Helen M. Farrell, MD

Advances in neuroimaging over the past 25 years have allowed for an increasingly sophisticated understanding of the structural and functional brain abnormalities associated with psychiatric disease.¹ It has been postulated that a better understanding of aberrant brain circuitry in psychiatric illness will be critical for transforming the diagnosis and treatment of these illnesses.² In fact, in 2008, the National Institute of Mental Health launched the Research Domain Criteria project to reformulate psychiatric diagnosis based on biologic underpinnings.³

In the midst of these scientific advances and the increased availability of neuroimaging, some private clinics have begun to offer routine brain scans as part of a comprehensive psychiatric evaluation.^4-7 These clinics suggest that single-photon emission computed tomography (SPECT) of the brain can provide objective, reliable psychiatric diagnoses. Unfortunately, using SPECT for psychiatric diagnosis lacks empirical support and carries risks, including exposing patients to radioisotopes and detracting from empirically validated treatments.⁸ Nonetheless, given the current diagnostic challenges in psychiatry, it is understandable that patients, parents, and clinicians alike have reported high receptivity to the use of neuroimaging for psychiatric diagnosis and treatment planning.⁹

While neuroimaging is central to the search for improved understanding of the biologic foundations of mental illness, progress in identifying biomarkers has been disappointing. There are currently no neuroimaging biomarkers that can reliably distinguish patients from controls, and no empirical evidence supports the use of neuroimaging in diagnosing psychiatric conditions.¹⁰ The current standard of clinical care is to use neuroimaging to diagnose neurologic diseases that are masquerading as psychiatric disorders. However, given the rapid advances and availability of this technology, determining if and when neuroimaging is clinically indicated will likely soon become increasingly complex. Prior to the widespread availability of this technology, it is worth considering the potential advantages and pitfalls to the adoption of neuroimaging in psychiatry. In this article, we:

• outline arguments that support the use of neuroimaging in psychiatry, and some of the limitations
• discuss special considerations for patients with first-episode psychosis (FEP) and forensic psychiatry
• suggest guidelines for best-practice models based on the current evidence.

Advantages of widespread use of neuroimaging in psychiatry

Currently, neuroimaging is used in psychiatry to rule out neurologic disorders such as seizures, tumors, or infectious illness that might be causing psychiatric symptoms. If neuroimaging were routinely used for this purpose, one theoretical advantage would be increased neurologic diagnostic accuracy. Furthermore, increased adoption of neuroimaging may eventually help broaden the phenotype of neurologic disorders. In other words, psychiatric symptoms may be more common in neurologic disorders than we currently recognize. A second advantage might be that early and definitive exclusion of a structural neurologic disorder may help patients and families more readily accept a psychiatric diagnosis and appropriate treatment.

In the future, if biomarkers of psychiatric illness are discerned, using neuroimaging for diagnosis, assessment, and treatment planning may help increase objectivity and reduce the stigma associated with mental illness. Currently, psychiatric diagnoses are based on emotional and behavioral self-report and clinical observations. It is not uncommon for patients to receive different diagnoses and even conflicting recommendations from different clinicians. Tools that aid objective diagnosis will likely improve the reliability of the diagnosis and help in assessing treatment response. Also, concrete biomarkers that respond to treatment may help align psychiatric disorders with other medical illnesses, thereby decreasing stigma.

Cautions against routine neuroimaging

There are several potential pitfalls to the routine use of neuroimaging in psychiatry. First, clinical psychiatry is centered on clinical acumen and the doctor–patient relationship. Many psychiatric clinicians are not accustomed to using lab measures or tests to support the diagnostic process or treatment planning. Psychiatrists may be resistant to technologies that threaten clinical acumen, the power of the therapeutic relationship, and the value of getting to know patients over time.¹¹ Overreliance on neuroimaging for psychiatric diagnosis also carries the risk of becoming overly reductionistic. This approach may overemphasize the biologic aspects of mental illness, while excluding social and psychological factors that may be responsive to treatment.

Second, the widespread use of neuroimaging is likely to result in many incidental findings. This is especially relevant because abnormality does not establish causality. Incidental findings may cause unnecessary anxiety for patients and families, particularly if there are minimal treatment options.

Continue to: Third, it remains unclear...

Third, it remains unclear whether widespread neuroimaging in psychiatry will be cost-effective. Unless imaging results are tied to effective treatments, neuroimaging is unlikely to result in cost savings. Presently, patients who can afford out-of-pocket care might be able to access neuroimaging. If neuroimaging were shown to improve clinical outcomes but remains costly, this unequal distribution of resources would create an ethical quandary.

Finally, neuroimaging is complex and almost certainly not as objective as one might hope. Interpreting images will require specialized knowledge and skills that are beyond those of currently certified general psychiatrists.¹² Because there is a great deal of overlap in brain anomalies across psychiatric illnesses, it is unclear whether using neuroimaging for diagnostic purposes will eclipse a thorough clinical assessment. For example, the amygdala and insula show activation across a range of anxiety disorders. Abnormal amygdala activation has also been reported in depression, bipolar disorder, schizophrenia, and psychopathy.¹³

In addition, psychiatric comorbidity is common. It is unclear how much neuro­imaging will add diagnostically when a patient presents with multiple psychiatric disorders. Comorbidity of psychiatric and neurologic disorders also is common. A neurologic illness that is detectable by structural neuroimaging does not necessarily exclude the presence of a psychiatric disorder. This poses yet another challenge to developing reliable, valid neuroimaging techniques for clinical use.

Areas of controversy

First-episode psychosis. Current practice guidelines for neuroimaging in patients with FEP are inconsistent. The Canadian Choosing Wisely Guidelines recommend against routinely ordering neuroimaging in first-episode psychoses in the absence of signs or symptoms that suggest intracranial pathology.¹⁴ Similarly, the American Psychiatric Association’s Practice Guideline for the Treatment of Patients with Schizophrenia recommends ordering neuroimaging in patients for whom the clinical picture is unclear or when examination reveals abnormal findings.¹⁵ In contrast, the Australian Clinical Guidelines for Early Psychosis recommend that all patients with FEP receive brain MRI.¹⁶ Freudenreich et al¹⁷ describe 2 philosophies regarding the initial medical workup of FEP: (1) a comprehensive medical workup requires extensive testing, and (2) in their natural histories, most illnesses eventually declare themselves.

Despite this inconsistency, the overall evidence does not seem to support routine brain imaging for patients with FEP in the absence of neurologic or cognitive impairment. A systematic review of 16 studies assessing the clinical utility of structural neuroimaging in FEP found that there was “insufficient evidence to suggest that brain imaging should be routinely ordered for patients presenting with first-episode psychosis without associated neurological or cognitive impairment.”¹⁸

Continue to: Forensic psychiatry

Forensic psychiatry. Two academic disciplines—neuroethics and neurolaw—attempt to study how medications and neuroimaging could impact forensic psychiatry.¹⁹ And in this golden age of neuroscience, psychiatrists specializing in forensics may be increasingly asked to opine on brain scans. This requires specific thoughtfulness and attention because forensic psychiatrists must “distinguish neuroscience from neuro-nonsense.”²⁰ These specialists will need to consider the Daubert standard, which resulted from the 1993 case Daubert v Merrell Dow Pharmaceuticals, Inc.²¹ In this case, the US Supreme Court ruled that evidence must be “‘generally accepted’ as reliable in the relevant scientific community” to be admissible. According to the Daubert standard, “evidentiary reliability” is based on scientific validity.²¹

How should we use neuroimaging?

While neuroimaging is a quickly evolving research tool, empirical support for its clinical use remains limited. The hope is that future neuroimaging research will yield biomarker profiles for mental illness, identification of risk factors, and predictors of vulnerability and treatment response, which will allow for more targeted treatments.¹

The current standard of clinical care for using neuroimaging in psychiatry is to diagnose neurologic diseases. Although there are no consensus guidelines for when to order imaging, it is reasonable to consider imaging when a patient has²²:

• abrupt onset of symptoms
• change in level of consciousness
• deficits in neurologic or cognitive examination
• a history of head trauma (with loss of consciousness), whole-brain radiation, neuro­logic comorbidities, or cancer
• late onset of symptoms (age >50)
• atypical presentation of psychiatric illness.

Advances in neuroimaging over the past 25 years have allowed for an increasingly sophisticated understanding of the structural and functional brain abnormalities associated with psychiatric disease.¹ It has been postulated that a better understanding of aberrant brain circuitry in psychiatric illness will be critical for transforming the diagnosis and treatment of these illnesses.² In fact, in 2008, the National Institute of Mental Health launched the Research Domain Criteria project to reformulate psychiatric diagnosis based on biologic underpinnings.³

In the midst of these scientific advances and the increased availability of neuroimaging, some private clinics have begun to offer routine brain scans as part of a comprehensive psychiatric evaluation.^4-7 These clinics suggest that single-photon emission computed tomography (SPECT) of the brain can provide objective, reliable psychiatric diagnoses. Unfortunately, using SPECT for psychiatric diagnosis lacks empirical support and carries risks, including exposing patients to radioisotopes and detracting from empirically validated treatments.⁸ Nonetheless, given the current diagnostic challenges in psychiatry, it is understandable that patients, parents, and clinicians alike have reported high receptivity to the use of neuroimaging for psychiatric diagnosis and treatment planning.⁹

While neuroimaging is central to the search for improved understanding of the biologic foundations of mental illness, progress in identifying biomarkers has been disappointing. There are currently no neuroimaging biomarkers that can reliably distinguish patients from controls, and no empirical evidence supports the use of neuroimaging in diagnosing psychiatric conditions.¹⁰ The current standard of clinical care is to use neuroimaging to diagnose neurologic diseases that are masquerading as psychiatric disorders. However, given the rapid advances and availability of this technology, determining if and when neuroimaging is clinically indicated will likely soon become increasingly complex. Prior to the widespread availability of this technology, it is worth considering the potential advantages and pitfalls to the adoption of neuroimaging in psychiatry. In this article, we:

• outline arguments that support the use of neuroimaging in psychiatry, and some of the limitations
• discuss special considerations for patients with first-episode psychosis (FEP) and forensic psychiatry
• suggest guidelines for best-practice models based on the current evidence.

Advantages of widespread use of neuroimaging in psychiatry

Currently, neuroimaging is used in psychiatry to rule out neurologic disorders such as seizures, tumors, or infectious illness that might be causing psychiatric symptoms. If neuroimaging were routinely used for this purpose, one theoretical advantage would be increased neurologic diagnostic accuracy. Furthermore, increased adoption of neuroimaging may eventually help broaden the phenotype of neurologic disorders. In other words, psychiatric symptoms may be more common in neurologic disorders than we currently recognize. A second advantage might be that early and definitive exclusion of a structural neurologic disorder may help patients and families more readily accept a psychiatric diagnosis and appropriate treatment.

In the future, if biomarkers of psychiatric illness are discerned, using neuroimaging for diagnosis, assessment, and treatment planning may help increase objectivity and reduce the stigma associated with mental illness. Currently, psychiatric diagnoses are based on emotional and behavioral self-report and clinical observations. It is not uncommon for patients to receive different diagnoses and even conflicting recommendations from different clinicians. Tools that aid objective diagnosis will likely improve the reliability of the diagnosis and help in assessing treatment response. Also, concrete biomarkers that respond to treatment may help align psychiatric disorders with other medical illnesses, thereby decreasing stigma.

Cautions against routine neuroimaging

There are several potential pitfalls to the routine use of neuroimaging in psychiatry. First, clinical psychiatry is centered on clinical acumen and the doctor–patient relationship. Many psychiatric clinicians are not accustomed to using lab measures or tests to support the diagnostic process or treatment planning. Psychiatrists may be resistant to technologies that threaten clinical acumen, the power of the therapeutic relationship, and the value of getting to know patients over time.¹¹ Overreliance on neuroimaging for psychiatric diagnosis also carries the risk of becoming overly reductionistic. This approach may overemphasize the biologic aspects of mental illness, while excluding social and psychological factors that may be responsive to treatment.

Second, the widespread use of neuroimaging is likely to result in many incidental findings. This is especially relevant because abnormality does not establish causality. Incidental findings may cause unnecessary anxiety for patients and families, particularly if there are minimal treatment options.

Continue to: Third, it remains unclear...

Third, it remains unclear whether widespread neuroimaging in psychiatry will be cost-effective. Unless imaging results are tied to effective treatments, neuroimaging is unlikely to result in cost savings. Presently, patients who can afford out-of-pocket care might be able to access neuroimaging. If neuroimaging were shown to improve clinical outcomes but remains costly, this unequal distribution of resources would create an ethical quandary.

Finally, neuroimaging is complex and almost certainly not as objective as one might hope. Interpreting images will require specialized knowledge and skills that are beyond those of currently certified general psychiatrists.¹² Because there is a great deal of overlap in brain anomalies across psychiatric illnesses, it is unclear whether using neuroimaging for diagnostic purposes will eclipse a thorough clinical assessment. For example, the amygdala and insula show activation across a range of anxiety disorders. Abnormal amygdala activation has also been reported in depression, bipolar disorder, schizophrenia, and psychopathy.¹³

In addition, psychiatric comorbidity is common. It is unclear how much neuro­imaging will add diagnostically when a patient presents with multiple psychiatric disorders. Comorbidity of psychiatric and neurologic disorders also is common. A neurologic illness that is detectable by structural neuroimaging does not necessarily exclude the presence of a psychiatric disorder. This poses yet another challenge to developing reliable, valid neuroimaging techniques for clinical use.

Areas of controversy

First-episode psychosis. Current practice guidelines for neuroimaging in patients with FEP are inconsistent. The Canadian Choosing Wisely Guidelines recommend against routinely ordering neuroimaging in first-episode psychoses in the absence of signs or symptoms that suggest intracranial pathology.¹⁴ Similarly, the American Psychiatric Association’s Practice Guideline for the Treatment of Patients with Schizophrenia recommends ordering neuroimaging in patients for whom the clinical picture is unclear or when examination reveals abnormal findings.¹⁵ In contrast, the Australian Clinical Guidelines for Early Psychosis recommend that all patients with FEP receive brain MRI.¹⁶ Freudenreich et al¹⁷ describe 2 philosophies regarding the initial medical workup of FEP: (1) a comprehensive medical workup requires extensive testing, and (2) in their natural histories, most illnesses eventually declare themselves.

Despite this inconsistency, the overall evidence does not seem to support routine brain imaging for patients with FEP in the absence of neurologic or cognitive impairment. A systematic review of 16 studies assessing the clinical utility of structural neuroimaging in FEP found that there was “insufficient evidence to suggest that brain imaging should be routinely ordered for patients presenting with first-episode psychosis without associated neurological or cognitive impairment.”¹⁸

Continue to: Forensic psychiatry

Forensic psychiatry. Two academic disciplines—neuroethics and neurolaw—attempt to study how medications and neuroimaging could impact forensic psychiatry.¹⁹ And in this golden age of neuroscience, psychiatrists specializing in forensics may be increasingly asked to opine on brain scans. This requires specific thoughtfulness and attention because forensic psychiatrists must “distinguish neuroscience from neuro-nonsense.”²⁰ These specialists will need to consider the Daubert standard, which resulted from the 1993 case Daubert v Merrell Dow Pharmaceuticals, Inc.²¹ In this case, the US Supreme Court ruled that evidence must be “‘generally accepted’ as reliable in the relevant scientific community” to be admissible. According to the Daubert standard, “evidentiary reliability” is based on scientific validity.²¹

How should we use neuroimaging?

While neuroimaging is a quickly evolving research tool, empirical support for its clinical use remains limited. The hope is that future neuroimaging research will yield biomarker profiles for mental illness, identification of risk factors, and predictors of vulnerability and treatment response, which will allow for more targeted treatments.¹

The current standard of clinical care for using neuroimaging in psychiatry is to diagnose neurologic diseases. Although there are no consensus guidelines for when to order imaging, it is reasonable to consider imaging when a patient has²²:

• abrupt onset of symptoms
• change in level of consciousness
• deficits in neurologic or cognitive examination
• a history of head trauma (with loss of consciousness), whole-brain radiation, neuro­logic comorbidities, or cancer
• late onset of symptoms (age >50)
• atypical presentation of psychiatric illness.

Advances in neuroimaging over the past 25 years have allowed for an increasingly sophisticated understanding of the structural and functional brain abnormalities associated with psychiatric disease.¹ It has been postulated that a better understanding of aberrant brain circuitry in psychiatric illness will be critical for transforming the diagnosis and treatment of these illnesses.² In fact, in 2008, the National Institute of Mental Health launched the Research Domain Criteria project to reformulate psychiatric diagnosis based on biologic underpinnings.³

In the midst of these scientific advances and the increased availability of neuroimaging, some private clinics have begun to offer routine brain scans as part of a comprehensive psychiatric evaluation.^4-7 These clinics suggest that single-photon emission computed tomography (SPECT) of the brain can provide objective, reliable psychiatric diagnoses. Unfortunately, using SPECT for psychiatric diagnosis lacks empirical support and carries risks, including exposing patients to radioisotopes and detracting from empirically validated treatments.⁸ Nonetheless, given the current diagnostic challenges in psychiatry, it is understandable that patients, parents, and clinicians alike have reported high receptivity to the use of neuroimaging for psychiatric diagnosis and treatment planning.⁹

While neuroimaging is central to the search for improved understanding of the biologic foundations of mental illness, progress in identifying biomarkers has been disappointing. There are currently no neuroimaging biomarkers that can reliably distinguish patients from controls, and no empirical evidence supports the use of neuroimaging in diagnosing psychiatric conditions.¹⁰ The current standard of clinical care is to use neuroimaging to diagnose neurologic diseases that are masquerading as psychiatric disorders. However, given the rapid advances and availability of this technology, determining if and when neuroimaging is clinically indicated will likely soon become increasingly complex. Prior to the widespread availability of this technology, it is worth considering the potential advantages and pitfalls to the adoption of neuroimaging in psychiatry. In this article, we:

• outline arguments that support the use of neuroimaging in psychiatry, and some of the limitations
• discuss special considerations for patients with first-episode psychosis (FEP) and forensic psychiatry
• suggest guidelines for best-practice models based on the current evidence.

Advantages of widespread use of neuroimaging in psychiatry

Currently, neuroimaging is used in psychiatry to rule out neurologic disorders such as seizures, tumors, or infectious illness that might be causing psychiatric symptoms. If neuroimaging were routinely used for this purpose, one theoretical advantage would be increased neurologic diagnostic accuracy. Furthermore, increased adoption of neuroimaging may eventually help broaden the phenotype of neurologic disorders. In other words, psychiatric symptoms may be more common in neurologic disorders than we currently recognize. A second advantage might be that early and definitive exclusion of a structural neurologic disorder may help patients and families more readily accept a psychiatric diagnosis and appropriate treatment.

In the future, if biomarkers of psychiatric illness are discerned, using neuroimaging for diagnosis, assessment, and treatment planning may help increase objectivity and reduce the stigma associated with mental illness. Currently, psychiatric diagnoses are based on emotional and behavioral self-report and clinical observations. It is not uncommon for patients to receive different diagnoses and even conflicting recommendations from different clinicians. Tools that aid objective diagnosis will likely improve the reliability of the diagnosis and help in assessing treatment response. Also, concrete biomarkers that respond to treatment may help align psychiatric disorders with other medical illnesses, thereby decreasing stigma.

Cautions against routine neuroimaging

There are several potential pitfalls to the routine use of neuroimaging in psychiatry. First, clinical psychiatry is centered on clinical acumen and the doctor–patient relationship. Many psychiatric clinicians are not accustomed to using lab measures or tests to support the diagnostic process or treatment planning. Psychiatrists may be resistant to technologies that threaten clinical acumen, the power of the therapeutic relationship, and the value of getting to know patients over time.¹¹ Overreliance on neuroimaging for psychiatric diagnosis also carries the risk of becoming overly reductionistic. This approach may overemphasize the biologic aspects of mental illness, while excluding social and psychological factors that may be responsive to treatment.

Second, the widespread use of neuroimaging is likely to result in many incidental findings. This is especially relevant because abnormality does not establish causality. Incidental findings may cause unnecessary anxiety for patients and families, particularly if there are minimal treatment options.

Continue to: Third, it remains unclear...

Third, it remains unclear whether widespread neuroimaging in psychiatry will be cost-effective. Unless imaging results are tied to effective treatments, neuroimaging is unlikely to result in cost savings. Presently, patients who can afford out-of-pocket care might be able to access neuroimaging. If neuroimaging were shown to improve clinical outcomes but remains costly, this unequal distribution of resources would create an ethical quandary.

Finally, neuroimaging is complex and almost certainly not as objective as one might hope. Interpreting images will require specialized knowledge and skills that are beyond those of currently certified general psychiatrists.¹² Because there is a great deal of overlap in brain anomalies across psychiatric illnesses, it is unclear whether using neuroimaging for diagnostic purposes will eclipse a thorough clinical assessment. For example, the amygdala and insula show activation across a range of anxiety disorders. Abnormal amygdala activation has also been reported in depression, bipolar disorder, schizophrenia, and psychopathy.¹³

In addition, psychiatric comorbidity is common. It is unclear how much neuro­imaging will add diagnostically when a patient presents with multiple psychiatric disorders. Comorbidity of psychiatric and neurologic disorders also is common. A neurologic illness that is detectable by structural neuroimaging does not necessarily exclude the presence of a psychiatric disorder. This poses yet another challenge to developing reliable, valid neuroimaging techniques for clinical use.

Areas of controversy

First-episode psychosis. Current practice guidelines for neuroimaging in patients with FEP are inconsistent. The Canadian Choosing Wisely Guidelines recommend against routinely ordering neuroimaging in first-episode psychoses in the absence of signs or symptoms that suggest intracranial pathology.¹⁴ Similarly, the American Psychiatric Association’s Practice Guideline for the Treatment of Patients with Schizophrenia recommends ordering neuroimaging in patients for whom the clinical picture is unclear or when examination reveals abnormal findings.¹⁵ In contrast, the Australian Clinical Guidelines for Early Psychosis recommend that all patients with FEP receive brain MRI.¹⁶ Freudenreich et al¹⁷ describe 2 philosophies regarding the initial medical workup of FEP: (1) a comprehensive medical workup requires extensive testing, and (2) in their natural histories, most illnesses eventually declare themselves.

Despite this inconsistency, the overall evidence does not seem to support routine brain imaging for patients with FEP in the absence of neurologic or cognitive impairment. A systematic review of 16 studies assessing the clinical utility of structural neuroimaging in FEP found that there was “insufficient evidence to suggest that brain imaging should be routinely ordered for patients presenting with first-episode psychosis without associated neurological or cognitive impairment.”¹⁸

Continue to: Forensic psychiatry

Forensic psychiatry. Two academic disciplines—neuroethics and neurolaw—attempt to study how medications and neuroimaging could impact forensic psychiatry.¹⁹ And in this golden age of neuroscience, psychiatrists specializing in forensics may be increasingly asked to opine on brain scans. This requires specific thoughtfulness and attention because forensic psychiatrists must “distinguish neuroscience from neuro-nonsense.”²⁰ These specialists will need to consider the Daubert standard, which resulted from the 1993 case Daubert v Merrell Dow Pharmaceuticals, Inc.²¹ In this case, the US Supreme Court ruled that evidence must be “‘generally accepted’ as reliable in the relevant scientific community” to be admissible. According to the Daubert standard, “evidentiary reliability” is based on scientific validity.²¹

How should we use neuroimaging?

While neuroimaging is a quickly evolving research tool, empirical support for its clinical use remains limited. The hope is that future neuroimaging research will yield biomarker profiles for mental illness, identification of risk factors, and predictors of vulnerability and treatment response, which will allow for more targeted treatments.¹

The current standard of clinical care for using neuroimaging in psychiatry is to diagnose neurologic diseases. Although there are no consensus guidelines for when to order imaging, it is reasonable to consider imaging when a patient has²²:

• abrupt onset of symptoms
• change in level of consciousness
• deficits in neurologic or cognitive examination
• a history of head trauma (with loss of consciousness), whole-brain radiation, neuro­logic comorbidities, or cancer
• late onset of symptoms (age >50)
• atypical presentation of psychiatric illness.

For a patient with a major mental illness, the road to wellness is long and uncertain. The medications commonly used to treat mood and thought disorders can take weeks to months to start providing benefits, and they carry significant risks for adverse effects, such as weight gain, sexual dysfunction, and movement disorders. Patients often have to take psychotropic medications for the rest of their lives. In addition to these downsides, there is no guarantee that these medications will provide complete or even partial relief.^2,3

Recently, there has been growing excitement about new treatments that might be “miracle cures” for patients with mental illness, particularly for individuals with treatment-resistant depression (TRD). Two of these treatments—ketamine-related compounds, and hallucinogenic drugs—seem to promise therapeutic effects that are vastly different from those of other psychiatric medications: They appear to improve patients’ symptoms very quickly, and their effects may persist long after these drugs have been cleared from the body.

Intravenous ketamine is an older generic drug used in anesthesia; recently, it has been used off-label for TRD and other mental illnesses. On March 5, 2019, the FDA approved an intranasal formulation of esketamine—the S-enantiomer of ketamine—for TRD.⁴ Hallucinogens have also been tested in small studies and have seemingly significant effects in alleviating depression in patients with terminal illnesses⁵ and reducing smoking behavior in patients with tobacco use disorder.^6,7

These miracle cures are becoming increasingly available to patients and continue to gain credibility among clinicians and researchers. How should we evaluate the usefulness of these new treatments? And how should we talk to our patients about them? To answer these questions, this article:

• explores our duty to our patients, ourselves, and our colleagues
• describes the dilemma
• discusses ways to evaluate claims made about these new miracle cures.

Duty: Protecting and helping our patients

The physician–patient relationship is a fiduciary relationship. According to both common law and medical ethics, a physician who enters into a treatment relationship with a patient creates a bond of special trust and confidence. Such a relationship requires a physician to act in good faith and in the patient’s best interests.⁸ As physicians, we have a duty to evaluate the safety and efficacy of new treatments that are available for our patients, whether or not they are FDA-approved.

We should also protect our patients from the adverse consequences of relatively untested drugs. For example, ketamine and hallucinogens both produce dissociative effects, and may carry high risks for patients who have a predisposition to psychosis.⁹ We should protect our patients from any false hopes that might lead them to abandon their current treatment regimens due to adverse effects and imperfect results. At the same time, we also have a duty to acknowledge our patients’ suffering and to recognize that they might be desperate for new treatment options. We should remain open-minded about new treatments, and acknowledge that they might work. Finally, we have a duty to be mindful of any financial benefits that we may derive from the development, marketing, and administration of these medications.

Dilemma: The need for new treatments

This is not the first time that novel treatments in mental health have seemed to hold incredible promise. In the late 1800s, Sigmund Freud began to regularly use a compound that led him to feel “the normal euphoria of a healthy person.” He wrote that this substance produced:

…exhilaration and lasting euphoria, which does not differ in any way from the normal euphoria of a healthy person. The feeling of excitement which accompanies stimulus by alcohol is completely lacking; the characteristic urge for immediate activity which alcohol produces is also absent. One senses an increase of self-control and feels more vigorous and more capable of work; on the other hand, if one works, one misses that heightening of the mental powers which alcohol, tea, or coffee induce. One is simply normal, and soon finds it difficult to believe that one is under the influence of any drug at all.¹

Continue to: The compound Freud was describing...

The compound Freud was describing is cocaine, which we now know is an addictive and dangerous drug that can in fact worsen depression.¹⁰ Another treatment regarded as a miracle cure in its time involved placing patients with schizophrenia into an insulin-induced coma to treat their symptoms; this therapy was used from 1933 to 1960.¹¹ We now recognize that this practice is unacceptably dangerous.

The past is filled with cautionary tales of the enthusiastic adoption of treatments for mental illness that later turned out to be ineffective, counterproductive, dangerous, or inhumane. Yet, the long, arduous journeys our patients go through continue to weigh heavily on us. We would love to offer our patients newer, more efficacious, and longer-lasting treatments with fewer adverse effects.

Discussion: How to best evaluate miracle cures

To help quickly assess a new treatment, the following 5 categories can help guide and organize our thought process.

1. Evidence

What type of evidence do we have that a new treatment is safe and effective? Psychiatric research may be even more susceptible to a placebo effect than other medical research, particularly for illnesses with subjective symptoms, such as depression.¹² Double-blinded, placebo-controlled studies, such as the IV ketamine trial conducted by Singh et al,¹³ are the gold standard for separating a substance’s actual biologic effect from a placebo effect. Studies that do not include a control group should not be regarded as providing scientific evidence of efficacy.

2. Mechanism

If a new compound appears to have a beneficial effect on mental health, it is important to consider the potential mechanism underlying this effect to determine if it is biologically plausible. A compound that is claimed to be a panacea for every symptom of every mental illness should be heavily scrutinized. For example, based on available research, ketamine’s long-lasting effects seem to come from 2 mechanisms^14,15:

• Activation of endogenous opioid receptors, which is also responsible for the euphoria induced by heroin and oxycodone.
• Blockade of N-methyl-D-aspartate receptors. N-methyl-D-aspartate receptor activation is a key mechanism by which learning and memory function in the brain, and blocking these receptors may increase brain plasticity.

Continue to: Therefore, it seems plausible...

Therefore, it seems plausible that ketamine could produce both short- and long-term improvements in mood. Hallucinogenic drugs are thought to profoundly alter brain function through several mechanisms, including activating serotonin receptors, enhancing brain plasticity, and increasing brain connectivity.¹⁶

3. Reinforcement

Psychiatric medications that are acutely reinforcing have significant potential for abuse. Antidepressants and mood stabilizers are not acutely rewarding. They don’t make patients feel good right away. Medications such as stimulants and opioids do, and must be used with extreme care because of their abuse potential. The problem with acutely reinforcing medications is that in the long run, they can worsen depression by decreasing the brain’s ability to produce endogenous opioids.¹⁷

4. No single solution?

A mental disorder is unlikely to have a single solution. Rather than regarding a new treatment as capable of rapidly alleviating every symptom of a patient’s illness, it should be viewed as a tool that can be helpful when used in combination with other treatments and lifestyle practices. In an interview with the web site STAT, Cristina Cusin, MD, co-director of the Intravenous Ketamine Clinic for Depression at Massachusetts General Hospital, said, “You don’t treat an advanced disease with just an infusion and a ‘see you next time.’ If [doctors] replace your knee but [you] don’t do physical therapy, you don’t walk again.”¹⁸ To sustain the benefits of a novel medication, patients with serious mental illnesses need to maintain strong social supports, see a mental health care provider regularly, and abstain from illicit drug and alcohol use.

5. Context matters

For a medication to obtain approval to treat a specific indication, the FDA usually require 2 trials that demonstrate efficacy. Off-label use of generic medications such as ketamine may have benefits, but it is unlikely that a generic drug would be put through a costly FDA-approval process.¹⁹

When learning about new medications, remember that patients might assume that these agents have undergone a thorough review process for safety and effectiveness. When our patients request such treatments—whether FDA-approved or off-label—it is our responsibility as physicians to educate them about the benefits, risks, effectiveness, and limitations of these treatments, as well as to evaluate the appropriateness of a treatment for a specific patient’s symptoms.

Continue to: Tempering excitement with caution

Our patients are not the only ones desperate for a miracle cure. As psychiatrists, many of us are desperate, too. New compounds may ultimately change the way we treat mental illness. However, we have an obligation to temper our excitement with caution by remembering past mistakes, and systematically evaluating new miracle cures to determine if they are safe and effective.

For a patient with a major mental illness, the road to wellness is long and uncertain. The medications commonly used to treat mood and thought disorders can take weeks to months to start providing benefits, and they carry significant risks for adverse effects, such as weight gain, sexual dysfunction, and movement disorders. Patients often have to take psychotropic medications for the rest of their lives. In addition to these downsides, there is no guarantee that these medications will provide complete or even partial relief.^2,3

Recently, there has been growing excitement about new treatments that might be “miracle cures” for patients with mental illness, particularly for individuals with treatment-resistant depression (TRD). Two of these treatments—ketamine-related compounds, and hallucinogenic drugs—seem to promise therapeutic effects that are vastly different from those of other psychiatric medications: They appear to improve patients’ symptoms very quickly, and their effects may persist long after these drugs have been cleared from the body.

Intravenous ketamine is an older generic drug used in anesthesia; recently, it has been used off-label for TRD and other mental illnesses. On March 5, 2019, the FDA approved an intranasal formulation of esketamine—the S-enantiomer of ketamine—for TRD.⁴ Hallucinogens have also been tested in small studies and have seemingly significant effects in alleviating depression in patients with terminal illnesses⁵ and reducing smoking behavior in patients with tobacco use disorder.^6,7

These miracle cures are becoming increasingly available to patients and continue to gain credibility among clinicians and researchers. How should we evaluate the usefulness of these new treatments? And how should we talk to our patients about them? To answer these questions, this article:

• explores our duty to our patients, ourselves, and our colleagues
• describes the dilemma
• discusses ways to evaluate claims made about these new miracle cures.

Duty: Protecting and helping our patients

The physician–patient relationship is a fiduciary relationship. According to both common law and medical ethics, a physician who enters into a treatment relationship with a patient creates a bond of special trust and confidence. Such a relationship requires a physician to act in good faith and in the patient’s best interests.⁸ As physicians, we have a duty to evaluate the safety and efficacy of new treatments that are available for our patients, whether or not they are FDA-approved.

We should also protect our patients from the adverse consequences of relatively untested drugs. For example, ketamine and hallucinogens both produce dissociative effects, and may carry high risks for patients who have a predisposition to psychosis.⁹ We should protect our patients from any false hopes that might lead them to abandon their current treatment regimens due to adverse effects and imperfect results. At the same time, we also have a duty to acknowledge our patients’ suffering and to recognize that they might be desperate for new treatment options. We should remain open-minded about new treatments, and acknowledge that they might work. Finally, we have a duty to be mindful of any financial benefits that we may derive from the development, marketing, and administration of these medications.

Dilemma: The need for new treatments

This is not the first time that novel treatments in mental health have seemed to hold incredible promise. In the late 1800s, Sigmund Freud began to regularly use a compound that led him to feel “the normal euphoria of a healthy person.” He wrote that this substance produced:

…exhilaration and lasting euphoria, which does not differ in any way from the normal euphoria of a healthy person. The feeling of excitement which accompanies stimulus by alcohol is completely lacking; the characteristic urge for immediate activity which alcohol produces is also absent. One senses an increase of self-control and feels more vigorous and more capable of work; on the other hand, if one works, one misses that heightening of the mental powers which alcohol, tea, or coffee induce. One is simply normal, and soon finds it difficult to believe that one is under the influence of any drug at all.¹

Continue to: The compound Freud was describing...

The compound Freud was describing is cocaine, which we now know is an addictive and dangerous drug that can in fact worsen depression.¹⁰ Another treatment regarded as a miracle cure in its time involved placing patients with schizophrenia into an insulin-induced coma to treat their symptoms; this therapy was used from 1933 to 1960.¹¹ We now recognize that this practice is unacceptably dangerous.

The past is filled with cautionary tales of the enthusiastic adoption of treatments for mental illness that later turned out to be ineffective, counterproductive, dangerous, or inhumane. Yet, the long, arduous journeys our patients go through continue to weigh heavily on us. We would love to offer our patients newer, more efficacious, and longer-lasting treatments with fewer adverse effects.

Discussion: How to best evaluate miracle cures

To help quickly assess a new treatment, the following 5 categories can help guide and organize our thought process.

1. Evidence

What type of evidence do we have that a new treatment is safe and effective? Psychiatric research may be even more susceptible to a placebo effect than other medical research, particularly for illnesses with subjective symptoms, such as depression.¹² Double-blinded, placebo-controlled studies, such as the IV ketamine trial conducted by Singh et al,¹³ are the gold standard for separating a substance’s actual biologic effect from a placebo effect. Studies that do not include a control group should not be regarded as providing scientific evidence of efficacy.

2. Mechanism

If a new compound appears to have a beneficial effect on mental health, it is important to consider the potential mechanism underlying this effect to determine if it is biologically plausible. A compound that is claimed to be a panacea for every symptom of every mental illness should be heavily scrutinized. For example, based on available research, ketamine’s long-lasting effects seem to come from 2 mechanisms^14,15:

• Activation of endogenous opioid receptors, which is also responsible for the euphoria induced by heroin and oxycodone.
• Blockade of N-methyl-D-aspartate receptors. N-methyl-D-aspartate receptor activation is a key mechanism by which learning and memory function in the brain, and blocking these receptors may increase brain plasticity.

Continue to: Therefore, it seems plausible...

Therefore, it seems plausible that ketamine could produce both short- and long-term improvements in mood. Hallucinogenic drugs are thought to profoundly alter brain function through several mechanisms, including activating serotonin receptors, enhancing brain plasticity, and increasing brain connectivity.¹⁶

3. Reinforcement

Psychiatric medications that are acutely reinforcing have significant potential for abuse. Antidepressants and mood stabilizers are not acutely rewarding. They don’t make patients feel good right away. Medications such as stimulants and opioids do, and must be used with extreme care because of their abuse potential. The problem with acutely reinforcing medications is that in the long run, they can worsen depression by decreasing the brain’s ability to produce endogenous opioids.¹⁷

4. No single solution?

A mental disorder is unlikely to have a single solution. Rather than regarding a new treatment as capable of rapidly alleviating every symptom of a patient’s illness, it should be viewed as a tool that can be helpful when used in combination with other treatments and lifestyle practices. In an interview with the web site STAT, Cristina Cusin, MD, co-director of the Intravenous Ketamine Clinic for Depression at Massachusetts General Hospital, said, “You don’t treat an advanced disease with just an infusion and a ‘see you next time.’ If [doctors] replace your knee but [you] don’t do physical therapy, you don’t walk again.”¹⁸ To sustain the benefits of a novel medication, patients with serious mental illnesses need to maintain strong social supports, see a mental health care provider regularly, and abstain from illicit drug and alcohol use.

5. Context matters

For a medication to obtain approval to treat a specific indication, the FDA usually require 2 trials that demonstrate efficacy. Off-label use of generic medications such as ketamine may have benefits, but it is unlikely that a generic drug would be put through a costly FDA-approval process.¹⁹

When learning about new medications, remember that patients might assume that these agents have undergone a thorough review process for safety and effectiveness. When our patients request such treatments—whether FDA-approved or off-label—it is our responsibility as physicians to educate them about the benefits, risks, effectiveness, and limitations of these treatments, as well as to evaluate the appropriateness of a treatment for a specific patient’s symptoms.

Continue to: Tempering excitement with caution

Our patients are not the only ones desperate for a miracle cure. As psychiatrists, many of us are desperate, too. New compounds may ultimately change the way we treat mental illness. However, we have an obligation to temper our excitement with caution by remembering past mistakes, and systematically evaluating new miracle cures to determine if they are safe and effective.

For a patient with a major mental illness, the road to wellness is long and uncertain. The medications commonly used to treat mood and thought disorders can take weeks to months to start providing benefits, and they carry significant risks for adverse effects, such as weight gain, sexual dysfunction, and movement disorders. Patients often have to take psychotropic medications for the rest of their lives. In addition to these downsides, there is no guarantee that these medications will provide complete or even partial relief.^2,3

Recently, there has been growing excitement about new treatments that might be “miracle cures” for patients with mental illness, particularly for individuals with treatment-resistant depression (TRD). Two of these treatments—ketamine-related compounds, and hallucinogenic drugs—seem to promise therapeutic effects that are vastly different from those of other psychiatric medications: They appear to improve patients’ symptoms very quickly, and their effects may persist long after these drugs have been cleared from the body.

Intravenous ketamine is an older generic drug used in anesthesia; recently, it has been used off-label for TRD and other mental illnesses. On March 5, 2019, the FDA approved an intranasal formulation of esketamine—the S-enantiomer of ketamine—for TRD.⁴ Hallucinogens have also been tested in small studies and have seemingly significant effects in alleviating depression in patients with terminal illnesses⁵ and reducing smoking behavior in patients with tobacco use disorder.^6,7

These miracle cures are becoming increasingly available to patients and continue to gain credibility among clinicians and researchers. How should we evaluate the usefulness of these new treatments? And how should we talk to our patients about them? To answer these questions, this article:

• explores our duty to our patients, ourselves, and our colleagues
• describes the dilemma
• discusses ways to evaluate claims made about these new miracle cures.

Duty: Protecting and helping our patients

The physician–patient relationship is a fiduciary relationship. According to both common law and medical ethics, a physician who enters into a treatment relationship with a patient creates a bond of special trust and confidence. Such a relationship requires a physician to act in good faith and in the patient’s best interests.⁸ As physicians, we have a duty to evaluate the safety and efficacy of new treatments that are available for our patients, whether or not they are FDA-approved.

We should also protect our patients from the adverse consequences of relatively untested drugs. For example, ketamine and hallucinogens both produce dissociative effects, and may carry high risks for patients who have a predisposition to psychosis.⁹ We should protect our patients from any false hopes that might lead them to abandon their current treatment regimens due to adverse effects and imperfect results. At the same time, we also have a duty to acknowledge our patients’ suffering and to recognize that they might be desperate for new treatment options. We should remain open-minded about new treatments, and acknowledge that they might work. Finally, we have a duty to be mindful of any financial benefits that we may derive from the development, marketing, and administration of these medications.

Dilemma: The need for new treatments

This is not the first time that novel treatments in mental health have seemed to hold incredible promise. In the late 1800s, Sigmund Freud began to regularly use a compound that led him to feel “the normal euphoria of a healthy person.” He wrote that this substance produced:

…exhilaration and lasting euphoria, which does not differ in any way from the normal euphoria of a healthy person. The feeling of excitement which accompanies stimulus by alcohol is completely lacking; the characteristic urge for immediate activity which alcohol produces is also absent. One senses an increase of self-control and feels more vigorous and more capable of work; on the other hand, if one works, one misses that heightening of the mental powers which alcohol, tea, or coffee induce. One is simply normal, and soon finds it difficult to believe that one is under the influence of any drug at all.¹

Continue to: The compound Freud was describing...

The compound Freud was describing is cocaine, which we now know is an addictive and dangerous drug that can in fact worsen depression.¹⁰ Another treatment regarded as a miracle cure in its time involved placing patients with schizophrenia into an insulin-induced coma to treat their symptoms; this therapy was used from 1933 to 1960.¹¹ We now recognize that this practice is unacceptably dangerous.

The past is filled with cautionary tales of the enthusiastic adoption of treatments for mental illness that later turned out to be ineffective, counterproductive, dangerous, or inhumane. Yet, the long, arduous journeys our patients go through continue to weigh heavily on us. We would love to offer our patients newer, more efficacious, and longer-lasting treatments with fewer adverse effects.

Discussion: How to best evaluate miracle cures

To help quickly assess a new treatment, the following 5 categories can help guide and organize our thought process.

1. Evidence

What type of evidence do we have that a new treatment is safe and effective? Psychiatric research may be even more susceptible to a placebo effect than other medical research, particularly for illnesses with subjective symptoms, such as depression.¹² Double-blinded, placebo-controlled studies, such as the IV ketamine trial conducted by Singh et al,¹³ are the gold standard for separating a substance’s actual biologic effect from a placebo effect. Studies that do not include a control group should not be regarded as providing scientific evidence of efficacy.

2. Mechanism

If a new compound appears to have a beneficial effect on mental health, it is important to consider the potential mechanism underlying this effect to determine if it is biologically plausible. A compound that is claimed to be a panacea for every symptom of every mental illness should be heavily scrutinized. For example, based on available research, ketamine’s long-lasting effects seem to come from 2 mechanisms^14,15:

• Activation of endogenous opioid receptors, which is also responsible for the euphoria induced by heroin and oxycodone.
• Blockade of N-methyl-D-aspartate receptors. N-methyl-D-aspartate receptor activation is a key mechanism by which learning and memory function in the brain, and blocking these receptors may increase brain plasticity.

Continue to: Therefore, it seems plausible...

Therefore, it seems plausible that ketamine could produce both short- and long-term improvements in mood. Hallucinogenic drugs are thought to profoundly alter brain function through several mechanisms, including activating serotonin receptors, enhancing brain plasticity, and increasing brain connectivity.¹⁶

3. Reinforcement

Psychiatric medications that are acutely reinforcing have significant potential for abuse. Antidepressants and mood stabilizers are not acutely rewarding. They don’t make patients feel good right away. Medications such as stimulants and opioids do, and must be used with extreme care because of their abuse potential. The problem with acutely reinforcing medications is that in the long run, they can worsen depression by decreasing the brain’s ability to produce endogenous opioids.¹⁷

4. No single solution?

A mental disorder is unlikely to have a single solution. Rather than regarding a new treatment as capable of rapidly alleviating every symptom of a patient’s illness, it should be viewed as a tool that can be helpful when used in combination with other treatments and lifestyle practices. In an interview with the web site STAT, Cristina Cusin, MD, co-director of the Intravenous Ketamine Clinic for Depression at Massachusetts General Hospital, said, “You don’t treat an advanced disease with just an infusion and a ‘see you next time.’ If [doctors] replace your knee but [you] don’t do physical therapy, you don’t walk again.”¹⁸ To sustain the benefits of a novel medication, patients with serious mental illnesses need to maintain strong social supports, see a mental health care provider regularly, and abstain from illicit drug and alcohol use.

5. Context matters

For a medication to obtain approval to treat a specific indication, the FDA usually require 2 trials that demonstrate efficacy. Off-label use of generic medications such as ketamine may have benefits, but it is unlikely that a generic drug would be put through a costly FDA-approval process.¹⁹

When learning about new medications, remember that patients might assume that these agents have undergone a thorough review process for safety and effectiveness. When our patients request such treatments—whether FDA-approved or off-label—it is our responsibility as physicians to educate them about the benefits, risks, effectiveness, and limitations of these treatments, as well as to evaluate the appropriateness of a treatment for a specific patient’s symptoms.

Continue to: Tempering excitement with caution

Our patients are not the only ones desperate for a miracle cure. As psychiatrists, many of us are desperate, too. New compounds may ultimately change the way we treat mental illness. However, we have an obligation to temper our excitement with caution by remembering past mistakes, and systematically evaluating new miracle cures to determine if they are safe and effective.

In today’s global society, smartphones are ubiquitous, used by >2.5 billion people.¹ They provide limitless availability of on-demand services and resources, unparalleled computing power by size, and the ability to connect with anyone in the world.

Digital applications and new mobile technologies can be used to change the nature of the psychiatrist–patient relationship. The future of clinical practice is changing with the help of smartphones and apps. Diagnosis, follow-up, and treatment will never look the same as we come to better understand and apply emerging technologies.²

Both Android and iOS—the 2 largest mobile operating systems by market share³—provide outlets for the dissemination of mobile applications. There are currently >10,000 mental health–related apps available for download.⁴ One particular use case of mental health–related apps is digital phenotyping.

In this article, we aim to:

• define digital phenotyping
• explore the potential advances in patient care afforded by emerging technology
• discuss the ethical dilemmas and future of mental health apps.

The possibilities of digital phenotyping

Digital phenotyping is capturing a patient’s real-time clinical state using digital technology to better understand the patient’s state outside of the clinic. While digital phenotyping may seem new, the concepts behind it are grounded in good clinical care.

For example, it is important to assess sleep and physical activity for nearly all patients, regardless of diagnosis. However, the patient’s retrospective recollection of sleep, mood, and other clinically relevant metrics is often unreliable, especially when visits are months apart. With smartphones, it is possible to automatically collect metrics for sleep, activity, mood, and much more in real time from the convenience of our patients’ personal devices (Figure 1).

Smartphones can capture a seemingly endless number of data streams, from patient-interfacing active data, such as journal entries, messaging, and games, to data that is captured passively, such as screen time, Global Positioning System information, and step count. Clinicians can work with patients to customize which digital phenotyping data they would like to capture. In one study, researchers worked with 17 patients with schizophrenia by capturing self-reported surveys, anonymized phone call logs, and location data to see if they could predict relapse by observing variations in how patients interact with their smartphones.⁵ They observed that the rate of behavioral anomalies was 71% higher in the 2 weeks prior to relapse than during other periods. The data captured by the smartphone will depend on the patient and the clinical needs. Some clinicians may only want to collect data on step count and screen time to learn if a patient is overusing his or her smartphone, which might be related to becoming less physically active.

Continue to: One novel data stream...

One novel data stream offered by smartphone digital phenotyping is cognition. While we know that impaired cognition is a core symptom of schizophrenia, and that cognition is affected by depression and anxiety, cognitive symptoms are clinically challenging to quantify. Thus, the cognitive burden of mental illness and the cognitive effects of treatment are often overlooked. However, smartphones are beginning to offer a novel means of capturing a patient’s cognitive state through the use of common clinical tests. For example, the Trail Making Test measures visual attention and executive function by having participants connect dots that differ in number, color, or shape in an ascending pattern.⁶ By having patients perform this test on a smartphone, clinicians can utilize the touchscreen to capture the user’s discrete actions, such as time to completion and misclicks. These data can be used to build novel measures of cognitive performance that can account for learning bias and other confounding variables.⁷ While these digital cognitive biomarkers are still in active research, it is likely that they will quickly be developed for broad clinical use.

In addition to the novel data offered by digital phenotyping, another benefit is the low cost and ease of use. Unlike wearable devices such as smartwatches, which can also offer data on steps and sleep, smartphone-based digital phenotyping does not require patients to purchase or use additional devices. Running on patients’ smartphones, digital phenotyping offers the ability to capture rich and continuous health data without added effort or cost. Given that the average person interacts with their phone more than 2,600 times per day,⁸ smartphones are well suited for capturing large amounts of information that may provide insights into patients’ mental health.

For illnesses such as depression and anxiety, the clinical relevance of digital phenotyping is in the ability to capture symptoms as they occur in context. Figure 2 provides a simplified example of how we can learn that for this fictitious patient, exercise greatly improves anxiety, whereas being in a certain environment worsens it. Other insights about sleep and social settings could also provide further information about the context of the patient’s symptoms. While these correlations alone will not lead to better clinical outcomes, it is easy to imagine how such data could help a patient and clinician start a conversation about making impactful changes.

Continue to: Case report...

Case report: Digital phenotyping

To illustrate how digital phenotyping could be put to clinical use, we created the following case report of a fictional patient who agrees to be monitored via her smartphone.

Consider a hypothetical patient we will call Ms. T who is in her mid-20s and has been diagnosed with schizophrenia. On a follow-up visit, she says she has insomnia. She also reports having a recent loss of appetite and higher levels of anxiety. After reviewing her smartphone data (Figure 3), the clinician sees an inversely proportional relationship between her sleep quality and symptoms of anxiety, psychosis, and depression, which suggests that these symptoms might be due to poor sleep. Her step count has been fairly stable, indicating that there is no significant correlation between physical activity and her other symptoms.

Continue to: The clinician shows...

The clinician shows Ms. T the data to help her understand why a trial of cognitive-behavioral therapy for insomnia, or at least improving sleep hygiene, may offer several benefits. The clinician advises her to continue to use the app to help assess her response to these interventions and monitor her progress in real time.

Dilemma: The ethics of continuous observation

The rich data captured by digital phenotyping afford many clinical opportunities, but also raise concerns. Among these are 3 significant ethical implications.

Firstly, the same data that may help a clinician learn about what environments are associated with less anxiety for the patient may also reveal personal details about where that patient has been or with whom they have interacted. In the wrong hands, such personal data could cause harm. And even in the hands of a trusted clinician, a breach in the patient’s privacy begs the question: “Should such information be anyone’s business at all?”

Secondly, many apps that offer digital phenotyping could also store patient data—something that currently pervades social media and causes reasonable discomfort for many people. You might have personally encountered this with social media platforms such as Facebook. When it comes to mobile mental health apps, clinicians should carefully understand the data usage agreement of any digital phenotyping app they wish to use and then share this information with their patients.

Finally, while it is possible to collect the types of data outlined in this article, less is known about how to use it directly in clinical care. Understanding for each patient which data streams are most meaningful and which data streams are noise that should be ignored is an area of ongoing research. A good first step may be to begin with data streams that are known to be clinically relevant and valuable, such as sleep and physical activity.^9-11

Continue to: Discussion...

Although smartphones can gather a wide range of active and passive data, other data streams hold potential for predicting relapse and performing other clinically relevant actions. One data stream that could be of clinical use is genomic sequencing.¹² The genotyping of patients provides a wealth of information about the underlying biology, and genomic sequencing has never been cheaper.¹³

Combining the data gathered via digital phenotyping with that of genotyping could help elucidate the mechanisms by which specific diseases and symptoms occur. This could be very promising to better understand and treat our patients. However, as is the case with genomics, digital phenotyping has important ethical implications. If used in the proper way to benefit our patients, the future for this new method is bright.

In today’s global society, smartphones are ubiquitous, used by >2.5 billion people.¹ They provide limitless availability of on-demand services and resources, unparalleled computing power by size, and the ability to connect with anyone in the world.

Digital applications and new mobile technologies can be used to change the nature of the psychiatrist–patient relationship. The future of clinical practice is changing with the help of smartphones and apps. Diagnosis, follow-up, and treatment will never look the same as we come to better understand and apply emerging technologies.²

Both Android and iOS—the 2 largest mobile operating systems by market share³—provide outlets for the dissemination of mobile applications. There are currently >10,000 mental health–related apps available for download.⁴ One particular use case of mental health–related apps is digital phenotyping.

In this article, we aim to:

• define digital phenotyping
• explore the potential advances in patient care afforded by emerging technology
• discuss the ethical dilemmas and future of mental health apps.

The possibilities of digital phenotyping

Digital phenotyping is capturing a patient’s real-time clinical state using digital technology to better understand the patient’s state outside of the clinic. While digital phenotyping may seem new, the concepts behind it are grounded in good clinical care.

For example, it is important to assess sleep and physical activity for nearly all patients, regardless of diagnosis. However, the patient’s retrospective recollection of sleep, mood, and other clinically relevant metrics is often unreliable, especially when visits are months apart. With smartphones, it is possible to automatically collect metrics for sleep, activity, mood, and much more in real time from the convenience of our patients’ personal devices (Figure 1).

Smartphones can capture a seemingly endless number of data streams, from patient-interfacing active data, such as journal entries, messaging, and games, to data that is captured passively, such as screen time, Global Positioning System information, and step count. Clinicians can work with patients to customize which digital phenotyping data they would like to capture. In one study, researchers worked with 17 patients with schizophrenia by capturing self-reported surveys, anonymized phone call logs, and location data to see if they could predict relapse by observing variations in how patients interact with their smartphones.⁵ They observed that the rate of behavioral anomalies was 71% higher in the 2 weeks prior to relapse than during other periods. The data captured by the smartphone will depend on the patient and the clinical needs. Some clinicians may only want to collect data on step count and screen time to learn if a patient is overusing his or her smartphone, which might be related to becoming less physically active.

Continue to: One novel data stream...

One novel data stream offered by smartphone digital phenotyping is cognition. While we know that impaired cognition is a core symptom of schizophrenia, and that cognition is affected by depression and anxiety, cognitive symptoms are clinically challenging to quantify. Thus, the cognitive burden of mental illness and the cognitive effects of treatment are often overlooked. However, smartphones are beginning to offer a novel means of capturing a patient’s cognitive state through the use of common clinical tests. For example, the Trail Making Test measures visual attention and executive function by having participants connect dots that differ in number, color, or shape in an ascending pattern.⁶ By having patients perform this test on a smartphone, clinicians can utilize the touchscreen to capture the user’s discrete actions, such as time to completion and misclicks. These data can be used to build novel measures of cognitive performance that can account for learning bias and other confounding variables.⁷ While these digital cognitive biomarkers are still in active research, it is likely that they will quickly be developed for broad clinical use.

In addition to the novel data offered by digital phenotyping, another benefit is the low cost and ease of use. Unlike wearable devices such as smartwatches, which can also offer data on steps and sleep, smartphone-based digital phenotyping does not require patients to purchase or use additional devices. Running on patients’ smartphones, digital phenotyping offers the ability to capture rich and continuous health data without added effort or cost. Given that the average person interacts with their phone more than 2,600 times per day,⁸ smartphones are well suited for capturing large amounts of information that may provide insights into patients’ mental health.

For illnesses such as depression and anxiety, the clinical relevance of digital phenotyping is in the ability to capture symptoms as they occur in context. Figure 2 provides a simplified example of how we can learn that for this fictitious patient, exercise greatly improves anxiety, whereas being in a certain environment worsens it. Other insights about sleep and social settings could also provide further information about the context of the patient’s symptoms. While these correlations alone will not lead to better clinical outcomes, it is easy to imagine how such data could help a patient and clinician start a conversation about making impactful changes.

Continue to: Case report...

Case report: Digital phenotyping

To illustrate how digital phenotyping could be put to clinical use, we created the following case report of a fictional patient who agrees to be monitored via her smartphone.

Consider a hypothetical patient we will call Ms. T who is in her mid-20s and has been diagnosed with schizophrenia. On a follow-up visit, she says she has insomnia. She also reports having a recent loss of appetite and higher levels of anxiety. After reviewing her smartphone data (Figure 3), the clinician sees an inversely proportional relationship between her sleep quality and symptoms of anxiety, psychosis, and depression, which suggests that these symptoms might be due to poor sleep. Her step count has been fairly stable, indicating that there is no significant correlation between physical activity and her other symptoms.

Continue to: The clinician shows...

The clinician shows Ms. T the data to help her understand why a trial of cognitive-behavioral therapy for insomnia, or at least improving sleep hygiene, may offer several benefits. The clinician advises her to continue to use the app to help assess her response to these interventions and monitor her progress in real time.

Dilemma: The ethics of continuous observation

The rich data captured by digital phenotyping afford many clinical opportunities, but also raise concerns. Among these are 3 significant ethical implications.

Firstly, the same data that may help a clinician learn about what environments are associated with less anxiety for the patient may also reveal personal details about where that patient has been or with whom they have interacted. In the wrong hands, such personal data could cause harm. And even in the hands of a trusted clinician, a breach in the patient’s privacy begs the question: “Should such information be anyone’s business at all?”

Secondly, many apps that offer digital phenotyping could also store patient data—something that currently pervades social media and causes reasonable discomfort for many people. You might have personally encountered this with social media platforms such as Facebook. When it comes to mobile mental health apps, clinicians should carefully understand the data usage agreement of any digital phenotyping app they wish to use and then share this information with their patients.

Finally, while it is possible to collect the types of data outlined in this article, less is known about how to use it directly in clinical care. Understanding for each patient which data streams are most meaningful and which data streams are noise that should be ignored is an area of ongoing research. A good first step may be to begin with data streams that are known to be clinically relevant and valuable, such as sleep and physical activity.^9-11

Continue to: Discussion...

Although smartphones can gather a wide range of active and passive data, other data streams hold potential for predicting relapse and performing other clinically relevant actions. One data stream that could be of clinical use is genomic sequencing.¹² The genotyping of patients provides a wealth of information about the underlying biology, and genomic sequencing has never been cheaper.¹³

Combining the data gathered via digital phenotyping with that of genotyping could help elucidate the mechanisms by which specific diseases and symptoms occur. This could be very promising to better understand and treat our patients. However, as is the case with genomics, digital phenotyping has important ethical implications. If used in the proper way to benefit our patients, the future for this new method is bright.

In today’s global society, smartphones are ubiquitous, used by >2.5 billion people.¹ They provide limitless availability of on-demand services and resources, unparalleled computing power by size, and the ability to connect with anyone in the world.

Digital applications and new mobile technologies can be used to change the nature of the psychiatrist–patient relationship. The future of clinical practice is changing with the help of smartphones and apps. Diagnosis, follow-up, and treatment will never look the same as we come to better understand and apply emerging technologies.²

Both Android and iOS—the 2 largest mobile operating systems by market share³—provide outlets for the dissemination of mobile applications. There are currently >10,000 mental health–related apps available for download.⁴ One particular use case of mental health–related apps is digital phenotyping.

In this article, we aim to:

• define digital phenotyping
• explore the potential advances in patient care afforded by emerging technology
• discuss the ethical dilemmas and future of mental health apps.

The possibilities of digital phenotyping

Digital phenotyping is capturing a patient’s real-time clinical state using digital technology to better understand the patient’s state outside of the clinic. While digital phenotyping may seem new, the concepts behind it are grounded in good clinical care.

For example, it is important to assess sleep and physical activity for nearly all patients, regardless of diagnosis. However, the patient’s retrospective recollection of sleep, mood, and other clinically relevant metrics is often unreliable, especially when visits are months apart. With smartphones, it is possible to automatically collect metrics for sleep, activity, mood, and much more in real time from the convenience of our patients’ personal devices (Figure 1).

Smartphones can capture a seemingly endless number of data streams, from patient-interfacing active data, such as journal entries, messaging, and games, to data that is captured passively, such as screen time, Global Positioning System information, and step count. Clinicians can work with patients to customize which digital phenotyping data they would like to capture. In one study, researchers worked with 17 patients with schizophrenia by capturing self-reported surveys, anonymized phone call logs, and location data to see if they could predict relapse by observing variations in how patients interact with their smartphones.⁵ They observed that the rate of behavioral anomalies was 71% higher in the 2 weeks prior to relapse than during other periods. The data captured by the smartphone will depend on the patient and the clinical needs. Some clinicians may only want to collect data on step count and screen time to learn if a patient is overusing his or her smartphone, which might be related to becoming less physically active.

Continue to: One novel data stream...

One novel data stream offered by smartphone digital phenotyping is cognition. While we know that impaired cognition is a core symptom of schizophrenia, and that cognition is affected by depression and anxiety, cognitive symptoms are clinically challenging to quantify. Thus, the cognitive burden of mental illness and the cognitive effects of treatment are often overlooked. However, smartphones are beginning to offer a novel means of capturing a patient’s cognitive state through the use of common clinical tests. For example, the Trail Making Test measures visual attention and executive function by having participants connect dots that differ in number, color, or shape in an ascending pattern.⁶ By having patients perform this test on a smartphone, clinicians can utilize the touchscreen to capture the user’s discrete actions, such as time to completion and misclicks. These data can be used to build novel measures of cognitive performance that can account for learning bias and other confounding variables.⁷ While these digital cognitive biomarkers are still in active research, it is likely that they will quickly be developed for broad clinical use.

In addition to the novel data offered by digital phenotyping, another benefit is the low cost and ease of use. Unlike wearable devices such as smartwatches, which can also offer data on steps and sleep, smartphone-based digital phenotyping does not require patients to purchase or use additional devices. Running on patients’ smartphones, digital phenotyping offers the ability to capture rich and continuous health data without added effort or cost. Given that the average person interacts with their phone more than 2,600 times per day,⁸ smartphones are well suited for capturing large amounts of information that may provide insights into patients’ mental health.

For illnesses such as depression and anxiety, the clinical relevance of digital phenotyping is in the ability to capture symptoms as they occur in context. Figure 2 provides a simplified example of how we can learn that for this fictitious patient, exercise greatly improves anxiety, whereas being in a certain environment worsens it. Other insights about sleep and social settings could also provide further information about the context of the patient’s symptoms. While these correlations alone will not lead to better clinical outcomes, it is easy to imagine how such data could help a patient and clinician start a conversation about making impactful changes.

Continue to: Case report...

Case report: Digital phenotyping

To illustrate how digital phenotyping could be put to clinical use, we created the following case report of a fictional patient who agrees to be monitored via her smartphone.

Consider a hypothetical patient we will call Ms. T who is in her mid-20s and has been diagnosed with schizophrenia. On a follow-up visit, she says she has insomnia. She also reports having a recent loss of appetite and higher levels of anxiety. After reviewing her smartphone data (Figure 3), the clinician sees an inversely proportional relationship between her sleep quality and symptoms of anxiety, psychosis, and depression, which suggests that these symptoms might be due to poor sleep. Her step count has been fairly stable, indicating that there is no significant correlation between physical activity and her other symptoms.

Continue to: The clinician shows...

The clinician shows Ms. T the data to help her understand why a trial of cognitive-behavioral therapy for insomnia, or at least improving sleep hygiene, may offer several benefits. The clinician advises her to continue to use the app to help assess her response to these interventions and monitor her progress in real time.

Dilemma: The ethics of continuous observation

The rich data captured by digital phenotyping afford many clinical opportunities, but also raise concerns. Among these are 3 significant ethical implications.

Firstly, the same data that may help a clinician learn about what environments are associated with less anxiety for the patient may also reveal personal details about where that patient has been or with whom they have interacted. In the wrong hands, such personal data could cause harm. And even in the hands of a trusted clinician, a breach in the patient’s privacy begs the question: “Should such information be anyone’s business at all?”

Secondly, many apps that offer digital phenotyping could also store patient data—something that currently pervades social media and causes reasonable discomfort for many people. You might have personally encountered this with social media platforms such as Facebook. When it comes to mobile mental health apps, clinicians should carefully understand the data usage agreement of any digital phenotyping app they wish to use and then share this information with their patients.

Finally, while it is possible to collect the types of data outlined in this article, less is known about how to use it directly in clinical care. Understanding for each patient which data streams are most meaningful and which data streams are noise that should be ignored is an area of ongoing research. A good first step may be to begin with data streams that are known to be clinically relevant and valuable, such as sleep and physical activity.^9-11

Continue to: Discussion...

Although smartphones can gather a wide range of active and passive data, other data streams hold potential for predicting relapse and performing other clinically relevant actions. One data stream that could be of clinical use is genomic sequencing.¹² The genotyping of patients provides a wealth of information about the underlying biology, and genomic sequencing has never been cheaper.¹³

Combining the data gathered via digital phenotyping with that of genotyping could help elucidate the mechanisms by which specific diseases and symptoms occur. This could be very promising to better understand and treat our patients. However, as is the case with genomics, digital phenotyping has important ethical implications. If used in the proper way to benefit our patients, the future for this new method is bright.

Raising a child is difficult. For working professional women, including doctors, that difficulty extends beyond bottles, bath time, and burping; it impacts day-to-day physiological function, time management, and emotional well-being.

The 1950s upheld a family model with traditional gender roles. By 1960, the family portrait of a breadwinner father and a stay-at-home mother with one or more children comprised 62% of American households.¹ Precipitous changes occurred over the next decades as the housing market soared, education costs increased, and divorce rates rose. The 1980s ushered the arrival of women’s power suits and the notion of women “having it all.”¹

Fast-forward to modern times. Medicine is changing, too. Women are slowly but surely starting to rise in this once male-led field. In 2017, for the first time more women than men enrolled in medical schools in the United States.² In a 2015 report, the Association of American Medical Colleges found that 57% of residents who were pursuing psychiatry were women.³ And the median age of women applying to medical school who enrolled in 2017 or 2018 was 23 years.⁴

Choosing to parent as a physician poses challenges for women and men alike. As the rates of women in medicine and psychiatry are increasing, this article focuses on unique obstacles faced by mothers and aims to:

• explore the dueling duties of mothers who practice medicine
• consider the dilemma women face when returning to the workforce during the postpartum period
• discuss options for enhanced recognition and care of maternal and child well-being.

Duty: Being both parent and physician

The working psychiatrist mother has a duty to her patients and profession—not to mention a duty to her child. The demands are endless on both sides. No matter what stage of her professional career (medical school, residency, fellowship, or beyond) she chooses to begin motherhood, the responsibilities and expectations can be overwhelming. Doctor appointments, nausea and vomiting, fatigue, discomfort, and stress do not fit well within a schedule of intensive studying, working 24-hour shifts, navigating complex schedules, treating patients, and sorting out the financial heft of loan repayment, home ownership, contract negotiation, or relocation.⁵

Psychiatry carries a notable dichotomy of lecturing at length on the importance of maternal-infant attachment. John Bowlby argued that a child’s attachment to the mother is instinctual and primary, noting that early loss creates true mourning due to the primal ties of child to mother.⁶ Bowlby also asserted that personality development and psychopathology are rooted in the concept of attachment and the emotional security built through early childhood experiences.⁶

Continue to: Dr. Donald Winnnicott introduced the concept of...

Dr. Donald Winnicott introduced the concept of a “good-enough” mother in 1953.⁷ Today, although Winnicott’s teachings are explored in psychiatry training programs and practice, his concept does not resonate with many working mothers. Most physicians strive for perfection while struggling to balance their personal and professional lives.⁷

It’s no wonder that tales abound of female physicians being praised for their ability to take on grueling shifts up to their due date, forego lunch to pump breast milk, or cover shifts beyond child daycare closing times. This raises an interesting dilemma: Is the primary goal the efficiency of promoting commerce, patient numbers, and the workings of the health care system? Or is it the wellness of expecting mothers and the development and attachment of an infant to the parent? Is the goal to slowly and carefully craft our next generation of young humans? Or is there a way to “have it all”?

Dilemma: Misperceptions after returning to work

As they regain control of their bodies, sleep, and overall health, women who return to work during the postpartum period battle a myriad of misperceptions along with the logistical hurdles of breast-feeding. In a study of surgical residencies, 61% of program directors reported that female trainees’ work was negatively affected by becoming parents.⁸ But other evidence suggests there is a disparity between perception and reality. In a broader population of working mothers in the United States, studies showed that employed mothers were actually more engaged than fathers at work and had equal levels of commitment and motivation.⁹ A lack of support from colleagues can produce a so-called “anti-mom” bias in the workplace.¹⁰

As a result, misperceptions can negatively affect maternity leave or lactation time. Women often rightfully fear they may be viewed as taking leisure time or making convenient excuses to shirk responsibility, rather than focusing on the necessities for recovery, care, and bonding. Such pressures can lead to burnout and resentment. The struggle with breast-feeding is pervasive across all medical specialties. In a 2018 survey of 347 women who had children during surgical residency, 39% of respondents strongly considered leaving their training, 95.6% indicated that breast-feeding was important to them, and 58.1% stopped breast-feeding earlier than desired due to challenges faced in the workplace, such as poor access to lactation facilities and difficulty leaving the operating room to express milk.¹¹

The American Academy of Pediatrics (AAP) recommends exclusive breast-feeding through 6 months of the postpartum period, and continued breast-feeding until the infant is at least 12 months old. Breast-feeding confers benefits to both the infant and mother, including positive impacts on the child’s cognitive development and health into adulthood, as well as higher productivity and lower absenteeism for breast-feeding mothers.¹² By 2009, only 23 states had adopted laws to encourage breast-feeding in the workplace. In 2010, the United States government enacted the “reasonable break time” provision in Section 4207 of the Patient Protection and Affordable Care Act (ACA), which requires all employers to provide a period of time and private space other than a bathroom in which female employees can express milk for a child up to age 1.¹²

Continue to: In 2016...

In 2016, a follow-up national survey of employed women explored workplace changes after the ACA, and noted that only 40% of women had access to both break time and a private space for lactation.¹³ If the goal is to give working women a true choice of whether to continue breast-feeding after returning to work, these mothers need to be provided with the proper social and structural supports in order to allow for that personal decision.¹⁴

Discussion: Barriers to change

Breast-feeding, it has been argued, is the most enduring investment in women’s physical, cognitive, and social capacities, and provides protection for children against death, disease, and poverty.¹⁵ Research has shown that breast-feeding every child until age 1 would yield medical benefits, including fewer infections, increased intelligence in children, protection against breast cancer in mothers, and economic savings of $300 billion for the United States.¹⁵

We are no longer in the 1950s, but modern times still present challenges for mothers who are working as physicians. Although the AAP recommends that new parents receive 12 weeks leave from work, policies for faculty at the 12 top medical schools in the United States offer new mothers only approximately 2 months of paid leave.¹⁶ There also are problems of inconsistency among approaches to parenthood in graduate medical education (GME) training, different specialty clinical requirements, and different residency training programs. These factors all contribute to negative attitudes towards parenthood.¹⁷

We know the barriers for women.¹⁸ With more women entering the medical profession, we need to continue finding creative and workable solutions as these problems become more pressing.¹⁹ In a 2018 Time article, Lily Rothman wrote, “you can’t talk about breastfeeding in the United States without pointing out that every other wealthy country has found a way to accommodate breastfeeding mothers, and usually in the form of lengthy paid maternity leave.”²⁰ However, maternity leave in the United States today dictates that mothers return to work while their children would still benefit from nursing.²¹

When it comes to GME and medical institutions, programs could look at barriers such as lack of accommodations for trainees who are pregnant or have young children. Addressing these barriers could include making private lactation rooms available and instituting flexible scheduling. It would be best if scheduling accommodations and policies were established by an institution’s administration, rather than leaving coverage up to the students or residents. Going further, institutions could consider offering flexible maternity leave and work schedules, allowing breaks for those who are breast-feeding, and creating lactation facilities.²² This could take the form of a breast-feeding support program that fits available budget resources.²³

Continue to: Psychiatrists frequently discuss...

Psychiatrists frequently discuss Winnicott’s “good-enough mother” concept, with the mother transitioning from focusing on her baby’s needs to her own sense of personhood that is unable to respond to her baby’s every wish.⁶ This concept was established well before the shifting demographics of the nuclear family, the short maternity leaves and early returns to work, early separation of one’s infants to childcare settings, and experiences with pumped lactation milk that working mothers experience today. Is it any wonder childbearing female psychiatrists face a special kind of working-mother guilt?

Raising a child is difficult. For working professional women, including doctors, that difficulty extends beyond bottles, bath time, and burping; it impacts day-to-day physiological function, time management, and emotional well-being.

The 1950s upheld a family model with traditional gender roles. By 1960, the family portrait of a breadwinner father and a stay-at-home mother with one or more children comprised 62% of American households.¹ Precipitous changes occurred over the next decades as the housing market soared, education costs increased, and divorce rates rose. The 1980s ushered the arrival of women’s power suits and the notion of women “having it all.”¹

Fast-forward to modern times. Medicine is changing, too. Women are slowly but surely starting to rise in this once male-led field. In 2017, for the first time more women than men enrolled in medical schools in the United States.² In a 2015 report, the Association of American Medical Colleges found that 57% of residents who were pursuing psychiatry were women.³ And the median age of women applying to medical school who enrolled in 2017 or 2018 was 23 years.⁴

Choosing to parent as a physician poses challenges for women and men alike. As the rates of women in medicine and psychiatry are increasing, this article focuses on unique obstacles faced by mothers and aims to:

• explore the dueling duties of mothers who practice medicine
• consider the dilemma women face when returning to the workforce during the postpartum period
• discuss options for enhanced recognition and care of maternal and child well-being.

Duty: Being both parent and physician

The working psychiatrist mother has a duty to her patients and profession—not to mention a duty to her child. The demands are endless on both sides. No matter what stage of her professional career (medical school, residency, fellowship, or beyond) she chooses to begin motherhood, the responsibilities and expectations can be overwhelming. Doctor appointments, nausea and vomiting, fatigue, discomfort, and stress do not fit well within a schedule of intensive studying, working 24-hour shifts, navigating complex schedules, treating patients, and sorting out the financial heft of loan repayment, home ownership, contract negotiation, or relocation.⁵

Psychiatry carries a notable dichotomy of lecturing at length on the importance of maternal-infant attachment. John Bowlby argued that a child’s attachment to the mother is instinctual and primary, noting that early loss creates true mourning due to the primal ties of child to mother.⁶ Bowlby also asserted that personality development and psychopathology are rooted in the concept of attachment and the emotional security built through early childhood experiences.⁶

Continue to: Dr. Donald Winnnicott introduced the concept of...

Dr. Donald Winnicott introduced the concept of a “good-enough” mother in 1953.⁷ Today, although Winnicott’s teachings are explored in psychiatry training programs and practice, his concept does not resonate with many working mothers. Most physicians strive for perfection while struggling to balance their personal and professional lives.⁷

It’s no wonder that tales abound of female physicians being praised for their ability to take on grueling shifts up to their due date, forego lunch to pump breast milk, or cover shifts beyond child daycare closing times. This raises an interesting dilemma: Is the primary goal the efficiency of promoting commerce, patient numbers, and the workings of the health care system? Or is it the wellness of expecting mothers and the development and attachment of an infant to the parent? Is the goal to slowly and carefully craft our next generation of young humans? Or is there a way to “have it all”?

Dilemma: Misperceptions after returning to work

As they regain control of their bodies, sleep, and overall health, women who return to work during the postpartum period battle a myriad of misperceptions along with the logistical hurdles of breast-feeding. In a study of surgical residencies, 61% of program directors reported that female trainees’ work was negatively affected by becoming parents.⁸ But other evidence suggests there is a disparity between perception and reality. In a broader population of working mothers in the United States, studies showed that employed mothers were actually more engaged than fathers at work and had equal levels of commitment and motivation.⁹ A lack of support from colleagues can produce a so-called “anti-mom” bias in the workplace.¹⁰

As a result, misperceptions can negatively affect maternity leave or lactation time. Women often rightfully fear they may be viewed as taking leisure time or making convenient excuses to shirk responsibility, rather than focusing on the necessities for recovery, care, and bonding. Such pressures can lead to burnout and resentment. The struggle with breast-feeding is pervasive across all medical specialties. In a 2018 survey of 347 women who had children during surgical residency, 39% of respondents strongly considered leaving their training, 95.6% indicated that breast-feeding was important to them, and 58.1% stopped breast-feeding earlier than desired due to challenges faced in the workplace, such as poor access to lactation facilities and difficulty leaving the operating room to express milk.¹¹

The American Academy of Pediatrics (AAP) recommends exclusive breast-feeding through 6 months of the postpartum period, and continued breast-feeding until the infant is at least 12 months old. Breast-feeding confers benefits to both the infant and mother, including positive impacts on the child’s cognitive development and health into adulthood, as well as higher productivity and lower absenteeism for breast-feeding mothers.¹² By 2009, only 23 states had adopted laws to encourage breast-feeding in the workplace. In 2010, the United States government enacted the “reasonable break time” provision in Section 4207 of the Patient Protection and Affordable Care Act (ACA), which requires all employers to provide a period of time and private space other than a bathroom in which female employees can express milk for a child up to age 1.¹²

Continue to: In 2016...

In 2016, a follow-up national survey of employed women explored workplace changes after the ACA, and noted that only 40% of women had access to both break time and a private space for lactation.¹³ If the goal is to give working women a true choice of whether to continue breast-feeding after returning to work, these mothers need to be provided with the proper social and structural supports in order to allow for that personal decision.¹⁴

Discussion: Barriers to change

Breast-feeding, it has been argued, is the most enduring investment in women’s physical, cognitive, and social capacities, and provides protection for children against death, disease, and poverty.¹⁵ Research has shown that breast-feeding every child until age 1 would yield medical benefits, including fewer infections, increased intelligence in children, protection against breast cancer in mothers, and economic savings of $300 billion for the United States.¹⁵

We are no longer in the 1950s, but modern times still present challenges for mothers who are working as physicians. Although the AAP recommends that new parents receive 12 weeks leave from work, policies for faculty at the 12 top medical schools in the United States offer new mothers only approximately 2 months of paid leave.¹⁶ There also are problems of inconsistency among approaches to parenthood in graduate medical education (GME) training, different specialty clinical requirements, and different residency training programs. These factors all contribute to negative attitudes towards parenthood.¹⁷

We know the barriers for women.¹⁸ With more women entering the medical profession, we need to continue finding creative and workable solutions as these problems become more pressing.¹⁹ In a 2018 Time article, Lily Rothman wrote, “you can’t talk about breastfeeding in the United States without pointing out that every other wealthy country has found a way to accommodate breastfeeding mothers, and usually in the form of lengthy paid maternity leave.”²⁰ However, maternity leave in the United States today dictates that mothers return to work while their children would still benefit from nursing.²¹

When it comes to GME and medical institutions, programs could look at barriers such as lack of accommodations for trainees who are pregnant or have young children. Addressing these barriers could include making private lactation rooms available and instituting flexible scheduling. It would be best if scheduling accommodations and policies were established by an institution’s administration, rather than leaving coverage up to the students or residents. Going further, institutions could consider offering flexible maternity leave and work schedules, allowing breaks for those who are breast-feeding, and creating lactation facilities.²² This could take the form of a breast-feeding support program that fits available budget resources.²³

Continue to: Psychiatrists frequently discuss...

Psychiatrists frequently discuss Winnicott’s “good-enough mother” concept, with the mother transitioning from focusing on her baby’s needs to her own sense of personhood that is unable to respond to her baby’s every wish.⁶ This concept was established well before the shifting demographics of the nuclear family, the short maternity leaves and early returns to work, early separation of one’s infants to childcare settings, and experiences with pumped lactation milk that working mothers experience today. Is it any wonder childbearing female psychiatrists face a special kind of working-mother guilt?

Raising a child is difficult. For working professional women, including doctors, that difficulty extends beyond bottles, bath time, and burping; it impacts day-to-day physiological function, time management, and emotional well-being.

The 1950s upheld a family model with traditional gender roles. By 1960, the family portrait of a breadwinner father and a stay-at-home mother with one or more children comprised 62% of American households.¹ Precipitous changes occurred over the next decades as the housing market soared, education costs increased, and divorce rates rose. The 1980s ushered the arrival of women’s power suits and the notion of women “having it all.”¹

Fast-forward to modern times. Medicine is changing, too. Women are slowly but surely starting to rise in this once male-led field. In 2017, for the first time more women than men enrolled in medical schools in the United States.² In a 2015 report, the Association of American Medical Colleges found that 57% of residents who were pursuing psychiatry were women.³ And the median age of women applying to medical school who enrolled in 2017 or 2018 was 23 years.⁴

Choosing to parent as a physician poses challenges for women and men alike. As the rates of women in medicine and psychiatry are increasing, this article focuses on unique obstacles faced by mothers and aims to:

• explore the dueling duties of mothers who practice medicine
• consider the dilemma women face when returning to the workforce during the postpartum period
• discuss options for enhanced recognition and care of maternal and child well-being.

Duty: Being both parent and physician

The working psychiatrist mother has a duty to her patients and profession—not to mention a duty to her child. The demands are endless on both sides. No matter what stage of her professional career (medical school, residency, fellowship, or beyond) she chooses to begin motherhood, the responsibilities and expectations can be overwhelming. Doctor appointments, nausea and vomiting, fatigue, discomfort, and stress do not fit well within a schedule of intensive studying, working 24-hour shifts, navigating complex schedules, treating patients, and sorting out the financial heft of loan repayment, home ownership, contract negotiation, or relocation.⁵

Psychiatry carries a notable dichotomy of lecturing at length on the importance of maternal-infant attachment. John Bowlby argued that a child’s attachment to the mother is instinctual and primary, noting that early loss creates true mourning due to the primal ties of child to mother.⁶ Bowlby also asserted that personality development and psychopathology are rooted in the concept of attachment and the emotional security built through early childhood experiences.⁶

Continue to: Dr. Donald Winnnicott introduced the concept of...

Dr. Donald Winnicott introduced the concept of a “good-enough” mother in 1953.⁷ Today, although Winnicott’s teachings are explored in psychiatry training programs and practice, his concept does not resonate with many working mothers. Most physicians strive for perfection while struggling to balance their personal and professional lives.⁷

It’s no wonder that tales abound of female physicians being praised for their ability to take on grueling shifts up to their due date, forego lunch to pump breast milk, or cover shifts beyond child daycare closing times. This raises an interesting dilemma: Is the primary goal the efficiency of promoting commerce, patient numbers, and the workings of the health care system? Or is it the wellness of expecting mothers and the development and attachment of an infant to the parent? Is the goal to slowly and carefully craft our next generation of young humans? Or is there a way to “have it all”?

Dilemma: Misperceptions after returning to work

As they regain control of their bodies, sleep, and overall health, women who return to work during the postpartum period battle a myriad of misperceptions along with the logistical hurdles of breast-feeding. In a study of surgical residencies, 61% of program directors reported that female trainees’ work was negatively affected by becoming parents.⁸ But other evidence suggests there is a disparity between perception and reality. In a broader population of working mothers in the United States, studies showed that employed mothers were actually more engaged than fathers at work and had equal levels of commitment and motivation.⁹ A lack of support from colleagues can produce a so-called “anti-mom” bias in the workplace.¹⁰

As a result, misperceptions can negatively affect maternity leave or lactation time. Women often rightfully fear they may be viewed as taking leisure time or making convenient excuses to shirk responsibility, rather than focusing on the necessities for recovery, care, and bonding. Such pressures can lead to burnout and resentment. The struggle with breast-feeding is pervasive across all medical specialties. In a 2018 survey of 347 women who had children during surgical residency, 39% of respondents strongly considered leaving their training, 95.6% indicated that breast-feeding was important to them, and 58.1% stopped breast-feeding earlier than desired due to challenges faced in the workplace, such as poor access to lactation facilities and difficulty leaving the operating room to express milk.¹¹

The American Academy of Pediatrics (AAP) recommends exclusive breast-feeding through 6 months of the postpartum period, and continued breast-feeding until the infant is at least 12 months old. Breast-feeding confers benefits to both the infant and mother, including positive impacts on the child’s cognitive development and health into adulthood, as well as higher productivity and lower absenteeism for breast-feeding mothers.¹² By 2009, only 23 states had adopted laws to encourage breast-feeding in the workplace. In 2010, the United States government enacted the “reasonable break time” provision in Section 4207 of the Patient Protection and Affordable Care Act (ACA), which requires all employers to provide a period of time and private space other than a bathroom in which female employees can express milk for a child up to age 1.¹²

Continue to: In 2016...

In 2016, a follow-up national survey of employed women explored workplace changes after the ACA, and noted that only 40% of women had access to both break time and a private space for lactation.¹³ If the goal is to give working women a true choice of whether to continue breast-feeding after returning to work, these mothers need to be provided with the proper social and structural supports in order to allow for that personal decision.¹⁴

Discussion: Barriers to change

Breast-feeding, it has been argued, is the most enduring investment in women’s physical, cognitive, and social capacities, and provides protection for children against death, disease, and poverty.¹⁵ Research has shown that breast-feeding every child until age 1 would yield medical benefits, including fewer infections, increased intelligence in children, protection against breast cancer in mothers, and economic savings of $300 billion for the United States.¹⁵

We are no longer in the 1950s, but modern times still present challenges for mothers who are working as physicians. Although the AAP recommends that new parents receive 12 weeks leave from work, policies for faculty at the 12 top medical schools in the United States offer new mothers only approximately 2 months of paid leave.¹⁶ There also are problems of inconsistency among approaches to parenthood in graduate medical education (GME) training, different specialty clinical requirements, and different residency training programs. These factors all contribute to negative attitudes towards parenthood.¹⁷

We know the barriers for women.¹⁸ With more women entering the medical profession, we need to continue finding creative and workable solutions as these problems become more pressing.¹⁹ In a 2018 Time article, Lily Rothman wrote, “you can’t talk about breastfeeding in the United States without pointing out that every other wealthy country has found a way to accommodate breastfeeding mothers, and usually in the form of lengthy paid maternity leave.”²⁰ However, maternity leave in the United States today dictates that mothers return to work while their children would still benefit from nursing.²¹

When it comes to GME and medical institutions, programs could look at barriers such as lack of accommodations for trainees who are pregnant or have young children. Addressing these barriers could include making private lactation rooms available and instituting flexible scheduling. It would be best if scheduling accommodations and policies were established by an institution’s administration, rather than leaving coverage up to the students or residents. Going further, institutions could consider offering flexible maternity leave and work schedules, allowing breaks for those who are breast-feeding, and creating lactation facilities.²² This could take the form of a breast-feeding support program that fits available budget resources.²³

Continue to: Psychiatrists frequently discuss...

Psychiatrists frequently discuss Winnicott’s “good-enough mother” concept, with the mother transitioning from focusing on her baby’s needs to her own sense of personhood that is unable to respond to her baby’s every wish.⁶ This concept was established well before the shifting demographics of the nuclear family, the short maternity leaves and early returns to work, early separation of one’s infants to childcare settings, and experiences with pumped lactation milk that working mothers experience today. Is it any wonder childbearing female psychiatrists face a special kind of working-mother guilt?

Performance enhancement in sports (“doping”) dates back to Ancient Greece. This was an era when Olympic athletes would attempt to improve their physical performance by consuming magic potions, herbal medications, and even exotic meats such as sheep testicles—a delicacy high in testosterone. Advances in medical and pharmaceutical technologies have increased both the range of enhancement agents available and their efficacy, leading to the development of anti-doping agencies and routine screening for doping in athletics. This has led to the renouncement of titles, medals, and financial sponsorship of athletes found to have been using prohibited substances during competition.

While doping in elite athletes often forms the nidus of media attention, the pressure to compete and perform at, or even beyond, one’s potential extends into many facets of today’s achievementfocused society. In the face of these pressures, individuals are increasingly seeking medications to enhance their performance across numerous domains, including cognitive, athletic, and artistic endeavors. Medication classes used to enhance performance include stimulants, which increase attention, executive function, and energy; cholinesterase inhibitors, which may ameliorate age-related memory decline; and beta-blockers, which decrease physiologic symptoms of anxiety and have been demonstrated to be beneficial for musical performance.¹ Fifty-three percent of college athletes report using prescription medications to enhance athletic performance,² and most college students who take stimulants without a prescription use them to study (84%) or stay awake (51%).³

Pharmacologic performance enhancement is the use of medications by healthy individuals to improve function in the absence of mental illness. Psychiatrists are increasingly finding themselves in the controversial position of “gatekeeper” of these medications for enhancement purposes. In this article we:

• outline arguments that support the use of psychopharmacology for performance enhancement, as well as some serious concerns with this practice
• discuss special considerations for pediatric populations and the risk of malpractice when prescribing for performance enhancement
• offer practice guidelines for approaching requests for psychopharmacologic performance enhancement.

Performance enhancement: The wave of the future?

The ethical principle that supports providing medication for performance enhancement is beneficence, the promotion of the patient’s well-being. In other words, it is a physician’s duty to help his or her patient in need. Individuals seeking performance enhancement typically present with suffering, and the principle of beneficence would call upon the psychiatrist to help ameliorate that suffering. Furthermore, patients who seek performance enhancement may present with impairing “subsyndromal” psychiatric symptoms (for example, low-grade attentional difficulty that occurs only in one setting), which, even if they do not rise to the threshold of a DSM diagnosis, may improve with psychiatric medications.

Using medical knowledge and skills beyond the traditional physician duty to diagnose and treat medical conditions is not unprecedented (eg, when surgeons perform cosmetic enhancement). Might elective enhancement of cognition and psychological performance through the judicious use of medication be part of the future of psychiatry? If cognitive and emotional enhancement becomes a more widely accepted standard of care, might this increase both individual and societal innovation and productivity?

Dilemma: Cautions against performance enhancement

One of the major cautions against prescribing psychotropics for the purpose of performance enhancement is the lack of clearly supported efficacy. Psychiatric medications generally are studied in individuals who meet criteria for mental illness, and they are FDA-approved for use in ill persons. It may be erroneous to extrapolate that a medication that improves symptoms in a patient with an illness would achieve the same target effect in a healthy individual. For example, data on whether stimulants provide neurocognitive enhancement in healthy individuals without attention-deficit/hyperactivity disorder is mixed, and these agents may even promote risky behavior in healthy controls.⁴ Furthermore, dopamine agonism may compress cognitive performance in both directions,⁵ as it has been observed that methylphenidate improves executive function in healthy controls, but is less beneficial for those with strong executive function at baseline.⁶

In the face of unclear benefit, it is particularly important to consider the risk of medications used for performance enhancement. Pharmacologic performance enhancement in individuals without psychopathology can be considered an “elective” intervention, for which individuals typically tolerate less risk. Physical risks, including medication-related adverse effects, must be considered, particularly in settings where there may be temptation to use more than prescribed, or to divert medication to others who may use it without medical monitoring. In addition to physical harm, there may be psychological harm associated with prescribing performance enhancers, such as pathologizing variants of “normal,” diminishing one’s sense of self-efficacy, or decreasing one’s ability to bear failure.

Continue to: Finally, there are ethical quandaries

Finally, there are ethical quandaries regarding using medications for performance enhancement. Widespread adoption of pharmacologic performance enhancement may lead to implicit coercion for all individuals to enhance their abilities. As a greater proportion of society receives pharmacologic enhancement, society as a whole faces stronger pressures to seek pharmacologic enhancement, ultimately constricting an individual’s freedom of choice to enhance.⁶ In this setting, distributive justice would become a consideration, because insurance companies are unlikely to reimburse for medications used for enhancement,⁷ which would give an advantage to individuals with higher socioeconomic status. Research shows that children from higher socioeconomic communities and from states with higher academic standards are more likely to use stimulants.⁸

Areas of controversy

Pediatric populations. There are special considerations when prescribing performance-enhancing medications for children and adolescents. First, such prescribing may inhibit normal child development, shifting the focus away from the normative tasks of social and emotional development that occur through leisure and creativity, experimentation, and play to an emphasis on performance and outcomes-based achievement.⁹ Second, during childhood and adolescence, one develops a sense of his or her identity, morals, and values. Taking a medication during childhood to enhance performance may inhibit the process of learning to tolerate failure, become aware of one’s weaknesses, and value effort in addition to outcome.

Malpractice risk. Practicing medicine beyond the scope of one’s expertise is unethical and unlawful. In the past 30 years, medical malpractice has become one of the most difficult health care issues in the U.S.¹⁰ In addition to billions of dollars in legal fees and court costs, medical malpractice premiums in the U.S. total more than $5 billion annually,¹¹ and “defensive medicine”— procedures performed to protect against litigation—is estimated to cost more than $14 billion a year.¹²

When considering performance-enhancing treatment, it is the physician’s duty to conduct a diagnostic assessment, including noting target symptoms that are interfering with the patient’s function, and to tailor such treatment toward measurable goals and outcomes. Aside from medication, this could include a therapeutic approach to improving performance that might include cognitive-behavioral therapy and promotion of a healthy diet and exercise.

Treatment rises to the level of malpractice when there is a dereliction of duty that directly leads to damages.¹³ Part of a physician’s duty is to educate patients about the pros and cons of different treatment options. For performance-enhancing medications, the risks of addiction and dependence are adverse effects that require discussion. And for a pediatric patient, this would require the guardian’s engagement and understanding.

Continue to: What to do if you decide to prescribe

Inevitably, the decision to prescribe psychotropic medications for performance enhancement is a physician-specific one. Certainly, psychiatrists should not feel obligated to prescribe performance enhancers. Given our current state of pharmacology, it is unclear whether medications would be helpful in the absence of psychopathology. When deciding whether to prescribe for performance enhancement in the absence of psychopathology, we suggest first carefully considering how to maintain the ethical value of nonmaleficence by weighing both the potential physical and psychologic harms of prescribing as well as the legal risks and rules of applicable sport governing bodies.

For a psychiatrist who chooses to prescribe for performance enhancement, we recommend conducting a thorough psychiatric assessment to determine whether the patient has a treatable mental illness. If so, then effective treatment of that illness should take priority. Before prescribing, the psychiatrist and patient should discuss the patient’s specific performance goals and how to measure them.

Any prescription for a performance-enhancing medication should be given in conjunction with nonpharmacologic approaches, including optimizing diet, exercise, and sleep. Therapy to address problem-solving techniques and skills to cope with stress may also be appropriate. The patient and psychiatrist should engage in regular follow-up to assess the efficacy of the medication, as well as its safety and tolerability. Finally, if a medication is not efficacious as a performance enhancer, then both the patient and psychiatrist should be open to re-evaluating the treatment plan, and when appropriate, stopping the medication.

Performance enhancement in sports (“doping”) dates back to Ancient Greece. This was an era when Olympic athletes would attempt to improve their physical performance by consuming magic potions, herbal medications, and even exotic meats such as sheep testicles—a delicacy high in testosterone. Advances in medical and pharmaceutical technologies have increased both the range of enhancement agents available and their efficacy, leading to the development of anti-doping agencies and routine screening for doping in athletics. This has led to the renouncement of titles, medals, and financial sponsorship of athletes found to have been using prohibited substances during competition.

While doping in elite athletes often forms the nidus of media attention, the pressure to compete and perform at, or even beyond, one’s potential extends into many facets of today’s achievementfocused society. In the face of these pressures, individuals are increasingly seeking medications to enhance their performance across numerous domains, including cognitive, athletic, and artistic endeavors. Medication classes used to enhance performance include stimulants, which increase attention, executive function, and energy; cholinesterase inhibitors, which may ameliorate age-related memory decline; and beta-blockers, which decrease physiologic symptoms of anxiety and have been demonstrated to be beneficial for musical performance.¹ Fifty-three percent of college athletes report using prescription medications to enhance athletic performance,² and most college students who take stimulants without a prescription use them to study (84%) or stay awake (51%).³

Pharmacologic performance enhancement is the use of medications by healthy individuals to improve function in the absence of mental illness. Psychiatrists are increasingly finding themselves in the controversial position of “gatekeeper” of these medications for enhancement purposes. In this article we:

• outline arguments that support the use of psychopharmacology for performance enhancement, as well as some serious concerns with this practice
• discuss special considerations for pediatric populations and the risk of malpractice when prescribing for performance enhancement
• offer practice guidelines for approaching requests for psychopharmacologic performance enhancement.

Performance enhancement: The wave of the future?

The ethical principle that supports providing medication for performance enhancement is beneficence, the promotion of the patient’s well-being. In other words, it is a physician’s duty to help his or her patient in need. Individuals seeking performance enhancement typically present with suffering, and the principle of beneficence would call upon the psychiatrist to help ameliorate that suffering. Furthermore, patients who seek performance enhancement may present with impairing “subsyndromal” psychiatric symptoms (for example, low-grade attentional difficulty that occurs only in one setting), which, even if they do not rise to the threshold of a DSM diagnosis, may improve with psychiatric medications.

Using medical knowledge and skills beyond the traditional physician duty to diagnose and treat medical conditions is not unprecedented (eg, when surgeons perform cosmetic enhancement). Might elective enhancement of cognition and psychological performance through the judicious use of medication be part of the future of psychiatry? If cognitive and emotional enhancement becomes a more widely accepted standard of care, might this increase both individual and societal innovation and productivity?

Dilemma: Cautions against performance enhancement

One of the major cautions against prescribing psychotropics for the purpose of performance enhancement is the lack of clearly supported efficacy. Psychiatric medications generally are studied in individuals who meet criteria for mental illness, and they are FDA-approved for use in ill persons. It may be erroneous to extrapolate that a medication that improves symptoms in a patient with an illness would achieve the same target effect in a healthy individual. For example, data on whether stimulants provide neurocognitive enhancement in healthy individuals without attention-deficit/hyperactivity disorder is mixed, and these agents may even promote risky behavior in healthy controls.⁴ Furthermore, dopamine agonism may compress cognitive performance in both directions,⁵ as it has been observed that methylphenidate improves executive function in healthy controls, but is less beneficial for those with strong executive function at baseline.⁶

In the face of unclear benefit, it is particularly important to consider the risk of medications used for performance enhancement. Pharmacologic performance enhancement in individuals without psychopathology can be considered an “elective” intervention, for which individuals typically tolerate less risk. Physical risks, including medication-related adverse effects, must be considered, particularly in settings where there may be temptation to use more than prescribed, or to divert medication to others who may use it without medical monitoring. In addition to physical harm, there may be psychological harm associated with prescribing performance enhancers, such as pathologizing variants of “normal,” diminishing one’s sense of self-efficacy, or decreasing one’s ability to bear failure.

Continue to: Finally, there are ethical quandaries

Finally, there are ethical quandaries regarding using medications for performance enhancement. Widespread adoption of pharmacologic performance enhancement may lead to implicit coercion for all individuals to enhance their abilities. As a greater proportion of society receives pharmacologic enhancement, society as a whole faces stronger pressures to seek pharmacologic enhancement, ultimately constricting an individual’s freedom of choice to enhance.⁶ In this setting, distributive justice would become a consideration, because insurance companies are unlikely to reimburse for medications used for enhancement,⁷ which would give an advantage to individuals with higher socioeconomic status. Research shows that children from higher socioeconomic communities and from states with higher academic standards are more likely to use stimulants.⁸

Areas of controversy

Pediatric populations. There are special considerations when prescribing performance-enhancing medications for children and adolescents. First, such prescribing may inhibit normal child development, shifting the focus away from the normative tasks of social and emotional development that occur through leisure and creativity, experimentation, and play to an emphasis on performance and outcomes-based achievement.⁹ Second, during childhood and adolescence, one develops a sense of his or her identity, morals, and values. Taking a medication during childhood to enhance performance may inhibit the process of learning to tolerate failure, become aware of one’s weaknesses, and value effort in addition to outcome.

Malpractice risk. Practicing medicine beyond the scope of one’s expertise is unethical and unlawful. In the past 30 years, medical malpractice has become one of the most difficult health care issues in the U.S.¹⁰ In addition to billions of dollars in legal fees and court costs, medical malpractice premiums in the U.S. total more than $5 billion annually,¹¹ and “defensive medicine”— procedures performed to protect against litigation—is estimated to cost more than $14 billion a year.¹²

When considering performance-enhancing treatment, it is the physician’s duty to conduct a diagnostic assessment, including noting target symptoms that are interfering with the patient’s function, and to tailor such treatment toward measurable goals and outcomes. Aside from medication, this could include a therapeutic approach to improving performance that might include cognitive-behavioral therapy and promotion of a healthy diet and exercise.

Treatment rises to the level of malpractice when there is a dereliction of duty that directly leads to damages.¹³ Part of a physician’s duty is to educate patients about the pros and cons of different treatment options. For performance-enhancing medications, the risks of addiction and dependence are adverse effects that require discussion. And for a pediatric patient, this would require the guardian’s engagement and understanding.

Continue to: What to do if you decide to prescribe

Inevitably, the decision to prescribe psychotropic medications for performance enhancement is a physician-specific one. Certainly, psychiatrists should not feel obligated to prescribe performance enhancers. Given our current state of pharmacology, it is unclear whether medications would be helpful in the absence of psychopathology. When deciding whether to prescribe for performance enhancement in the absence of psychopathology, we suggest first carefully considering how to maintain the ethical value of nonmaleficence by weighing both the potential physical and psychologic harms of prescribing as well as the legal risks and rules of applicable sport governing bodies.

For a psychiatrist who chooses to prescribe for performance enhancement, we recommend conducting a thorough psychiatric assessment to determine whether the patient has a treatable mental illness. If so, then effective treatment of that illness should take priority. Before prescribing, the psychiatrist and patient should discuss the patient’s specific performance goals and how to measure them.

Any prescription for a performance-enhancing medication should be given in conjunction with nonpharmacologic approaches, including optimizing diet, exercise, and sleep. Therapy to address problem-solving techniques and skills to cope with stress may also be appropriate. The patient and psychiatrist should engage in regular follow-up to assess the efficacy of the medication, as well as its safety and tolerability. Finally, if a medication is not efficacious as a performance enhancer, then both the patient and psychiatrist should be open to re-evaluating the treatment plan, and when appropriate, stopping the medication.

Performance enhancement in sports (“doping”) dates back to Ancient Greece. This was an era when Olympic athletes would attempt to improve their physical performance by consuming magic potions, herbal medications, and even exotic meats such as sheep testicles—a delicacy high in testosterone. Advances in medical and pharmaceutical technologies have increased both the range of enhancement agents available and their efficacy, leading to the development of anti-doping agencies and routine screening for doping in athletics. This has led to the renouncement of titles, medals, and financial sponsorship of athletes found to have been using prohibited substances during competition.

While doping in elite athletes often forms the nidus of media attention, the pressure to compete and perform at, or even beyond, one’s potential extends into many facets of today’s achievementfocused society. In the face of these pressures, individuals are increasingly seeking medications to enhance their performance across numerous domains, including cognitive, athletic, and artistic endeavors. Medication classes used to enhance performance include stimulants, which increase attention, executive function, and energy; cholinesterase inhibitors, which may ameliorate age-related memory decline; and beta-blockers, which decrease physiologic symptoms of anxiety and have been demonstrated to be beneficial for musical performance.¹ Fifty-three percent of college athletes report using prescription medications to enhance athletic performance,² and most college students who take stimulants without a prescription use them to study (84%) or stay awake (51%).³

Pharmacologic performance enhancement is the use of medications by healthy individuals to improve function in the absence of mental illness. Psychiatrists are increasingly finding themselves in the controversial position of “gatekeeper” of these medications for enhancement purposes. In this article we:

• outline arguments that support the use of psychopharmacology for performance enhancement, as well as some serious concerns with this practice
• discuss special considerations for pediatric populations and the risk of malpractice when prescribing for performance enhancement
• offer practice guidelines for approaching requests for psychopharmacologic performance enhancement.

Performance enhancement: The wave of the future?

The ethical principle that supports providing medication for performance enhancement is beneficence, the promotion of the patient’s well-being. In other words, it is a physician’s duty to help his or her patient in need. Individuals seeking performance enhancement typically present with suffering, and the principle of beneficence would call upon the psychiatrist to help ameliorate that suffering. Furthermore, patients who seek performance enhancement may present with impairing “subsyndromal” psychiatric symptoms (for example, low-grade attentional difficulty that occurs only in one setting), which, even if they do not rise to the threshold of a DSM diagnosis, may improve with psychiatric medications.

Using medical knowledge and skills beyond the traditional physician duty to diagnose and treat medical conditions is not unprecedented (eg, when surgeons perform cosmetic enhancement). Might elective enhancement of cognition and psychological performance through the judicious use of medication be part of the future of psychiatry? If cognitive and emotional enhancement becomes a more widely accepted standard of care, might this increase both individual and societal innovation and productivity?

Dilemma: Cautions against performance enhancement

One of the major cautions against prescribing psychotropics for the purpose of performance enhancement is the lack of clearly supported efficacy. Psychiatric medications generally are studied in individuals who meet criteria for mental illness, and they are FDA-approved for use in ill persons. It may be erroneous to extrapolate that a medication that improves symptoms in a patient with an illness would achieve the same target effect in a healthy individual. For example, data on whether stimulants provide neurocognitive enhancement in healthy individuals without attention-deficit/hyperactivity disorder is mixed, and these agents may even promote risky behavior in healthy controls.⁴ Furthermore, dopamine agonism may compress cognitive performance in both directions,⁵ as it has been observed that methylphenidate improves executive function in healthy controls, but is less beneficial for those with strong executive function at baseline.⁶

In the face of unclear benefit, it is particularly important to consider the risk of medications used for performance enhancement. Pharmacologic performance enhancement in individuals without psychopathology can be considered an “elective” intervention, for which individuals typically tolerate less risk. Physical risks, including medication-related adverse effects, must be considered, particularly in settings where there may be temptation to use more than prescribed, or to divert medication to others who may use it without medical monitoring. In addition to physical harm, there may be psychological harm associated with prescribing performance enhancers, such as pathologizing variants of “normal,” diminishing one’s sense of self-efficacy, or decreasing one’s ability to bear failure.

Continue to: Finally, there are ethical quandaries

Finally, there are ethical quandaries regarding using medications for performance enhancement. Widespread adoption of pharmacologic performance enhancement may lead to implicit coercion for all individuals to enhance their abilities. As a greater proportion of society receives pharmacologic enhancement, society as a whole faces stronger pressures to seek pharmacologic enhancement, ultimately constricting an individual’s freedom of choice to enhance.⁶ In this setting, distributive justice would become a consideration, because insurance companies are unlikely to reimburse for medications used for enhancement,⁷ which would give an advantage to individuals with higher socioeconomic status. Research shows that children from higher socioeconomic communities and from states with higher academic standards are more likely to use stimulants.⁸

Areas of controversy

Pediatric populations. There are special considerations when prescribing performance-enhancing medications for children and adolescents. First, such prescribing may inhibit normal child development, shifting the focus away from the normative tasks of social and emotional development that occur through leisure and creativity, experimentation, and play to an emphasis on performance and outcomes-based achievement.⁹ Second, during childhood and adolescence, one develops a sense of his or her identity, morals, and values. Taking a medication during childhood to enhance performance may inhibit the process of learning to tolerate failure, become aware of one’s weaknesses, and value effort in addition to outcome.

Malpractice risk. Practicing medicine beyond the scope of one’s expertise is unethical and unlawful. In the past 30 years, medical malpractice has become one of the most difficult health care issues in the U.S.¹⁰ In addition to billions of dollars in legal fees and court costs, medical malpractice premiums in the U.S. total more than $5 billion annually,¹¹ and “defensive medicine”— procedures performed to protect against litigation—is estimated to cost more than $14 billion a year.¹²

When considering performance-enhancing treatment, it is the physician’s duty to conduct a diagnostic assessment, including noting target symptoms that are interfering with the patient’s function, and to tailor such treatment toward measurable goals and outcomes. Aside from medication, this could include a therapeutic approach to improving performance that might include cognitive-behavioral therapy and promotion of a healthy diet and exercise.

Treatment rises to the level of malpractice when there is a dereliction of duty that directly leads to damages.¹³ Part of a physician’s duty is to educate patients about the pros and cons of different treatment options. For performance-enhancing medications, the risks of addiction and dependence are adverse effects that require discussion. And for a pediatric patient, this would require the guardian’s engagement and understanding.

Continue to: What to do if you decide to prescribe

Inevitably, the decision to prescribe psychotropic medications for performance enhancement is a physician-specific one. Certainly, psychiatrists should not feel obligated to prescribe performance enhancers. Given our current state of pharmacology, it is unclear whether medications would be helpful in the absence of psychopathology. When deciding whether to prescribe for performance enhancement in the absence of psychopathology, we suggest first carefully considering how to maintain the ethical value of nonmaleficence by weighing both the potential physical and psychologic harms of prescribing as well as the legal risks and rules of applicable sport governing bodies.

For a psychiatrist who chooses to prescribe for performance enhancement, we recommend conducting a thorough psychiatric assessment to determine whether the patient has a treatable mental illness. If so, then effective treatment of that illness should take priority. Before prescribing, the psychiatrist and patient should discuss the patient’s specific performance goals and how to measure them.

Any prescription for a performance-enhancing medication should be given in conjunction with nonpharmacologic approaches, including optimizing diet, exercise, and sleep. Therapy to address problem-solving techniques and skills to cope with stress may also be appropriate. The patient and psychiatrist should engage in regular follow-up to assess the efficacy of the medication, as well as its safety and tolerability. Finally, if a medication is not efficacious as a performance enhancer, then both the patient and psychiatrist should be open to re-evaluating the treatment plan, and when appropriate, stopping the medication.

Psychiatry is a field of passion. The reward of experiencing growth and change alongside our patients is what bolsters us through years of difficult training, overnight shifts, endless paperwork, regulatory mandates, and frequent worry about our patients. As physicians, we don’t live for weekends as many other professionals do. To the contrary, we spend them on call, moonlighting, laboring over journal articles, and perfecting lectures.

That passion is what makes us trusted clinicians and experts in our field. It can also make it difficult for us to disconnect from our work, frequently leading to burnout. Physician self-care, support, and professional development are critical topics that modern-day medicine minimizes at the peril of physicians and public health.¹

Psychiatry lends itself to a deep and intimate understanding of another human being. The therapist delves into the lives of his or her patients, hears their stories, and holds their secrets. In some cases, we might be the only ones who truly see patients for who they uniquely are, and come to understand them on a deeper level than their closest family and friends. This can be both thrilling and intense. As we delve into the psyche of another individual, contemplate which interpretation we should share, and resonate with our patients, it is easy to become bogged down with our own countertransference, sentiment, and worry, and to become consumed by our work. A professional hazard, some might quip.

Therefore, personal restoration—a tool that keeps our clinical skills sharp—is vitally important to caring for oneself and one’s patient. Surprisingly, this can be neglected until we begin to experience burnout, which over time could transform into impairment, thus endangering ourselves, our patients, and our profession.

Over the past decade, physician impairment has been exhaustively described, researched, and addressed. However, most analyses have focused on identifying impairment, and offering guidance on how to properly report it. How do we shift from managing the crisis to preventing it? To answer this question, this article:

• reviews the dilemma of physician impairment
• explores the duty we have to patients, ourselves, and the profession
• discusses shifting the focus on impairment to prevention through well-being.

Continue to: Dilemma

The cornerstone for well-being is a balanced life. No matter how much one loves his or her work, there must be balance between work, relationships, and hobbies. Without that equilibrium, everyone is put at risk.²

Just as our patients, we are not immune to mental illness, cognitive decline, or substance abuse.³ We might even be more susceptible. For many physicians, their identity is intimately tied to their work.⁴ Dr. Robin Weiss captured that intimate relationship⁵:

“… [A] therapist may spend hundreds of hours, perhaps more than a thousand, hearing about a patient’s most exalted aspirations and most murderous, hateful fantasies. During this time, the patient may endure excruciating losses, unbearable shame, bitter sadness and great triumphs. You may accompany patients through torturous adolescence into adulthood. Or you may meet them in middle age and be with them as they age and eventually die. You collaborate in a deep process of discovery. Few encounters are this deeply honest, and therefore intimate.”

Given the stories we hear and the resulting intimacy and countertransference that inevitably arise, psychiatrists are even more prone to burnout than other physicians.⁶ Physician impairment is a public health issue that affects not just physicians but also their families, colleagues, and patients.

“Impairment” for the purpose of this article means a physical, mental, or substance-related disorder that interferes with a physician’s ability to undertake professional activities competently and safely.⁷ Predisposing factors for physician impairment include an obsessive-compulsive personality type, a family history of mental illness, sensation-seeking behavior, denial of personal problems, perfectionism, and idealism.^8,9 Also, work stress becomes a significant factor in already vulnerable physicians, leading to a greater risk for mental illness.¹⁰

Continue to: Some warning signs of impairment include...

Duty: To ourselves, our colleagues, and our patients

There has been much discussion on how to report impaired colleagues, but little on how to help and support ourselves and our colleagues before things escalate into serious problems. And this lack of discussion is at the detriment of individual practitioners, their families, and patients. Physicians-in-training, including psychiatric residents, are at particularly high risk for developing stress-related problems, depression, and substance misuse.¹² Occupational demands, self-criticism, and denial of one’s distress are common among physicians, as is self-treatment with drugs and alcohol.¹³

We all know by now that doctors and physician health programs (PHPs) have a duty to report impaired colleagues who continue to practice despite reasonable offers of assistance. There are an abundance of PHPs that are in place to assist with such situations. The American Medical Association’s official position on reporting impairment is outlined in Policy H-275.952.⁷ There also is the Federation of State Medical Boards. Its policy states that PHPs have “a primary commitment to [help] state medical boards … protect the public … [These] programs [should] demonstrate an ongoing track of record of ensuring safety to the public and reveal deficiencies if they occur.”¹⁴

Legal and ethical issues, however, complicate interventions for colleagues who need assistance.¹⁵ Despite the existence of PHPs, it would be much easier—not to mention helpful—to help a colleague by carrying out early interventions.

Discussion: Prevention as a solution

More emphasis should be placed on prevention. That’s where self-care and well-being come into play. Awareness of and sensitivity to physician vulnerability, early detection, and prevention of impairment are important.

Continue to: There has been a paradigm shift in focus...

There has been a paradigm shift in focus across medical boards, professional societies, and medical colleges. They are recognizing that personal well-being can help prevent burnout and, in turn, change the landscape of medicine from endless work to balanced lives that yield more satisfying and joyful work. It is becoming an accepted fact in medicine that well-being is just as important as integrity, professionalism, and patient safety. For example, the American Academy of Medical Colleges (AAMC) issued a statement emphasizing the importance of clinician well-being and dedicated its June 2016 Leadership Forum to a range of topics addressing depression, resilience, burnout, and suicide in academic medicine.¹⁶

Anita Everett, MD, put the spotlight on physician well-being during her term as American Psychiatric Association President (2017 to 2018). She formed a specific workgroup on Physician Wellness and Burnout where there is a community focus on prevention and self-care.¹⁷ A strong sense of community and purpose is almost always part of the prescription for promoting greater well-being.²

The importance of this issue is also trickling down from policymakers into hospitals and community health centers. Consider an initiative at Minneapolis’s Hennepin County Medical Center. Leaders there created a “reset room” for physicians to quietly decompress. The room is complete with LED lights, flameless candles, a sound machine, comfortable chairs, several plants, and an “in use” sign on the door.¹⁸ Other personal strategies to help prevent burnout include making environmental changes, encouraging hobbies, and streamlining burdensome tasks such as paperwork and electronic medical record systems.

As physician health and well-being are finally emerging as a “hot topic,”² educational and treatment resources are increasingly available for any of us to explore. Consider a simple Google search to look into your State’s PHPs, and get involved in your professional societies to make change.

The culture is starting to shift, and leading by example will be a key to propelling further progress in this area. Model our own self-care for colleagues and patients alike. As Mark Twain said, we might love our work, but we must remember that being solely defined by work comes to the detriment of our health. Maintaining balance is what will allow us to sustain long careers ahead doing what we love.

Psychiatry is a field of passion. The reward of experiencing growth and change alongside our patients is what bolsters us through years of difficult training, overnight shifts, endless paperwork, regulatory mandates, and frequent worry about our patients. As physicians, we don’t live for weekends as many other professionals do. To the contrary, we spend them on call, moonlighting, laboring over journal articles, and perfecting lectures.

That passion is what makes us trusted clinicians and experts in our field. It can also make it difficult for us to disconnect from our work, frequently leading to burnout. Physician self-care, support, and professional development are critical topics that modern-day medicine minimizes at the peril of physicians and public health.¹

Psychiatry lends itself to a deep and intimate understanding of another human being. The therapist delves into the lives of his or her patients, hears their stories, and holds their secrets. In some cases, we might be the only ones who truly see patients for who they uniquely are, and come to understand them on a deeper level than their closest family and friends. This can be both thrilling and intense. As we delve into the psyche of another individual, contemplate which interpretation we should share, and resonate with our patients, it is easy to become bogged down with our own countertransference, sentiment, and worry, and to become consumed by our work. A professional hazard, some might quip.

Therefore, personal restoration—a tool that keeps our clinical skills sharp—is vitally important to caring for oneself and one’s patient. Surprisingly, this can be neglected until we begin to experience burnout, which over time could transform into impairment, thus endangering ourselves, our patients, and our profession.

Over the past decade, physician impairment has been exhaustively described, researched, and addressed. However, most analyses have focused on identifying impairment, and offering guidance on how to properly report it. How do we shift from managing the crisis to preventing it? To answer this question, this article:

• reviews the dilemma of physician impairment
• explores the duty we have to patients, ourselves, and the profession
• discusses shifting the focus on impairment to prevention through well-being.

Continue to: Dilemma

The cornerstone for well-being is a balanced life. No matter how much one loves his or her work, there must be balance between work, relationships, and hobbies. Without that equilibrium, everyone is put at risk.²

Just as our patients, we are not immune to mental illness, cognitive decline, or substance abuse.³ We might even be more susceptible. For many physicians, their identity is intimately tied to their work.⁴ Dr. Robin Weiss captured that intimate relationship⁵:

“… [A] therapist may spend hundreds of hours, perhaps more than a thousand, hearing about a patient’s most exalted aspirations and most murderous, hateful fantasies. During this time, the patient may endure excruciating losses, unbearable shame, bitter sadness and great triumphs. You may accompany patients through torturous adolescence into adulthood. Or you may meet them in middle age and be with them as they age and eventually die. You collaborate in a deep process of discovery. Few encounters are this deeply honest, and therefore intimate.”

Given the stories we hear and the resulting intimacy and countertransference that inevitably arise, psychiatrists are even more prone to burnout than other physicians.⁶ Physician impairment is a public health issue that affects not just physicians but also their families, colleagues, and patients.

“Impairment” for the purpose of this article means a physical, mental, or substance-related disorder that interferes with a physician’s ability to undertake professional activities competently and safely.⁷ Predisposing factors for physician impairment include an obsessive-compulsive personality type, a family history of mental illness, sensation-seeking behavior, denial of personal problems, perfectionism, and idealism.^8,9 Also, work stress becomes a significant factor in already vulnerable physicians, leading to a greater risk for mental illness.¹⁰

Continue to: Some warning signs of impairment include...

Duty: To ourselves, our colleagues, and our patients

There has been much discussion on how to report impaired colleagues, but little on how to help and support ourselves and our colleagues before things escalate into serious problems. And this lack of discussion is at the detriment of individual practitioners, their families, and patients. Physicians-in-training, including psychiatric residents, are at particularly high risk for developing stress-related problems, depression, and substance misuse.¹² Occupational demands, self-criticism, and denial of one’s distress are common among physicians, as is self-treatment with drugs and alcohol.¹³

We all know by now that doctors and physician health programs (PHPs) have a duty to report impaired colleagues who continue to practice despite reasonable offers of assistance. There are an abundance of PHPs that are in place to assist with such situations. The American Medical Association’s official position on reporting impairment is outlined in Policy H-275.952.⁷ There also is the Federation of State Medical Boards. Its policy states that PHPs have “a primary commitment to [help] state medical boards … protect the public … [These] programs [should] demonstrate an ongoing track of record of ensuring safety to the public and reveal deficiencies if they occur.”¹⁴

Legal and ethical issues, however, complicate interventions for colleagues who need assistance.¹⁵ Despite the existence of PHPs, it would be much easier—not to mention helpful—to help a colleague by carrying out early interventions.

Discussion: Prevention as a solution

More emphasis should be placed on prevention. That’s where self-care and well-being come into play. Awareness of and sensitivity to physician vulnerability, early detection, and prevention of impairment are important.

Continue to: There has been a paradigm shift in focus...

There has been a paradigm shift in focus across medical boards, professional societies, and medical colleges. They are recognizing that personal well-being can help prevent burnout and, in turn, change the landscape of medicine from endless work to balanced lives that yield more satisfying and joyful work. It is becoming an accepted fact in medicine that well-being is just as important as integrity, professionalism, and patient safety. For example, the American Academy of Medical Colleges (AAMC) issued a statement emphasizing the importance of clinician well-being and dedicated its June 2016 Leadership Forum to a range of topics addressing depression, resilience, burnout, and suicide in academic medicine.¹⁶

Anita Everett, MD, put the spotlight on physician well-being during her term as American Psychiatric Association President (2017 to 2018). She formed a specific workgroup on Physician Wellness and Burnout where there is a community focus on prevention and self-care.¹⁷ A strong sense of community and purpose is almost always part of the prescription for promoting greater well-being.²

The importance of this issue is also trickling down from policymakers into hospitals and community health centers. Consider an initiative at Minneapolis’s Hennepin County Medical Center. Leaders there created a “reset room” for physicians to quietly decompress. The room is complete with LED lights, flameless candles, a sound machine, comfortable chairs, several plants, and an “in use” sign on the door.¹⁸ Other personal strategies to help prevent burnout include making environmental changes, encouraging hobbies, and streamlining burdensome tasks such as paperwork and electronic medical record systems.

As physician health and well-being are finally emerging as a “hot topic,”² educational and treatment resources are increasingly available for any of us to explore. Consider a simple Google search to look into your State’s PHPs, and get involved in your professional societies to make change.

The culture is starting to shift, and leading by example will be a key to propelling further progress in this area. Model our own self-care for colleagues and patients alike. As Mark Twain said, we might love our work, but we must remember that being solely defined by work comes to the detriment of our health. Maintaining balance is what will allow us to sustain long careers ahead doing what we love.

Psychiatry is a field of passion. The reward of experiencing growth and change alongside our patients is what bolsters us through years of difficult training, overnight shifts, endless paperwork, regulatory mandates, and frequent worry about our patients. As physicians, we don’t live for weekends as many other professionals do. To the contrary, we spend them on call, moonlighting, laboring over journal articles, and perfecting lectures.

That passion is what makes us trusted clinicians and experts in our field. It can also make it difficult for us to disconnect from our work, frequently leading to burnout. Physician self-care, support, and professional development are critical topics that modern-day medicine minimizes at the peril of physicians and public health.¹

Psychiatry lends itself to a deep and intimate understanding of another human being. The therapist delves into the lives of his or her patients, hears their stories, and holds their secrets. In some cases, we might be the only ones who truly see patients for who they uniquely are, and come to understand them on a deeper level than their closest family and friends. This can be both thrilling and intense. As we delve into the psyche of another individual, contemplate which interpretation we should share, and resonate with our patients, it is easy to become bogged down with our own countertransference, sentiment, and worry, and to become consumed by our work. A professional hazard, some might quip.

Therefore, personal restoration—a tool that keeps our clinical skills sharp—is vitally important to caring for oneself and one’s patient. Surprisingly, this can be neglected until we begin to experience burnout, which over time could transform into impairment, thus endangering ourselves, our patients, and our profession.

Over the past decade, physician impairment has been exhaustively described, researched, and addressed. However, most analyses have focused on identifying impairment, and offering guidance on how to properly report it. How do we shift from managing the crisis to preventing it? To answer this question, this article:

• reviews the dilemma of physician impairment
• explores the duty we have to patients, ourselves, and the profession
• discusses shifting the focus on impairment to prevention through well-being.

Continue to: Dilemma

The cornerstone for well-being is a balanced life. No matter how much one loves his or her work, there must be balance between work, relationships, and hobbies. Without that equilibrium, everyone is put at risk.²

Just as our patients, we are not immune to mental illness, cognitive decline, or substance abuse.³ We might even be more susceptible. For many physicians, their identity is intimately tied to their work.⁴ Dr. Robin Weiss captured that intimate relationship⁵:

“… [A] therapist may spend hundreds of hours, perhaps more than a thousand, hearing about a patient’s most exalted aspirations and most murderous, hateful fantasies. During this time, the patient may endure excruciating losses, unbearable shame, bitter sadness and great triumphs. You may accompany patients through torturous adolescence into adulthood. Or you may meet them in middle age and be with them as they age and eventually die. You collaborate in a deep process of discovery. Few encounters are this deeply honest, and therefore intimate.”

Given the stories we hear and the resulting intimacy and countertransference that inevitably arise, psychiatrists are even more prone to burnout than other physicians.⁶ Physician impairment is a public health issue that affects not just physicians but also their families, colleagues, and patients.

“Impairment” for the purpose of this article means a physical, mental, or substance-related disorder that interferes with a physician’s ability to undertake professional activities competently and safely.⁷ Predisposing factors for physician impairment include an obsessive-compulsive personality type, a family history of mental illness, sensation-seeking behavior, denial of personal problems, perfectionism, and idealism.^8,9 Also, work stress becomes a significant factor in already vulnerable physicians, leading to a greater risk for mental illness.¹⁰

Continue to: Some warning signs of impairment include...

Duty: To ourselves, our colleagues, and our patients

There has been much discussion on how to report impaired colleagues, but little on how to help and support ourselves and our colleagues before things escalate into serious problems. And this lack of discussion is at the detriment of individual practitioners, their families, and patients. Physicians-in-training, including psychiatric residents, are at particularly high risk for developing stress-related problems, depression, and substance misuse.¹² Occupational demands, self-criticism, and denial of one’s distress are common among physicians, as is self-treatment with drugs and alcohol.¹³

We all know by now that doctors and physician health programs (PHPs) have a duty to report impaired colleagues who continue to practice despite reasonable offers of assistance. There are an abundance of PHPs that are in place to assist with such situations. The American Medical Association’s official position on reporting impairment is outlined in Policy H-275.952.⁷ There also is the Federation of State Medical Boards. Its policy states that PHPs have “a primary commitment to [help] state medical boards … protect the public … [These] programs [should] demonstrate an ongoing track of record of ensuring safety to the public and reveal deficiencies if they occur.”¹⁴

Legal and ethical issues, however, complicate interventions for colleagues who need assistance.¹⁵ Despite the existence of PHPs, it would be much easier—not to mention helpful—to help a colleague by carrying out early interventions.

Discussion: Prevention as a solution

More emphasis should be placed on prevention. That’s where self-care and well-being come into play. Awareness of and sensitivity to physician vulnerability, early detection, and prevention of impairment are important.

Continue to: There has been a paradigm shift in focus...

There has been a paradigm shift in focus across medical boards, professional societies, and medical colleges. They are recognizing that personal well-being can help prevent burnout and, in turn, change the landscape of medicine from endless work to balanced lives that yield more satisfying and joyful work. It is becoming an accepted fact in medicine that well-being is just as important as integrity, professionalism, and patient safety. For example, the American Academy of Medical Colleges (AAMC) issued a statement emphasizing the importance of clinician well-being and dedicated its June 2016 Leadership Forum to a range of topics addressing depression, resilience, burnout, and suicide in academic medicine.¹⁶

Anita Everett, MD, put the spotlight on physician well-being during her term as American Psychiatric Association President (2017 to 2018). She formed a specific workgroup on Physician Wellness and Burnout where there is a community focus on prevention and self-care.¹⁷ A strong sense of community and purpose is almost always part of the prescription for promoting greater well-being.²

The importance of this issue is also trickling down from policymakers into hospitals and community health centers. Consider an initiative at Minneapolis’s Hennepin County Medical Center. Leaders there created a “reset room” for physicians to quietly decompress. The room is complete with LED lights, flameless candles, a sound machine, comfortable chairs, several plants, and an “in use” sign on the door.¹⁸ Other personal strategies to help prevent burnout include making environmental changes, encouraging hobbies, and streamlining burdensome tasks such as paperwork and electronic medical record systems.

As physician health and well-being are finally emerging as a “hot topic,”² educational and treatment resources are increasingly available for any of us to explore. Consider a simple Google search to look into your State’s PHPs, and get involved in your professional societies to make change.

The culture is starting to shift, and leading by example will be a key to propelling further progress in this area. Model our own self-care for colleagues and patients alike. As Mark Twain said, we might love our work, but we must remember that being solely defined by work comes to the detriment of our health. Maintaining balance is what will allow us to sustain long careers ahead doing what we love.

Sexual harassment hit a peak of cultural awareness over the past year. Will medicine be the next field to experience a reckoning?

In 2017, Time magazine’s Person of the Year Award went to the Silence Breakers who spoke out against sexual assault and harassment.¹ The exposure of predatory behavior exhibited by once-celebrated movie producers, newscasters, and actors has given rise to a powerful change. The #MeToo movement has risen to support survivors and end sexual violence.

Just like show business, other industries have rich histories of discrimination and power. Think Wall Street, Silicon Valley, hospitality services, and the list goes on and on.² But what about medicine? To answer this question, this article aims to:

• review the dilemma
• explore our duty to our patients and each other
• discuss solutions to address the problem.

Sexual harassment: A brief history

Decades ago, Anita Hill accused U.S. Supreme Court nominee Clarence Thomas, her boss at the U.S. Department of Education and the Equal Employment Opportunity Commission (EEOC), of sexual harassment.³

The year was 1991, and President George H. W. Bush had nominated Thomas, a federal Circuit Judge, to succeed retiring Associate Supreme Court Justice Thurgood Marshall. With Thomas’s good character presented as a primary qualification, he appeared to be a sure thing.

Continue to: That was until an FBI interview...

That was until an FBI interview of Hill was leaked to the press. Hill asserted that Thomas had sexually harassed her while he was her supervisor at the Department of Education and the EEOC.⁴ Heavily scrutinized for her choice to follow Thomas to a second job after he had already allegedly harassed her, Hill was in a conundrum shared by many women—putting up with abuse in exchange for a reputable position and the opportunity to fulfill a career ambition.

Hill is a trailblazer for women yearning to speak the truth, and she brought national attention to sexual harassment in the early 1990s. On December 16, 2017, the Commission on Sexual Harassment and Advancing Equality in the Workplace was formed. Hill was selected to lead the charge against sexual harassment in the entertainment industry.⁵

A forensic assessment of harassment

Hill’s courageous story is one of many touched upon in the 2016 book Because of Sex.⁶ Author Gillian Thomas, a senior staff attorney with the American Civil Liberties Union’s Women’s Rights Project, explores how Title VII of the Civil Rights Act of 1964 made it illegal to discriminate “because of sex.”

The field of forensic psychiatry has long been attentive to themes of sexual harassment and discrimination. The American Academy of Psychiatry and Law has a robust list of landmark cases thought to be especially important and significant for forensic psychiatry.⁷ This list includes cases brought forth by tenacious, yet ordinary women who used the law to advocate, and some have taken their fight all the way to the Supreme Court. Let’s consider 2 such cases:

Meritor Savings Bank, FSB v Vinson (1986).⁸ This was a U.S. labor law case. Michelle Vinson rose through the ranks at Meritor Savings Bank, only to be fired for excessive sick leave. She filed a Title VII suit against the bank. Vinson alleged that the bank was liable for sexual harassment perpetrated by its employee and vice president, Sidney Taylor. Vinson claimed that there had been 40 to 50 sexual encounters over 4 years, ranging from fondling to indecent exposure to rape. Vinson asserted that she never reported these events for fear of losing her job. The Supreme Court, in a 9-to-0 decision, recognized sexual harassment as a violation of Title VII of the Civil Rights Act of 1964.

Continue to: Harris v Forklift Systems, Inc. (1993)

Harris v Forklift Systems, Inc. (1993).⁹ Teresa Harris, a manager at Forklift Systems, Inc., claimed that the company’s president frequently directed offensive remarks at her that were sexual and discriminatory. The Supreme Court clarified the definition of a “hostile” or “abusive” work environment under Title VII of the Civil Rights Act of 1964. Associate Justice Sandra Day O’Connor was joined by a unanimous majority opinion in agreement with Harris.

Physicians are not immune

Clinicians are affected by sexual harassment, too. We have a duty to protect our patients, colleagues, and ourselves. Psychiatrists in particular often are on the frontlines of helping victims process their trauma.¹⁰

But will the field of medicine also face a reckoning when it comes to perpetrating harassment? It seems likely that the medical field would be ripe with harassment when you consider its history of male domination and a hierarchical structure with strong power differentials—not to mention the late nights, exhaustion, easy access to beds, and late-night encounters where inhibitions may be lowered.¹¹

A shocking number of female doctors are sexually harassed. Thirty percent of the top female clinician-researchers have experienced blatant sexual harassment on the job, according to a survey of 573 men and 493 women who received career development awards from the National Institutes of Health in 2006 to 2009.¹² In this survey, harassment covered the scope of sexist remarks or behavior, unwanted sexual advances, bribery, threats, and coercion. The majority of those affected said the experience undermined their confidence as professionals, and many said the harassment negatively affected their career advancement.¹²

Continue to: But what about the progress women have made...

But what about the progress women have made in medicine? Women are surpassing men in terms of admittance to medical school. Last year, for the first time, women accounted for more than half of the enrollees in U.S. medical schools, according to the Association of American Medical Colleges.¹³ Yet there has been a stalling in terms of change when it comes to harassment.¹² Women may be more vulnerable to harassment, both when they’re perceived as weak and when they’re so strong that they challenge traditional hierarchies.

Perpetuating the problem is the trouble with reporting sexual harassment. Victims do not fare well in our society. Even in the #MeToo era, reporting such behavior is far from straightforward.¹¹ Women fear that reporting any harassment will make them a target. Think of Anita Hill—her testimony against Clarence Thomas during his confirmation hearings for the Supreme Court showed that women who report sexual harassment experience marginalization, retaliation, stigmatization, and worse.

The result is that medical professionals tend to suppress the recognition of harassment. We make excuses for it, blame ourselves, or just take it on the chin and move on. There’s also confusion regarding what constitutes harassment. As doctors, especially psychiatrists, we hear harrowing stories. It’s reasonable to downplay our own experiences. Turning everyone into a victim of sexual harassment could detract from the stories of women who were raped, molested, and severely taken advantage of. There is a reasonable fear that diluting their message could be further damaging.¹⁴

Time for action

The field of medicine needs to do better in terms of education, support, anticipation, prevention, and reaction to harassment. We have the awareness. Now, we need action.

Continue to: One way to change any culture...

One way to change any culture of harassment or discrimination would be the advancement of more female physicians into leadership positions. The Association of American Medical Colleges has reported that fewer women than men hold faculty positions and full professorships.^15,16 There’s also a striking imbalance among fields of medicine practiced by men and women, with more women seen in pediatrics, obstetrics, and gynecology as opposed to surgery. Advancement into policy-setting echelons of medicine is essential for change. Sexual harassment can be a silent problem that will be corrected only when institutions and leaders put it on the forefront of discussions.¹⁷

Another possible solution would be to shift problem-solving from punishment to prevention. Many institutions set expectations about intolerance of sexual harassment and conduct occasional lectures about it. However, enforcing protocols and safeguards that support and enforce policy are difficult on the ground level. In any event, punishment alone won’t change a culture.¹⁷

Working with students until they are comfortable disclosing details of incidents can be helpful. For example, the University of Wisconsin-Madison employs an ombuds to help with this process.¹⁸ All institutions should encourage reporting along confidential pathways and have multiple ways to report.¹⁷ Tracking complaints, even seemingly minor infractions, can help identify patterns of behavior and anticipate future incidents.

Some solutions seem obvious, such as informal and retaliation-free reporting that allows institutions to track perpetrators’ behavior; mandatory training that includes bystander training; and disciplining and monitoring transgressors and terminating their employment when appropriate—something along the lines of a zero-tolerance policy. There needs to be more research on the prevalence, severity, and outcomes of sexual harassment, and subsequent investigations, along with research into evidence-based prevention and intervention strategies.¹⁷

Continue to: Although this article focuses...

Although this article focuses on harassment of women, men are equally important to this conversation because they, too, can be victims. Men also can serve a pivotal role in mentoring and championing their female counterparts as they strive for advancement, equality, and respect.

The task ahead is large, and this discussion is not over.

Sexual harassment hit a peak of cultural awareness over the past year. Will medicine be the next field to experience a reckoning?

In 2017, Time magazine’s Person of the Year Award went to the Silence Breakers who spoke out against sexual assault and harassment.¹ The exposure of predatory behavior exhibited by once-celebrated movie producers, newscasters, and actors has given rise to a powerful change. The #MeToo movement has risen to support survivors and end sexual violence.

Just like show business, other industries have rich histories of discrimination and power. Think Wall Street, Silicon Valley, hospitality services, and the list goes on and on.² But what about medicine? To answer this question, this article aims to:

• review the dilemma
• explore our duty to our patients and each other
• discuss solutions to address the problem.

Sexual harassment: A brief history

Decades ago, Anita Hill accused U.S. Supreme Court nominee Clarence Thomas, her boss at the U.S. Department of Education and the Equal Employment Opportunity Commission (EEOC), of sexual harassment.³

The year was 1991, and President George H. W. Bush had nominated Thomas, a federal Circuit Judge, to succeed retiring Associate Supreme Court Justice Thurgood Marshall. With Thomas’s good character presented as a primary qualification, he appeared to be a sure thing.

Continue to: That was until an FBI interview...

That was until an FBI interview of Hill was leaked to the press. Hill asserted that Thomas had sexually harassed her while he was her supervisor at the Department of Education and the EEOC.⁴ Heavily scrutinized for her choice to follow Thomas to a second job after he had already allegedly harassed her, Hill was in a conundrum shared by many women—putting up with abuse in exchange for a reputable position and the opportunity to fulfill a career ambition.

Hill is a trailblazer for women yearning to speak the truth, and she brought national attention to sexual harassment in the early 1990s. On December 16, 2017, the Commission on Sexual Harassment and Advancing Equality in the Workplace was formed. Hill was selected to lead the charge against sexual harassment in the entertainment industry.⁵

A forensic assessment of harassment

Hill’s courageous story is one of many touched upon in the 2016 book Because of Sex.⁶ Author Gillian Thomas, a senior staff attorney with the American Civil Liberties Union’s Women’s Rights Project, explores how Title VII of the Civil Rights Act of 1964 made it illegal to discriminate “because of sex.”

The field of forensic psychiatry has long been attentive to themes of sexual harassment and discrimination. The American Academy of Psychiatry and Law has a robust list of landmark cases thought to be especially important and significant for forensic psychiatry.⁷ This list includes cases brought forth by tenacious, yet ordinary women who used the law to advocate, and some have taken their fight all the way to the Supreme Court. Let’s consider 2 such cases:

Meritor Savings Bank, FSB v Vinson (1986).⁸ This was a U.S. labor law case. Michelle Vinson rose through the ranks at Meritor Savings Bank, only to be fired for excessive sick leave. She filed a Title VII suit against the bank. Vinson alleged that the bank was liable for sexual harassment perpetrated by its employee and vice president, Sidney Taylor. Vinson claimed that there had been 40 to 50 sexual encounters over 4 years, ranging from fondling to indecent exposure to rape. Vinson asserted that she never reported these events for fear of losing her job. The Supreme Court, in a 9-to-0 decision, recognized sexual harassment as a violation of Title VII of the Civil Rights Act of 1964.

Continue to: Harris v Forklift Systems, Inc. (1993)

Harris v Forklift Systems, Inc. (1993).⁹ Teresa Harris, a manager at Forklift Systems, Inc., claimed that the company’s president frequently directed offensive remarks at her that were sexual and discriminatory. The Supreme Court clarified the definition of a “hostile” or “abusive” work environment under Title VII of the Civil Rights Act of 1964. Associate Justice Sandra Day O’Connor was joined by a unanimous majority opinion in agreement with Harris.

Physicians are not immune

Clinicians are affected by sexual harassment, too. We have a duty to protect our patients, colleagues, and ourselves. Psychiatrists in particular often are on the frontlines of helping victims process their trauma.¹⁰

But will the field of medicine also face a reckoning when it comes to perpetrating harassment? It seems likely that the medical field would be ripe with harassment when you consider its history of male domination and a hierarchical structure with strong power differentials—not to mention the late nights, exhaustion, easy access to beds, and late-night encounters where inhibitions may be lowered.¹¹

A shocking number of female doctors are sexually harassed. Thirty percent of the top female clinician-researchers have experienced blatant sexual harassment on the job, according to a survey of 573 men and 493 women who received career development awards from the National Institutes of Health in 2006 to 2009.¹² In this survey, harassment covered the scope of sexist remarks or behavior, unwanted sexual advances, bribery, threats, and coercion. The majority of those affected said the experience undermined their confidence as professionals, and many said the harassment negatively affected their career advancement.¹²

Continue to: But what about the progress women have made...

But what about the progress women have made in medicine? Women are surpassing men in terms of admittance to medical school. Last year, for the first time, women accounted for more than half of the enrollees in U.S. medical schools, according to the Association of American Medical Colleges.¹³ Yet there has been a stalling in terms of change when it comes to harassment.¹² Women may be more vulnerable to harassment, both when they’re perceived as weak and when they’re so strong that they challenge traditional hierarchies.

Perpetuating the problem is the trouble with reporting sexual harassment. Victims do not fare well in our society. Even in the #MeToo era, reporting such behavior is far from straightforward.¹¹ Women fear that reporting any harassment will make them a target. Think of Anita Hill—her testimony against Clarence Thomas during his confirmation hearings for the Supreme Court showed that women who report sexual harassment experience marginalization, retaliation, stigmatization, and worse.

The result is that medical professionals tend to suppress the recognition of harassment. We make excuses for it, blame ourselves, or just take it on the chin and move on. There’s also confusion regarding what constitutes harassment. As doctors, especially psychiatrists, we hear harrowing stories. It’s reasonable to downplay our own experiences. Turning everyone into a victim of sexual harassment could detract from the stories of women who were raped, molested, and severely taken advantage of. There is a reasonable fear that diluting their message could be further damaging.¹⁴

Time for action

The field of medicine needs to do better in terms of education, support, anticipation, prevention, and reaction to harassment. We have the awareness. Now, we need action.

Continue to: One way to change any culture...

One way to change any culture of harassment or discrimination would be the advancement of more female physicians into leadership positions. The Association of American Medical Colleges has reported that fewer women than men hold faculty positions and full professorships.^15,16 There’s also a striking imbalance among fields of medicine practiced by men and women, with more women seen in pediatrics, obstetrics, and gynecology as opposed to surgery. Advancement into policy-setting echelons of medicine is essential for change. Sexual harassment can be a silent problem that will be corrected only when institutions and leaders put it on the forefront of discussions.¹⁷

Another possible solution would be to shift problem-solving from punishment to prevention. Many institutions set expectations about intolerance of sexual harassment and conduct occasional lectures about it. However, enforcing protocols and safeguards that support and enforce policy are difficult on the ground level. In any event, punishment alone won’t change a culture.¹⁷

Working with students until they are comfortable disclosing details of incidents can be helpful. For example, the University of Wisconsin-Madison employs an ombuds to help with this process.¹⁸ All institutions should encourage reporting along confidential pathways and have multiple ways to report.¹⁷ Tracking complaints, even seemingly minor infractions, can help identify patterns of behavior and anticipate future incidents.

Some solutions seem obvious, such as informal and retaliation-free reporting that allows institutions to track perpetrators’ behavior; mandatory training that includes bystander training; and disciplining and monitoring transgressors and terminating their employment when appropriate—something along the lines of a zero-tolerance policy. There needs to be more research on the prevalence, severity, and outcomes of sexual harassment, and subsequent investigations, along with research into evidence-based prevention and intervention strategies.¹⁷

Continue to: Although this article focuses...

Although this article focuses on harassment of women, men are equally important to this conversation because they, too, can be victims. Men also can serve a pivotal role in mentoring and championing their female counterparts as they strive for advancement, equality, and respect.

The task ahead is large, and this discussion is not over.

Sexual harassment hit a peak of cultural awareness over the past year. Will medicine be the next field to experience a reckoning?

In 2017, Time magazine’s Person of the Year Award went to the Silence Breakers who spoke out against sexual assault and harassment.¹ The exposure of predatory behavior exhibited by once-celebrated movie producers, newscasters, and actors has given rise to a powerful change. The #MeToo movement has risen to support survivors and end sexual violence.

Just like show business, other industries have rich histories of discrimination and power. Think Wall Street, Silicon Valley, hospitality services, and the list goes on and on.² But what about medicine? To answer this question, this article aims to:

• review the dilemma
• explore our duty to our patients and each other
• discuss solutions to address the problem.

Sexual harassment: A brief history

Decades ago, Anita Hill accused U.S. Supreme Court nominee Clarence Thomas, her boss at the U.S. Department of Education and the Equal Employment Opportunity Commission (EEOC), of sexual harassment.³

The year was 1991, and President George H. W. Bush had nominated Thomas, a federal Circuit Judge, to succeed retiring Associate Supreme Court Justice Thurgood Marshall. With Thomas’s good character presented as a primary qualification, he appeared to be a sure thing.

Continue to: That was until an FBI interview...

That was until an FBI interview of Hill was leaked to the press. Hill asserted that Thomas had sexually harassed her while he was her supervisor at the Department of Education and the EEOC.⁴ Heavily scrutinized for her choice to follow Thomas to a second job after he had already allegedly harassed her, Hill was in a conundrum shared by many women—putting up with abuse in exchange for a reputable position and the opportunity to fulfill a career ambition.

Hill is a trailblazer for women yearning to speak the truth, and she brought national attention to sexual harassment in the early 1990s. On December 16, 2017, the Commission on Sexual Harassment and Advancing Equality in the Workplace was formed. Hill was selected to lead the charge against sexual harassment in the entertainment industry.⁵

A forensic assessment of harassment

Hill’s courageous story is one of many touched upon in the 2016 book Because of Sex.⁶ Author Gillian Thomas, a senior staff attorney with the American Civil Liberties Union’s Women’s Rights Project, explores how Title VII of the Civil Rights Act of 1964 made it illegal to discriminate “because of sex.”

The field of forensic psychiatry has long been attentive to themes of sexual harassment and discrimination. The American Academy of Psychiatry and Law has a robust list of landmark cases thought to be especially important and significant for forensic psychiatry.⁷ This list includes cases brought forth by tenacious, yet ordinary women who used the law to advocate, and some have taken their fight all the way to the Supreme Court. Let’s consider 2 such cases:

Meritor Savings Bank, FSB v Vinson (1986).⁸ This was a U.S. labor law case. Michelle Vinson rose through the ranks at Meritor Savings Bank, only to be fired for excessive sick leave. She filed a Title VII suit against the bank. Vinson alleged that the bank was liable for sexual harassment perpetrated by its employee and vice president, Sidney Taylor. Vinson claimed that there had been 40 to 50 sexual encounters over 4 years, ranging from fondling to indecent exposure to rape. Vinson asserted that she never reported these events for fear of losing her job. The Supreme Court, in a 9-to-0 decision, recognized sexual harassment as a violation of Title VII of the Civil Rights Act of 1964.

Continue to: Harris v Forklift Systems, Inc. (1993)

Harris v Forklift Systems, Inc. (1993).⁹ Teresa Harris, a manager at Forklift Systems, Inc., claimed that the company’s president frequently directed offensive remarks at her that were sexual and discriminatory. The Supreme Court clarified the definition of a “hostile” or “abusive” work environment under Title VII of the Civil Rights Act of 1964. Associate Justice Sandra Day O’Connor was joined by a unanimous majority opinion in agreement with Harris.

Physicians are not immune

Clinicians are affected by sexual harassment, too. We have a duty to protect our patients, colleagues, and ourselves. Psychiatrists in particular often are on the frontlines of helping victims process their trauma.¹⁰

But will the field of medicine also face a reckoning when it comes to perpetrating harassment? It seems likely that the medical field would be ripe with harassment when you consider its history of male domination and a hierarchical structure with strong power differentials—not to mention the late nights, exhaustion, easy access to beds, and late-night encounters where inhibitions may be lowered.¹¹

A shocking number of female doctors are sexually harassed. Thirty percent of the top female clinician-researchers have experienced blatant sexual harassment on the job, according to a survey of 573 men and 493 women who received career development awards from the National Institutes of Health in 2006 to 2009.¹² In this survey, harassment covered the scope of sexist remarks or behavior, unwanted sexual advances, bribery, threats, and coercion. The majority of those affected said the experience undermined their confidence as professionals, and many said the harassment negatively affected their career advancement.¹²

Continue to: But what about the progress women have made...

But what about the progress women have made in medicine? Women are surpassing men in terms of admittance to medical school. Last year, for the first time, women accounted for more than half of the enrollees in U.S. medical schools, according to the Association of American Medical Colleges.¹³ Yet there has been a stalling in terms of change when it comes to harassment.¹² Women may be more vulnerable to harassment, both when they’re perceived as weak and when they’re so strong that they challenge traditional hierarchies.

Perpetuating the problem is the trouble with reporting sexual harassment. Victims do not fare well in our society. Even in the #MeToo era, reporting such behavior is far from straightforward.¹¹ Women fear that reporting any harassment will make them a target. Think of Anita Hill—her testimony against Clarence Thomas during his confirmation hearings for the Supreme Court showed that women who report sexual harassment experience marginalization, retaliation, stigmatization, and worse.

The result is that medical professionals tend to suppress the recognition of harassment. We make excuses for it, blame ourselves, or just take it on the chin and move on. There’s also confusion regarding what constitutes harassment. As doctors, especially psychiatrists, we hear harrowing stories. It’s reasonable to downplay our own experiences. Turning everyone into a victim of sexual harassment could detract from the stories of women who were raped, molested, and severely taken advantage of. There is a reasonable fear that diluting their message could be further damaging.¹⁴

Time for action

The field of medicine needs to do better in terms of education, support, anticipation, prevention, and reaction to harassment. We have the awareness. Now, we need action.

Continue to: One way to change any culture...

One way to change any culture of harassment or discrimination would be the advancement of more female physicians into leadership positions. The Association of American Medical Colleges has reported that fewer women than men hold faculty positions and full professorships.^15,16 There’s also a striking imbalance among fields of medicine practiced by men and women, with more women seen in pediatrics, obstetrics, and gynecology as opposed to surgery. Advancement into policy-setting echelons of medicine is essential for change. Sexual harassment can be a silent problem that will be corrected only when institutions and leaders put it on the forefront of discussions.¹⁷

Another possible solution would be to shift problem-solving from punishment to prevention. Many institutions set expectations about intolerance of sexual harassment and conduct occasional lectures about it. However, enforcing protocols and safeguards that support and enforce policy are difficult on the ground level. In any event, punishment alone won’t change a culture.¹⁷

Working with students until they are comfortable disclosing details of incidents can be helpful. For example, the University of Wisconsin-Madison employs an ombuds to help with this process.¹⁸ All institutions should encourage reporting along confidential pathways and have multiple ways to report.¹⁷ Tracking complaints, even seemingly minor infractions, can help identify patterns of behavior and anticipate future incidents.

Some solutions seem obvious, such as informal and retaliation-free reporting that allows institutions to track perpetrators’ behavior; mandatory training that includes bystander training; and disciplining and monitoring transgressors and terminating their employment when appropriate—something along the lines of a zero-tolerance policy. There needs to be more research on the prevalence, severity, and outcomes of sexual harassment, and subsequent investigations, along with research into evidence-based prevention and intervention strategies.¹⁷

Continue to: Although this article focuses...

Although this article focuses on harassment of women, men are equally important to this conversation because they, too, can be victims. Men also can serve a pivotal role in mentoring and championing their female counterparts as they strive for advancement, equality, and respect.

The task ahead is large, and this discussion is not over.

“It is beyond a doubt that all our knowledge begins with experience.”
- Immanuel Kant

Medicine, a highly experiential profession, is constantly evolving. The consistency of change and the psychiatrist’s inherent wonder offers a paradoxical sense of comfort and conundrum.

As students, we look to our predecessors, associations, and peers to master concepts both concrete and abstract. And once we achieve competence at understanding mechanisms, applying biopsychosocial formulations, and effectively teaching what we’ve learned—everything changes!

We journey through a new era of medicine together. With burgeoning technology, intense politics, and confounding social media, we are undergoing new applications, hurdles to health care, and personal exposure to extremes that have never been experienced before. The landscape of psychiatric practice is changing. Its transformation inherently challenges our existing practices and standards.

It wasn’t too long ago that classroom fodder included how to deal with seeing your patient at a cocktail party. Contemporary discussions are more likely to address the patient who follows you on Twitter (and whom you follow back). Long ago are the days of educating students through a didactic model. Learning now occurs in collaborative group settings with a focus on the practical and hands-on experience. Budding psychiatrists are interested these days in talking about setting up their own apps, establishing a start-up company for health care, working on policy reform, and innovating new approaches to achieve social justice.

A history of challenge and change

Developing variables and expectations in this Millennial Age makes it an exciting time for psychiatrists to explore, adapt, and lead into the future. Fortunately, the field has had ample practice with challenge and changes. Social constructs of how individuals with mental illness were treated altered with William Battie, an English physician whose 1758 Treatise on Madness called for treatments to be utilized on rich and poor mental patients alike in asylums.¹ Remember the days of chaining patients to bedposts on psychiatric wards? Of course not! Such archaic practices thankfully disappeared, due in large part to French physician Philippe Pinel. Patient care has evolved to encompass empathy, rights, and dignity.²

German physician Johann Christian Reil, who coined the term “psychiatry” more than 200 years ago, asserted that mental illness should be treated by the most highly qualified physicians.³ Such thinking seems obvious in 2018, but before Reil, the mental and physical states were seen as unrelated.

Modern psychiatry has certainly come a long way.⁴ We recognize mental health as being essential to overall health. Medications have evolved beyond lithium, chlorpromazine, and fluoxetine. We now have quarterly injectable antipsychotics and pills that patients can swallow and actually be monitored by their clinicians!⁴

The American Psychiatric Association (APA) has published multiple iterations of the Diagnostic and Statistical Manual of Mental Disorders since its inception in 1968.⁵ And with those revisions have come changes that most contemporary colleagues could only describe as self-evident—such as the declassification of homosexuality as a mental disorder in 1973.

Despite these advances and the advent of the Mental Health Parity Act of 2008, experience has shown us that some things have seen little progress. Reil, who saw a nexus between mental and physical health, launched an anti-stigma campaign more than 200 years ago. This begs a question to colleagues: How far have we come? Or better yet, capitalizing on our knowledge, experience, and hopes: What else can we do?

The essential interaction between mental, chemical, and physical domains has given rise to psychiatry and its many subspecialties. Among them is forensic psychiatry, which deals with the overlap of mental health and legal matters.⁶

While often recognized for its relation to criminology, forensic psychiatry encompasses the entirety of legal mental health matters.⁷ These are things that the daily practitioner faces on a routine basis.

My mentor, Dr. Douglas Mossman, author of Current Psychiatry’s Malpractice Rx department, passed away on January 4, 2018. Dr. Mossman emphasized to his trainees that above all else, understanding forensic matters simply makes one a better psychiatrist. Legal matters and psychiatry go hand-in-hand. Involuntary hospitalization, Health Insurance Portability and Accountability Act violations, licensure boards, telepsychiatry, guardianship, and informed consent are just a few areas that psychiatrists interface with routinely.

A new department for a new era

The world is changing very rapidly, and we face new dilemmas in the midst of trying to uphold our duties to patients and the profession. There are emerging domains that psychiatrists will experience for the first time—leaving us with more questions than direction. And that is the impetus for this new department, Psychiatry 2.0.

The ever-evolving Internet opens doors for psychiatrists to access and educate a larger audience. It also provides a tool for psychiatrists to keep a web-based presence, something essential for competitive business practices to stay relevant. We are languishing in a political climate that challenges our sense of duty to the public, which often is in contrast with the ethical principles of our association. Technology also poses problems, whether it’s tracking our patients through the pills they ingest, following them on an app, or relying on data from wearable devices in lieu of a patient’s report. All of this suggests a potential for progress as well as problems.

The goal of Psychiatry 2.0 is to experience new challenges together. As Department Editor, I will cover an array of cutting-edge and controversial topics. Continuing with Dr. Mossman’s teachings—that forensic understanding enhances the clinical practice—this department will routinely combine evidence-based information with legal concepts.

Each article in Psychiatry 2.0 will be divided into 3 parts, focusing on a clinician’s dilemma, a duty, and a discussion. The dilemma will be relatable to the clinician in everyday practice. A practical and evidence-based approach will be taken to expound upon our duty as physicians. And finally, there will be discussion about where the field is going, and how it will likely change. In its quarterly publication, Psychiatry 2.0 will explore a diverse range of topics, including technology, social media, stigma, social justice, and politics.

In my role as Department Editor, I find myself already reflecting on the experience, wisdom, compassion, encouragement, and legacy of Dr. Mossman. A distinguished psychiatrist, gifted musician, and inspiring mentor and academician, Dr. Mossman embodied knowledge, creativity, and devotion.

Among Dr. Mossman’s many accolades, including more than 180 authored publications, he was recipient of the Guttmacher Award (2008, the APA) and Golden Apple (2017, the American Academy of Psychiatry and Law). Dr. Mossman was further known to many as a mentor and friend. He was generous with his experiences as a highly accomplished physician and thoughtful in his teachings and publications, leaving an enduring legacy.

Remembering Dr. Mossman’s sage voice and articulate writings will be essential to moving forward in this modern age of psychiatry, as we experience new dilemmas and opportunities.

“It is beyond a doubt that all our knowledge begins with experience.”
- Immanuel Kant

Medicine, a highly experiential profession, is constantly evolving. The consistency of change and the psychiatrist’s inherent wonder offers a paradoxical sense of comfort and conundrum.

As students, we look to our predecessors, associations, and peers to master concepts both concrete and abstract. And once we achieve competence at understanding mechanisms, applying biopsychosocial formulations, and effectively teaching what we’ve learned—everything changes!

We journey through a new era of medicine together. With burgeoning technology, intense politics, and confounding social media, we are undergoing new applications, hurdles to health care, and personal exposure to extremes that have never been experienced before. The landscape of psychiatric practice is changing. Its transformation inherently challenges our existing practices and standards.

It wasn’t too long ago that classroom fodder included how to deal with seeing your patient at a cocktail party. Contemporary discussions are more likely to address the patient who follows you on Twitter (and whom you follow back). Long ago are the days of educating students through a didactic model. Learning now occurs in collaborative group settings with a focus on the practical and hands-on experience. Budding psychiatrists are interested these days in talking about setting up their own apps, establishing a start-up company for health care, working on policy reform, and innovating new approaches to achieve social justice.

A history of challenge and change

Developing variables and expectations in this Millennial Age makes it an exciting time for psychiatrists to explore, adapt, and lead into the future. Fortunately, the field has had ample practice with challenge and changes. Social constructs of how individuals with mental illness were treated altered with William Battie, an English physician whose 1758 Treatise on Madness called for treatments to be utilized on rich and poor mental patients alike in asylums.¹ Remember the days of chaining patients to bedposts on psychiatric wards? Of course not! Such archaic practices thankfully disappeared, due in large part to French physician Philippe Pinel. Patient care has evolved to encompass empathy, rights, and dignity.²

German physician Johann Christian Reil, who coined the term “psychiatry” more than 200 years ago, asserted that mental illness should be treated by the most highly qualified physicians.³ Such thinking seems obvious in 2018, but before Reil, the mental and physical states were seen as unrelated.

Modern psychiatry has certainly come a long way.⁴ We recognize mental health as being essential to overall health. Medications have evolved beyond lithium, chlorpromazine, and fluoxetine. We now have quarterly injectable antipsychotics and pills that patients can swallow and actually be monitored by their clinicians!⁴

The American Psychiatric Association (APA) has published multiple iterations of the Diagnostic and Statistical Manual of Mental Disorders since its inception in 1968.⁵ And with those revisions have come changes that most contemporary colleagues could only describe as self-evident—such as the declassification of homosexuality as a mental disorder in 1973.

Despite these advances and the advent of the Mental Health Parity Act of 2008, experience has shown us that some things have seen little progress. Reil, who saw a nexus between mental and physical health, launched an anti-stigma campaign more than 200 years ago. This begs a question to colleagues: How far have we come? Or better yet, capitalizing on our knowledge, experience, and hopes: What else can we do?

The essential interaction between mental, chemical, and physical domains has given rise to psychiatry and its many subspecialties. Among them is forensic psychiatry, which deals with the overlap of mental health and legal matters.⁶

While often recognized for its relation to criminology, forensic psychiatry encompasses the entirety of legal mental health matters.⁷ These are things that the daily practitioner faces on a routine basis.

My mentor, Dr. Douglas Mossman, author of Current Psychiatry’s Malpractice Rx department, passed away on January 4, 2018. Dr. Mossman emphasized to his trainees that above all else, understanding forensic matters simply makes one a better psychiatrist. Legal matters and psychiatry go hand-in-hand. Involuntary hospitalization, Health Insurance Portability and Accountability Act violations, licensure boards, telepsychiatry, guardianship, and informed consent are just a few areas that psychiatrists interface with routinely.

A new department for a new era

The world is changing very rapidly, and we face new dilemmas in the midst of trying to uphold our duties to patients and the profession. There are emerging domains that psychiatrists will experience for the first time—leaving us with more questions than direction. And that is the impetus for this new department, Psychiatry 2.0.

The ever-evolving Internet opens doors for psychiatrists to access and educate a larger audience. It also provides a tool for psychiatrists to keep a web-based presence, something essential for competitive business practices to stay relevant. We are languishing in a political climate that challenges our sense of duty to the public, which often is in contrast with the ethical principles of our association. Technology also poses problems, whether it’s tracking our patients through the pills they ingest, following them on an app, or relying on data from wearable devices in lieu of a patient’s report. All of this suggests a potential for progress as well as problems.

The goal of Psychiatry 2.0 is to experience new challenges together. As Department Editor, I will cover an array of cutting-edge and controversial topics. Continuing with Dr. Mossman’s teachings—that forensic understanding enhances the clinical practice—this department will routinely combine evidence-based information with legal concepts.

Each article in Psychiatry 2.0 will be divided into 3 parts, focusing on a clinician’s dilemma, a duty, and a discussion. The dilemma will be relatable to the clinician in everyday practice. A practical and evidence-based approach will be taken to expound upon our duty as physicians. And finally, there will be discussion about where the field is going, and how it will likely change. In its quarterly publication, Psychiatry 2.0 will explore a diverse range of topics, including technology, social media, stigma, social justice, and politics.

In my role as Department Editor, I find myself already reflecting on the experience, wisdom, compassion, encouragement, and legacy of Dr. Mossman. A distinguished psychiatrist, gifted musician, and inspiring mentor and academician, Dr. Mossman embodied knowledge, creativity, and devotion.

Among Dr. Mossman’s many accolades, including more than 180 authored publications, he was recipient of the Guttmacher Award (2008, the APA) and Golden Apple (2017, the American Academy of Psychiatry and Law). Dr. Mossman was further known to many as a mentor and friend. He was generous with his experiences as a highly accomplished physician and thoughtful in his teachings and publications, leaving an enduring legacy.

Remembering Dr. Mossman’s sage voice and articulate writings will be essential to moving forward in this modern age of psychiatry, as we experience new dilemmas and opportunities.

“It is beyond a doubt that all our knowledge begins with experience.”
- Immanuel Kant

Medicine, a highly experiential profession, is constantly evolving. The consistency of change and the psychiatrist’s inherent wonder offers a paradoxical sense of comfort and conundrum.

As students, we look to our predecessors, associations, and peers to master concepts both concrete and abstract. And once we achieve competence at understanding mechanisms, applying biopsychosocial formulations, and effectively teaching what we’ve learned—everything changes!

We journey through a new era of medicine together. With burgeoning technology, intense politics, and confounding social media, we are undergoing new applications, hurdles to health care, and personal exposure to extremes that have never been experienced before. The landscape of psychiatric practice is changing. Its transformation inherently challenges our existing practices and standards.

It wasn’t too long ago that classroom fodder included how to deal with seeing your patient at a cocktail party. Contemporary discussions are more likely to address the patient who follows you on Twitter (and whom you follow back). Long ago are the days of educating students through a didactic model. Learning now occurs in collaborative group settings with a focus on the practical and hands-on experience. Budding psychiatrists are interested these days in talking about setting up their own apps, establishing a start-up company for health care, working on policy reform, and innovating new approaches to achieve social justice.

A history of challenge and change

Developing variables and expectations in this Millennial Age makes it an exciting time for psychiatrists to explore, adapt, and lead into the future. Fortunately, the field has had ample practice with challenge and changes. Social constructs of how individuals with mental illness were treated altered with William Battie, an English physician whose 1758 Treatise on Madness called for treatments to be utilized on rich and poor mental patients alike in asylums.¹ Remember the days of chaining patients to bedposts on psychiatric wards? Of course not! Such archaic practices thankfully disappeared, due in large part to French physician Philippe Pinel. Patient care has evolved to encompass empathy, rights, and dignity.²

German physician Johann Christian Reil, who coined the term “psychiatry” more than 200 years ago, asserted that mental illness should be treated by the most highly qualified physicians.³ Such thinking seems obvious in 2018, but before Reil, the mental and physical states were seen as unrelated.

Modern psychiatry has certainly come a long way.⁴ We recognize mental health as being essential to overall health. Medications have evolved beyond lithium, chlorpromazine, and fluoxetine. We now have quarterly injectable antipsychotics and pills that patients can swallow and actually be monitored by their clinicians!⁴

The American Psychiatric Association (APA) has published multiple iterations of the Diagnostic and Statistical Manual of Mental Disorders since its inception in 1968.⁵ And with those revisions have come changes that most contemporary colleagues could only describe as self-evident—such as the declassification of homosexuality as a mental disorder in 1973.

Despite these advances and the advent of the Mental Health Parity Act of 2008, experience has shown us that some things have seen little progress. Reil, who saw a nexus between mental and physical health, launched an anti-stigma campaign more than 200 years ago. This begs a question to colleagues: How far have we come? Or better yet, capitalizing on our knowledge, experience, and hopes: What else can we do?

The essential interaction between mental, chemical, and physical domains has given rise to psychiatry and its many subspecialties. Among them is forensic psychiatry, which deals with the overlap of mental health and legal matters.⁶

While often recognized for its relation to criminology, forensic psychiatry encompasses the entirety of legal mental health matters.⁷ These are things that the daily practitioner faces on a routine basis.

My mentor, Dr. Douglas Mossman, author of Current Psychiatry’s Malpractice Rx department, passed away on January 4, 2018. Dr. Mossman emphasized to his trainees that above all else, understanding forensic matters simply makes one a better psychiatrist. Legal matters and psychiatry go hand-in-hand. Involuntary hospitalization, Health Insurance Portability and Accountability Act violations, licensure boards, telepsychiatry, guardianship, and informed consent are just a few areas that psychiatrists interface with routinely.

A new department for a new era

The world is changing very rapidly, and we face new dilemmas in the midst of trying to uphold our duties to patients and the profession. There are emerging domains that psychiatrists will experience for the first time—leaving us with more questions than direction. And that is the impetus for this new department, Psychiatry 2.0.

The ever-evolving Internet opens doors for psychiatrists to access and educate a larger audience. It also provides a tool for psychiatrists to keep a web-based presence, something essential for competitive business practices to stay relevant. We are languishing in a political climate that challenges our sense of duty to the public, which often is in contrast with the ethical principles of our association. Technology also poses problems, whether it’s tracking our patients through the pills they ingest, following them on an app, or relying on data from wearable devices in lieu of a patient’s report. All of this suggests a potential for progress as well as problems.

The goal of Psychiatry 2.0 is to experience new challenges together. As Department Editor, I will cover an array of cutting-edge and controversial topics. Continuing with Dr. Mossman’s teachings—that forensic understanding enhances the clinical practice—this department will routinely combine evidence-based information with legal concepts.

Each article in Psychiatry 2.0 will be divided into 3 parts, focusing on a clinician’s dilemma, a duty, and a discussion. The dilemma will be relatable to the clinician in everyday practice. A practical and evidence-based approach will be taken to expound upon our duty as physicians. And finally, there will be discussion about where the field is going, and how it will likely change. In its quarterly publication, Psychiatry 2.0 will explore a diverse range of topics, including technology, social media, stigma, social justice, and politics.

In my role as Department Editor, I find myself already reflecting on the experience, wisdom, compassion, encouragement, and legacy of Dr. Mossman. A distinguished psychiatrist, gifted musician, and inspiring mentor and academician, Dr. Mossman embodied knowledge, creativity, and devotion.

Among Dr. Mossman’s many accolades, including more than 180 authored publications, he was recipient of the Guttmacher Award (2008, the APA) and Golden Apple (2017, the American Academy of Psychiatry and Law). Dr. Mossman was further known to many as a mentor and friend. He was generous with his experiences as a highly accomplished physician and thoughtful in his teachings and publications, leaving an enduring legacy.

Remembering Dr. Mossman’s sage voice and articulate writings will be essential to moving forward in this modern age of psychiatry, as we experience new dilemmas and opportunities.

Imagine you’re on call in a busy emergency department (ED) overnight. Things are tough. The consults are piling up, no one is returning your calls for collateral information, and you’re dealing with a myriad of emergencies.

In walks Mr. D, age 45, complaining of hearing voices, feeling unsafe, and asking for admission. It’s now 2 am. What would you do?

Of course, like all qualified psychiatrists, you will dig a little deeper, and in doing so you learn that Mr. D has visited this hospital before and has been admitted to the psychiatry unit. Now you go from having a dearth of information to having more records than you can count.

You discover that Mr. D has a history of coming to the ED during precarious hours, with similar complaints, demanding admission.

Mr. D, you learn, is unemployed, single, and homeless. Your meticulous search through his hospital records and previous admission and discharge notes reveal that once he has slept for a night, eaten a hot meal, and received narcotics for his back pain and benzodiazepines for his “symptoms” he demands to leave the hospital. His psychotic symptoms disappear despite his consistent refusal to take antipsychotics throughout his stay.

Now, what would you do?

As earnest medical students and psychiatrists, we enjoy helping patients on their path toward recovery. We want to advocate for our patients and give them the benefit of the doubt. We’re taught in medical school to be non-judgmental and invite patients to share their narrative. But through experience, we start to become aware of malingering.

Suspecting malingering, diagnosed as a condition, often is avoided by psychiatrists.¹ This makes sense—it goes against the essence of our training and imposes a pejorative label on someone who has reached out for help.

Often persons with mental illness will suffer for years until they to receive help.² That’s exactly why, when patients like Mr. D come to the ED and report hearing voices, we’re not likely to shout, “Liar!” and invite them to leave.

However, malingering is a real problem, especially because the number of psychiatric hospital beds have dwindled to record lows, thereby overcrowding EDs. Resources are skimpy, and clinicians want to help those who need it the most and not waste resources on someone who is “faking it” for secondary gain.

To navigate this diagnostic challenge, psychiatrists need the skills to detect malingering and the confidence to deal with it appropriately. This article aims to:

• define psychosis and malingering
• review the prevalence and historical considerations of malingering
• offer practical strategies to deal with malingering.

Clinicians first must have the clinical acumen and expertise to identify a true mental illness such as psychosis² (Table 1). The differential diagnosis for psychotic symptoms is broad. The astute clinician might suspect that untreated bipolar disorder or depression led to the emergence of perceptual disturbances or disordered thinking. Transient psychotic symptoms can be associated with trauma disorders, borderline personality disorder, and acute intoxication. Psychotic spectrum disorders range from brief psychosis to schizophreniform to schizoaffective disorder or schizophrenia.

Malingering—which is a condition, not a diagnosis—is characterized by the intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives.^3,4 The presence of external incentives differentiates malingering from true psychiatric disorders, including factitious disorder, somatoform disorder, and dissociative disorder, and specific medical conditions.¹ In those disorders, there is no external incentive.

It is important to remember that malingering can coexist with a serious mental illness. For example, a truly psychotic person might malinger, feign, or exaggerate symptoms to try to receive much needed help. Individuals with true psychosis might have become disenchanted with the mental health system, and thereby have a tendency to over-report or exaggerate symptoms in an effort to obtain treatment. This also could explain why many clinicians intuitively are reluctant to make the determination that someone is malingering. Malingering also can be present in an individual who has antisocial personality disorder, factitious disorder, Ganser syndrome, and Munchausen syndrome.⁴ When symptoms or diseases that either are thought to be exaggerated or do not exist, consider a diagnosis of malingering.

A key challenge in any discussion of abnormal health care–seeking behavior is the extent to which a person’s reported symptoms are considered to be a product of choice, psychopathology beyond volitional control, or perhaps both. Clinical skills alone typically are not sufficient for diagnosing or detecting malingering. Medical education needs to provide doctors with the conceptual, developmental, and management frameworks to understand and manage patients whose symptoms appear to be simulated. Central to understanding factitious disorders and malingering are the explanatory models and beliefs used to provide meaning for both patients and doctors.⁷

When considering malingered psychosis, the suspecting physician must stay alert to possible motives. Also, the patient’s presentation might provide some clues when there is marked variability, such as discrepancies in the history, gross inconsistencies, or blatant contradictions. Hallucinations are a heterogeneous experience, and discerning between true vs feigned symptoms can be challenging for even the seasoned clinician. It can be helpful to study the phenomenology of typical vs atypical hallucinatory symptoms.⁸ Examples of atypical symptoms include:

• vague hallucinations
• experiencing hallucinations of only 1 sensory modality (such as voices alone, visual images in black and white only)
• delusions that have an abrupt onset
• bizarre content without disordered thinking.^2,6,9,10

The truth about an untruthful condition

Although the exact prevalence of malingering varies by circumstance, Rissmiller et al^12,13 demonstrated—and later replicated—a prevalence of approximately 10% among patients hospitalized for suicidal ideation or suicide attempts. Studies have demonstrated even higher prevalence within forensic populations, which seems reasonable because evading criminal responsibility is a large incentive to feign symptoms. Studies also have shown that 5% of military recruits will feign symptoms to avoid service. Moreover, 1% of psychiatric patients, such as Mr. D, feign symptoms for secondary gain.¹³

Although there are no psychometrically validated assessment tools to distinguish between real vs feigned hallucinations, several standardized tests can help tease out the truth.⁹ The preferred personality test used in forensic settings is the Minnesota Multiphasic Personality Inventory,¹⁴ which consists of 567 items, with 10 clinical scales and several validity scales. The F scale, “faking good” or “faking bad,” detects people who are answering questions with the goal of appearing better or worse than they actually are. In studies of patients hospitalized for being at risk for suicide who were administered tests of self-reported malingering, approximately 10% of people admitted to psychiatric units were “faking” their symptoms.¹⁴

It is important to identify malingering from a professional and public health standpoint. Society incurs incremental costs when a person uses dwindling mental health resources for their own reward, leaving others to suffer without treatment. The number of psychiatric hospital beds has fallen from half a million in the 1950s to approximately 100,000 today.¹⁵

Practical guidelines

Malingering presents specific challenges to clinicians, such as:

• diagnostic uncertainty
• inaccurately branding one a liar
• countertransference
• personal reactions.

Our ethical and fiduciary responsibility is to our patient. In examining the art in medicine, it has been suggested that malingering could be viewed as an immature or primitive defense.¹⁶

Although there often is suspicion that a person is malingering, a definitive statement of such must be confirmed. Without clarity, labeling an individual as a malingerer could have detrimental effects to his (her) future care, defames his character, and places a thoughtless examiner at risk of a lawsuit. Confirmation can be achieved by observation or psychological testing methods.

Observation. When in doubt of what to do with someone such as Mr. D, there is little harm in acting prudently by holding him in a controlled setting—whether keeping him overnight in an ED or admitting him for a brief psychiatric stay. By observing someone in a controlled environment, where there are multiple professional watchful eyes, inferences will be more accurate.¹

Structured assessments have been developed to help detect malingering—one example is the Test of Memory Malingering—however, in daily practice, the physician generally should suspect malingering when there are tangible incentives and when reported symptoms do not match the physical examination or there is no organic basis for the physical complaints.¹⁷ Detecting illness deception relies on converging evidence sources, including detailed interview assessments, clinical notes, and consultations.⁷

When you feel certain that you are encountering someone who is malingering, the final step is to get a consult. Malingering is a serious label and warrants due diligence by the provider, rather than a haphazard guess that a patient is lying. Once you receive confirmatory opinions, great care should be taken in documenting a clear and accurate note that will benefit your clinical counterpart who might encounter a patient such as Mr. D when he (she) shows up again, and will go a long way toward appropriately directing his care.

Imagine you’re on call in a busy emergency department (ED) overnight. Things are tough. The consults are piling up, no one is returning your calls for collateral information, and you’re dealing with a myriad of emergencies.

In walks Mr. D, age 45, complaining of hearing voices, feeling unsafe, and asking for admission. It’s now 2 am. What would you do?

Of course, like all qualified psychiatrists, you will dig a little deeper, and in doing so you learn that Mr. D has visited this hospital before and has been admitted to the psychiatry unit. Now you go from having a dearth of information to having more records than you can count.

You discover that Mr. D has a history of coming to the ED during precarious hours, with similar complaints, demanding admission.

Mr. D, you learn, is unemployed, single, and homeless. Your meticulous search through his hospital records and previous admission and discharge notes reveal that once he has slept for a night, eaten a hot meal, and received narcotics for his back pain and benzodiazepines for his “symptoms” he demands to leave the hospital. His psychotic symptoms disappear despite his consistent refusal to take antipsychotics throughout his stay.

Now, what would you do?

As earnest medical students and psychiatrists, we enjoy helping patients on their path toward recovery. We want to advocate for our patients and give them the benefit of the doubt. We’re taught in medical school to be non-judgmental and invite patients to share their narrative. But through experience, we start to become aware of malingering.

Suspecting malingering, diagnosed as a condition, often is avoided by psychiatrists.¹ This makes sense—it goes against the essence of our training and imposes a pejorative label on someone who has reached out for help.

Often persons with mental illness will suffer for years until they to receive help.² That’s exactly why, when patients like Mr. D come to the ED and report hearing voices, we’re not likely to shout, “Liar!” and invite them to leave.

However, malingering is a real problem, especially because the number of psychiatric hospital beds have dwindled to record lows, thereby overcrowding EDs. Resources are skimpy, and clinicians want to help those who need it the most and not waste resources on someone who is “faking it” for secondary gain.

To navigate this diagnostic challenge, psychiatrists need the skills to detect malingering and the confidence to deal with it appropriately. This article aims to:

• define psychosis and malingering
• review the prevalence and historical considerations of malingering
• offer practical strategies to deal with malingering.

Clinicians first must have the clinical acumen and expertise to identify a true mental illness such as psychosis² (Table 1). The differential diagnosis for psychotic symptoms is broad. The astute clinician might suspect that untreated bipolar disorder or depression led to the emergence of perceptual disturbances or disordered thinking. Transient psychotic symptoms can be associated with trauma disorders, borderline personality disorder, and acute intoxication. Psychotic spectrum disorders range from brief psychosis to schizophreniform to schizoaffective disorder or schizophrenia.

Malingering—which is a condition, not a diagnosis—is characterized by the intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives.^3,4 The presence of external incentives differentiates malingering from true psychiatric disorders, including factitious disorder, somatoform disorder, and dissociative disorder, and specific medical conditions.¹ In those disorders, there is no external incentive.

It is important to remember that malingering can coexist with a serious mental illness. For example, a truly psychotic person might malinger, feign, or exaggerate symptoms to try to receive much needed help. Individuals with true psychosis might have become disenchanted with the mental health system, and thereby have a tendency to over-report or exaggerate symptoms in an effort to obtain treatment. This also could explain why many clinicians intuitively are reluctant to make the determination that someone is malingering. Malingering also can be present in an individual who has antisocial personality disorder, factitious disorder, Ganser syndrome, and Munchausen syndrome.⁴ When symptoms or diseases that either are thought to be exaggerated or do not exist, consider a diagnosis of malingering.

A key challenge in any discussion of abnormal health care–seeking behavior is the extent to which a person’s reported symptoms are considered to be a product of choice, psychopathology beyond volitional control, or perhaps both. Clinical skills alone typically are not sufficient for diagnosing or detecting malingering. Medical education needs to provide doctors with the conceptual, developmental, and management frameworks to understand and manage patients whose symptoms appear to be simulated. Central to understanding factitious disorders and malingering are the explanatory models and beliefs used to provide meaning for both patients and doctors.⁷

When considering malingered psychosis, the suspecting physician must stay alert to possible motives. Also, the patient’s presentation might provide some clues when there is marked variability, such as discrepancies in the history, gross inconsistencies, or blatant contradictions. Hallucinations are a heterogeneous experience, and discerning between true vs feigned symptoms can be challenging for even the seasoned clinician. It can be helpful to study the phenomenology of typical vs atypical hallucinatory symptoms.⁸ Examples of atypical symptoms include:

• vague hallucinations
• experiencing hallucinations of only 1 sensory modality (such as voices alone, visual images in black and white only)
• delusions that have an abrupt onset
• bizarre content without disordered thinking.^2,6,9,10

The truth about an untruthful condition

Although the exact prevalence of malingering varies by circumstance, Rissmiller et al^12,13 demonstrated—and later replicated—a prevalence of approximately 10% among patients hospitalized for suicidal ideation or suicide attempts. Studies have demonstrated even higher prevalence within forensic populations, which seems reasonable because evading criminal responsibility is a large incentive to feign symptoms. Studies also have shown that 5% of military recruits will feign symptoms to avoid service. Moreover, 1% of psychiatric patients, such as Mr. D, feign symptoms for secondary gain.¹³

Although there are no psychometrically validated assessment tools to distinguish between real vs feigned hallucinations, several standardized tests can help tease out the truth.⁹ The preferred personality test used in forensic settings is the Minnesota Multiphasic Personality Inventory,¹⁴ which consists of 567 items, with 10 clinical scales and several validity scales. The F scale, “faking good” or “faking bad,” detects people who are answering questions with the goal of appearing better or worse than they actually are. In studies of patients hospitalized for being at risk for suicide who were administered tests of self-reported malingering, approximately 10% of people admitted to psychiatric units were “faking” their symptoms.¹⁴

It is important to identify malingering from a professional and public health standpoint. Society incurs incremental costs when a person uses dwindling mental health resources for their own reward, leaving others to suffer without treatment. The number of psychiatric hospital beds has fallen from half a million in the 1950s to approximately 100,000 today.¹⁵

Practical guidelines

Malingering presents specific challenges to clinicians, such as:

• diagnostic uncertainty
• inaccurately branding one a liar
• countertransference
• personal reactions.

Our ethical and fiduciary responsibility is to our patient. In examining the art in medicine, it has been suggested that malingering could be viewed as an immature or primitive defense.¹⁶

Although there often is suspicion that a person is malingering, a definitive statement of such must be confirmed. Without clarity, labeling an individual as a malingerer could have detrimental effects to his (her) future care, defames his character, and places a thoughtless examiner at risk of a lawsuit. Confirmation can be achieved by observation or psychological testing methods.

Observation. When in doubt of what to do with someone such as Mr. D, there is little harm in acting prudently by holding him in a controlled setting—whether keeping him overnight in an ED or admitting him for a brief psychiatric stay. By observing someone in a controlled environment, where there are multiple professional watchful eyes, inferences will be more accurate.¹

Structured assessments have been developed to help detect malingering—one example is the Test of Memory Malingering—however, in daily practice, the physician generally should suspect malingering when there are tangible incentives and when reported symptoms do not match the physical examination or there is no organic basis for the physical complaints.¹⁷ Detecting illness deception relies on converging evidence sources, including detailed interview assessments, clinical notes, and consultations.⁷

When you feel certain that you are encountering someone who is malingering, the final step is to get a consult. Malingering is a serious label and warrants due diligence by the provider, rather than a haphazard guess that a patient is lying. Once you receive confirmatory opinions, great care should be taken in documenting a clear and accurate note that will benefit your clinical counterpart who might encounter a patient such as Mr. D when he (she) shows up again, and will go a long way toward appropriately directing his care.

Imagine you’re on call in a busy emergency department (ED) overnight. Things are tough. The consults are piling up, no one is returning your calls for collateral information, and you’re dealing with a myriad of emergencies.

In walks Mr. D, age 45, complaining of hearing voices, feeling unsafe, and asking for admission. It’s now 2 am. What would you do?

Of course, like all qualified psychiatrists, you will dig a little deeper, and in doing so you learn that Mr. D has visited this hospital before and has been admitted to the psychiatry unit. Now you go from having a dearth of information to having more records than you can count.

You discover that Mr. D has a history of coming to the ED during precarious hours, with similar complaints, demanding admission.

Mr. D, you learn, is unemployed, single, and homeless. Your meticulous search through his hospital records and previous admission and discharge notes reveal that once he has slept for a night, eaten a hot meal, and received narcotics for his back pain and benzodiazepines for his “symptoms” he demands to leave the hospital. His psychotic symptoms disappear despite his consistent refusal to take antipsychotics throughout his stay.

Now, what would you do?

As earnest medical students and psychiatrists, we enjoy helping patients on their path toward recovery. We want to advocate for our patients and give them the benefit of the doubt. We’re taught in medical school to be non-judgmental and invite patients to share their narrative. But through experience, we start to become aware of malingering.

Suspecting malingering, diagnosed as a condition, often is avoided by psychiatrists.¹ This makes sense—it goes against the essence of our training and imposes a pejorative label on someone who has reached out for help.

Often persons with mental illness will suffer for years until they to receive help.² That’s exactly why, when patients like Mr. D come to the ED and report hearing voices, we’re not likely to shout, “Liar!” and invite them to leave.

However, malingering is a real problem, especially because the number of psychiatric hospital beds have dwindled to record lows, thereby overcrowding EDs. Resources are skimpy, and clinicians want to help those who need it the most and not waste resources on someone who is “faking it” for secondary gain.

To navigate this diagnostic challenge, psychiatrists need the skills to detect malingering and the confidence to deal with it appropriately. This article aims to:

• define psychosis and malingering
• review the prevalence and historical considerations of malingering
• offer practical strategies to deal with malingering.

Clinicians first must have the clinical acumen and expertise to identify a true mental illness such as psychosis² (Table 1). The differential diagnosis for psychotic symptoms is broad. The astute clinician might suspect that untreated bipolar disorder or depression led to the emergence of perceptual disturbances or disordered thinking. Transient psychotic symptoms can be associated with trauma disorders, borderline personality disorder, and acute intoxication. Psychotic spectrum disorders range from brief psychosis to schizophreniform to schizoaffective disorder or schizophrenia.

Malingering—which is a condition, not a diagnosis—is characterized by the intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives.^3,4 The presence of external incentives differentiates malingering from true psychiatric disorders, including factitious disorder, somatoform disorder, and dissociative disorder, and specific medical conditions.¹ In those disorders, there is no external incentive.

It is important to remember that malingering can coexist with a serious mental illness. For example, a truly psychotic person might malinger, feign, or exaggerate symptoms to try to receive much needed help. Individuals with true psychosis might have become disenchanted with the mental health system, and thereby have a tendency to over-report or exaggerate symptoms in an effort to obtain treatment. This also could explain why many clinicians intuitively are reluctant to make the determination that someone is malingering. Malingering also can be present in an individual who has antisocial personality disorder, factitious disorder, Ganser syndrome, and Munchausen syndrome.⁴ When symptoms or diseases that either are thought to be exaggerated or do not exist, consider a diagnosis of malingering.

A key challenge in any discussion of abnormal health care–seeking behavior is the extent to which a person’s reported symptoms are considered to be a product of choice, psychopathology beyond volitional control, or perhaps both. Clinical skills alone typically are not sufficient for diagnosing or detecting malingering. Medical education needs to provide doctors with the conceptual, developmental, and management frameworks to understand and manage patients whose symptoms appear to be simulated. Central to understanding factitious disorders and malingering are the explanatory models and beliefs used to provide meaning for both patients and doctors.⁷

When considering malingered psychosis, the suspecting physician must stay alert to possible motives. Also, the patient’s presentation might provide some clues when there is marked variability, such as discrepancies in the history, gross inconsistencies, or blatant contradictions. Hallucinations are a heterogeneous experience, and discerning between true vs feigned symptoms can be challenging for even the seasoned clinician. It can be helpful to study the phenomenology of typical vs atypical hallucinatory symptoms.⁸ Examples of atypical symptoms include:

• vague hallucinations
• experiencing hallucinations of only 1 sensory modality (such as voices alone, visual images in black and white only)
• delusions that have an abrupt onset
• bizarre content without disordered thinking.^2,6,9,10

The truth about an untruthful condition

Although the exact prevalence of malingering varies by circumstance, Rissmiller et al^12,13 demonstrated—and later replicated—a prevalence of approximately 10% among patients hospitalized for suicidal ideation or suicide attempts. Studies have demonstrated even higher prevalence within forensic populations, which seems reasonable because evading criminal responsibility is a large incentive to feign symptoms. Studies also have shown that 5% of military recruits will feign symptoms to avoid service. Moreover, 1% of psychiatric patients, such as Mr. D, feign symptoms for secondary gain.¹³

Although there are no psychometrically validated assessment tools to distinguish between real vs feigned hallucinations, several standardized tests can help tease out the truth.⁹ The preferred personality test used in forensic settings is the Minnesota Multiphasic Personality Inventory,¹⁴ which consists of 567 items, with 10 clinical scales and several validity scales. The F scale, “faking good” or “faking bad,” detects people who are answering questions with the goal of appearing better or worse than they actually are. In studies of patients hospitalized for being at risk for suicide who were administered tests of self-reported malingering, approximately 10% of people admitted to psychiatric units were “faking” their symptoms.¹⁴

It is important to identify malingering from a professional and public health standpoint. Society incurs incremental costs when a person uses dwindling mental health resources for their own reward, leaving others to suffer without treatment. The number of psychiatric hospital beds has fallen from half a million in the 1950s to approximately 100,000 today.¹⁵

Practical guidelines

Malingering presents specific challenges to clinicians, such as:

• diagnostic uncertainty
• inaccurately branding one a liar
• countertransference
• personal reactions.

Our ethical and fiduciary responsibility is to our patient. In examining the art in medicine, it has been suggested that malingering could be viewed as an immature or primitive defense.¹⁶

Although there often is suspicion that a person is malingering, a definitive statement of such must be confirmed. Without clarity, labeling an individual as a malingerer could have detrimental effects to his (her) future care, defames his character, and places a thoughtless examiner at risk of a lawsuit. Confirmation can be achieved by observation or psychological testing methods.

Observation. When in doubt of what to do with someone such as Mr. D, there is little harm in acting prudently by holding him in a controlled setting—whether keeping him overnight in an ED or admitting him for a brief psychiatric stay. By observing someone in a controlled environment, where there are multiple professional watchful eyes, inferences will be more accurate.¹

Structured assessments have been developed to help detect malingering—one example is the Test of Memory Malingering—however, in daily practice, the physician generally should suspect malingering when there are tangible incentives and when reported symptoms do not match the physical examination or there is no organic basis for the physical complaints.¹⁷ Detecting illness deception relies on converging evidence sources, including detailed interview assessments, clinical notes, and consultations.⁷

When you feel certain that you are encountering someone who is malingering, the final step is to get a consult. Malingering is a serious label and warrants due diligence by the provider, rather than a haphazard guess that a patient is lying. Once you receive confirmatory opinions, great care should be taken in documenting a clear and accurate note that will benefit your clinical counterpart who might encounter a patient such as Mr. D when he (she) shows up again, and will go a long way toward appropriately directing his care.