From the Editor

Do you practice sophisticated psychiatry? 10 Proposed foundations of advanced care

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Progress in scientific and clinical knowledge of psychiatry is proceeding at a furious pace. Psychiatrists have to be diligent to remain on the cutting edge of rapid advances in brain−behavior linkages—keeping up not only with the “what” but the “how” of optimal psychiatric practice.


Some psychiatrists are rapid adopt­ers of the latest discoveries. Others wait before they adopt new modalities and change their practice accordingly. Then, there are some—admittedly, a minority—who stubbornly persist in practicing exactly as they did 30 or 40 years ago when they completed residency.

What are the foundations of exemplary, advanced, brain-based psychiatric care?
Here are my 10 proposed tenets of excel­lence in psychiatric practice. They reflect superior assessment and management of patients as well as personal growth and contributions to the specialty.

Provide a complete medical assess­ment for every patient at the first lifetime psychiatric contact, whether inpatient or outpatient. This includes routine physical and neurologic exami­nations and a panel of basic laboratory tests (complete blood count, liver and kidney functions, urine screen, thyroid-stimulating hormone, electrolytes, fast­ing glucose, and fasting lipids). All vital signs are measured and recorded. Referrals to other medical specialists are made as needed.

This medical assessment must, of course, include a comprehensive psy­chiatric evaluation: personal history, social history, medical history, family history, and a complete neuropsychiat­ric mental status examination.

Create a thorough 3-generation pedigree of all relatives, indicating not only psychopathology, addiction, and legal problems but also medical (espe­cially neurologic) disorders and cause of death.

Perform basic assessment of brain structure and function (a MRI scan, a neurocognitive battery, and tests of neu­rologic soft signs).

Measure biomarkers that reflect potential harm to the brain according to emerging research—eg, pro-inflam­matory markers (such as C-reactive protein [CRP], interleukin-6, and tumor necrosis factor alpha [TNF-α]) and oxidative stress biomarkers of increased free radical activity (super­oxide dismutase [SOD], glutathione, thiobarbituric acid [GSH] reactive sub­stances [TBARS], and catalase).

Maintain measurement-based prac­tice, in which:
severity of illness is measured by a specific, appropriate rating scale (eg, Positive and Negative Syndrome Scale for schizophre­nia [PANSS], Young Mania Rating Scale [YMRS], Montgomery-Åsberg Depression Rating Scale [MADRS] for depression, Hamilton Anxiety Rating Scale [HAM-A] for anxiety, Yale-Brown Obsessive Compulsive Scale [Y-BOCS] for obsessions and compulsions)
degree of response to treatment is measured as a reflection of the extent of drop in the total score of those rat­ing scales, which are administered at every visit
severity of common side effects is measured by the Simpson-Angus Scale (SAS) for parkinsonism, the Barnes Akathisia Rating Scale (BARS), the Abnormal Involuntary Movement Scale (AIMS) for tardive dyskinesia, the Glasgow Antipsychotic Side-effect Scale (GASS), etc.

Use tier-1 evidence-based psychiatry (that is, findings from large, placebo-controlled, double-blind studies) to select best treatments. This includes being familiar with:
• principles of meta-analysis
• the meaning of low, medium, and large effect sizes
• for every medication used, the calculation and clinical implications of number needed to treat (NNT) and num­ber needed to harm (NNH).

Always combine the dual manage­ment approaches of pharmacother­apy plus psychotherapy/psychosocial therapy.

Share knowledge and experience gleaned from practice with the commu­nity of psychiatrists, including:
• writing letters to the editor about a clinical matter
• submitting case reports or case series for publication
• teaching students or residents at the local medical school (after obtaining adjunct faculty status).

In addition, psychiatrists should educate the public to eliminate misper­ceptions and erase stigma about mental illness.

Participate in creating new psychiat­ric knowledge by developing skills to become a clinical trialist, so that you can participate as an investigator in multi­center clinical trials of new medications, or, at least, refer patients for possible participation in ongoing clinical trials conducted at local academic centers.

Engage in effective and continuous life-learning, by:
• attending weekly Grand Rounds at the nearest academic department of psychiatry
• attending national continu­ing medical education conferences annually
• scanning PubMed regularly (at least 3 times a week, if not daily) for the latest research related to one’s patients or to read about advances in one’s clini­cal subspecialty; read the abstracts and download several PDFs a week for subsequent reading.

Some readers will agree with part, but not all, of these proposed compo­nents of advanced psychiatric practice. That’s to be expected; I welcome your letters rebutting some tenets, or propos­ing additional ones, of a sophisticated psychiatric practice. After all, sophisti­cation is a journey, not a destination.

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