in support groups, including one that addresses bereavement for parents of children who died of COVID and other causes. “I didn’t have a chance to say goodbye,” she said. But what she calls her “brain fog” has dissipated. She walks better, and she is getting evaluation of radiculopathy, probably from nerve root injury during her 3 weeks in bed on the ventilator. She’s still experiencing pain in her feet.

With regard to her symptoms she said: “I cry almost every day.” Her PTSD has abated, but she sometimes has nightmares. Elvira is writing a book about the induced coma and the “hallucinations from hell to heaven” she experienced. She wonders:“Did Tony go through the same thing?” Her empathy is enhanced by her background as a retired social worker with the Administration for Children’s Services in New York.
 

The role of psychiatry

In its early, most virulent form, SARS-CoV-2 devastated thousands of people, especially the elderly medically vulnerable. With scientific tools we developed vaccines and treatments and continue to study the dynamics of this virus.

As Andy Miller, MD, chief of the division of infectious diseases at the Hospital for Special Surgery, said when I spoke with him about the virus, because of the way in which viruses mutate, “we must remain aware” of the trajectory of SARS-CoV-2 and “counter irrational beliefs.”

How should psychiatry deal with COVID? As scientists, we seek the truth without bias and politics. Mental illness is our domain. Other specialties have the expertise to treat and even prevent infectious disease. We can assist our doctor colleagues to understand depression, anxiety, PTSD, and cognitive issues when they occur. Our medical mission should be, as always, to treat those who suffer mental illness. Now that extends to the consequences of COVID.
 

Suggested reading

Camus A. The Plague. New York: Vintage Books,. 1991.

Defoe D. A Journal of the Plague Year. Mineola, N.Y.: Dover Publications, 2001.

Kelly J. The Great Mortality: An Intimate History of the Black Death, The Most Devastating Plague of All Time. New York: Harper Perennial, 2005.

Pepys S. The Diary of Samuel Pepys: The Great Plague of London & The Great Fire of London, 1665-1666. Oxford, England: Benediction Classics, 2020.

Emerg Infect Dis. 2005 Mar 11(3):402-96.

Zinsser H. Rats, Lice and History. Boston/Toronto: Little Brown and Co., 1935.

Dr. Cohen is in private practice of psychotherapy and medication management in New York. She has been a consultant at the Hospital for Special Surgery and at New York–Presbyterian, and a forensic psychiatry expert. She changed key facts about Elvira’s case to protect her anonymity.

A social worker called with a plea in April 2020, when the hospital was filled with COVID-19 patients, some so sick they were on ventilators. “I need your help with a family. Mom is in the ICU, intubated; her son died here 2 weeks ago of COVID and her daughters are overwhelmed, unable to visit because of restrictions. The staff anticipates extubating Elvira imminently, but she will be fragile and alone. When is the right time to tell Elvira that Tony died?”

That happened at the beginning of the COVID pandemic. I handled the case remotely with heroic help from overburdened nurses and doctors who were acting as medical staff, social workers, and substitute family to an isolated patient in the hospital. Such was the confusion with the new virus before vaccines and treatments.
 

The impact of pandemics: A historical perspective

Beginning in antiquity, there were pandemics that decimated populations. Before antibiotics, vaccines or awareness of microorganisms, people feared contagion and sought isolation from the sick. People also thought that those who recovered were less likely to fall ill again, and if they did get sick, the illness would be milder.

There is abundant documentation of bubonic plague outbreaks, such as the “Black Death” in the Middle Ages. The Spanish flu of 1918 struck down robust young Americans and spread worldwide. Although the bubonic plague was at the center of major infectious outbreaks, including the pandemic of the Justinian era (500s) and the Great Plague of London (1665-1666), other infectious diseases, untreatable at the time, prevailed simultaneously. Wars, world trade, unsanitary conditions, and urban crowding enhanced the spread. Pandemics shaped history. Some historians attribute the fall of the Roman Empire to unrelenting infectious disease carried in migratory battles.

Even in the earliest outbreaks, the poor populace died more readily than the well off, who had means to escape and seclude themselves from congested areas. Samuel Pepys, a diarist of the London Plague, was a famed businessman and government official; he wrote of seeing the suffering in his city, but he escaped to live with his wife in their country home. What Samuel Pepys wrote of London during the Plague can apply to the early period of the COVID pandemic: “How few people I see, and those looking like people that had taken leave of the world.”

There are lurid descriptions of the chaos of pandemics, especially of the Black Death and the Plague of London. First published in 1722, Daniel Defoe’s “A Journal of the Plague Year” describes the suffering of the sick that included people abandoning the afflicted and others running rampant with delirium in the streets, screaming in pain. City officials took cruel measures that they considered necessary, such as locking away families in their homes, sick and well together, when an individual member showed symptoms. The Middle Ages saw deadly anti-Semitism. During the Black Death, fanatics murdered Jews in the belief that they brought on the pestilence. Ignorance created panic.

As happens in tragedy, there was also bravery. Some stayed to tend to the sick; charities provided food for poor people during the London Plague.
 

Back to the 21st century

After 3 weeks on the ventilator, Elvira got extubated. A team including her doctor, nurse, and Connie, one of her daughters, told Elvira that her 28-year-old son had died of COVID. I began telepsychiatry with Elvira and her two daughters. Treatment continued after Elvira returned home. In telephone sessions, we discussed bereavement and how to cope with the emotional and physical challenges in recovery.

Before he contracted COVID, Tony, Elvira’s son, had compromised health. He was on dialysis awaiting a kidney transplant. His mother prepared his meals and often accompanied Tony to doctor appointments. Still, Elvira said, “I wasn’t there to hold his hand.” At age 71, Elvira was also at high risk. She suffered from diabetes, high blood pressure, hyperlipidemia, and had coronary stents. Elvira was compliant with medications for her conditions.
 

What we know; where we are

“Infectious diseases are not static conditions but depend upon a constantly changing relationship between parasite and invaded species which is bound to result in modifications of both clinical and epidemiological manifestations.”

Hans Zinsser, Rats, Lice and History

We need to be informed by history and grateful to the geniuses who brought us into the modern age of medicine. We can prevent diseases with public health measures, and by understanding and treating crises. Edward Jenner, who recognized the protective effect of cowpox against smallpox, developed inoculations beginning in 1796; he ushered in immunology and saved the lives of millions. Smallpox is now eradicated. A succession of microbe hunters, including Louis Pasteur and Robert Koch, benefited from the development of the microscope by Antonie van Leeuwenhoek. With the advent and use of penicillin in the early 1940s, Alexander Fleming welcomed antibiotics; by the 1960s this modality became widespread. In the mid-20th century, immunologists recognized that bacteria and viruses change and adapt to the environment.

The planet has seen ravaging pandemics that then dissipated and, although untreatable at the time, disappeared into a reservoir, such as rats or lice. People also developed herd immunity from exposure to the offending microorganisms within the population. Less toxic, these agents no longer kill those who get infected but they can be transmissible and endemic to humans.

The mental health consequences of pandemics are reminiscent of other severe illnesses. The seriously ill develop cognitive aberrations and can become delirious. The population at risk and those who get sick can experience depression, PTSD, and anxiety – including panic.
 

Update on Elvira

Elvira continues to improve. She also participates in support groups, including one that addresses bereavement for parents of children who died of COVID and other causes. “I didn’t have a chance to say goodbye,” she said. But what she calls her “brain fog” has dissipated. She walks better, and she is getting evaluation of radiculopathy, probably from nerve root injury during her 3 weeks in bed on the ventilator. She’s still experiencing pain in her feet.

With regard to her symptoms she said: “I cry almost every day.” Her PTSD has abated, but she sometimes has nightmares. Elvira is writing a book about the induced coma and the “hallucinations from hell to heaven” she experienced. She wonders:“Did Tony go through the same thing?” Her empathy is enhanced by her background as a retired social worker with the Administration for Children’s Services in New York.
 

The role of psychiatry

In its early, most virulent form, SARS-CoV-2 devastated thousands of people, especially the elderly medically vulnerable. With scientific tools we developed vaccines and treatments and continue to study the dynamics of this virus.

As Andy Miller, MD, chief of the division of infectious diseases at the Hospital for Special Surgery, said when I spoke with him about the virus, because of the way in which viruses mutate, “we must remain aware” of the trajectory of SARS-CoV-2 and “counter irrational beliefs.”

How should psychiatry deal with COVID? As scientists, we seek the truth without bias and politics. Mental illness is our domain. Other specialties have the expertise to treat and even prevent infectious disease. We can assist our doctor colleagues to understand depression, anxiety, PTSD, and cognitive issues when they occur. Our medical mission should be, as always, to treat those who suffer mental illness. Now that extends to the consequences of COVID.
 

Suggested reading

Camus A. The Plague. New York: Vintage Books,. 1991.

Defoe D. A Journal of the Plague Year. Mineola, N.Y.: Dover Publications, 2001.

Kelly J. The Great Mortality: An Intimate History of the Black Death, The Most Devastating Plague of All Time. New York: Harper Perennial, 2005.

Pepys S. The Diary of Samuel Pepys: The Great Plague of London & The Great Fire of London, 1665-1666. Oxford, England: Benediction Classics, 2020.

Emerg Infect Dis. 2005 Mar 11(3):402-96.

Zinsser H. Rats, Lice and History. Boston/Toronto: Little Brown and Co., 1935.

Dr. Cohen is in private practice of psychotherapy and medication management in New York. She has been a consultant at the Hospital for Special Surgery and at New York–Presbyterian, and a forensic psychiatry expert. She changed key facts about Elvira’s case to protect her anonymity.

A social worker called with a plea in April 2020, when the hospital was filled with COVID-19 patients, some so sick they were on ventilators. “I need your help with a family. Mom is in the ICU, intubated; her son died here 2 weeks ago of COVID and her daughters are overwhelmed, unable to visit because of restrictions. The staff anticipates extubating Elvira imminently, but she will be fragile and alone. When is the right time to tell Elvira that Tony died?”

That happened at the beginning of the COVID pandemic. I handled the case remotely with heroic help from overburdened nurses and doctors who were acting as medical staff, social workers, and substitute family to an isolated patient in the hospital. Such was the confusion with the new virus before vaccines and treatments.
 

The impact of pandemics: A historical perspective

Beginning in antiquity, there were pandemics that decimated populations. Before antibiotics, vaccines or awareness of microorganisms, people feared contagion and sought isolation from the sick. People also thought that those who recovered were less likely to fall ill again, and if they did get sick, the illness would be milder.

There is abundant documentation of bubonic plague outbreaks, such as the “Black Death” in the Middle Ages. The Spanish flu of 1918 struck down robust young Americans and spread worldwide. Although the bubonic plague was at the center of major infectious outbreaks, including the pandemic of the Justinian era (500s) and the Great Plague of London (1665-1666), other infectious diseases, untreatable at the time, prevailed simultaneously. Wars, world trade, unsanitary conditions, and urban crowding enhanced the spread. Pandemics shaped history. Some historians attribute the fall of the Roman Empire to unrelenting infectious disease carried in migratory battles.

Even in the earliest outbreaks, the poor populace died more readily than the well off, who had means to escape and seclude themselves from congested areas. Samuel Pepys, a diarist of the London Plague, was a famed businessman and government official; he wrote of seeing the suffering in his city, but he escaped to live with his wife in their country home. What Samuel Pepys wrote of London during the Plague can apply to the early period of the COVID pandemic: “How few people I see, and those looking like people that had taken leave of the world.”

There are lurid descriptions of the chaos of pandemics, especially of the Black Death and the Plague of London. First published in 1722, Daniel Defoe’s “A Journal of the Plague Year” describes the suffering of the sick that included people abandoning the afflicted and others running rampant with delirium in the streets, screaming in pain. City officials took cruel measures that they considered necessary, such as locking away families in their homes, sick and well together, when an individual member showed symptoms. The Middle Ages saw deadly anti-Semitism. During the Black Death, fanatics murdered Jews in the belief that they brought on the pestilence. Ignorance created panic.

As happens in tragedy, there was also bravery. Some stayed to tend to the sick; charities provided food for poor people during the London Plague.
 

Back to the 21st century

After 3 weeks on the ventilator, Elvira got extubated. A team including her doctor, nurse, and Connie, one of her daughters, told Elvira that her 28-year-old son had died of COVID. I began telepsychiatry with Elvira and her two daughters. Treatment continued after Elvira returned home. In telephone sessions, we discussed bereavement and how to cope with the emotional and physical challenges in recovery.

Before he contracted COVID, Tony, Elvira’s son, had compromised health. He was on dialysis awaiting a kidney transplant. His mother prepared his meals and often accompanied Tony to doctor appointments. Still, Elvira said, “I wasn’t there to hold his hand.” At age 71, Elvira was also at high risk. She suffered from diabetes, high blood pressure, hyperlipidemia, and had coronary stents. Elvira was compliant with medications for her conditions.
 

What we know; where we are

“Infectious diseases are not static conditions but depend upon a constantly changing relationship between parasite and invaded species which is bound to result in modifications of both clinical and epidemiological manifestations.”

Hans Zinsser, Rats, Lice and History

We need to be informed by history and grateful to the geniuses who brought us into the modern age of medicine. We can prevent diseases with public health measures, and by understanding and treating crises. Edward Jenner, who recognized the protective effect of cowpox against smallpox, developed inoculations beginning in 1796; he ushered in immunology and saved the lives of millions. Smallpox is now eradicated. A succession of microbe hunters, including Louis Pasteur and Robert Koch, benefited from the development of the microscope by Antonie van Leeuwenhoek. With the advent and use of penicillin in the early 1940s, Alexander Fleming welcomed antibiotics; by the 1960s this modality became widespread. In the mid-20th century, immunologists recognized that bacteria and viruses change and adapt to the environment.

The planet has seen ravaging pandemics that then dissipated and, although untreatable at the time, disappeared into a reservoir, such as rats or lice. People also developed herd immunity from exposure to the offending microorganisms within the population. Less toxic, these agents no longer kill those who get infected but they can be transmissible and endemic to humans.

The mental health consequences of pandemics are reminiscent of other severe illnesses. The seriously ill develop cognitive aberrations and can become delirious. The population at risk and those who get sick can experience depression, PTSD, and anxiety – including panic.
 

Update on Elvira

Elvira continues to improve. She also participates in support groups, including one that addresses bereavement for parents of children who died of COVID and other causes. “I didn’t have a chance to say goodbye,” she said. But what she calls her “brain fog” has dissipated. She walks better, and she is getting evaluation of radiculopathy, probably from nerve root injury during her 3 weeks in bed on the ventilator. She’s still experiencing pain in her feet.

With regard to her symptoms she said: “I cry almost every day.” Her PTSD has abated, but she sometimes has nightmares. Elvira is writing a book about the induced coma and the “hallucinations from hell to heaven” she experienced. She wonders:“Did Tony go through the same thing?” Her empathy is enhanced by her background as a retired social worker with the Administration for Children’s Services in New York.
 

The role of psychiatry

In its early, most virulent form, SARS-CoV-2 devastated thousands of people, especially the elderly medically vulnerable. With scientific tools we developed vaccines and treatments and continue to study the dynamics of this virus.

As Andy Miller, MD, chief of the division of infectious diseases at the Hospital for Special Surgery, said when I spoke with him about the virus, because of the way in which viruses mutate, “we must remain aware” of the trajectory of SARS-CoV-2 and “counter irrational beliefs.”

How should psychiatry deal with COVID? As scientists, we seek the truth without bias and politics. Mental illness is our domain. Other specialties have the expertise to treat and even prevent infectious disease. We can assist our doctor colleagues to understand depression, anxiety, PTSD, and cognitive issues when they occur. Our medical mission should be, as always, to treat those who suffer mental illness. Now that extends to the consequences of COVID.
 

Suggested reading

Camus A. The Plague. New York: Vintage Books,. 1991.

Defoe D. A Journal of the Plague Year. Mineola, N.Y.: Dover Publications, 2001.

Kelly J. The Great Mortality: An Intimate History of the Black Death, The Most Devastating Plague of All Time. New York: Harper Perennial, 2005.

Pepys S. The Diary of Samuel Pepys: The Great Plague of London & The Great Fire of London, 1665-1666. Oxford, England: Benediction Classics, 2020.

Emerg Infect Dis. 2005 Mar 11(3):402-96.

Zinsser H. Rats, Lice and History. Boston/Toronto: Little Brown and Co., 1935.

Dr. Cohen is in private practice of psychotherapy and medication management in New York. She has been a consultant at the Hospital for Special Surgery and at New York–Presbyterian, and a forensic psychiatry expert. She changed key facts about Elvira’s case to protect her anonymity.