Commentary

In 2018, when Naomi Osaka won the U.S. Open by defeating Serena Williams, the trophy ceremony was painful to watch.

Photo by Tim Clayton/Corbis via Getty Images

Ms. Williams had argued with an umpire over a controversial call, and the ceremony began with the crowd booing. Ms. Osaka, the victor, cried while Ms. Williams comforted her and quietly assured Ms. Osaka that the crowd was not booing at her. When asked how her dream of playing against Ms. Williams compared with the reality, the new champion, looking anything but victorious, responded: “Umm, I’m gonna sort of defer from your question, I’m sorry. I know that everyone was cheering for her, and I’m sorry it had to end like this.”

It was hardly the joyous moment it should have been in this young tennis player’s life.

Ms. Osaka, now 23, entered this year’s French Open as the Women’s Tennis Association’s second-ranked player and as the highest-paid female athlete of all time. She is known for her support of Black Lives Matter. Ms. Osaka announced that she would not be attending press conferences in an Instagram post days before the competition began. “If the organizations think they can keep saying, ‘do press or you’re going to get fined,’ and continue to ignore the mental health of the athletes that are the centerpiece of their cooperation then I just gotta laugh,” Ms. Osaka posted.

She was fined $15,000 on Sunday, May 30, when she did not appear at a press conference after winning her first match. Officials noted that she would be subjected to higher fines and expulsion from the tournament if she did not attend the mandatory media briefings. On June 1, Ms. Osaka withdrew from the French Open and explained her reasons on Instagram in a post where she announced that she has been struggling with depression and social anxiety and did not mean to become a distraction for the competition.
 

Psychiatrists weigh in

Sue Kim, MD, a psychiatrist who both plays and watches tennis, brought up Ms. Osaka’s resignation for discussion on the Maryland Psychiatric Society’s listserv. “[Ms.] Osaka put out on social media her depression and wanted to have rules reviewed and revised by the governing body of tennis, for future occasions. I feel it is so unfortunate and unfair and I am interested in hearing your opinions.”

Photo by Mark Brown/Getty Images

Yusuke Sagawa, MD, a psychiatrist and tennis fan, wrote in: “During the COVID-19 pandemic, I rekindled my interest in tennis and I followed what transpired this past weekend. Naomi Osaka is an exceptionally shy and introverted person. I have noted that her speech is somewhat akin to (for lack of a better term) ‘Valley Girl’ talk, and from reading comments on tennis-related blogs, it appears she has garnered a significant amount of hatred as a result. Most of it is along the lines of people feeling her shyness and modesty is simply a masquerade.

“I have also seen YouTube videos of her signing autographs for fans. She is cooperative and pleasant, but clearly uncomfortable around large groups of people.

“Having seen many press conferences after a match,” Dr. Sagawa continued, “tennis journalists have a penchant for asking questions that are either personal or seemingly an attempt to stir up acrimony amongst players. Whatever the case, I truly do believe that this is not some sort of ruse on her part, and I hope that people come to her defense. It is disturbing to hear the comments already coming out from the ‘big names’ in the sport that have mostly been nonsupportive. Fortunately, there have also been a number of her contemporaries who have expressed this support for her.”

In the days following Ms. Osaka’s departure from the French Open, the situation has become more complex. She is now the keystone for discussions of athletes and gender, race, power, mental illness, and the role of social media as it is used in these types of communications.

Maryland psychiatrist Erik Roskes, MD, wrote: “I have followed this story from a distance and what strikes me is the intermixing of athleticism – which is presumably why we watch sports – and entertainment, the money-making part of it. The athletes are both athletes and entertainers, and [Ms.] Osaka seems to be unable to fully fulfill the latter part due to her unique traits. But like many, I wonder what if this had been Michael Phelps? Is there a gender issue at play?”

Stephanie Durruthy, MD, added: “[Ms.] Osaka brings complexity to the mental health conversations. There is no one answer to her current plight, but her being a person of color cannot be minimized. She magnified the race conversation in tennis to a higher level.

“When she was new to the Grand Slam scene, her Haitian, Japanese, and Black heritage became an issue with unending curiosity.

“[Ms.] Osaka used her platform during the 2020 U.S. Open to single-handedly highlight Black Lives Matter,” Dr. Durruthy continued. “Afterward, the tennis fans could not avoid seeing her face mask. In each match, she displayed another mask depicting the name of those killed. She described on social media her fears of being a Black person in America. The biases of gender and race are well described in the sports world.”

Lindsay Crouse wrote June 1 in the New York Times: “When Naomi Osaka dropped out of the French Open, after declining to attend media interviews that she said could trigger her anxiety, she wasn’t just protecting her mental health. She was sending a message to the establishment of one of the world’s most elite sports: I will not be controlled. This was a power move – and it packed more punch coming from a young woman of color. When the system hasn’t historically stood for you, why sacrifice yourself to uphold it? Especially when you have the power to change it instead.”

Professional sports are grueling on athletes, both physically and mentally. People will speculate about Ms. Osaka’s motives for refusing to participate in the media briefings that are mandated by her contract. Some will see it as manipulative, others as the desire of a young woman struggling with anxiety and depression to push back against a system that makes few allowances for those who suffer. As psychiatrists, we see how crippling these illnesses can be and admire those who achieve at these superhuman levels, often at the expense of their own well-being.

Dr. Kim, who started the MPS listserv discussion, ended it with: “I feel bad if Naomi Osaka needs to play a mental ‘illness’ card, as opposed to mental ‘wellness’ card.”

Let’s hope that Ms. Osaka’s withdrawal from the French Open sparks more conversation about how to accommodate athletes as they endeavor to meet both the demands of their contracts and when it might be more appropriate to be flexible for those with individual struggles.

Dr. Miller is coauthor of “ Committed: The Battle Over Involuntary Psychiatric Care ” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore.

In 2018, when Naomi Osaka won the U.S. Open by defeating Serena Williams, the trophy ceremony was painful to watch.

Photo by Tim Clayton/Corbis via Getty Images

Ms. Williams had argued with an umpire over a controversial call, and the ceremony began with the crowd booing. Ms. Osaka, the victor, cried while Ms. Williams comforted her and quietly assured Ms. Osaka that the crowd was not booing at her. When asked how her dream of playing against Ms. Williams compared with the reality, the new champion, looking anything but victorious, responded: “Umm, I’m gonna sort of defer from your question, I’m sorry. I know that everyone was cheering for her, and I’m sorry it had to end like this.”

It was hardly the joyous moment it should have been in this young tennis player’s life.

Ms. Osaka, now 23, entered this year’s French Open as the Women’s Tennis Association’s second-ranked player and as the highest-paid female athlete of all time. She is known for her support of Black Lives Matter. Ms. Osaka announced that she would not be attending press conferences in an Instagram post days before the competition began. “If the organizations think they can keep saying, ‘do press or you’re going to get fined,’ and continue to ignore the mental health of the athletes that are the centerpiece of their cooperation then I just gotta laugh,” Ms. Osaka posted.

She was fined $15,000 on Sunday, May 30, when she did not appear at a press conference after winning her first match. Officials noted that she would be subjected to higher fines and expulsion from the tournament if she did not attend the mandatory media briefings. On June 1, Ms. Osaka withdrew from the French Open and explained her reasons on Instagram in a post where she announced that she has been struggling with depression and social anxiety and did not mean to become a distraction for the competition.
 

Psychiatrists weigh in

Sue Kim, MD, a psychiatrist who both plays and watches tennis, brought up Ms. Osaka’s resignation for discussion on the Maryland Psychiatric Society’s listserv. “[Ms.] Osaka put out on social media her depression and wanted to have rules reviewed and revised by the governing body of tennis, for future occasions. I feel it is so unfortunate and unfair and I am interested in hearing your opinions.”

Photo by Mark Brown/Getty Images

Yusuke Sagawa, MD, a psychiatrist and tennis fan, wrote in: “During the COVID-19 pandemic, I rekindled my interest in tennis and I followed what transpired this past weekend. Naomi Osaka is an exceptionally shy and introverted person. I have noted that her speech is somewhat akin to (for lack of a better term) ‘Valley Girl’ talk, and from reading comments on tennis-related blogs, it appears she has garnered a significant amount of hatred as a result. Most of it is along the lines of people feeling her shyness and modesty is simply a masquerade.

“I have also seen YouTube videos of her signing autographs for fans. She is cooperative and pleasant, but clearly uncomfortable around large groups of people.

“Having seen many press conferences after a match,” Dr. Sagawa continued, “tennis journalists have a penchant for asking questions that are either personal or seemingly an attempt to stir up acrimony amongst players. Whatever the case, I truly do believe that this is not some sort of ruse on her part, and I hope that people come to her defense. It is disturbing to hear the comments already coming out from the ‘big names’ in the sport that have mostly been nonsupportive. Fortunately, there have also been a number of her contemporaries who have expressed this support for her.”

In the days following Ms. Osaka’s departure from the French Open, the situation has become more complex. She is now the keystone for discussions of athletes and gender, race, power, mental illness, and the role of social media as it is used in these types of communications.

Maryland psychiatrist Erik Roskes, MD, wrote: “I have followed this story from a distance and what strikes me is the intermixing of athleticism – which is presumably why we watch sports – and entertainment, the money-making part of it. The athletes are both athletes and entertainers, and [Ms.] Osaka seems to be unable to fully fulfill the latter part due to her unique traits. But like many, I wonder what if this had been Michael Phelps? Is there a gender issue at play?”

Stephanie Durruthy, MD, added: “[Ms.] Osaka brings complexity to the mental health conversations. There is no one answer to her current plight, but her being a person of color cannot be minimized. She magnified the race conversation in tennis to a higher level.

“When she was new to the Grand Slam scene, her Haitian, Japanese, and Black heritage became an issue with unending curiosity.

“[Ms.] Osaka used her platform during the 2020 U.S. Open to single-handedly highlight Black Lives Matter,” Dr. Durruthy continued. “Afterward, the tennis fans could not avoid seeing her face mask. In each match, she displayed another mask depicting the name of those killed. She described on social media her fears of being a Black person in America. The biases of gender and race are well described in the sports world.”

Lindsay Crouse wrote June 1 in the New York Times: “When Naomi Osaka dropped out of the French Open, after declining to attend media interviews that she said could trigger her anxiety, she wasn’t just protecting her mental health. She was sending a message to the establishment of one of the world’s most elite sports: I will not be controlled. This was a power move – and it packed more punch coming from a young woman of color. When the system hasn’t historically stood for you, why sacrifice yourself to uphold it? Especially when you have the power to change it instead.”

Professional sports are grueling on athletes, both physically and mentally. People will speculate about Ms. Osaka’s motives for refusing to participate in the media briefings that are mandated by her contract. Some will see it as manipulative, others as the desire of a young woman struggling with anxiety and depression to push back against a system that makes few allowances for those who suffer. As psychiatrists, we see how crippling these illnesses can be and admire those who achieve at these superhuman levels, often at the expense of their own well-being.

Dr. Kim, who started the MPS listserv discussion, ended it with: “I feel bad if Naomi Osaka needs to play a mental ‘illness’ card, as opposed to mental ‘wellness’ card.”

Let’s hope that Ms. Osaka’s withdrawal from the French Open sparks more conversation about how to accommodate athletes as they endeavor to meet both the demands of their contracts and when it might be more appropriate to be flexible for those with individual struggles.

Dr. Miller is coauthor of “ Committed: The Battle Over Involuntary Psychiatric Care ” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore.

In 2018, when Naomi Osaka won the U.S. Open by defeating Serena Williams, the trophy ceremony was painful to watch.

Photo by Tim Clayton/Corbis via Getty Images

Ms. Williams had argued with an umpire over a controversial call, and the ceremony began with the crowd booing. Ms. Osaka, the victor, cried while Ms. Williams comforted her and quietly assured Ms. Osaka that the crowd was not booing at her. When asked how her dream of playing against Ms. Williams compared with the reality, the new champion, looking anything but victorious, responded: “Umm, I’m gonna sort of defer from your question, I’m sorry. I know that everyone was cheering for her, and I’m sorry it had to end like this.”

It was hardly the joyous moment it should have been in this young tennis player’s life.

Ms. Osaka, now 23, entered this year’s French Open as the Women’s Tennis Association’s second-ranked player and as the highest-paid female athlete of all time. She is known for her support of Black Lives Matter. Ms. Osaka announced that she would not be attending press conferences in an Instagram post days before the competition began. “If the organizations think they can keep saying, ‘do press or you’re going to get fined,’ and continue to ignore the mental health of the athletes that are the centerpiece of their cooperation then I just gotta laugh,” Ms. Osaka posted.

She was fined $15,000 on Sunday, May 30, when she did not appear at a press conference after winning her first match. Officials noted that she would be subjected to higher fines and expulsion from the tournament if she did not attend the mandatory media briefings. On June 1, Ms. Osaka withdrew from the French Open and explained her reasons on Instagram in a post where she announced that she has been struggling with depression and social anxiety and did not mean to become a distraction for the competition.
 

Psychiatrists weigh in

Sue Kim, MD, a psychiatrist who both plays and watches tennis, brought up Ms. Osaka’s resignation for discussion on the Maryland Psychiatric Society’s listserv. “[Ms.] Osaka put out on social media her depression and wanted to have rules reviewed and revised by the governing body of tennis, for future occasions. I feel it is so unfortunate and unfair and I am interested in hearing your opinions.”

Photo by Mark Brown/Getty Images

Yusuke Sagawa, MD, a psychiatrist and tennis fan, wrote in: “During the COVID-19 pandemic, I rekindled my interest in tennis and I followed what transpired this past weekend. Naomi Osaka is an exceptionally shy and introverted person. I have noted that her speech is somewhat akin to (for lack of a better term) ‘Valley Girl’ talk, and from reading comments on tennis-related blogs, it appears she has garnered a significant amount of hatred as a result. Most of it is along the lines of people feeling her shyness and modesty is simply a masquerade.

“I have also seen YouTube videos of her signing autographs for fans. She is cooperative and pleasant, but clearly uncomfortable around large groups of people.

“Having seen many press conferences after a match,” Dr. Sagawa continued, “tennis journalists have a penchant for asking questions that are either personal or seemingly an attempt to stir up acrimony amongst players. Whatever the case, I truly do believe that this is not some sort of ruse on her part, and I hope that people come to her defense. It is disturbing to hear the comments already coming out from the ‘big names’ in the sport that have mostly been nonsupportive. Fortunately, there have also been a number of her contemporaries who have expressed this support for her.”

In the days following Ms. Osaka’s departure from the French Open, the situation has become more complex. She is now the keystone for discussions of athletes and gender, race, power, mental illness, and the role of social media as it is used in these types of communications.

Maryland psychiatrist Erik Roskes, MD, wrote: “I have followed this story from a distance and what strikes me is the intermixing of athleticism – which is presumably why we watch sports – and entertainment, the money-making part of it. The athletes are both athletes and entertainers, and [Ms.] Osaka seems to be unable to fully fulfill the latter part due to her unique traits. But like many, I wonder what if this had been Michael Phelps? Is there a gender issue at play?”

Stephanie Durruthy, MD, added: “[Ms.] Osaka brings complexity to the mental health conversations. There is no one answer to her current plight, but her being a person of color cannot be minimized. She magnified the race conversation in tennis to a higher level.

“When she was new to the Grand Slam scene, her Haitian, Japanese, and Black heritage became an issue with unending curiosity.

“[Ms.] Osaka used her platform during the 2020 U.S. Open to single-handedly highlight Black Lives Matter,” Dr. Durruthy continued. “Afterward, the tennis fans could not avoid seeing her face mask. In each match, she displayed another mask depicting the name of those killed. She described on social media her fears of being a Black person in America. The biases of gender and race are well described in the sports world.”

Lindsay Crouse wrote June 1 in the New York Times: “When Naomi Osaka dropped out of the French Open, after declining to attend media interviews that she said could trigger her anxiety, she wasn’t just protecting her mental health. She was sending a message to the establishment of one of the world’s most elite sports: I will not be controlled. This was a power move – and it packed more punch coming from a young woman of color. When the system hasn’t historically stood for you, why sacrifice yourself to uphold it? Especially when you have the power to change it instead.”

Professional sports are grueling on athletes, both physically and mentally. People will speculate about Ms. Osaka’s motives for refusing to participate in the media briefings that are mandated by her contract. Some will see it as manipulative, others as the desire of a young woman struggling with anxiety and depression to push back against a system that makes few allowances for those who suffer. As psychiatrists, we see how crippling these illnesses can be and admire those who achieve at these superhuman levels, often at the expense of their own well-being.

Dr. Kim, who started the MPS listserv discussion, ended it with: “I feel bad if Naomi Osaka needs to play a mental ‘illness’ card, as opposed to mental ‘wellness’ card.”

Let’s hope that Ms. Osaka’s withdrawal from the French Open sparks more conversation about how to accommodate athletes as they endeavor to meet both the demands of their contracts and when it might be more appropriate to be flexible for those with individual struggles.

Dr. Miller is coauthor of “ Committed: The Battle Over Involuntary Psychiatric Care ” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore.

Burnout is seldom the result of a single factor. It is more often a tragic case of death by a thousand cuts: a balky user-unfriendly electronic medical record system, administrative pressure to see more patients and the resulting frustration of not being able to provide the care you feel they deserve, an overemphasis on documentation or you won’t get paid, the dark cloud of malpractice always overhead, and of course the difficult balance between family responsibilities and work. It often boils down to feeling that there aren’t enough hours in the day to get everything done and still have time to recharge your physical and psychological batteries.

A recent report in the Harvard Business School newsletter, Working Knowledge (“Commuting Hurts Productivity and Your Best Talent Suffers Most.” Lane Lambert. 2021 Mar 30) describes an interesting study by Andy Wu, assistant professor of business administration, in which he discovered that, for every 10 kilometers of commuting distance, there was a decrease in the productivity of high-tech inventors as measured by the number of patents registered by their companies. The quality of their inventions declined even more (7%) for each additional 10 kilometers of commute.

You might question the relevance of these findings with your work in an outpatient clinic, but a conscientious physician is also an inventor and a creator. Every patient, even those with what sounds like a routine complaint, presents a novel collection of management challenges. The best physicians treat their profession as an art and must be invent solutions on the fly.

There is abundant evidence that commuting also can have a negative effect on the physical and mental health of workers. (“The astonishing human potential wasted on commutes.” The Washington Post .Christopher Ingraham. 2016 Feb 25). Watching my father walk into the house after an hour-long train ride out of the city and listening to him grumble created an image that influenced every decision I made about where my wife and I would live and work.

Did I benefit from the luxury of growing up in a small suburban community? Of course I did and I shall be forever grateful for the sacrifice my father made to allow that to happen. But, I promised myself that, while I would make sacrifices for my family, a long or unpleasant commute was not going to be on that list. For a few years I tolerated a 10- to 12-minute car commute (three stoplights) but asked to dissolve the partnership because even that 9-mile ride was too much for me and instead spent the bulk of my 40-year career a 10-minute bike ride from my office and the two hospitals. It meant we didn’t have a view of the ocean or a gentleman’s farm but we had an extra hour together as a family and I arrived at work and at home happy.

The pandemic has been a wake-up call for many of the fortunate folks who have found that they can work from home, eliminating what may have been a time-gobbling commute that was creating more stress than they may have realized. Even if telemedicine continues to maintain some postpandemic presence, I suspect that most physicians will continue to be faced with the challenge of traveling to an office or hospital.

If work is losing some of its luster and/or you are arriving home grumpy from a long day in the office, it is easy to blame an insensitive office administrator or the clunky electronic medical record system ... they deserve it. But, it may be the journey and not just the destination that is the contributing to the problem. I realize that rethinking the decision about where one lives can be painful and the options may be limited. However, I hope that at least some of you can rethink the role your journey is playing in your life.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Burnout is seldom the result of a single factor. It is more often a tragic case of death by a thousand cuts: a balky user-unfriendly electronic medical record system, administrative pressure to see more patients and the resulting frustration of not being able to provide the care you feel they deserve, an overemphasis on documentation or you won’t get paid, the dark cloud of malpractice always overhead, and of course the difficult balance between family responsibilities and work. It often boils down to feeling that there aren’t enough hours in the day to get everything done and still have time to recharge your physical and psychological batteries.

A recent report in the Harvard Business School newsletter, Working Knowledge (“Commuting Hurts Productivity and Your Best Talent Suffers Most.” Lane Lambert. 2021 Mar 30) describes an interesting study by Andy Wu, assistant professor of business administration, in which he discovered that, for every 10 kilometers of commuting distance, there was a decrease in the productivity of high-tech inventors as measured by the number of patents registered by their companies. The quality of their inventions declined even more (7%) for each additional 10 kilometers of commute.

You might question the relevance of these findings with your work in an outpatient clinic, but a conscientious physician is also an inventor and a creator. Every patient, even those with what sounds like a routine complaint, presents a novel collection of management challenges. The best physicians treat their profession as an art and must be invent solutions on the fly.

There is abundant evidence that commuting also can have a negative effect on the physical and mental health of workers. (“The astonishing human potential wasted on commutes.” The Washington Post .Christopher Ingraham. 2016 Feb 25). Watching my father walk into the house after an hour-long train ride out of the city and listening to him grumble created an image that influenced every decision I made about where my wife and I would live and work.

Did I benefit from the luxury of growing up in a small suburban community? Of course I did and I shall be forever grateful for the sacrifice my father made to allow that to happen. But, I promised myself that, while I would make sacrifices for my family, a long or unpleasant commute was not going to be on that list. For a few years I tolerated a 10- to 12-minute car commute (three stoplights) but asked to dissolve the partnership because even that 9-mile ride was too much for me and instead spent the bulk of my 40-year career a 10-minute bike ride from my office and the two hospitals. It meant we didn’t have a view of the ocean or a gentleman’s farm but we had an extra hour together as a family and I arrived at work and at home happy.

The pandemic has been a wake-up call for many of the fortunate folks who have found that they can work from home, eliminating what may have been a time-gobbling commute that was creating more stress than they may have realized. Even if telemedicine continues to maintain some postpandemic presence, I suspect that most physicians will continue to be faced with the challenge of traveling to an office or hospital.

If work is losing some of its luster and/or you are arriving home grumpy from a long day in the office, it is easy to blame an insensitive office administrator or the clunky electronic medical record system ... they deserve it. But, it may be the journey and not just the destination that is the contributing to the problem. I realize that rethinking the decision about where one lives can be painful and the options may be limited. However, I hope that at least some of you can rethink the role your journey is playing in your life.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Burnout is seldom the result of a single factor. It is more often a tragic case of death by a thousand cuts: a balky user-unfriendly electronic medical record system, administrative pressure to see more patients and the resulting frustration of not being able to provide the care you feel they deserve, an overemphasis on documentation or you won’t get paid, the dark cloud of malpractice always overhead, and of course the difficult balance between family responsibilities and work. It often boils down to feeling that there aren’t enough hours in the day to get everything done and still have time to recharge your physical and psychological batteries.

A recent report in the Harvard Business School newsletter, Working Knowledge (“Commuting Hurts Productivity and Your Best Talent Suffers Most.” Lane Lambert. 2021 Mar 30) describes an interesting study by Andy Wu, assistant professor of business administration, in which he discovered that, for every 10 kilometers of commuting distance, there was a decrease in the productivity of high-tech inventors as measured by the number of patents registered by their companies. The quality of their inventions declined even more (7%) for each additional 10 kilometers of commute.

You might question the relevance of these findings with your work in an outpatient clinic, but a conscientious physician is also an inventor and a creator. Every patient, even those with what sounds like a routine complaint, presents a novel collection of management challenges. The best physicians treat their profession as an art and must be invent solutions on the fly.

There is abundant evidence that commuting also can have a negative effect on the physical and mental health of workers. (“The astonishing human potential wasted on commutes.” The Washington Post .Christopher Ingraham. 2016 Feb 25). Watching my father walk into the house after an hour-long train ride out of the city and listening to him grumble created an image that influenced every decision I made about where my wife and I would live and work.

Did I benefit from the luxury of growing up in a small suburban community? Of course I did and I shall be forever grateful for the sacrifice my father made to allow that to happen. But, I promised myself that, while I would make sacrifices for my family, a long or unpleasant commute was not going to be on that list. For a few years I tolerated a 10- to 12-minute car commute (three stoplights) but asked to dissolve the partnership because even that 9-mile ride was too much for me and instead spent the bulk of my 40-year career a 10-minute bike ride from my office and the two hospitals. It meant we didn’t have a view of the ocean or a gentleman’s farm but we had an extra hour together as a family and I arrived at work and at home happy.

The pandemic has been a wake-up call for many of the fortunate folks who have found that they can work from home, eliminating what may have been a time-gobbling commute that was creating more stress than they may have realized. Even if telemedicine continues to maintain some postpandemic presence, I suspect that most physicians will continue to be faced with the challenge of traveling to an office or hospital.

If work is losing some of its luster and/or you are arriving home grumpy from a long day in the office, it is easy to blame an insensitive office administrator or the clunky electronic medical record system ... they deserve it. But, it may be the journey and not just the destination that is the contributing to the problem. I realize that rethinking the decision about where one lives can be painful and the options may be limited. However, I hope that at least some of you can rethink the role your journey is playing in your life.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact letters@currentpsychiatry.com.

The COVID-19 pandemic has brought to the fore inequalities in health care.¹ In a letter recently published in the American Journal of Psychiatry, Nadkarni et al² addressed the reality that there is not equal access to quality care (in this case, telepsychiatry). They reported challenges in converting their psychiatry ambulatory care center to a virtual platform at Brigham and Women’s Hospital, which is affiliated with Harvard Medical School.

Previously, I had reported in Current Psychiatry that patients at our small community mental health clinic outside Baltimore have much less audiovisual capability (they were able to receive telepsychiatry services via phone only, and not via video conferencing on a computer, smartphone, or tablet).³ Of 100 consecutive patients, we used telepsychiatry for 82 (18 were seen in person, including 14 who were seen for administration of long-acting injectable medications). Of the 82 patients receiving telepsychiatry from our facility, only 9 had video conferencing sessions (10.9%).

I repeated the survey approximately 3 months later. Preliminary data of these 125 total patients showed a slightly higher percentage (12.6%) had video conferencing sessions.

Factors associated with limited access to technology

Similar to what was reported by Nadkarni et al,² in our extremely vulnerable population, socioeconomic factors affect access. Our patients are low income, and often do not own computers or smart phones. Nearly all our patients receive medical assistance and/or Medicare. Our patients are more likely to be members of a racial minority group—4 times the national average. Our patients are older.⁴ Patient age varies from 16 to 83 years; the mean age is 54, and the median age is 56. Educational level is low. Nearly all of our patients who participate in video conferencing sessions are female. Approximately 15 of our patients have comorbid intellectual and developmental disabilities diagnoses, and at least that many have subsyndromal symptoms. Constantino et al⁵ commented on the multiple negative consequences of the COVID-19 pandemic on individuals with intellectual and developmental disabilities, including “frank disparities in access” to technology as well as gaps left by relying exclusively on telehealth.

Among our patients, being low income, a member of a racial minority group, older, less educated, male, and developmentally and/or intellectually disabled are risk factors for less access to video conferencing.³ Nadkarni et al² also noted less broadband access for rural residents and less access and lack of digital health literacy in patients with limited English proficiency.

As Nadkarni et al² suggested, we did contact our legislators, and emergency rules are continuing. For now, we are managing fiscally. Although that certainly is important, it does not address the issue of inequality.

Continue to: With this information...

With this information, we are strongly encouraging our patients to participate in video conferencing sessions. We suspect that for some patients, the possibility of them participating in video conferencing sessions is greater than they have acknowledged. We are stepping up education and support, both informally through the patient’s family and friends, and more formally through case managers who “lend” patients a device during home visits.

In summary, this inequality in access to the technology needed for telepsychiatry will loom even more prominently as we all move forward, both clinically and in policymaking.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact letters@currentpsychiatry.com.

The COVID-19 pandemic has brought to the fore inequalities in health care.¹ In a letter recently published in the American Journal of Psychiatry, Nadkarni et al² addressed the reality that there is not equal access to quality care (in this case, telepsychiatry). They reported challenges in converting their psychiatry ambulatory care center to a virtual platform at Brigham and Women’s Hospital, which is affiliated with Harvard Medical School.

Previously, I had reported in Current Psychiatry that patients at our small community mental health clinic outside Baltimore have much less audiovisual capability (they were able to receive telepsychiatry services via phone only, and not via video conferencing on a computer, smartphone, or tablet).³ Of 100 consecutive patients, we used telepsychiatry for 82 (18 were seen in person, including 14 who were seen for administration of long-acting injectable medications). Of the 82 patients receiving telepsychiatry from our facility, only 9 had video conferencing sessions (10.9%).

I repeated the survey approximately 3 months later. Preliminary data of these 125 total patients showed a slightly higher percentage (12.6%) had video conferencing sessions.

Factors associated with limited access to technology

Similar to what was reported by Nadkarni et al,² in our extremely vulnerable population, socioeconomic factors affect access. Our patients are low income, and often do not own computers or smart phones. Nearly all our patients receive medical assistance and/or Medicare. Our patients are more likely to be members of a racial minority group—4 times the national average. Our patients are older.⁴ Patient age varies from 16 to 83 years; the mean age is 54, and the median age is 56. Educational level is low. Nearly all of our patients who participate in video conferencing sessions are female. Approximately 15 of our patients have comorbid intellectual and developmental disabilities diagnoses, and at least that many have subsyndromal symptoms. Constantino et al⁵ commented on the multiple negative consequences of the COVID-19 pandemic on individuals with intellectual and developmental disabilities, including “frank disparities in access” to technology as well as gaps left by relying exclusively on telehealth.

Among our patients, being low income, a member of a racial minority group, older, less educated, male, and developmentally and/or intellectually disabled are risk factors for less access to video conferencing.³ Nadkarni et al² also noted less broadband access for rural residents and less access and lack of digital health literacy in patients with limited English proficiency.

As Nadkarni et al² suggested, we did contact our legislators, and emergency rules are continuing. For now, we are managing fiscally. Although that certainly is important, it does not address the issue of inequality.

Continue to: With this information...

With this information, we are strongly encouraging our patients to participate in video conferencing sessions. We suspect that for some patients, the possibility of them participating in video conferencing sessions is greater than they have acknowledged. We are stepping up education and support, both informally through the patient’s family and friends, and more formally through case managers who “lend” patients a device during home visits.

In summary, this inequality in access to the technology needed for telepsychiatry will loom even more prominently as we all move forward, both clinically and in policymaking.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact letters@currentpsychiatry.com.

The COVID-19 pandemic has brought to the fore inequalities in health care.¹ In a letter recently published in the American Journal of Psychiatry, Nadkarni et al² addressed the reality that there is not equal access to quality care (in this case, telepsychiatry). They reported challenges in converting their psychiatry ambulatory care center to a virtual platform at Brigham and Women’s Hospital, which is affiliated with Harvard Medical School.

Previously, I had reported in Current Psychiatry that patients at our small community mental health clinic outside Baltimore have much less audiovisual capability (they were able to receive telepsychiatry services via phone only, and not via video conferencing on a computer, smartphone, or tablet).³ Of 100 consecutive patients, we used telepsychiatry for 82 (18 were seen in person, including 14 who were seen for administration of long-acting injectable medications). Of the 82 patients receiving telepsychiatry from our facility, only 9 had video conferencing sessions (10.9%).

I repeated the survey approximately 3 months later. Preliminary data of these 125 total patients showed a slightly higher percentage (12.6%) had video conferencing sessions.

Factors associated with limited access to technology

Similar to what was reported by Nadkarni et al,² in our extremely vulnerable population, socioeconomic factors affect access. Our patients are low income, and often do not own computers or smart phones. Nearly all our patients receive medical assistance and/or Medicare. Our patients are more likely to be members of a racial minority group—4 times the national average. Our patients are older.⁴ Patient age varies from 16 to 83 years; the mean age is 54, and the median age is 56. Educational level is low. Nearly all of our patients who participate in video conferencing sessions are female. Approximately 15 of our patients have comorbid intellectual and developmental disabilities diagnoses, and at least that many have subsyndromal symptoms. Constantino et al⁵ commented on the multiple negative consequences of the COVID-19 pandemic on individuals with intellectual and developmental disabilities, including “frank disparities in access” to technology as well as gaps left by relying exclusively on telehealth.

Among our patients, being low income, a member of a racial minority group, older, less educated, male, and developmentally and/or intellectually disabled are risk factors for less access to video conferencing.³ Nadkarni et al² also noted less broadband access for rural residents and less access and lack of digital health literacy in patients with limited English proficiency.

As Nadkarni et al² suggested, we did contact our legislators, and emergency rules are continuing. For now, we are managing fiscally. Although that certainly is important, it does not address the issue of inequality.

Continue to: With this information...

With this information, we are strongly encouraging our patients to participate in video conferencing sessions. We suspect that for some patients, the possibility of them participating in video conferencing sessions is greater than they have acknowledged. We are stepping up education and support, both informally through the patient’s family and friends, and more formally through case managers who “lend” patients a device during home visits.

In summary, this inequality in access to the technology needed for telepsychiatry will loom even more prominently as we all move forward, both clinically and in policymaking.

I wanted to thank Dr. Nasrallah for his bold article, “Treatment resistance is a myth!” (From the Editor, Current Psychiatry, March 2021, p. 14-16,28). “Treatment resistance” has become an overused catchphrase, largely for commercial purposes, that sends a distorted view to the public that current psychiatric treatments are ineffective. We have proven, safe, and effective treatments as covered in the article. So, instead of “treatment resistance,” we should be publicizing that “treatment works!” to encourage people to seek help for mental disorders and addictions.

Stanley N. Caroff, MD
Professor of Psychiatry
Perelman School of Medicine
University of Pennsylvania
Philadelphia, Pennsylvania

I thought Dr. Nasrallah’s editorial on treatment resistance was excellent. In my experience, bipolar depression often is not diagnosed in patients with long-standing depression. These patients do worse on antidepressants, which is interpreted by the clinician as treatment-resistant major depressive disorder. The other issue for me is that individuals with bipolar disorder with psychotic features are often diagnosed with schizophrenia or schizo­affective disorder and never receive a trial of lithium, which could alter the course of their illness in a dramatic fashion. For me, the under­utilization of lithium is a real quality problem in our field. Keep up the good work!

Bruce J. Schwartz, MD
Deputy Chairman & Professor of PsychiatryMontefiore Medical Center and Albert Einstein College of Medicine
New York, New York

 

 

Are psychiatric advances still science fiction?

I read with great enthusiasm Dr. Nasrallah’s editorial “Today’s psychiatric neuroscience advances were science fiction during my residency” (From the Editor, Current Psychiatry, April 2021, p. 5-7,12,24) and I, too, can see how our field has come a long way since my days of residency. However, as I read the article, I could not stop thinking about how many of the advances Dr. Nasrallah mentioned are still science fiction for the communities I work with.

I have spent all my professional life serving in the public sector, mainly in New York, and can tell you that many of the brain exploration methods, methodologies, and clinical advances mentioned in this article unfortunately are still a dream for us. Still, we remain hopeful that someday those transformative advances will come to us, too, especially as the technology innovates and improves!

Vania Castillo, MD
New York, New York

Dr. Nasrallah responds

Thank you for your comments. Please remember that every single treatment you are currently using in the public mental health system was a research discovery at one point in the past, and it took many years to bring it to clinical practice. Translating basic neuroscience discoveries, such as the ones I mentioned in my editorial, into clinical practice not only takes time to develop and get approved for use, but also requires substantial funding and a cadre of psychiatric physician-scientists, both of which are in short supply.

“Warp speed” COVID-19 vaccine development was possible only because the deadly pandemic became such an urgent national crisis that the government opened its coffers and diverted billions of dollars to pharmaceutical companies, with a massive infrastructure of human talent and biotechnology, making this veritable “moonshot” a reality in 1 year instead of many. Regrettably, even though neuropsychiatric disorders are a serious societal plague that causes disability and early mortality from suicide, homicide, substance use, cardiovascular risk, and accelerated aging, they do not command the urgency of an infectious viral pandemic that rapidly killed millions and shut down societies all over the world.

You probably heard the saying “a journey of a thousand miles begins with a single step.” I believe we are more than one step—maybe more than 100 steps—toward the type of breakthroughs that we all crave for our long-suffering psychiatric patients. I am grateful for the medical advances we have made over the past 10 to 15 years, such as neuromodulation, rapid-acting parenteral antidepressants, nondopaminergic antipsychotics, therapeutic hallucinogens, early recognition and intervention, and many promising neurobiologic leads and novel therapeutic targets for the brain disorders we deal with every day.

The brain is the most complex, challenging, and physically inaccessible organ to explore and treat. In medicine, we can do heart, lung, liver, and kidney biopsies, but it is far too dangerous to do brain biopsies that would help uncover the molecular and cellular underpinnings of neuropsychiatric disorders. Yet thankfully, our knowledge of the brain structure and function in health and disease has grown by >100,000% over the past few decades compared to the preceding millennia of dark ignorance. Someday, we shall overcome.

Disclosures
The authors report no financial relationships with any companies whose products are mentioned in their letters, or with manufacturers of competing products.

I wanted to thank Dr. Nasrallah for his bold article, “Treatment resistance is a myth!” (From the Editor, Current Psychiatry, March 2021, p. 14-16,28). “Treatment resistance” has become an overused catchphrase, largely for commercial purposes, that sends a distorted view to the public that current psychiatric treatments are ineffective. We have proven, safe, and effective treatments as covered in the article. So, instead of “treatment resistance,” we should be publicizing that “treatment works!” to encourage people to seek help for mental disorders and addictions.

Stanley N. Caroff, MD
Professor of Psychiatry
Perelman School of Medicine
University of Pennsylvania
Philadelphia, Pennsylvania

I thought Dr. Nasrallah’s editorial on treatment resistance was excellent. In my experience, bipolar depression often is not diagnosed in patients with long-standing depression. These patients do worse on antidepressants, which is interpreted by the clinician as treatment-resistant major depressive disorder. The other issue for me is that individuals with bipolar disorder with psychotic features are often diagnosed with schizophrenia or schizo­affective disorder and never receive a trial of lithium, which could alter the course of their illness in a dramatic fashion. For me, the under­utilization of lithium is a real quality problem in our field. Keep up the good work!

Bruce J. Schwartz, MD
Deputy Chairman & Professor of PsychiatryMontefiore Medical Center and Albert Einstein College of Medicine
New York, New York

 

 

Are psychiatric advances still science fiction?

I read with great enthusiasm Dr. Nasrallah’s editorial “Today’s psychiatric neuroscience advances were science fiction during my residency” (From the Editor, Current Psychiatry, April 2021, p. 5-7,12,24) and I, too, can see how our field has come a long way since my days of residency. However, as I read the article, I could not stop thinking about how many of the advances Dr. Nasrallah mentioned are still science fiction for the communities I work with.

I have spent all my professional life serving in the public sector, mainly in New York, and can tell you that many of the brain exploration methods, methodologies, and clinical advances mentioned in this article unfortunately are still a dream for us. Still, we remain hopeful that someday those transformative advances will come to us, too, especially as the technology innovates and improves!

Vania Castillo, MD
New York, New York

Dr. Nasrallah responds

Thank you for your comments. Please remember that every single treatment you are currently using in the public mental health system was a research discovery at one point in the past, and it took many years to bring it to clinical practice. Translating basic neuroscience discoveries, such as the ones I mentioned in my editorial, into clinical practice not only takes time to develop and get approved for use, but also requires substantial funding and a cadre of psychiatric physician-scientists, both of which are in short supply.

“Warp speed” COVID-19 vaccine development was possible only because the deadly pandemic became such an urgent national crisis that the government opened its coffers and diverted billions of dollars to pharmaceutical companies, with a massive infrastructure of human talent and biotechnology, making this veritable “moonshot” a reality in 1 year instead of many. Regrettably, even though neuropsychiatric disorders are a serious societal plague that causes disability and early mortality from suicide, homicide, substance use, cardiovascular risk, and accelerated aging, they do not command the urgency of an infectious viral pandemic that rapidly killed millions and shut down societies all over the world.

You probably heard the saying “a journey of a thousand miles begins with a single step.” I believe we are more than one step—maybe more than 100 steps—toward the type of breakthroughs that we all crave for our long-suffering psychiatric patients. I am grateful for the medical advances we have made over the past 10 to 15 years, such as neuromodulation, rapid-acting parenteral antidepressants, nondopaminergic antipsychotics, therapeutic hallucinogens, early recognition and intervention, and many promising neurobiologic leads and novel therapeutic targets for the brain disorders we deal with every day.

The brain is the most complex, challenging, and physically inaccessible organ to explore and treat. In medicine, we can do heart, lung, liver, and kidney biopsies, but it is far too dangerous to do brain biopsies that would help uncover the molecular and cellular underpinnings of neuropsychiatric disorders. Yet thankfully, our knowledge of the brain structure and function in health and disease has grown by >100,000% over the past few decades compared to the preceding millennia of dark ignorance. Someday, we shall overcome.

Disclosures
The authors report no financial relationships with any companies whose products are mentioned in their letters, or with manufacturers of competing products.

I wanted to thank Dr. Nasrallah for his bold article, “Treatment resistance is a myth!” (From the Editor, Current Psychiatry, March 2021, p. 14-16,28). “Treatment resistance” has become an overused catchphrase, largely for commercial purposes, that sends a distorted view to the public that current psychiatric treatments are ineffective. We have proven, safe, and effective treatments as covered in the article. So, instead of “treatment resistance,” we should be publicizing that “treatment works!” to encourage people to seek help for mental disorders and addictions.

Stanley N. Caroff, MD
Professor of Psychiatry
Perelman School of Medicine
University of Pennsylvania
Philadelphia, Pennsylvania

I thought Dr. Nasrallah’s editorial on treatment resistance was excellent. In my experience, bipolar depression often is not diagnosed in patients with long-standing depression. These patients do worse on antidepressants, which is interpreted by the clinician as treatment-resistant major depressive disorder. The other issue for me is that individuals with bipolar disorder with psychotic features are often diagnosed with schizophrenia or schizo­affective disorder and never receive a trial of lithium, which could alter the course of their illness in a dramatic fashion. For me, the under­utilization of lithium is a real quality problem in our field. Keep up the good work!

Bruce J. Schwartz, MD
Deputy Chairman & Professor of PsychiatryMontefiore Medical Center and Albert Einstein College of Medicine
New York, New York

 

 

Are psychiatric advances still science fiction?

I read with great enthusiasm Dr. Nasrallah’s editorial “Today’s psychiatric neuroscience advances were science fiction during my residency” (From the Editor, Current Psychiatry, April 2021, p. 5-7,12,24) and I, too, can see how our field has come a long way since my days of residency. However, as I read the article, I could not stop thinking about how many of the advances Dr. Nasrallah mentioned are still science fiction for the communities I work with.

I have spent all my professional life serving in the public sector, mainly in New York, and can tell you that many of the brain exploration methods, methodologies, and clinical advances mentioned in this article unfortunately are still a dream for us. Still, we remain hopeful that someday those transformative advances will come to us, too, especially as the technology innovates and improves!

Vania Castillo, MD
New York, New York

Dr. Nasrallah responds

Thank you for your comments. Please remember that every single treatment you are currently using in the public mental health system was a research discovery at one point in the past, and it took many years to bring it to clinical practice. Translating basic neuroscience discoveries, such as the ones I mentioned in my editorial, into clinical practice not only takes time to develop and get approved for use, but also requires substantial funding and a cadre of psychiatric physician-scientists, both of which are in short supply.

“Warp speed” COVID-19 vaccine development was possible only because the deadly pandemic became such an urgent national crisis that the government opened its coffers and diverted billions of dollars to pharmaceutical companies, with a massive infrastructure of human talent and biotechnology, making this veritable “moonshot” a reality in 1 year instead of many. Regrettably, even though neuropsychiatric disorders are a serious societal plague that causes disability and early mortality from suicide, homicide, substance use, cardiovascular risk, and accelerated aging, they do not command the urgency of an infectious viral pandemic that rapidly killed millions and shut down societies all over the world.

You probably heard the saying “a journey of a thousand miles begins with a single step.” I believe we are more than one step—maybe more than 100 steps—toward the type of breakthroughs that we all crave for our long-suffering psychiatric patients. I am grateful for the medical advances we have made over the past 10 to 15 years, such as neuromodulation, rapid-acting parenteral antidepressants, nondopaminergic antipsychotics, therapeutic hallucinogens, early recognition and intervention, and many promising neurobiologic leads and novel therapeutic targets for the brain disorders we deal with every day.

The brain is the most complex, challenging, and physically inaccessible organ to explore and treat. In medicine, we can do heart, lung, liver, and kidney biopsies, but it is far too dangerous to do brain biopsies that would help uncover the molecular and cellular underpinnings of neuropsychiatric disorders. Yet thankfully, our knowledge of the brain structure and function in health and disease has grown by >100,000% over the past few decades compared to the preceding millennia of dark ignorance. Someday, we shall overcome.

Disclosures
The authors report no financial relationships with any companies whose products are mentioned in their letters, or with manufacturers of competing products.

For this Psychiatry Leaders’ Perspectives, Awais Aftab, MD, interviewed Altha J. Stewart, MD. Dr. Stewart is Senior Associate Dean for Community Health Engagement at the University of Tennessee Health Science Center (UTHSC)–Memphis. She also serves as Chief of the Division of Social and Community Psychiatry and Director, Center for Health in Justice Involved Youth at UTHSC, where she manages community-based programs serving children impacted by trauma and mental illness and their families. In 2018, she was elected President of the American Psychiatric Association, the first African American individual elected in the 175-year history of the organization.

Dr. Aftab: Structural racism in academic and organized psychiatry is an issue that is close to your heart. What is your perspective on the current state of structural racism in American psychiatry, and what do you think we can do about it?

Dr. Stewart: That’s a good question to start with because I think the conversations that we need to have in academia in general and in academic psychiatry specifically really do frame the current issues that we are facing, whether we’re talking about eliminating health disparities or achieving mental health equity. Historically, from the very beginning these discussions have been structured in a racist manner. The early days of American psychiatry were very clearly directed towards maintaining a system that excluded large segments of the population of the time, since a particularly violent form of chattel slavery was being practiced in this country.

The mental health care system was primarily designed for the landowning white men of some standing in society, and so there was never any intent to do much in the way of providing quality humane service to people who were not part of that group. What we have today is a system that was designed for a racist societal structure, that was intended to perpetuate certain behaviors, policies, and practices that had at their core a racist framework. We have to acknowledge and start from this beginning point. This is not to blame anyone currently alive. These are larger structural problems. Before we can begin setting up strategic plans and other actions, we have to go back and acknowledge how we got here. We have to accept the responsibility for being here, and then we have to allow the conversations that need to happen to happen in a safe way, without further alienating people, or maligning and demeaning people who are for the most part well-intentioned but perhaps operating on automatic pilot in a system that is structurally racist.

Dr. Aftab: Do you think that the conversations that need to happen are taking place?

Dr. Stewart: Yes, I think they are beginning to happen. I do a fair number of talks and grand rounds, and what I discover when I meet with different academic departments and different groups is that most places now have a diversity committee, or the residents and students have assigned themselves as diversity leaders. They are really pushing to have these conversations, to insert these conversations into the training and education curricula. The structures in power are so deeply entrenched that many people, particularly younger people, are easily frustrated by the lack of forward motion. One of the things that seasoned leaders in psychiatry have to do is to help everyone understand that the movement forward might be glacial in the beginning, but any movement forward is good when it comes to this. The psychiatrists of my generation talked about cultural competence in psychiatry, but generations of today talk about structural competence. These are similar concepts, except that cultural competency worked within the traditional model, while structural competency recognizes that the system itself needs to change. I find this development very encouraging.

Dr. Aftab: What do you see as some of the strengths of our profession?

Continue to: Dr. Stewart

Dr. Stewart: I am a hopeful optimist when it comes to psychiatry. I have dedicated my professional life to psychiatry and specifically to community psychiatry. Throughout the time that I have practiced psychiatry, I have been encouraged that what we do as a medical specialty really does improve the quality of life for the people we serve. Situationally right now, we’re in a unique position because the COVID pandemic has laid open and then laid bare the whole issue of how we deal with psychological distress, whether it’s diagnosed mental illness or a natural, normal response to a catastrophic event. We are the experts in this. This is our sweet spot, our wheelhouse, whatever analogy you prefer. This is the moment where we assert our expertise as the leaders—not as service add-ons, not as followers, not as adjuncts, but as the leaders.

I am so impressed with the next generation of psychiatrists. They have a wonderful blend of pride and privilege at what they have been able to accomplish to get to the point where they are doctors and psychiatrists, but they have aligned that with a strong core sense of social justice, and they are moved by their responsibility to the people in the society around them.

Another strength of our profession is what we consider to be the “art” of psychiatry. That is, the way we marry the relational aspects of psychiatry with the biological, technical, and digital aspects to arrive at a happy collaboration that benefits people. It is our great skill to engage people, to interact with them therapeutically, to recognize and acknowledge the nonverbal cues. This skill will be even more important in the age of online mental health services. I’m an “old-school” therapist. I like that face-to-face interaction. I think it’s important to preserve that aspect of our practice, even as we move towards online services.

Dr. Aftab: Are there ways in which the status quo in psychiatry falls short of the ideal? What are our areas of relative weakness?

Dr. Stewart: I don’t think we can afford to remain in status quo, because we need to constantly think and rethink, evaluate and re-evaluate, assess things in the light of new information. Particularly if we’re talking about people who rely on public funding to get even the bare minimum services, status quo doesn’t cut it. It’s not good enough. I had a teacher during my residency, a child psychiatrist, who used to say, “Good, better, best. Never let it rest, until your good is better and your better is best.” Something about that has stuck with me. As my career progressed, I heard variations of it, including one from former Surgeon General of the United States David Satcher, who was not a psychiatrist, but pulled together the group that published the first Surgeon General’s report on mental health, followed by the Surgeon General’s report on mental health, culture, race, and ethnicity. He had the penetrating insight that risk factors are not to be accepted as predictive factors due to protective factors. If I am at risk for mental illness or a chronic medical condition based on my race or ethnicity or socioeconomic status or employment status, this does not mean that I am destined to experience that illness. In fact, we are not doing our job if we accept these outcomes as inevitable and make no attempt to change them. So, for me, if we accept the status quo, we give up on the message of “Good, better, best. Never let it rest, until your good is better and your better is best.”

Continue to: Dr. Aftab

Dr. Aftab: What is your perception of the threats that psychiatry faces or is likely to face in the future?

Dr. Stewart: Well, this is going to sound harsh, and I do hope that the readers do not feel that I intend it to be harsh. We get in our own way. I work in the public sector, for example, and the reality is that there aren’t enough psychiatrists to provide all the necessary psychiatric services for the people who need them. So many mental health clinics and practices employ other mental health professionals, whether they are psychologists or nurse practitioners or physician assistants with special training in mental health to provide those services. To have a blanket concern about anyone who is not an MD practicing in what is considered “our area” just begs the question that if we can’t do it and we don’t have enough psychiatrists to do it, should people just not get mental health treatment? Is that the solution? I don’t think so. I don’t think that’s what people want, either, but because of the energy that gets aroused around these issues, we lose sight of that end goal. I think the answer is that we must take leadership for ensuring that our colleagues are well-trained, maybe not as well-trained as physicians, but well-trained enough to provide good care working under our supervision.

Dr. Aftab: What do you envision for the future of psychiatry? What sort of opportunities lie ahead for us?

Dr. Stewart: I think we are moving naturally into the space of integrated or collaborative care. I think we’re going to have to acknowledge that going forward, the path to being a good psychiatrist means that we will also be consultants. Not just the consultation-liaison kind of consultant that we typically think of, but a consultant to the rest of medicine around shaping programs, addressing how we treat comorbid illness, looking at ways to minimize the morbidity and mortality associated with some of the chronic medical and mental diseases. We’re moving naturally in that direction. For some people, that must be frightening. All throughout medicine people are witnessing change, and we need to adapt. I would hope that the specialty that is designed to help others deal with change will figure out how to use those skills to help themselves deal with the changes that are coming!

For this Psychiatry Leaders’ Perspectives, Awais Aftab, MD, interviewed Altha J. Stewart, MD. Dr. Stewart is Senior Associate Dean for Community Health Engagement at the University of Tennessee Health Science Center (UTHSC)–Memphis. She also serves as Chief of the Division of Social and Community Psychiatry and Director, Center for Health in Justice Involved Youth at UTHSC, where she manages community-based programs serving children impacted by trauma and mental illness and their families. In 2018, she was elected President of the American Psychiatric Association, the first African American individual elected in the 175-year history of the organization.

Dr. Aftab: Structural racism in academic and organized psychiatry is an issue that is close to your heart. What is your perspective on the current state of structural racism in American psychiatry, and what do you think we can do about it?

Dr. Stewart: That’s a good question to start with because I think the conversations that we need to have in academia in general and in academic psychiatry specifically really do frame the current issues that we are facing, whether we’re talking about eliminating health disparities or achieving mental health equity. Historically, from the very beginning these discussions have been structured in a racist manner. The early days of American psychiatry were very clearly directed towards maintaining a system that excluded large segments of the population of the time, since a particularly violent form of chattel slavery was being practiced in this country.

The mental health care system was primarily designed for the landowning white men of some standing in society, and so there was never any intent to do much in the way of providing quality humane service to people who were not part of that group. What we have today is a system that was designed for a racist societal structure, that was intended to perpetuate certain behaviors, policies, and practices that had at their core a racist framework. We have to acknowledge and start from this beginning point. This is not to blame anyone currently alive. These are larger structural problems. Before we can begin setting up strategic plans and other actions, we have to go back and acknowledge how we got here. We have to accept the responsibility for being here, and then we have to allow the conversations that need to happen to happen in a safe way, without further alienating people, or maligning and demeaning people who are for the most part well-intentioned but perhaps operating on automatic pilot in a system that is structurally racist.

Dr. Aftab: Do you think that the conversations that need to happen are taking place?

Dr. Stewart: Yes, I think they are beginning to happen. I do a fair number of talks and grand rounds, and what I discover when I meet with different academic departments and different groups is that most places now have a diversity committee, or the residents and students have assigned themselves as diversity leaders. They are really pushing to have these conversations, to insert these conversations into the training and education curricula. The structures in power are so deeply entrenched that many people, particularly younger people, are easily frustrated by the lack of forward motion. One of the things that seasoned leaders in psychiatry have to do is to help everyone understand that the movement forward might be glacial in the beginning, but any movement forward is good when it comes to this. The psychiatrists of my generation talked about cultural competence in psychiatry, but generations of today talk about structural competence. These are similar concepts, except that cultural competency worked within the traditional model, while structural competency recognizes that the system itself needs to change. I find this development very encouraging.

Dr. Aftab: What do you see as some of the strengths of our profession?

Continue to: Dr. Stewart

Dr. Stewart: I am a hopeful optimist when it comes to psychiatry. I have dedicated my professional life to psychiatry and specifically to community psychiatry. Throughout the time that I have practiced psychiatry, I have been encouraged that what we do as a medical specialty really does improve the quality of life for the people we serve. Situationally right now, we’re in a unique position because the COVID pandemic has laid open and then laid bare the whole issue of how we deal with psychological distress, whether it’s diagnosed mental illness or a natural, normal response to a catastrophic event. We are the experts in this. This is our sweet spot, our wheelhouse, whatever analogy you prefer. This is the moment where we assert our expertise as the leaders—not as service add-ons, not as followers, not as adjuncts, but as the leaders.

I am so impressed with the next generation of psychiatrists. They have a wonderful blend of pride and privilege at what they have been able to accomplish to get to the point where they are doctors and psychiatrists, but they have aligned that with a strong core sense of social justice, and they are moved by their responsibility to the people in the society around them.

Another strength of our profession is what we consider to be the “art” of psychiatry. That is, the way we marry the relational aspects of psychiatry with the biological, technical, and digital aspects to arrive at a happy collaboration that benefits people. It is our great skill to engage people, to interact with them therapeutically, to recognize and acknowledge the nonverbal cues. This skill will be even more important in the age of online mental health services. I’m an “old-school” therapist. I like that face-to-face interaction. I think it’s important to preserve that aspect of our practice, even as we move towards online services.

Dr. Aftab: Are there ways in which the status quo in psychiatry falls short of the ideal? What are our areas of relative weakness?

Dr. Stewart: I don’t think we can afford to remain in status quo, because we need to constantly think and rethink, evaluate and re-evaluate, assess things in the light of new information. Particularly if we’re talking about people who rely on public funding to get even the bare minimum services, status quo doesn’t cut it. It’s not good enough. I had a teacher during my residency, a child psychiatrist, who used to say, “Good, better, best. Never let it rest, until your good is better and your better is best.” Something about that has stuck with me. As my career progressed, I heard variations of it, including one from former Surgeon General of the United States David Satcher, who was not a psychiatrist, but pulled together the group that published the first Surgeon General’s report on mental health, followed by the Surgeon General’s report on mental health, culture, race, and ethnicity. He had the penetrating insight that risk factors are not to be accepted as predictive factors due to protective factors. If I am at risk for mental illness or a chronic medical condition based on my race or ethnicity or socioeconomic status or employment status, this does not mean that I am destined to experience that illness. In fact, we are not doing our job if we accept these outcomes as inevitable and make no attempt to change them. So, for me, if we accept the status quo, we give up on the message of “Good, better, best. Never let it rest, until your good is better and your better is best.”

Continue to: Dr. Aftab

Dr. Aftab: What is your perception of the threats that psychiatry faces or is likely to face in the future?

Dr. Stewart: Well, this is going to sound harsh, and I do hope that the readers do not feel that I intend it to be harsh. We get in our own way. I work in the public sector, for example, and the reality is that there aren’t enough psychiatrists to provide all the necessary psychiatric services for the people who need them. So many mental health clinics and practices employ other mental health professionals, whether they are psychologists or nurse practitioners or physician assistants with special training in mental health to provide those services. To have a blanket concern about anyone who is not an MD practicing in what is considered “our area” just begs the question that if we can’t do it and we don’t have enough psychiatrists to do it, should people just not get mental health treatment? Is that the solution? I don’t think so. I don’t think that’s what people want, either, but because of the energy that gets aroused around these issues, we lose sight of that end goal. I think the answer is that we must take leadership for ensuring that our colleagues are well-trained, maybe not as well-trained as physicians, but well-trained enough to provide good care working under our supervision.

Dr. Aftab: What do you envision for the future of psychiatry? What sort of opportunities lie ahead for us?

Dr. Stewart: I think we are moving naturally into the space of integrated or collaborative care. I think we’re going to have to acknowledge that going forward, the path to being a good psychiatrist means that we will also be consultants. Not just the consultation-liaison kind of consultant that we typically think of, but a consultant to the rest of medicine around shaping programs, addressing how we treat comorbid illness, looking at ways to minimize the morbidity and mortality associated with some of the chronic medical and mental diseases. We’re moving naturally in that direction. For some people, that must be frightening. All throughout medicine people are witnessing change, and we need to adapt. I would hope that the specialty that is designed to help others deal with change will figure out how to use those skills to help themselves deal with the changes that are coming!

For this Psychiatry Leaders’ Perspectives, Awais Aftab, MD, interviewed Altha J. Stewart, MD. Dr. Stewart is Senior Associate Dean for Community Health Engagement at the University of Tennessee Health Science Center (UTHSC)–Memphis. She also serves as Chief of the Division of Social and Community Psychiatry and Director, Center for Health in Justice Involved Youth at UTHSC, where she manages community-based programs serving children impacted by trauma and mental illness and their families. In 2018, she was elected President of the American Psychiatric Association, the first African American individual elected in the 175-year history of the organization.

Dr. Aftab: Structural racism in academic and organized psychiatry is an issue that is close to your heart. What is your perspective on the current state of structural racism in American psychiatry, and what do you think we can do about it?

Dr. Stewart: That’s a good question to start with because I think the conversations that we need to have in academia in general and in academic psychiatry specifically really do frame the current issues that we are facing, whether we’re talking about eliminating health disparities or achieving mental health equity. Historically, from the very beginning these discussions have been structured in a racist manner. The early days of American psychiatry were very clearly directed towards maintaining a system that excluded large segments of the population of the time, since a particularly violent form of chattel slavery was being practiced in this country.

The mental health care system was primarily designed for the landowning white men of some standing in society, and so there was never any intent to do much in the way of providing quality humane service to people who were not part of that group. What we have today is a system that was designed for a racist societal structure, that was intended to perpetuate certain behaviors, policies, and practices that had at their core a racist framework. We have to acknowledge and start from this beginning point. This is not to blame anyone currently alive. These are larger structural problems. Before we can begin setting up strategic plans and other actions, we have to go back and acknowledge how we got here. We have to accept the responsibility for being here, and then we have to allow the conversations that need to happen to happen in a safe way, without further alienating people, or maligning and demeaning people who are for the most part well-intentioned but perhaps operating on automatic pilot in a system that is structurally racist.

Dr. Aftab: Do you think that the conversations that need to happen are taking place?

Dr. Stewart: Yes, I think they are beginning to happen. I do a fair number of talks and grand rounds, and what I discover when I meet with different academic departments and different groups is that most places now have a diversity committee, or the residents and students have assigned themselves as diversity leaders. They are really pushing to have these conversations, to insert these conversations into the training and education curricula. The structures in power are so deeply entrenched that many people, particularly younger people, are easily frustrated by the lack of forward motion. One of the things that seasoned leaders in psychiatry have to do is to help everyone understand that the movement forward might be glacial in the beginning, but any movement forward is good when it comes to this. The psychiatrists of my generation talked about cultural competence in psychiatry, but generations of today talk about structural competence. These are similar concepts, except that cultural competency worked within the traditional model, while structural competency recognizes that the system itself needs to change. I find this development very encouraging.

Dr. Aftab: What do you see as some of the strengths of our profession?

Continue to: Dr. Stewart

Dr. Stewart: I am a hopeful optimist when it comes to psychiatry. I have dedicated my professional life to psychiatry and specifically to community psychiatry. Throughout the time that I have practiced psychiatry, I have been encouraged that what we do as a medical specialty really does improve the quality of life for the people we serve. Situationally right now, we’re in a unique position because the COVID pandemic has laid open and then laid bare the whole issue of how we deal with psychological distress, whether it’s diagnosed mental illness or a natural, normal response to a catastrophic event. We are the experts in this. This is our sweet spot, our wheelhouse, whatever analogy you prefer. This is the moment where we assert our expertise as the leaders—not as service add-ons, not as followers, not as adjuncts, but as the leaders.

I am so impressed with the next generation of psychiatrists. They have a wonderful blend of pride and privilege at what they have been able to accomplish to get to the point where they are doctors and psychiatrists, but they have aligned that with a strong core sense of social justice, and they are moved by their responsibility to the people in the society around them.

Another strength of our profession is what we consider to be the “art” of psychiatry. That is, the way we marry the relational aspects of psychiatry with the biological, technical, and digital aspects to arrive at a happy collaboration that benefits people. It is our great skill to engage people, to interact with them therapeutically, to recognize and acknowledge the nonverbal cues. This skill will be even more important in the age of online mental health services. I’m an “old-school” therapist. I like that face-to-face interaction. I think it’s important to preserve that aspect of our practice, even as we move towards online services.

Dr. Aftab: Are there ways in which the status quo in psychiatry falls short of the ideal? What are our areas of relative weakness?

Dr. Stewart: I don’t think we can afford to remain in status quo, because we need to constantly think and rethink, evaluate and re-evaluate, assess things in the light of new information. Particularly if we’re talking about people who rely on public funding to get even the bare minimum services, status quo doesn’t cut it. It’s not good enough. I had a teacher during my residency, a child psychiatrist, who used to say, “Good, better, best. Never let it rest, until your good is better and your better is best.” Something about that has stuck with me. As my career progressed, I heard variations of it, including one from former Surgeon General of the United States David Satcher, who was not a psychiatrist, but pulled together the group that published the first Surgeon General’s report on mental health, followed by the Surgeon General’s report on mental health, culture, race, and ethnicity. He had the penetrating insight that risk factors are not to be accepted as predictive factors due to protective factors. If I am at risk for mental illness or a chronic medical condition based on my race or ethnicity or socioeconomic status or employment status, this does not mean that I am destined to experience that illness. In fact, we are not doing our job if we accept these outcomes as inevitable and make no attempt to change them. So, for me, if we accept the status quo, we give up on the message of “Good, better, best. Never let it rest, until your good is better and your better is best.”

Continue to: Dr. Aftab

Dr. Aftab: What is your perception of the threats that psychiatry faces or is likely to face in the future?

Dr. Stewart: Well, this is going to sound harsh, and I do hope that the readers do not feel that I intend it to be harsh. We get in our own way. I work in the public sector, for example, and the reality is that there aren’t enough psychiatrists to provide all the necessary psychiatric services for the people who need them. So many mental health clinics and practices employ other mental health professionals, whether they are psychologists or nurse practitioners or physician assistants with special training in mental health to provide those services. To have a blanket concern about anyone who is not an MD practicing in what is considered “our area” just begs the question that if we can’t do it and we don’t have enough psychiatrists to do it, should people just not get mental health treatment? Is that the solution? I don’t think so. I don’t think that’s what people want, either, but because of the energy that gets aroused around these issues, we lose sight of that end goal. I think the answer is that we must take leadership for ensuring that our colleagues are well-trained, maybe not as well-trained as physicians, but well-trained enough to provide good care working under our supervision.

Dr. Aftab: What do you envision for the future of psychiatry? What sort of opportunities lie ahead for us?

Dr. Stewart: I think we are moving naturally into the space of integrated or collaborative care. I think we’re going to have to acknowledge that going forward, the path to being a good psychiatrist means that we will also be consultants. Not just the consultation-liaison kind of consultant that we typically think of, but a consultant to the rest of medicine around shaping programs, addressing how we treat comorbid illness, looking at ways to minimize the morbidity and mortality associated with some of the chronic medical and mental diseases. We’re moving naturally in that direction. For some people, that must be frightening. All throughout medicine people are witnessing change, and we need to adapt. I would hope that the specialty that is designed to help others deal with change will figure out how to use those skills to help themselves deal with the changes that are coming!

DDW is now history. While rejoicing that DDW happened (as opposed to when it couldn’t in 2020), the virtual format precluded all those hallway conversations, meetings with mentors and small group (after hour) discussions. This year, AGA saved substantial monies in travel costs. Of note, at Michigan Medicine, we track the miles patients did not have to travel because of our conversion to virtual care (currently about 30% of all ambulatory visits). To date, our “virtual first” protocol has saved over 24 million patient travel-miles since February 2020 (average of 62 miles per patient visit).

The pandemic forced rapid adoption of virtual care and alternative care delivery models. As patients adapted to telehealth, businesses saw opportunities. Health systems have begun to downsize their brick-and-mortar footprints for both clinical and office space. Hospital at Home models are developing as viable alternatives to inpatient care using a hybrid system of on-site nurses and remote physician supervision.

Digital health start-ups are developing rapidly, and equity funding for digital health companies has reached an all-time high of $26.5 billion in 2020. Multiple companies went public through traditional initial public offerings or special purpose acquisition companies. Sameer Berry, MD, recently collected an inventory of major GI digital health companies counted at least 16 with more appearing each month. These companies focus on management of a single condition (for example IBS or Celiac) or full-service virtual GI care that includes “at-risk” financial contracts

I am delighted to announce that Megan Adams, MD, JD, MSc, has been chosen to be the fourth editor in chief of GI & Hepatology News. She and her team will transition into editorial control during Fall 2021. I have known Megan since meeting her at an AGA young faculty function almost 10 years ago. She is extremely talented and knowledgeable about gastroenterology from a variety of viewpoints. She has recruited a strong and dedicated editorial board.

I have enjoyed the last 5 years leading the current board as we have brought breaking news to the GI community. I wish to publicly thank our editorial board and the Frontline staff who monthly publish AGA’s official newspaper.

John I. Allen, MD, MBA, AGAF
Editor in Chief

DDW is now history. While rejoicing that DDW happened (as opposed to when it couldn’t in 2020), the virtual format precluded all those hallway conversations, meetings with mentors and small group (after hour) discussions. This year, AGA saved substantial monies in travel costs. Of note, at Michigan Medicine, we track the miles patients did not have to travel because of our conversion to virtual care (currently about 30% of all ambulatory visits). To date, our “virtual first” protocol has saved over 24 million patient travel-miles since February 2020 (average of 62 miles per patient visit).

The pandemic forced rapid adoption of virtual care and alternative care delivery models. As patients adapted to telehealth, businesses saw opportunities. Health systems have begun to downsize their brick-and-mortar footprints for both clinical and office space. Hospital at Home models are developing as viable alternatives to inpatient care using a hybrid system of on-site nurses and remote physician supervision.

Digital health start-ups are developing rapidly, and equity funding for digital health companies has reached an all-time high of $26.5 billion in 2020. Multiple companies went public through traditional initial public offerings or special purpose acquisition companies. Sameer Berry, MD, recently collected an inventory of major GI digital health companies counted at least 16 with more appearing each month. These companies focus on management of a single condition (for example IBS or Celiac) or full-service virtual GI care that includes “at-risk” financial contracts

I am delighted to announce that Megan Adams, MD, JD, MSc, has been chosen to be the fourth editor in chief of GI & Hepatology News. She and her team will transition into editorial control during Fall 2021. I have known Megan since meeting her at an AGA young faculty function almost 10 years ago. She is extremely talented and knowledgeable about gastroenterology from a variety of viewpoints. She has recruited a strong and dedicated editorial board.

I have enjoyed the last 5 years leading the current board as we have brought breaking news to the GI community. I wish to publicly thank our editorial board and the Frontline staff who monthly publish AGA’s official newspaper.

John I. Allen, MD, MBA, AGAF
Editor in Chief

DDW is now history. While rejoicing that DDW happened (as opposed to when it couldn’t in 2020), the virtual format precluded all those hallway conversations, meetings with mentors and small group (after hour) discussions. This year, AGA saved substantial monies in travel costs. Of note, at Michigan Medicine, we track the miles patients did not have to travel because of our conversion to virtual care (currently about 30% of all ambulatory visits). To date, our “virtual first” protocol has saved over 24 million patient travel-miles since February 2020 (average of 62 miles per patient visit).

The pandemic forced rapid adoption of virtual care and alternative care delivery models. As patients adapted to telehealth, businesses saw opportunities. Health systems have begun to downsize their brick-and-mortar footprints for both clinical and office space. Hospital at Home models are developing as viable alternatives to inpatient care using a hybrid system of on-site nurses and remote physician supervision.

Digital health start-ups are developing rapidly, and equity funding for digital health companies has reached an all-time high of $26.5 billion in 2020. Multiple companies went public through traditional initial public offerings or special purpose acquisition companies. Sameer Berry, MD, recently collected an inventory of major GI digital health companies counted at least 16 with more appearing each month. These companies focus on management of a single condition (for example IBS or Celiac) or full-service virtual GI care that includes “at-risk” financial contracts

I am delighted to announce that Megan Adams, MD, JD, MSc, has been chosen to be the fourth editor in chief of GI & Hepatology News. She and her team will transition into editorial control during Fall 2021. I have known Megan since meeting her at an AGA young faculty function almost 10 years ago. She is extremely talented and knowledgeable about gastroenterology from a variety of viewpoints. She has recruited a strong and dedicated editorial board.

I have enjoyed the last 5 years leading the current board as we have brought breaking news to the GI community. I wish to publicly thank our editorial board and the Frontline staff who monthly publish AGA’s official newspaper.

John I. Allen, MD, MBA, AGAF
Editor in Chief

During the course of my residency training, I have experienced and witnessed patients and visitors harassing health care workers (HCWs) by cursing or directing racial slurs at them, making sexist comments, or threatening their lives. What should be the correct response to this harassment? To say nothing may avoid conflict, but the silence perpetuates such abuse. To speak up may provoke aggression or even a physical assault. Further, does our response change if it is not the patient but someone who is accompanying them who exhibits this behavior?

I conducted a survey of psychiatry HCWs at our institution to evaluate the prevalence of and factors associated with such harassment.

An all-too-common problem

In a December 2020 internal survey at the University of Missouri Department of Psychiatry, 59 of 158 HCWs responded, and 26 (44%) reported experiencing or witnessing on-the-job harassment or abuse. Factors that were statistically significantly associated with experiencing or witnessing on-the-job harassment or abuse included being non-White, working in a patient-facing position, and being a nonphysician patient-facing HCW (Table 1). Factors that were not significantly associated with experiencing or witnessing on-the-job harassment or abuse included clinical setting, HCW age, and HCW gender (Table 2).

In addition to comments from patients and visitors, respondents stated that the harassment or abuse also included:

• physically threatening behavior and assault
• reporting a HCW for HIPAA (Health Insurance Portability and Accountability Act) violations after the HCW declined to provide an early refill of a controlled substance
• being accused of being a bad person for declining to prescribe a specific medication
• insults about not being intelligent enough to be on the treatment team
• comments from colleagues.

At the most basic level of response, the emergency department (ED) remains under the Emergency Medical Treatment and Labor Act (EMTALA) obligation to see, screen, and stabilize any patient, and if psychiatry is consulted in the ED, we should similarly provide this standard of care. Beyond this, we can create behavioral plans for when a relevant diagnosis exists or does not exist, and patients and/or visitors can be terminated from their stay at the location/service/health care system. Whether or not a patient is receiving psychiatric care and/or treatment is irrelevant to the responses to harassment we might consider.

During the incident itself, we are empowered to remove ourselves from the patient encounter. Historically, HCWs have had strong opinions on the next steps, either deciding, “Yes, I am a professional and I will not be bullied,” or “No, I am a professional and I don’t need to deal with this.” Just as we prioritize our patients’ dignities, we should also respect our own and our colleagues’ dignities.

How harassment is handled at our facility

HCWs are commonly unsure whether to “call out” abusive comments during the encounter itself or afterwards. In our hospital, HCWs are encouraged to independently choose to immediately respond, immediately report to a supervisor or hospital security, or defer and report to leadership afterwards via the Patient Safety Network (PSN). The PSN is our hospital’s reporting system for medical errors, near misses, and abuse, neglect, and workplace violence. Relevant examples of abuse, neglect, and workplace violence include:

• Threats. Expression of intent to cause harm, including verbal or written threats and threatening body language
• Physical assault. Attacks ranging from slapping and beating to rape, the use of weapons, or homicide
• Sexual assault. Any type of sexual contact or behavior that occurs without the explicit consent of the recipient, such as forced sexual intercourse, forcible sodomy, child molestation, incest, fondling, and attempted rape.

Continue to: Once complete...

Once complete, the PSN report is sent to Risk Management and other relevant groups, such as a 5-person team of security investigators, who are trained in trauma-informed interviewing and re-directive techniques. This team can immediately speak to the patient face-to-face in the inpatient setting or follow-up via phone in the outpatient setting.

The PSN report may result in the creation of a behavior plan for the patient that outlines the behaviors of concern, staff interventions, and consequences for persistent violations. The behavior plan is saved in the patient’s medical chart, and an alert pops up every time the chart is opened. The behavior plan is reviewed once annually for revision or deletion, as appropriate.

Lessons from our facility’s policy

In our health care system, our primary response to HCW harassment is to create a patient behavior plan that lays out specific expectations, care parameters, and consequences (up to terminating a patient from the entire health care system, except for EMTALA-level care). Clinicians are encouraged to report harassment to hospital administration, and a team of security investigators discusses expectations with the patient and/or visitors to prevent further abuse. We believe that describing our policies may be helpful to other health care systems and HCWs who confront this widespread issue.

During the course of my residency training, I have experienced and witnessed patients and visitors harassing health care workers (HCWs) by cursing or directing racial slurs at them, making sexist comments, or threatening their lives. What should be the correct response to this harassment? To say nothing may avoid conflict, but the silence perpetuates such abuse. To speak up may provoke aggression or even a physical assault. Further, does our response change if it is not the patient but someone who is accompanying them who exhibits this behavior?

I conducted a survey of psychiatry HCWs at our institution to evaluate the prevalence of and factors associated with such harassment.

An all-too-common problem

In a December 2020 internal survey at the University of Missouri Department of Psychiatry, 59 of 158 HCWs responded, and 26 (44%) reported experiencing or witnessing on-the-job harassment or abuse. Factors that were statistically significantly associated with experiencing or witnessing on-the-job harassment or abuse included being non-White, working in a patient-facing position, and being a nonphysician patient-facing HCW (Table 1). Factors that were not significantly associated with experiencing or witnessing on-the-job harassment or abuse included clinical setting, HCW age, and HCW gender (Table 2).

In addition to comments from patients and visitors, respondents stated that the harassment or abuse also included:

• physically threatening behavior and assault
• reporting a HCW for HIPAA (Health Insurance Portability and Accountability Act) violations after the HCW declined to provide an early refill of a controlled substance
• being accused of being a bad person for declining to prescribe a specific medication
• insults about not being intelligent enough to be on the treatment team
• comments from colleagues.

At the most basic level of response, the emergency department (ED) remains under the Emergency Medical Treatment and Labor Act (EMTALA) obligation to see, screen, and stabilize any patient, and if psychiatry is consulted in the ED, we should similarly provide this standard of care. Beyond this, we can create behavioral plans for when a relevant diagnosis exists or does not exist, and patients and/or visitors can be terminated from their stay at the location/service/health care system. Whether or not a patient is receiving psychiatric care and/or treatment is irrelevant to the responses to harassment we might consider.

During the incident itself, we are empowered to remove ourselves from the patient encounter. Historically, HCWs have had strong opinions on the next steps, either deciding, “Yes, I am a professional and I will not be bullied,” or “No, I am a professional and I don’t need to deal with this.” Just as we prioritize our patients’ dignities, we should also respect our own and our colleagues’ dignities.

How harassment is handled at our facility

HCWs are commonly unsure whether to “call out” abusive comments during the encounter itself or afterwards. In our hospital, HCWs are encouraged to independently choose to immediately respond, immediately report to a supervisor or hospital security, or defer and report to leadership afterwards via the Patient Safety Network (PSN). The PSN is our hospital’s reporting system for medical errors, near misses, and abuse, neglect, and workplace violence. Relevant examples of abuse, neglect, and workplace violence include:

• Threats. Expression of intent to cause harm, including verbal or written threats and threatening body language
• Physical assault. Attacks ranging from slapping and beating to rape, the use of weapons, or homicide
• Sexual assault. Any type of sexual contact or behavior that occurs without the explicit consent of the recipient, such as forced sexual intercourse, forcible sodomy, child molestation, incest, fondling, and attempted rape.

Continue to: Once complete...

Once complete, the PSN report is sent to Risk Management and other relevant groups, such as a 5-person team of security investigators, who are trained in trauma-informed interviewing and re-directive techniques. This team can immediately speak to the patient face-to-face in the inpatient setting or follow-up via phone in the outpatient setting.

The PSN report may result in the creation of a behavior plan for the patient that outlines the behaviors of concern, staff interventions, and consequences for persistent violations. The behavior plan is saved in the patient’s medical chart, and an alert pops up every time the chart is opened. The behavior plan is reviewed once annually for revision or deletion, as appropriate.

Lessons from our facility’s policy

In our health care system, our primary response to HCW harassment is to create a patient behavior plan that lays out specific expectations, care parameters, and consequences (up to terminating a patient from the entire health care system, except for EMTALA-level care). Clinicians are encouraged to report harassment to hospital administration, and a team of security investigators discusses expectations with the patient and/or visitors to prevent further abuse. We believe that describing our policies may be helpful to other health care systems and HCWs who confront this widespread issue.

During the course of my residency training, I have experienced and witnessed patients and visitors harassing health care workers (HCWs) by cursing or directing racial slurs at them, making sexist comments, or threatening their lives. What should be the correct response to this harassment? To say nothing may avoid conflict, but the silence perpetuates such abuse. To speak up may provoke aggression or even a physical assault. Further, does our response change if it is not the patient but someone who is accompanying them who exhibits this behavior?

I conducted a survey of psychiatry HCWs at our institution to evaluate the prevalence of and factors associated with such harassment.

An all-too-common problem

In a December 2020 internal survey at the University of Missouri Department of Psychiatry, 59 of 158 HCWs responded, and 26 (44%) reported experiencing or witnessing on-the-job harassment or abuse. Factors that were statistically significantly associated with experiencing or witnessing on-the-job harassment or abuse included being non-White, working in a patient-facing position, and being a nonphysician patient-facing HCW (Table 1). Factors that were not significantly associated with experiencing or witnessing on-the-job harassment or abuse included clinical setting, HCW age, and HCW gender (Table 2).

In addition to comments from patients and visitors, respondents stated that the harassment or abuse also included:

• physically threatening behavior and assault
• reporting a HCW for HIPAA (Health Insurance Portability and Accountability Act) violations after the HCW declined to provide an early refill of a controlled substance
• being accused of being a bad person for declining to prescribe a specific medication
• insults about not being intelligent enough to be on the treatment team
• comments from colleagues.

At the most basic level of response, the emergency department (ED) remains under the Emergency Medical Treatment and Labor Act (EMTALA) obligation to see, screen, and stabilize any patient, and if psychiatry is consulted in the ED, we should similarly provide this standard of care. Beyond this, we can create behavioral plans for when a relevant diagnosis exists or does not exist, and patients and/or visitors can be terminated from their stay at the location/service/health care system. Whether or not a patient is receiving psychiatric care and/or treatment is irrelevant to the responses to harassment we might consider.

During the incident itself, we are empowered to remove ourselves from the patient encounter. Historically, HCWs have had strong opinions on the next steps, either deciding, “Yes, I am a professional and I will not be bullied,” or “No, I am a professional and I don’t need to deal with this.” Just as we prioritize our patients’ dignities, we should also respect our own and our colleagues’ dignities.

How harassment is handled at our facility

HCWs are commonly unsure whether to “call out” abusive comments during the encounter itself or afterwards. In our hospital, HCWs are encouraged to independently choose to immediately respond, immediately report to a supervisor or hospital security, or defer and report to leadership afterwards via the Patient Safety Network (PSN). The PSN is our hospital’s reporting system for medical errors, near misses, and abuse, neglect, and workplace violence. Relevant examples of abuse, neglect, and workplace violence include:

• Threats. Expression of intent to cause harm, including verbal or written threats and threatening body language
• Physical assault. Attacks ranging from slapping and beating to rape, the use of weapons, or homicide
• Sexual assault. Any type of sexual contact or behavior that occurs without the explicit consent of the recipient, such as forced sexual intercourse, forcible sodomy, child molestation, incest, fondling, and attempted rape.

Continue to: Once complete...

Once complete, the PSN report is sent to Risk Management and other relevant groups, such as a 5-person team of security investigators, who are trained in trauma-informed interviewing and re-directive techniques. This team can immediately speak to the patient face-to-face in the inpatient setting or follow-up via phone in the outpatient setting.

The PSN report may result in the creation of a behavior plan for the patient that outlines the behaviors of concern, staff interventions, and consequences for persistent violations. The behavior plan is saved in the patient’s medical chart, and an alert pops up every time the chart is opened. The behavior plan is reviewed once annually for revision or deletion, as appropriate.

Lessons from our facility’s policy

In our health care system, our primary response to HCW harassment is to create a patient behavior plan that lays out specific expectations, care parameters, and consequences (up to terminating a patient from the entire health care system, except for EMTALA-level care). Clinicians are encouraged to report harassment to hospital administration, and a team of security investigators discusses expectations with the patient and/or visitors to prevent further abuse. We believe that describing our policies may be helpful to other health care systems and HCWs who confront this widespread issue.

Many psychiatry trainees consider private practice as a career option or form of supplemental income. In my experience, however, residency training may provide limited introduction to the general steps involved in starting a practice. In this article, I briefly summarize what I learned while exploring the private practice option as a psychiatry resident.

A good specialty for private practice

Trainees in the earlier stages of their education should be aware that the first step toward private practice may actually occur during medical school, when they are considering which specialty to pursue. If a student is particularly interested in solo private practice, they may want to select a specialty with the potential for less overhead in an independent setting. Psychiatry typically has lower overhead costs than some other specialties. This gap widens even further with the increased popularity and acceptance of telepsychiatry.

Budgeting and finance

Once you decide to pursue private practice, you will want to consider whether you prefer solo practice or group practice, and part-time or full-time. If working for yourself, you will need to understand business planning and budgeting, including how to project revenue and expenses. When first starting in solo practice—especially if you are not taking over a previously established practice—it is useful to have secondary sources of income. This can be a part-time clinical position, working with on-demand health care companies, contracting, consulting, etc. Many new physicians begin with a full-time position and decide to initiate their private practice on a part-time basis. This approach provides a level of financial security that you otherwise would not have. However, a full-time position requires full-time energy, hours, and attention, and it can be challenging to balance full-time and part-time work. Whichever approach you decide to take, it can be most helpful to simply keep an open mind and always consider looking further into any new opportunity that interests you.

Insurance and licensing

You don’t have to wait to establish your own practice to purchase malpractice insurance. Shop around for the best rates and the coverage that most comprehensively fits your needs. If your training program allows “moonlighting,” you might need your own insurance to work at sites other than your training hospital. Many residents begin to apply for independent state licensure at the same time they begin pursuing moonlighting opportunities. It may be helpful not to wait until the last minute to do this, because the process has quite a few steps and can take a while. If your state requires letters of reference, think about which of your supervisors you can ask for one. If you plan to work in a state other than that of your training location, it may be helpful to simultaneously apply for your medical license in that state, because you will already be going through the process. Certain states offer reciprocity regarding medical licenses. The Interstate Medical Licensure Compact offers an expedited pathway to licensure for qualified physicians who want to practice in multiple states.¹

Marketing your practice

Potential sources for building a panel of patients include referral networks, insurance panels, professional organizations, social media, networking, directories, and word of mouth. If you plan to accept health insurance, the directories provided by insurance panels will allow potential patients to find you when searching for practitioners who accept their plan. Professional organizations offer similar directories, and some private companies also provide directories, either for free or for a fee.

Use technology to your advantage

The exciting thing about starting a private practice today is that the technology available to support a small practice has drastically improved. Many software applications can help with scheduling and billing, which minimizes the need for office staff and enables you to be more productive. These programs typically are available via an online subscription that gives you access to an electronic medical record and other features for a monthly fee. Many of these programs provide add-ons such as a website for your practice and integrated telehealth services. While these programs typically perform many of the same functions, each has a different setup and varying workflows. An online search can facilitate a side-by-side comparison of the software programs that most closely meet your needs.

Seek out mentors and consultants

Finally, try to find a private practice mentor, and reach out to as many people as possible who have worked in any type of private practice setting. A mentor can alert you to factors you might not otherwise have considered. It also may be helpful to establish some form of supervision; such opportunities can be found through professional societies and other groups for private practice clinicians. In these groups, you also can ask other clinicians to recommend private practice and practice management consultants.

Stepping into the unknown can be an intimidating experience; however, you will not know what you are capable of until you try. Fortunately, psychiatry offers the flexibility to create a hybrid career that allows you to follow your passion and maintain your level of comfort. The American Psychiatric Association offers members additional information in the practice management resources section of its website.²

Many psychiatry trainees consider private practice as a career option or form of supplemental income. In my experience, however, residency training may provide limited introduction to the general steps involved in starting a practice. In this article, I briefly summarize what I learned while exploring the private practice option as a psychiatry resident.

A good specialty for private practice

Trainees in the earlier stages of their education should be aware that the first step toward private practice may actually occur during medical school, when they are considering which specialty to pursue. If a student is particularly interested in solo private practice, they may want to select a specialty with the potential for less overhead in an independent setting. Psychiatry typically has lower overhead costs than some other specialties. This gap widens even further with the increased popularity and acceptance of telepsychiatry.

Budgeting and finance

Once you decide to pursue private practice, you will want to consider whether you prefer solo practice or group practice, and part-time or full-time. If working for yourself, you will need to understand business planning and budgeting, including how to project revenue and expenses. When first starting in solo practice—especially if you are not taking over a previously established practice—it is useful to have secondary sources of income. This can be a part-time clinical position, working with on-demand health care companies, contracting, consulting, etc. Many new physicians begin with a full-time position and decide to initiate their private practice on a part-time basis. This approach provides a level of financial security that you otherwise would not have. However, a full-time position requires full-time energy, hours, and attention, and it can be challenging to balance full-time and part-time work. Whichever approach you decide to take, it can be most helpful to simply keep an open mind and always consider looking further into any new opportunity that interests you.

Insurance and licensing

You don’t have to wait to establish your own practice to purchase malpractice insurance. Shop around for the best rates and the coverage that most comprehensively fits your needs. If your training program allows “moonlighting,” you might need your own insurance to work at sites other than your training hospital. Many residents begin to apply for independent state licensure at the same time they begin pursuing moonlighting opportunities. It may be helpful not to wait until the last minute to do this, because the process has quite a few steps and can take a while. If your state requires letters of reference, think about which of your supervisors you can ask for one. If you plan to work in a state other than that of your training location, it may be helpful to simultaneously apply for your medical license in that state, because you will already be going through the process. Certain states offer reciprocity regarding medical licenses. The Interstate Medical Licensure Compact offers an expedited pathway to licensure for qualified physicians who want to practice in multiple states.¹

Marketing your practice

Potential sources for building a panel of patients include referral networks, insurance panels, professional organizations, social media, networking, directories, and word of mouth. If you plan to accept health insurance, the directories provided by insurance panels will allow potential patients to find you when searching for practitioners who accept their plan. Professional organizations offer similar directories, and some private companies also provide directories, either for free or for a fee.

Use technology to your advantage

The exciting thing about starting a private practice today is that the technology available to support a small practice has drastically improved. Many software applications can help with scheduling and billing, which minimizes the need for office staff and enables you to be more productive. These programs typically are available via an online subscription that gives you access to an electronic medical record and other features for a monthly fee. Many of these programs provide add-ons such as a website for your practice and integrated telehealth services. While these programs typically perform many of the same functions, each has a different setup and varying workflows. An online search can facilitate a side-by-side comparison of the software programs that most closely meet your needs.

Seek out mentors and consultants

Finally, try to find a private practice mentor, and reach out to as many people as possible who have worked in any type of private practice setting. A mentor can alert you to factors you might not otherwise have considered. It also may be helpful to establish some form of supervision; such opportunities can be found through professional societies and other groups for private practice clinicians. In these groups, you also can ask other clinicians to recommend private practice and practice management consultants.

Stepping into the unknown can be an intimidating experience; however, you will not know what you are capable of until you try. Fortunately, psychiatry offers the flexibility to create a hybrid career that allows you to follow your passion and maintain your level of comfort. The American Psychiatric Association offers members additional information in the practice management resources section of its website.²

Many psychiatry trainees consider private practice as a career option or form of supplemental income. In my experience, however, residency training may provide limited introduction to the general steps involved in starting a practice. In this article, I briefly summarize what I learned while exploring the private practice option as a psychiatry resident.

A good specialty for private practice

Trainees in the earlier stages of their education should be aware that the first step toward private practice may actually occur during medical school, when they are considering which specialty to pursue. If a student is particularly interested in solo private practice, they may want to select a specialty with the potential for less overhead in an independent setting. Psychiatry typically has lower overhead costs than some other specialties. This gap widens even further with the increased popularity and acceptance of telepsychiatry.

Budgeting and finance

Once you decide to pursue private practice, you will want to consider whether you prefer solo practice or group practice, and part-time or full-time. If working for yourself, you will need to understand business planning and budgeting, including how to project revenue and expenses. When first starting in solo practice—especially if you are not taking over a previously established practice—it is useful to have secondary sources of income. This can be a part-time clinical position, working with on-demand health care companies, contracting, consulting, etc. Many new physicians begin with a full-time position and decide to initiate their private practice on a part-time basis. This approach provides a level of financial security that you otherwise would not have. However, a full-time position requires full-time energy, hours, and attention, and it can be challenging to balance full-time and part-time work. Whichever approach you decide to take, it can be most helpful to simply keep an open mind and always consider looking further into any new opportunity that interests you.

Insurance and licensing

You don’t have to wait to establish your own practice to purchase malpractice insurance. Shop around for the best rates and the coverage that most comprehensively fits your needs. If your training program allows “moonlighting,” you might need your own insurance to work at sites other than your training hospital. Many residents begin to apply for independent state licensure at the same time they begin pursuing moonlighting opportunities. It may be helpful not to wait until the last minute to do this, because the process has quite a few steps and can take a while. If your state requires letters of reference, think about which of your supervisors you can ask for one. If you plan to work in a state other than that of your training location, it may be helpful to simultaneously apply for your medical license in that state, because you will already be going through the process. Certain states offer reciprocity regarding medical licenses. The Interstate Medical Licensure Compact offers an expedited pathway to licensure for qualified physicians who want to practice in multiple states.¹

Marketing your practice

Potential sources for building a panel of patients include referral networks, insurance panels, professional organizations, social media, networking, directories, and word of mouth. If you plan to accept health insurance, the directories provided by insurance panels will allow potential patients to find you when searching for practitioners who accept their plan. Professional organizations offer similar directories, and some private companies also provide directories, either for free or for a fee.

Use technology to your advantage

The exciting thing about starting a private practice today is that the technology available to support a small practice has drastically improved. Many software applications can help with scheduling and billing, which minimizes the need for office staff and enables you to be more productive. These programs typically are available via an online subscription that gives you access to an electronic medical record and other features for a monthly fee. Many of these programs provide add-ons such as a website for your practice and integrated telehealth services. While these programs typically perform many of the same functions, each has a different setup and varying workflows. An online search can facilitate a side-by-side comparison of the software programs that most closely meet your needs.

Seek out mentors and consultants

Finally, try to find a private practice mentor, and reach out to as many people as possible who have worked in any type of private practice setting. A mentor can alert you to factors you might not otherwise have considered. It also may be helpful to establish some form of supervision; such opportunities can be found through professional societies and other groups for private practice clinicians. In these groups, you also can ask other clinicians to recommend private practice and practice management consultants.

Stepping into the unknown can be an intimidating experience; however, you will not know what you are capable of until you try. Fortunately, psychiatry offers the flexibility to create a hybrid career that allows you to follow your passion and maintain your level of comfort. The American Psychiatric Association offers members additional information in the practice management resources section of its website.²

Ask neurologists or psychiatrists to name a white matter (WM) brain disease and they are very likely to say multiple sclerosis (MS), a demyelinating brain disorder caused by immune-mediated destruction of oligodendrocytes, the glial cells that manufacture myelin without which brain communications would come to a standstill.

MS is often associated with mood or psychotic disorders, yet it is regarded as a neurologic illness, not a psychiatric disorder.

Many neurologists and psychiatrists may not be aware that during the past few years, multiple diffusion tensor imaging (DTI) studies have revealed that many psychiatric disorders are associated with WM pathology.¹

Most people think that the brain is composed mostly of neurons, but in fact the bulk of brain volume (60%) is comprised of WM and only 40% is gray matter, which includes both neurons and glial cells (astroglia, microglia, and oligodendroglia). WM includes >137,000 km of myelinated fibers, an extensive network that connects all brain regions and integrates its complex, multifaceted functions, culminating in a unified sense of self and agency.

The role of the corpus callosum

Early in my research career, I became interested in the corpus callosum, the largest interhemispheric WM commissure connecting homologous areas across the 2 cerebral hemispheres. It is comprised of 200 million fibers of various diameters. Reasons for my fascination with the corpus callosum were:

The studies of Roger Sperry, the 1981 Nobel Laureate who led the team that was awarded the prize for split-brain research, which involved patients whose corpus callosum was cut to prevent the transfer of intractable epilepsy from 1 hemisphere to the other. Using a tachistoscope that he designed, Sperry discovered that the right and left hemispheres are 2 independent spheres of consciousness (ie, 2 individuals) with different skills.² Cerebral dominance (laterality) fully integrates the 2 hemispheres via the corpus callosum, with a verbal hemisphere (the left, in 90% of people) dominating the other hemisphere and serving as the “spokesman self.” Thus, we all have 2 persons in our brain completely integrated into 1 “self.”² This led me to wonder about the effects of an impaired corpus callosum on the “unified self.”

Postmortem and MRI studies conducted by our research group showed a significant difference in the thickness of the corpus callosum in a group of patients with schizophrenia vs healthy controls, which implied abnormal connectivity across the left and right hemispheres.³

Continue to: I then conducted a clinical study

I then conducted a clinical study examining patients with tumors impinging on the corpus callosum, which revealed that they developed psychotic symptoms (delusions and hallucinations).⁴ This study suggested that disrupting the integrity of the callosal inter-hemispheric fibers can trigger fixed false beliefs and perceptual anomalies.⁴

A ‘dysconnection’ between hemispheres

I translated those observations about the corpus callosum into a published hypothesis⁵ in which I proposed that Schneider’s First-Rank Symptoms of schizophrenia of thought insertion, thought withdrawal, and thought broadcasting—as well as delusional experiences of “external control”—may be due to a neurobiologic abnormality in the corpus callosum that disrupts the flow of ongoing bits of information transmitted from the left to the right hemisphere, and vice versa. I proposed in my model that this disruption leads to the verbal left hemisphere of a psychotic patient to describe having thoughts inserted into it from an alien source, failing to recognize that the thoughts it is receiving are being transmitted from the disconnected right hemisphere, which is no longer part of the “self.” Similarly, impulses from the right hemispheric consciousness are now perceived by the patient’s verbal left hemisphere (which talks to the examining physician) as “external control.” Thus, I postulated that an abnormal corpus callosum structure would lead to a “dysconnection” (not “disconnection”) between the 2 hemispheres, and that anomalous dysconnectivity may generate both delusions and hallucinations. ⁶

Two decades later, my assumptions were vindicated when DTI was invented, enabling the measurement of WM integrity, including the corpus callosum, the largest body of WM in the brain. Table 1 defines the main parameters of WM integrity, anisotropy and diffusivity, which measure water flow inside WM fibers.

During the past 15 years, many studies have confirmed the presence of significant abnormalities in the myelinated fibers of the corpus callosum in schizophrenia, which can be considered a validation of my hypothesis that the corpus callosum becomes a dysfunctional channel of communications between the right and left hemisphere. Subsequently, DTI studies have reported a spectrum of WM pathologies in various other cerebral bundles and not only in schizophrenia, but also in other major psychiatric disorders (Table 2^7-19).

The pathophysiology of WM pathology in many psychiatric disorders may include neurodevelopmental aberrations (genetic, environmental, or both, which may alter WM structure and/or myelination), neuroinflammation, or oxidative stress (free radicals), which can cause disintegration of the vital myelin sheaths, leading to disruption of brain connectivity.^6,7 Researchers now consider the brain’s WM network dysconnectivity as generating a variety of psychiatric symptoms, including psychosis, depression, mania, anxiety, autism, aggression, impulsivity, psychopathy, and cognitive impairments.

It is not surprising that WM repair has become a therapeutic target in psychiatry and neurology. Among the strategies being investigated are inhibiting the Nogo-A signaling pathways²⁰ or modulating the Lingo-1 signaling.²¹ However, the most well-established myelin repair pathway is prolactin, a neuroprotective hormone with several beneficial effects on the brain (Table 3^22,23), including the proliferation of oligodendroglia, the main source of myelin (and the number of which declines in schizophrenia). Antipsychotics that increase prolactin have been shown to increase WM volume.^24,25 It has even been proposed that a decline in oligodendrocytes and low myelin synthesis may be one of the neurobiologic pathologies in schizophrenia.²⁶ One of the 24 neuroprotective properties of the second-generation antipsychotics (SGAs) is the restoration of WM integrity.²⁷ It’s worth noting that WM pathology has been found to be present at the onset of schizophrenia before treatment, and that SGAs have been reported to correct it.²⁸

Continue to: In conclusion...

In conclusion, psychiatric disorders, usually referred to as “mental illnesses,” are unquestionably neurologic disorders. Similarly, all neurologic disorders are associated with psychiatric manifestations. WM pathology is only 1 of numerous structural brain abnormalities that have been documented across psychiatric disorders, which proves that psychiatry is a clinical neuroscience, just like neurology. I strongly advocate that psychiatry and neurology reunite into a single medical specialty. Both focus on disorders of brain structure and/or function, and these disorders also share much more than WM pathology.²⁹

Ask neurologists or psychiatrists to name a white matter (WM) brain disease and they are very likely to say multiple sclerosis (MS), a demyelinating brain disorder caused by immune-mediated destruction of oligodendrocytes, the glial cells that manufacture myelin without which brain communications would come to a standstill.

MS is often associated with mood or psychotic disorders, yet it is regarded as a neurologic illness, not a psychiatric disorder.

Many neurologists and psychiatrists may not be aware that during the past few years, multiple diffusion tensor imaging (DTI) studies have revealed that many psychiatric disorders are associated with WM pathology.¹

Most people think that the brain is composed mostly of neurons, but in fact the bulk of brain volume (60%) is comprised of WM and only 40% is gray matter, which includes both neurons and glial cells (astroglia, microglia, and oligodendroglia). WM includes >137,000 km of myelinated fibers, an extensive network that connects all brain regions and integrates its complex, multifaceted functions, culminating in a unified sense of self and agency.

The role of the corpus callosum

Early in my research career, I became interested in the corpus callosum, the largest interhemispheric WM commissure connecting homologous areas across the 2 cerebral hemispheres. It is comprised of 200 million fibers of various diameters. Reasons for my fascination with the corpus callosum were:

The studies of Roger Sperry, the 1981 Nobel Laureate who led the team that was awarded the prize for split-brain research, which involved patients whose corpus callosum was cut to prevent the transfer of intractable epilepsy from 1 hemisphere to the other. Using a tachistoscope that he designed, Sperry discovered that the right and left hemispheres are 2 independent spheres of consciousness (ie, 2 individuals) with different skills.² Cerebral dominance (laterality) fully integrates the 2 hemispheres via the corpus callosum, with a verbal hemisphere (the left, in 90% of people) dominating the other hemisphere and serving as the “spokesman self.” Thus, we all have 2 persons in our brain completely integrated into 1 “self.”² This led me to wonder about the effects of an impaired corpus callosum on the “unified self.”

Postmortem and MRI studies conducted by our research group showed a significant difference in the thickness of the corpus callosum in a group of patients with schizophrenia vs healthy controls, which implied abnormal connectivity across the left and right hemispheres.³

Continue to: I then conducted a clinical study

I then conducted a clinical study examining patients with tumors impinging on the corpus callosum, which revealed that they developed psychotic symptoms (delusions and hallucinations).⁴ This study suggested that disrupting the integrity of the callosal inter-hemispheric fibers can trigger fixed false beliefs and perceptual anomalies.⁴

A ‘dysconnection’ between hemispheres

I translated those observations about the corpus callosum into a published hypothesis⁵ in which I proposed that Schneider’s First-Rank Symptoms of schizophrenia of thought insertion, thought withdrawal, and thought broadcasting—as well as delusional experiences of “external control”—may be due to a neurobiologic abnormality in the corpus callosum that disrupts the flow of ongoing bits of information transmitted from the left to the right hemisphere, and vice versa. I proposed in my model that this disruption leads to the verbal left hemisphere of a psychotic patient to describe having thoughts inserted into it from an alien source, failing to recognize that the thoughts it is receiving are being transmitted from the disconnected right hemisphere, which is no longer part of the “self.” Similarly, impulses from the right hemispheric consciousness are now perceived by the patient’s verbal left hemisphere (which talks to the examining physician) as “external control.” Thus, I postulated that an abnormal corpus callosum structure would lead to a “dysconnection” (not “disconnection”) between the 2 hemispheres, and that anomalous dysconnectivity may generate both delusions and hallucinations. ⁶

Two decades later, my assumptions were vindicated when DTI was invented, enabling the measurement of WM integrity, including the corpus callosum, the largest body of WM in the brain. Table 1 defines the main parameters of WM integrity, anisotropy and diffusivity, which measure water flow inside WM fibers.

During the past 15 years, many studies have confirmed the presence of significant abnormalities in the myelinated fibers of the corpus callosum in schizophrenia, which can be considered a validation of my hypothesis that the corpus callosum becomes a dysfunctional channel of communications between the right and left hemisphere. Subsequently, DTI studies have reported a spectrum of WM pathologies in various other cerebral bundles and not only in schizophrenia, but also in other major psychiatric disorders (Table 2^7-19).

The pathophysiology of WM pathology in many psychiatric disorders may include neurodevelopmental aberrations (genetic, environmental, or both, which may alter WM structure and/or myelination), neuroinflammation, or oxidative stress (free radicals), which can cause disintegration of the vital myelin sheaths, leading to disruption of brain connectivity.^6,7 Researchers now consider the brain’s WM network dysconnectivity as generating a variety of psychiatric symptoms, including psychosis, depression, mania, anxiety, autism, aggression, impulsivity, psychopathy, and cognitive impairments.

It is not surprising that WM repair has become a therapeutic target in psychiatry and neurology. Among the strategies being investigated are inhibiting the Nogo-A signaling pathways²⁰ or modulating the Lingo-1 signaling.²¹ However, the most well-established myelin repair pathway is prolactin, a neuroprotective hormone with several beneficial effects on the brain (Table 3^22,23), including the proliferation of oligodendroglia, the main source of myelin (and the number of which declines in schizophrenia). Antipsychotics that increase prolactin have been shown to increase WM volume.^24,25 It has even been proposed that a decline in oligodendrocytes and low myelin synthesis may be one of the neurobiologic pathologies in schizophrenia.²⁶ One of the 24 neuroprotective properties of the second-generation antipsychotics (SGAs) is the restoration of WM integrity.²⁷ It’s worth noting that WM pathology has been found to be present at the onset of schizophrenia before treatment, and that SGAs have been reported to correct it.²⁸

Continue to: In conclusion...

In conclusion, psychiatric disorders, usually referred to as “mental illnesses,” are unquestionably neurologic disorders. Similarly, all neurologic disorders are associated with psychiatric manifestations. WM pathology is only 1 of numerous structural brain abnormalities that have been documented across psychiatric disorders, which proves that psychiatry is a clinical neuroscience, just like neurology. I strongly advocate that psychiatry and neurology reunite into a single medical specialty. Both focus on disorders of brain structure and/or function, and these disorders also share much more than WM pathology.²⁹

Ask neurologists or psychiatrists to name a white matter (WM) brain disease and they are very likely to say multiple sclerosis (MS), a demyelinating brain disorder caused by immune-mediated destruction of oligodendrocytes, the glial cells that manufacture myelin without which brain communications would come to a standstill.

MS is often associated with mood or psychotic disorders, yet it is regarded as a neurologic illness, not a psychiatric disorder.

Many neurologists and psychiatrists may not be aware that during the past few years, multiple diffusion tensor imaging (DTI) studies have revealed that many psychiatric disorders are associated with WM pathology.¹

Most people think that the brain is composed mostly of neurons, but in fact the bulk of brain volume (60%) is comprised of WM and only 40% is gray matter, which includes both neurons and glial cells (astroglia, microglia, and oligodendroglia). WM includes >137,000 km of myelinated fibers, an extensive network that connects all brain regions and integrates its complex, multifaceted functions, culminating in a unified sense of self and agency.

The role of the corpus callosum

Early in my research career, I became interested in the corpus callosum, the largest interhemispheric WM commissure connecting homologous areas across the 2 cerebral hemispheres. It is comprised of 200 million fibers of various diameters. Reasons for my fascination with the corpus callosum were:

The studies of Roger Sperry, the 1981 Nobel Laureate who led the team that was awarded the prize for split-brain research, which involved patients whose corpus callosum was cut to prevent the transfer of intractable epilepsy from 1 hemisphere to the other. Using a tachistoscope that he designed, Sperry discovered that the right and left hemispheres are 2 independent spheres of consciousness (ie, 2 individuals) with different skills.² Cerebral dominance (laterality) fully integrates the 2 hemispheres via the corpus callosum, with a verbal hemisphere (the left, in 90% of people) dominating the other hemisphere and serving as the “spokesman self.” Thus, we all have 2 persons in our brain completely integrated into 1 “self.”² This led me to wonder about the effects of an impaired corpus callosum on the “unified self.”

Postmortem and MRI studies conducted by our research group showed a significant difference in the thickness of the corpus callosum in a group of patients with schizophrenia vs healthy controls, which implied abnormal connectivity across the left and right hemispheres.³

Continue to: I then conducted a clinical study

I then conducted a clinical study examining patients with tumors impinging on the corpus callosum, which revealed that they developed psychotic symptoms (delusions and hallucinations).⁴ This study suggested that disrupting the integrity of the callosal inter-hemispheric fibers can trigger fixed false beliefs and perceptual anomalies.⁴

A ‘dysconnection’ between hemispheres

I translated those observations about the corpus callosum into a published hypothesis⁵ in which I proposed that Schneider’s First-Rank Symptoms of schizophrenia of thought insertion, thought withdrawal, and thought broadcasting—as well as delusional experiences of “external control”—may be due to a neurobiologic abnormality in the corpus callosum that disrupts the flow of ongoing bits of information transmitted from the left to the right hemisphere, and vice versa. I proposed in my model that this disruption leads to the verbal left hemisphere of a psychotic patient to describe having thoughts inserted into it from an alien source, failing to recognize that the thoughts it is receiving are being transmitted from the disconnected right hemisphere, which is no longer part of the “self.” Similarly, impulses from the right hemispheric consciousness are now perceived by the patient’s verbal left hemisphere (which talks to the examining physician) as “external control.” Thus, I postulated that an abnormal corpus callosum structure would lead to a “dysconnection” (not “disconnection”) between the 2 hemispheres, and that anomalous dysconnectivity may generate both delusions and hallucinations. ⁶

Two decades later, my assumptions were vindicated when DTI was invented, enabling the measurement of WM integrity, including the corpus callosum, the largest body of WM in the brain. Table 1 defines the main parameters of WM integrity, anisotropy and diffusivity, which measure water flow inside WM fibers.

During the past 15 years, many studies have confirmed the presence of significant abnormalities in the myelinated fibers of the corpus callosum in schizophrenia, which can be considered a validation of my hypothesis that the corpus callosum becomes a dysfunctional channel of communications between the right and left hemisphere. Subsequently, DTI studies have reported a spectrum of WM pathologies in various other cerebral bundles and not only in schizophrenia, but also in other major psychiatric disorders (Table 2^7-19).

The pathophysiology of WM pathology in many psychiatric disorders may include neurodevelopmental aberrations (genetic, environmental, or both, which may alter WM structure and/or myelination), neuroinflammation, or oxidative stress (free radicals), which can cause disintegration of the vital myelin sheaths, leading to disruption of brain connectivity.^6,7 Researchers now consider the brain’s WM network dysconnectivity as generating a variety of psychiatric symptoms, including psychosis, depression, mania, anxiety, autism, aggression, impulsivity, psychopathy, and cognitive impairments.

It is not surprising that WM repair has become a therapeutic target in psychiatry and neurology. Among the strategies being investigated are inhibiting the Nogo-A signaling pathways²⁰ or modulating the Lingo-1 signaling.²¹ However, the most well-established myelin repair pathway is prolactin, a neuroprotective hormone with several beneficial effects on the brain (Table 3^22,23), including the proliferation of oligodendroglia, the main source of myelin (and the number of which declines in schizophrenia). Antipsychotics that increase prolactin have been shown to increase WM volume.^24,25 It has even been proposed that a decline in oligodendrocytes and low myelin synthesis may be one of the neurobiologic pathologies in schizophrenia.²⁶ One of the 24 neuroprotective properties of the second-generation antipsychotics (SGAs) is the restoration of WM integrity.²⁷ It’s worth noting that WM pathology has been found to be present at the onset of schizophrenia before treatment, and that SGAs have been reported to correct it.²⁸

Continue to: In conclusion...

In conclusion, psychiatric disorders, usually referred to as “mental illnesses,” are unquestionably neurologic disorders. Similarly, all neurologic disorders are associated with psychiatric manifestations. WM pathology is only 1 of numerous structural brain abnormalities that have been documented across psychiatric disorders, which proves that psychiatry is a clinical neuroscience, just like neurology. I strongly advocate that psychiatry and neurology reunite into a single medical specialty. Both focus on disorders of brain structure and/or function, and these disorders also share much more than WM pathology.²⁹

Remember FOMO (fear of missing out)? The pandemic cured most of us of that! In its place, many are suffering from a new syndrome that has been coined “FOGO” (fear of going out). As the COVID-19 vaccines roll out, restrictions lessen, and cases decline, we face new challenges. The pandemic showed us that “we are all in it together.” Now our patients, family, friends – and even we, ourselves – may face similar anxieties as we transition back.

Our brains love routines. They save energy as we transverse the same pathway with ease. We created new patterns in the first 30 days of quarantine, and we spent more than a year engraining them. Many people remain reluctant to send their children back to school, don’t want to return to the office, and are still avoiding travel and social situations. Many people are feeling even more anxiety as restrictions are lifting and expectations are rising. Those with preexisting anxiety disorders may have an even more difficult time resuming routine activities.

Since the virus is still among us, we need to maintain caution, so some degree of FOGO is wise. But when we limit our activities too much, we create a whole new host of issues. The pandemic gave us all a taste of the agoraphobic lifestyle. It is difficult to know where exactly to draw the line right now between healthy anxiety and anxiety that becomes the disease for ourselves, our families and friends – and our patients.
 

Recommendations for FOGO

• Talk to your families, friends, and patients about what activities you recommend, which they might resume and which they should continue to avoid. People should make plans to optimize their physical and mental health while continuing to protect themselves from COVID-19. If anxiety is becoming the main problem, psychotherapy or medication may be necessary to treat their symptoms.
• Continue to encourage those with FOGO to practice techniques to be calm. Suggest that they take deep breaths with long exhales. This breathing pattern activates the parasympathetic nervous system and will help them feel calmer. We have all been under chronic stress, and our sympathetic nervous system has been in overdrive. We need to be calm to make the best decisions so our frontal lobe can be in charge rather than our primitive, fear-based brain that has been running the show for more a year. Encourage calming activities, such as yoga, meditation, warm baths, spending time in nature, hugging a pet, and more.
• Advise sufferers to start slowly. They should resume activities where they feel the safest. Walking outside with a friend is a good way to start. We now know that transmission is remarkably low or nonexistent if both parties are vaccinated. Exercise is a great way to combat many psychological issues, including FOGO.
• FOGO sufferers should build confidence gradually. Recommend taking one day at a time and trying to find ways to enjoy new ventures out. Soon, our brains will adapt to the new routines and the days of COVID-19 will recede from our thoughts.
• Respect whatever feelings emerge. The closer we and our patients were to trauma, the more challenging it may be to recover. If you or your patients suffered from COVID-19 or had a close family member or friend who did, be prepared to reemerge more slowly. Don’t feel pressured by what others are doing. Go at your own pace. Only you can decide what is the right way to move forward in these times.
• Look for signs of substance overuse or misuse. FOGO sufferers may turn to drugs or alcohol to mask their anxiety. This is a common pothole and should be avoided. Be alert for this problem and discuss it with patients, friends, or family members who may be making unhealthy choices.

Time is a great healer, and remind others that “this too shall pass.” FOGO will give rise to another yet-to-be named syndrome. We seem to be moving in a very positive direction at a remarkable pace. As Alexander Pope so wisely wrote, “Hope springs eternal.” Better times are ahead.
 

Dr. Ritvo, who has almost 30 years’ experience in psychiatry, practices in Miami Beach, Fla. She is the author of “Bekindr – The Transformative Power of Kindness” (Hellertown, Pa. Momosa Publishing, 2018). Dr. Ritvo has no disclosures.

Remember FOMO (fear of missing out)? The pandemic cured most of us of that! In its place, many are suffering from a new syndrome that has been coined “FOGO” (fear of going out). As the COVID-19 vaccines roll out, restrictions lessen, and cases decline, we face new challenges. The pandemic showed us that “we are all in it together.” Now our patients, family, friends – and even we, ourselves – may face similar anxieties as we transition back.

Our brains love routines. They save energy as we transverse the same pathway with ease. We created new patterns in the first 30 days of quarantine, and we spent more than a year engraining them. Many people remain reluctant to send their children back to school, don’t want to return to the office, and are still avoiding travel and social situations. Many people are feeling even more anxiety as restrictions are lifting and expectations are rising. Those with preexisting anxiety disorders may have an even more difficult time resuming routine activities.

Since the virus is still among us, we need to maintain caution, so some degree of FOGO is wise. But when we limit our activities too much, we create a whole new host of issues. The pandemic gave us all a taste of the agoraphobic lifestyle. It is difficult to know where exactly to draw the line right now between healthy anxiety and anxiety that becomes the disease for ourselves, our families and friends – and our patients.
 

Recommendations for FOGO

• Talk to your families, friends, and patients about what activities you recommend, which they might resume and which they should continue to avoid. People should make plans to optimize their physical and mental health while continuing to protect themselves from COVID-19. If anxiety is becoming the main problem, psychotherapy or medication may be necessary to treat their symptoms.
• Continue to encourage those with FOGO to practice techniques to be calm. Suggest that they take deep breaths with long exhales. This breathing pattern activates the parasympathetic nervous system and will help them feel calmer. We have all been under chronic stress, and our sympathetic nervous system has been in overdrive. We need to be calm to make the best decisions so our frontal lobe can be in charge rather than our primitive, fear-based brain that has been running the show for more a year. Encourage calming activities, such as yoga, meditation, warm baths, spending time in nature, hugging a pet, and more.
• Advise sufferers to start slowly. They should resume activities where they feel the safest. Walking outside with a friend is a good way to start. We now know that transmission is remarkably low or nonexistent if both parties are vaccinated. Exercise is a great way to combat many psychological issues, including FOGO.
• FOGO sufferers should build confidence gradually. Recommend taking one day at a time and trying to find ways to enjoy new ventures out. Soon, our brains will adapt to the new routines and the days of COVID-19 will recede from our thoughts.
• Respect whatever feelings emerge. The closer we and our patients were to trauma, the more challenging it may be to recover. If you or your patients suffered from COVID-19 or had a close family member or friend who did, be prepared to reemerge more slowly. Don’t feel pressured by what others are doing. Go at your own pace. Only you can decide what is the right way to move forward in these times.
• Look for signs of substance overuse or misuse. FOGO sufferers may turn to drugs or alcohol to mask their anxiety. This is a common pothole and should be avoided. Be alert for this problem and discuss it with patients, friends, or family members who may be making unhealthy choices.

Time is a great healer, and remind others that “this too shall pass.” FOGO will give rise to another yet-to-be named syndrome. We seem to be moving in a very positive direction at a remarkable pace. As Alexander Pope so wisely wrote, “Hope springs eternal.” Better times are ahead.
 

Dr. Ritvo, who has almost 30 years’ experience in psychiatry, practices in Miami Beach, Fla. She is the author of “Bekindr – The Transformative Power of Kindness” (Hellertown, Pa. Momosa Publishing, 2018). Dr. Ritvo has no disclosures.

Remember FOMO (fear of missing out)? The pandemic cured most of us of that! In its place, many are suffering from a new syndrome that has been coined “FOGO” (fear of going out). As the COVID-19 vaccines roll out, restrictions lessen, and cases decline, we face new challenges. The pandemic showed us that “we are all in it together.” Now our patients, family, friends – and even we, ourselves – may face similar anxieties as we transition back.

Our brains love routines. They save energy as we transverse the same pathway with ease. We created new patterns in the first 30 days of quarantine, and we spent more than a year engraining them. Many people remain reluctant to send their children back to school, don’t want to return to the office, and are still avoiding travel and social situations. Many people are feeling even more anxiety as restrictions are lifting and expectations are rising. Those with preexisting anxiety disorders may have an even more difficult time resuming routine activities.

Since the virus is still among us, we need to maintain caution, so some degree of FOGO is wise. But when we limit our activities too much, we create a whole new host of issues. The pandemic gave us all a taste of the agoraphobic lifestyle. It is difficult to know where exactly to draw the line right now between healthy anxiety and anxiety that becomes the disease for ourselves, our families and friends – and our patients.
 

Recommendations for FOGO

• Talk to your families, friends, and patients about what activities you recommend, which they might resume and which they should continue to avoid. People should make plans to optimize their physical and mental health while continuing to protect themselves from COVID-19. If anxiety is becoming the main problem, psychotherapy or medication may be necessary to treat their symptoms.
• Continue to encourage those with FOGO to practice techniques to be calm. Suggest that they take deep breaths with long exhales. This breathing pattern activates the parasympathetic nervous system and will help them feel calmer. We have all been under chronic stress, and our sympathetic nervous system has been in overdrive. We need to be calm to make the best decisions so our frontal lobe can be in charge rather than our primitive, fear-based brain that has been running the show for more a year. Encourage calming activities, such as yoga, meditation, warm baths, spending time in nature, hugging a pet, and more.
• Advise sufferers to start slowly. They should resume activities where they feel the safest. Walking outside with a friend is a good way to start. We now know that transmission is remarkably low or nonexistent if both parties are vaccinated. Exercise is a great way to combat many psychological issues, including FOGO.
• FOGO sufferers should build confidence gradually. Recommend taking one day at a time and trying to find ways to enjoy new ventures out. Soon, our brains will adapt to the new routines and the days of COVID-19 will recede from our thoughts.
• Respect whatever feelings emerge. The closer we and our patients were to trauma, the more challenging it may be to recover. If you or your patients suffered from COVID-19 or had a close family member or friend who did, be prepared to reemerge more slowly. Don’t feel pressured by what others are doing. Go at your own pace. Only you can decide what is the right way to move forward in these times.
• Look for signs of substance overuse or misuse. FOGO sufferers may turn to drugs or alcohol to mask their anxiety. This is a common pothole and should be avoided. Be alert for this problem and discuss it with patients, friends, or family members who may be making unhealthy choices.

Time is a great healer, and remind others that “this too shall pass.” FOGO will give rise to another yet-to-be named syndrome. We seem to be moving in a very positive direction at a remarkable pace. As Alexander Pope so wisely wrote, “Hope springs eternal.” Better times are ahead.
 

Dr. Ritvo, who has almost 30 years’ experience in psychiatry, practices in Miami Beach, Fla. She is the author of “Bekindr – The Transformative Power of Kindness” (Hellertown, Pa. Momosa Publishing, 2018). Dr. Ritvo has no disclosures.