The Maryland Psychiatrist: Fall 2026
Table of Contents:
Bridging Science & Society: The SPA/MPS Meeting in Baltimore
Post-Partum Psychosis
From the Ground Up: A New Psychiatry Residency Takes Root in Baltimore
Cheers from the Chair: Drs. Alessi and Reti
In Memoriam: Paul Roberts, MD
Confidence, Consciousness, and Compressions: Navigating a Medical Student’s First Resuscitation Attempt
Conditional S.I. Is Actually Secondary S.I.
The Prescription Isn’t Enough: Why Psychiatry Can’t Outsource OCD
Bridging Science & Society: The SPA/MPS Meeting in Baltimore
September 17–19, 2026
A Summary of Some of the Key Points
by Bruce Hershfield, MD & Jose Hawayek, MD
DAY ONE
Dr. Cynthia Major Lewis of Johns Hopkins opened the scientific presentations by discussing Assisted Outpatient Treatment. She described the outpatient civil commitment pilot program in Baltimore. Because she wondered why Maryland was one of the three states without an outpatient commitment law, she joined the MPS Legislative Committee and helped pass one in 2024. Under it, petitions must be accompanied by affidavits signed by psychiatrists; serious and persistent mental illness must be present. A care coordination team can then present a treatment plan. The law will be implemented statewide in 2027, with a 5-year “sun-setting” period..
Dr. Tiffany Buckley and David Wolinsky, MD, then discussed cannabis. They told us that THC is a partial agonist at CB-1, while CBD has only a low affinity for it. They discussed the potential psychiatric risks of cannabis, particularly in patients with mood disorders, and how the increased of developing psychosis depends in part on the percentage of THC in the product and genetic vulnerability. Cannabis can cause addiction and has a well-known withdrawal phenomenon; synthetic versions can be worse. Useful questions include, “What is driving the person to use it?” and “How do they take it, how much do they use, and how often?” It can also be helpful to ask, “How can we work together to make your use safer?” This helps us understand what purpose the cannabis is serving for patients, rather than simply telling them to stop.
E. Thomas Lewis III, MD, then lectured on Involuntary Treatment from a Forensic Psychiatrist’s Perspective. He said fewer than half of the community mental health centers planned under the 1963 Community Mental Health Act were actually built. He described “police powers” and “parens patriae” as the two bases for involuntary treatment. He mentioned some of the famous cases that restricted involuntary treatment and described the APA’s position on involuntary outpatient treatment as skeptical—and the WHO’s as even more so.
Drs. Cordner, Franklin, and Nikhinson from the MindWork Group in Baltimore then described their Intensive & Innovative Community-Based Treatment for People with Complex Psychiatric Problems. They described the provision of a “continuum of psychiatric care” as “hypothetical” and remarked, “It’s fraying everywhere.” The bed-to-population ratio in Maryland in 2020 was only 21.3 per 100,000, though the minimum recommended is 30. They also noted how difficult it has become to obtain appropriate outpatient care. Patients stay an average of 5 to 6 months in their program and receive a great deal of psychotherapy; some also receive TMS. They find their intensive partial-hospitalization approach to be “feasible” and continue to refine it.
DAY TWO
After a lovely social event at the Little Havana restaurant on Thursday evening, the sessions resumed on Friday with the first of three “Product Theaters.” Dr. Manish Zinzuvadia spoke about Uvedy, a subcutaneous long-acting risperidone preparation for schizophrenia that can be given monthly or bi,pnthly. His position is that we frequently overestimate how reliably patients take their oral medication and that long-acting preparations may therefore help many patients, even relatively early in the course of psychotic illness.
Dr. Joshua Sharfstein then gave us “A Public Health Perspective on Mental Health Challenges Facing the U.S.” He asked us to think beyond what happens in the examining room and consider why entire populations develop similar problems and what environmental or policy changes might improve their health. He used examples involving asthma, diabetes, opioid use disorder, homelessness, and youth mental health. Housing, neighborhood safety, food availability, medication costs, transportation, poverty, and access to care can influence health just as surely as what happens during an office visit. He advocated for a “portfolio” approach: achieve practical short-term victories while continuing to work toward larger structural changes.
He also discussed our response to the fentanyl-contaminated drug supply, emphasizing both harm reduction and access to treatments. He warned about efforts to criminalize homelessness and described the growing problems of adolescent anxiety, social media, school absenteeism, food insecurity, and social isolation. His larger point was that psychiatrists should not limit themselves to treating the consequences of social problems one patient at a time.
Drs. Julie Brownley and Bernadette Wharton-Hawthorne then talked about GLP-1s in Psychiatry and Eating Disorders. These medications decrease hunger, increase satiety, and slow stomach emptying. Patients think about food less. As their use becomes increasingly common. psychiatrists may find ourselves monitoring problems created by medications that we did not prescribe.
The speakers emphasized the importance of asking not merely how much weight a patient has lost, but what the patient is actually eating, whether nutrition and hydration remain adequate, how rapidly the weight is changing, and whether gastrointestinal symptoms are interfering with psychiatric medications.
Eating disorders make the issue still more complicated. GLP-1s may eventually prove useful for some patients with binge eating, but the evidence is limited. On the other hand, appetite suppression and continued weight loss can be dangerous in restrictive disorders and can potentially reinforce the very behavior we are trying to treat. Patients with atypical anorexia may be especially easy to miss because BMI alone does not tell us whether someone is well. Therefore, it is important to monitor eating-disorder symptoms, not simply the scale.
Dr. Corey Jackson then delivered the second Product Theater, concerning Cobenfy. He discussed positive and negative symptoms of schizophrenia on the PANSS scale and pointed out that Cobenfy does not work through the traditional D-2 receptor mechanism. Its two components are xanomeline and trospium, the latter being used to limit peripheral side effects. Side effects .are chiefly gastrointestinal.
David Goodman, MD, then lectured about ADHD in older adults, which remains clinically relevant well into later life and is much more common in psychiatric populations than general-population figures would suggest. One particularly useful point was that diagnosing ADHD in older adults still requires establishing that the disorder began in childhood. Unfortunately, 60- or 70-year-old patients may remember very little from elementary school by themselves. He therefore suggested looking for what he called “collateral by proxy.” Did teachers move the child to the front of the classroom? Did people repeatedly complain about disorganization or talkativeness? Did family members or friends change their own behavior to compensate for the patient’s distractibility? Spouses and siblings can also provide important information.
The problem becomes especially interesting when an older patient presents with cognitive complaints. ADHD, depression, sleep disorders, medication effects, mild cognitive impairment, vascular disease, and neurodegenerative illness can overlap. Testing does not always separate ADHD from MCI very well, and the two can coexist. Age of onset therefore becomes particularly important: ADHD begins in childhood, while most neurodegenerative processes begin much later.
His case involved a physician whose cognition and functioning improved dramatically after ADHD treatment.. Persistent language and memory problems, however, eventually led to biomarker testing that confirmed Alzheimer’s disease. Treating one condition did not make the other disappear, but it did allow the patient to function much better..
We next heard from Drs. Mark Ehrenreich and Farooq Mohyuddin about current trends in Residency Training. One new feature is an electronic residency training application process that lets applicants indicate where in the country they want to train and which programs they want to be considered for. Since the pandemic, interviews have largely been done virtually. Among U.S. medical school seniors, 7.2% are applying for psychiatric positions. There remains a growing gap between the number of psychiatrists and the need for them–worse in some of the subspecialties.
The second part of the presentation focused on what we should teach Residents now that AI is beginning to play an important role in making diagnoses, creating treatment plans, and determining prognoses. They will need skills beyond obtaining information and generating a differential diagnosis. They will also need experience with interventions such as ketamine, vagal nerve stimulation, and ECT, while learning when technology helps clinical judgment and when it does not.
Dr. Greti Barokas gave the day’s last presentation, based on her Resident Research Award for “Anorexia & Cannabinoids.” She reviewed studies examining cannabinoids and the endocannabinoid system in anorexia nervosa. Exogenous cannabinoids—primarily dronabinol—have produced modest weight gain in several small trials, but they did not improve attitudes toward eating or body weight. Her conclusion was that, although although cannabinoids may cause some short-term weight gain, there is not enough evidence to recommend them as a treatment for anorexia nervosa. Longer studies, more diverse populations, and better characterization of what patients are actually taking are needed.
DAY THREE
The final day began with a lecture by Glenn Treisman, MD, PhD, entitled “Seeing the Whole Elephant—Dysautonomia,” concerning patients whose diagnoses do not fit cleanly into our usual system-based framework. They may present with cardiovascular, gastrointestinal, neurological, immune, and psychiatric complaints at the same time. Historically, some have been labeled as having “functional” or psychosomatic disorders because no single structural lesion explains all of their symptoms. He noted that objective abnormalities can still be found, including abnormal tilt-table testing, small-fiber neuropathy, chronic immune activation, abnormal gastrointestinal motility, and functional MRI findings. Autonomic dysfunction can also produce fatigue, fear, hopelessness, and depressive symptoms that may look psychiatric even when the underlying process is broader. They frequently remain sympathetically overactivated and may have hypermobility, abnormal sodium-channel activity, or symptoms that begin after infections. Because their difficulties cross specialty boundaries, they may be passed from one specialist to another without anyone seeing the “whole elephant.” He emphasized individualized treatment, physical rehabilitation, and persistent clinical curiosity rather than giving up simply because a patient does not fit neatly into one diagnostic box.
We next heard from Jonathan Hershfield, MFT and Dr. Michael Young about the diagnostic and treatment gray zone where Autism meets OCD. Many features overlap, particularly repetitive behaviors. Autistic patients may use routines, predictable sequences, or repetitive behaviors to regulate sensory overload and cognitive discomfort. Compulsions characteristic of OCD, in contrast, are usually fear-driven attempts to decrease anxiety, prevent some feared outcome, or obtain certainty. Mistaking necessary self-regulation for a compulsion can destabilize a patient; mistaking an OCD compulsion for autistic regulation can reinforce the OCD. Exposure and Response Prevention can be very effective, but it may need adaptation. Some autistic patients will nod along with the therapist and then “white-knuckle” their way through an exposure without understanding what they were supposed to learn. The rationale may need to be explained repeatedly and concretely, and successful skills may need to be practiced in several different settings before they generalize. The goal is not to take away useful autistic regulation but to increase flexibility and reduce the behaviors being driven by OCD.
We then had the third Product Theater—Kenny Perez, MD, describing how Auvelity can help Alzheimer’s patients who are agitated. Adding dextromethorphan to bupropion can triple its half-life, leading to improvement in as many as 82% of patients.
This was followed by the meeting’s final presentation, a discussion of The King’s Speech movie and stuttering. After reviewing some of the movie’s key scenes, Vivian Sisskin, MS, a noted stuttering expert, summarized important aspects of the condition and its treatment. Dr. J. Corey Jackson followed, discussing its clinical presentation and treatment and how accurately—or inaccurately—the movie portrayed it.
We covered a lot of information over these three days, with many opportunities to discuss what is new and how we can cope with changes. The speakers asked us to look beyond the first or most obvious explanation: the “psychiatric” patient whose problem is also autonomic, the older patient whose forgetfulness might represent ADHD and dementia, the repetitive behavior that might represent autism or OCD, or the patient losing weight on a new medication. Fortunately, there were also many opportunities to relax with colleagues in delightful surroundings. Starting with an open-air welcome reception on the 16th and continuing throughout the meeting, it was easy to learn a great deal while having a good time.
Post-Partum Psychosis
by Robert Herman, MD
A recent criminal trial in Massachusetts has highlighted awareness of postpartum psychosis which is an extremely rare, but extremely serious, psychiatric disorder. In nearly 40 years of practice, I have seen very few of these patients, Their presentations and clinical course were extremely varied. but quite memorable, and not always as described in textbooks.
The sudden onset of unusual thoughts in a young mother shortly after giving birth may initially puzzle everyone involved. Patients may be reluctant to divulge these thoughts as they may be afraid that their children may be taken away from them. There are cases in which there is no prior history of psychiatric illness.
Because the presentation can vary tremendously, the diagnosis may be missed for some time. In one case a patient shortly after birth of her child suspected that her husband was having an extramarital affair (which he was not). Her parents, sister, therapist and lawyer all believed her version of reality, Her illness was not suspected until it became much more pronounced nearly one year after the birth of her child. Only then was she hospitalized and treated.
Another patient presented to an emergency room exhibiting psychotically manic behavior and was hospitalized as a “Jane Doe”. It was only discovered after several weeks that she had recently given birth; that is when the diagnosis of postpartum psychosis was finally made.
Postpartum psychosis was listed as a diagnosis in DSM and DSM-II, but was omitted from subsequent editions. So textbooks, courses of instruction, and other educational materials may not adequately describe it. This omission from the DSM is puzzling. Authorities such as Veere Bergink of Mount Sinai in New York say that it is basically an atypical presentation of bipolar disorder and responds to lithium and antipsychotic medications. This is my thinking as well.
A large majority of these patients will not go on to further episodes of psychosis if they do not have another child, but the risk of another episode if they do become pregnant is quite high. Some go on to develop classic bipolar disorder and require maintenance prophylaxis with lithium or other mood stabilizers
When they commit acts of endangering or harming their children the response of the legal community is extremely varied, but often quite harsh. One state, Illinois, has enacted laws specifically reducing criminal punishments for women who have had documented postpartum psychosis when committing illegal acts. In other states the only defense is generally the standard defense of insanity, The McNaughton rule states that a person is not responsible for a crime if, at the time of the act, a mental illness caused a “defect of reason”–the person either: did not know the nature and quality of the act they were doing or did not know that the act was wrong . This may be extremely difficult to prove at a criminal trial that typically occurs months or years after the act has occurred and the psychosis has remitted. Careful psychiatric examination and documentation of this at the time of the episode can be crucial in establishing this defense.
Postpartum psychosis is an extremely serious and potentially lethal psychiatric illness that can be quite difficult to detect early. Nevertheless it is extremely treatable and therefore it is important that we educate ourselves and the public to be alert, so that it can be treated before serious complications occur.
From the Ground Up
A New Psychiatry Residency Takes Root in Baltimore
by Keeran Navaratnam, MS4 & Shyam H. Bhatt, MD, MPH
The shortage of psychiatrists in Maryland has persisted for years. A recent change has begun to emerge, most notably in the 2024 establishment of Baltimore’s new psychiatry program.
Linked through Georgetown University, both the D.C. and Baltimore campuses train toward the same goal: psychiatrists who “think like scientists and act like humanitarians.” While the D.C. program leans on sites like MedStar Washington Hospital Center, the VA and NIMH, Baltimore’s version is built around two community hospitals instead: MedStar Franklin Square Medical Center and MedStar Harbor Hospital.
Functioning as a distinctive microcosm of healthcare, both serve complex patient populations that many training programs fail to reach. The design of the residency program is deliberate: train people in the kind of Psychiatry the neighborhoods around Franklin Square and Harbor Hospital actually need. Residents take rotations through inpatient Medicine, Neurology and Psychiatry, along with outpatient care, child and adolescent psychiatry, addictions, geriatrics, consultation-liaison, forensics and Community Psychiatry electives.
At the helm is Theodora Balis, MD, Vice Chair for education in MedStar’s Baltimore region and the residency’s program director. She is not new to Maryland psychiatry. She trained at the University of Maryland and stayed on as faculty there from 1998 to 2024, directing its Cultural Psychiatry Training and serving as PGY-1 coordinator at one point. She joined Bon Secours in 2013 and remained through its transition to Grace Medical Center and later LifeBridge Health, where she directed the ACT team and oversaw medical education in Psychiatry. She joined the faculty at George Washington University from 2022 to 2023, before she arrived at MedStar Franklin Square Medical Center in July 2023 to build the program from scratch.
She also served as President of the MPS from 2024 to 2025. In her inaugural column for MPS News, she wrote that one of her goals was to increase Psychiatry’s relevance to the people making policy decisions about how psychiatric care is provided, adding that doing so “may include collaboration with law enforcement and emergency medical services to ensure the best possible outcomes for individuals experiencing psychiatric emergencies.” That same concept– that Psychiatry must actively engage beyond its institutional walls–runs through the residency itself. Placing Residents in settings designed to bring psychiatric care to underserved patients combats the assumption that patients from complex communities can independently navigate an opaque healthcare system.
The inaugural class, four Residents chosen from more than 1,000 applicants, arrived in the summer of 2025. The program will train roughly 16 residents at a time, once each of the four residency years reaches full capacity. The program treats the variety of Residents’ backgrounds as an exemplification of its mission rather than a footnote, recognizing that diversity of experience is helpful to training psychiatrists equipped to serve marginalized communities. Residents also gain research opportunities through the program’s partnership with Georgetown, part of an academic track that runs alongside its community psychiatry focus.
What this means for Maryland is bigger than one residency class. Because physicians often establish roots in the communities where they train, a residency built around Baltimore’s community hospitals aims to keep psychiatrists in the places that most need them. Its vision works alongside Morgan State’s forthcoming School of Medicine and the Meritus School of Osteopathic Medicine in Hagerstown.
The four residents in the first class currently seeing patients at Franklin Square and Harbor Hospital still have a long journey ahead. It will take time to see what emerges from a residency program built around community psychiatry and cultural responsiveness. The additional recruitment of psychiatrists to Baltimore—a city that is in desperate need of well-trained clinicians– can only be beneficial.
Cheers from the Chair: Drs. Alessi and Reti
by Jimmy Potash, MD
Chair, Johns Hopkins School of Medicine Dept of Psychiatry & Behavioral Services
Ed’S Note: This was originally sent to department members by Dr. Potash on June 19, 2026
Under a spreading chestnut-tree
The village smithy stands;
The smith, a mighty man is he,
With large and sinewy hands,
And the muscles of his brawny arms
Are strong as iron bands…
…Thanks, thanks to thee, my worthy friend,
For the lesson thou hast taught!
Thus at the flaming forge of life
Our fortunes must be wrought;
Thus on its sounding anvil shaped
Each burning deed and thought.
– The Village Blacksmith, Henry Wadsworth Longfellow
Good morning,
We celebrated and bade a fond farewell to Dr. Larry Alessi yesterday in the lobby of the building where he got his start in our department, the former Henry Phipps Psychiatric Clinic. Larry joined us as a resident in 1969, the year the Baltimore Orioles lost to the New York Mets in baseball’s World Series. Now, Dr. Alessi is finishing up 50 years of leading the General Psychiatry inpatient service, coming in five days a week at 7:00 am, 11 months of every year, training every chief resident who has come through our doors, as each of them rotated through as the sub-attending. I am tempted to compare Larry Alessi to Lionel Messi, who is still a star soccer player despite his advanced age. But the more apt comparison is to Orioles standout Cal Ripken, with his consecutive games streak of 2,632, the all-time longest in baseball. It led to Cal being called the Iron Man. Well, Larry is at ~11,450 consecutive attending days. They say Cal’s streak will never be broken, and I think it is safe to assume that our Iron Man of Hopkins Psychiatry’s streak will forever remain unbroken as well. We owe an incalculable debt of gratitude to Larry for the tremendous work he has done as a clinician and an educator, and for his remarkable dedication to our department and to Johns Hopkins. Cheers to Dr. Alessi!
During Dr. Alessi’s first year on the faculty, in 1974, California passed laws making it more difficult to perform electroconvulsive therapy (ECT). The anti-ECT movement was especially strong in the Golden State at that time, and this highly safe and effective treatment for depression was almost banned by the legislature that year. A group of psychiatrists there came together in a lawsuit to challenge these new rules, and one of them began publishing a newsletter. This group would evolve into the International Psychiatric Association for the Advancement of Electrotherapy, more recently rebranded as the International Society for ECT and Neurostimulation (ISEN) to reflect the growth in other electromagnetic approaches, most notably, Transcranial Magnetic Stimulation (TMS). Many of the luminaries in the field have led ISEN, and last month, our own Professor Irving Reti took over as president. He presides over an organization composed of hundreds of providers spread across 23 countries on six continents, including Irving’s native Australia. ISEN offers an online and an in-person ECT course, and a webinar series, and they publish the Journal of ECT. Dr. Reti has authored more than 50 papers related to ECT or TMS, and is a leading authority in the field. Congratulations to Irving on this weighty leadership role and this great honor!
I will leave you with Electric Avenue by Guyanese-British musician Eddy Grant: https://tinyurl.com/bd7hmp93. When this video appeared on MTV in 1983, it was among the first on that network by a Black artist. It quickly rose to #2 on the charts. Happy Juneteenth!
In Memoriam: Paul Roberts, MD
by Bruce Hershfield, MD
Dr. Paul Roberts, a long-time member of the MPS until 2014, died at age 91 on April 4th. Originally from Oklahoma, he came to Baltimore to do his psychiatric training, which he started at Baltimore City Hospitals and completed at Sheppard–Pratt. He earned his analytic certification in 1975 and practiced in the Mt. Vernon neighborhood of Baltimore.
He played an important role in the Analytic Institute for many years, supervised at the Johns Hopkins School of Medicine, and worked part-time in the counseling center on the Homewood campus Homewood. He and his wife, Mary (who was an OB-GYN) were very supportive of the local arts. The Baltimore Museum of Art (where he served as a trustee from 2006-11) held a show of the works they had donated–”The Mary and Paul Roberts Collection”– in 2019.
MPS members George Gallahorn and Samuel Goldberg both commented about him after they learned of his death. Dr. Gallahorn cited his administrative work for the Institute, where he was “thoughtful, evenhanded and retained a positive outlook regardless of the problems that arose.” Dr. Gold berg wrote, “I found him not only invaluable in establishing my analytic identity and clinical approach, but also invariably warm, interested, and supportive”.
Confidence, Consciousness, and Compressions
Navigating a Medical Student’s First Resuscitation Attempt
by Caroline Yi, BS1
Nobody told me that it’s hard to start an IV on a dead person. I’m a third year medical student in the ED on my second rotation. A 20-year-old patient, B, was brought in unresponsive, likely from an overdose. She was discharged yesterday after a week of treatment for suicidal ideation. Recently, her father overdosed and died.
Now in Room 22, I awkwardly stand by B, unsure of what’s happening. I’m in the intern’s way. She palpates B’s thigh and advances a large needle into an anatomic structure that I should probably know, but don’t. Feeling useless, I inch towards the door to watch from a distance, but now I’m blocking nurses wheeling in ultrasound machines. I shuffle into the hallway and flatten myself against the wall, trying to shrink into the smallest inconvenience possible.
Suddenly, my attending appears from the bowels of the ED. “Jump in,” she chastises. “Be an active learner.” And that’s how I find myself trying to start an IV on a dead woman.
I’ve started IVs on living patients before—six, to be exact. But now, B’s arm feels like pizza dough. I look for a faint blue vein, but her entire body is a strange, purplish hue. I ask if I should try blindly, but a nurse advises against it, warning I might stick an artery. I’m not sure if a dead woman can bleed out, but I step aside to let her try.
The room is chaotic—beeps and buzzes, white fluorescent lights. People with established roles are doing important things. Suddenly, the senior resident announces the automatic compression device isn’t working.
“We need people for compressions!” she calls.
Moments later, I’m standing on a stool, two feet above B. I lock my arms straight and press down as hard as I can. Over, and over, and over again. I’m sweating. Her entire body moves.
Looking down, I see her closed eyes and tattoos. She does not look like she is asleep; she looks unmistakably dead. This feels surreal. Unexpectedly, anger wells up in me. Anger against the social systems that failed her. Anger at the addiction that consumed her. Anger at whoever sold her the drugs that killed her. I wish I could go back in time and rip them from her hands.
I channel that anger into my compressions.
After six minutes, a nursing student takes over. We give the dead woman epinephrine. We shock the dead woman with electricity. We push air into the dead woman’s lungs.
And then we repeat.
And repeat again.
Back on the stool, I push into her chest.
“It’s been two minutes,” the senior resident announces. “Do we feel a pulse?”
I rest my hand on B’s chest. I don’t feel anything. I glance at the nurse opposite me, who’s also checking. She’s undoubtedly better at this than I am.
“Do we have a pulse?” the senior resident asks, again.
I hesitate. I could be mistaken, but I feel a faint heartbeat. Nervously, I say, “I think we do?”.
The senior resident snaps, “Do we or don’t we?”.
Looking up, I see a new electrical rhythm on the monitor. “We do,” I say, with more confidence.
The monitor makes a different beeping sound—the sound of someone who is not dead. I look at the woman who is not dead. I look at the monitor. I am now a trained medical student who can, confidently, feel a pulse.
The senior resident doesn’t skip a beat. “We need access!”.
The intern is still trying to stick a large needle into B’s thigh. There is a lot of blood. She is visibly frustrated. I later learn she is trying to start an arterial line.
Suddenly, she straightens and stares at her finger. “I’ve stuck myself,” she says, quietly.
A pause hangs in the air.
The senior resident sighs. “I’ll finish up,” she says. “You can go.” The intern scurries away, ripping off her gloves.
The patient is transferred to the ICU. She never regains consciousness. She’s not dead, but she’s not alive, either. The next day, she donates her heart, lungs, liver, and kidneys. B’s chart is closed. She does not need a discharge plan. In the end, B completes a 48-h round trip from death to liminality and back.
Long after my clerkship ends, I wrestle with the dialectic of success and failure that defines clinical medicine. The psych team successfully stabilized B enough for discharge— yet she overdosed the next day. A senior resident confidently led a code—yet an intern failed to safely obtain an arterial line. The ED team obtained ROSC—yet B did not regain consciousness. B’s organs saved lives—yet B is gone.
In B’s absence, I stand a little taller. My first resuscitation effort taught me that confidence is not just knowing what to do but executing it under pressure. It is built one action at a
time. Taking a pulse. Recognizing a rhythm. Making a decision that alters the next step.
That moment became more than a clinical milestone— it marked the beginning of a deeper lesson. Confidence is shaped not only by the triumphs of good outcomes, but also by the lessons learned in the face of impossibility. As medicine has yet to find the panacea for the many determinants of health, physicians are confronted daily with situations beyond their control. The trauma of our profession exerts a relentless undertow of depersonalization, threatening to pull us away from ourselves and our patients. Defining success not only by outcomes, but also by presence and growth, allows us to remain conscious and connected—for the patient in front of us.
Conditional S.I. Is Actually Secondary S.I.
by Idris Leppla Shubow, MD
Voicing suicidal ideation (SI) is a behavior driven by a mix of classical and operant conditioning. In other words, patients voice SI because they have learned that doing this is the only way to get their needs met. In many cases, their needs may be basic—and can include shelter, abstinence from the ongoing cycle of substance abuse, and pain. They have learned over time that other ways of asking do not get the attention or care that “SI” gets.
For example–a patient comes to the ED saying, “I’m homeless. It’s cold outside and I’m scared.” It depends on the resources of the healthcare system, but many patients will at best be referred to a social worker who will give them a list of nearby shelters and possibly pay for a cab ride to one of them. The patient who voices SI has probably done that many times. He or she may have been raped at the shelter or had a backpack stolen there. So they learn that simply complaining of homelessness is not adequate to free them from their troubles. Perhaps they return to the ED with wounds that need healing and they are hospitalized, where they are given IV antibiotics as well as food and shelter for several days. They learn about the respite a hospital stay can bring. Once discharged, they may overhear friends on the street telling them, “Just tell them you’re suicidal. They can’t discharge you from the ER.” So the patient tries it—and it works. They stay in the hospital several days, even go to a place called the “psych ward” and meet other people who struggle with exactly the same problems. They learn that the hospital system is a safe, clean place to be and when things get too trying on the streets or at a relative’s house, this feels like a good solution.
The ER doctor needs to answer in this quick clinical encounter whether this particular set of circumstances is a good use of the healthcare system. A 3-5 day stay in a psych ward will not solve the underlying homelessness or substance abuse pattern that has brought this patient in. But is the patient deserving of a “break” at this moment in time? That is a hard question to answer as it requires thinking about resource allocation (questions of justice in ethical terms) weighed against the danger of conditioning this already vulnerable patient that the only way to get immediate help is to voice SI.
Is there another way? This depends on how much time and energy you are willing to take to figure out, “What is the underlying problem that is causing this person to voice suicidal ideation?” If the answer is homelessness, then is there a social worker who can closely work with this patient to figure out a long-term solution? Does this person qualify for governmental benefits? Is there a family member who can be asked to house this person again?
If it is substance abuse leading to homelessness and despair, are there programs that will support their recovery (half-way houses, recovery treatment programs?) Does your hospital have access to recovery specialists who place patients in these situations?
Sometimes, if the person is so downcast that their internal resources cannot be mustered to face either the streets or a recovery program, perhaps a brief medical (if they have wounds) or psychiatric (if they feel hopeless) stay is in order. But that should only be considered after trying first to meet their primary needs. We need to reframe conditional SI to secondary SI–typically secondary to substance abuse, homelessness or untreated pain–and first try to address these problems.
The Prescription Isn’t Enough:
Why Psychiatry Can’t Outsource OCD
by Jennifer Palmer, MD
Two years ago, I would have said I understood OCD. I prescribed serotonergic medications as supported by evidence and referred patients for ERP. Then I began seeing patients alongside specialists who have spent their careers managing it, and I realized how little I really knew: I saw suffering of a depth I had not appreciated.
OCD affects 2-3% of the population. Its evidence-based treatments look more effective in studies than in the real world. Part of the reason is how long people wait: the time between symptom onset and diagnosis has been estimated at as much as 21 years, and treatment is often delayed further by the avoidance that is itself a feature of OCD. Those years can be costly: OCD is one of the 10 most disabling conditions identified by the World Health Organization. It erodes work, relationships, and family life, and nearly half of those who live with it experience suicidal thoughts at some point.
Ultimately, we have treatments that work, but we don’t deliver them well enough. The reasons are largely systemic, and they implicate my own training and practice. Psychiatry has been drifting away from therapy since at least the mid-1990s, when close to half of office-based psychiatric visits still involved psychotherapy. By 2016, half of psychiatrists reported providing none at all. The explanation is mostly economic: insurers rewarded brief medication-management visits over longer psychotherapeutic ones, and the “med check” became the dominant model — the model I practiced for many years.
As Psychiatry stepped back, the behavioral treatment of OCD migrated almost entirely to clinical psychology. Psychologists are now the dominant providers of ERP in nearly every setting, and hands-on ERP has largely disappeared from psychiatry residency training. I didn’t learn how the treatment works.
One telling example was a patient who had both depression and OCD. I would provide reassurance when the patient expressed harsh thoughts about himself, taking them for the ego-syntonic rumination of depression. My experienced OCD colleague — an expert in ERP — pointed out that I had mistaken moral scrupulosity for depressive self-criticism, and that my reassurance was quietly undermining his ERP. That was the moment I decided I needed to learn more — and that both the patient and I needed to learn to sit with his uncertainty.
There is also a conceptual habit I find hard to break. OCD was reclassified in 2015 as its own category, distinct from the anxiety disorders, and yet I continue reaching for the anxiety-disorder playbook. The reclassification tracks emerging neurobiology, which points less to the fear circuitry of anxiety than to circuits — regulated by glutamate — involved in terminating the urge to act on a feeling. That distinction may explain why the anxiety reflexes, anxiolytics and reassurance, can fail or backfire in OCD.
Benzodiazepines are the clearest example: prescribed for anxiety, they can blunt the very fear-extinction learning ERP depends on. A psychiatrist may not know this. A therapist cannot adjust the medication. It takes both of us to maximize the effectiveness of treatment. In addition, the two providers must communicate.
Perinatal OCD provides the sharpest illustration I have encountered. Its hallmark — ego-dystonic intrusive thoughts of harming the infant — is under-detected and rarely reported spontaneously, and can be mistaken for depression or–at the extreme–for postpartum psychosis. Getting it right requires accurate recognition. Decisions about medication must consider the stakes of pregnancy and lactation — judgments that only a prescriber and an ERP clinician in close contact can reliably deliver. Effective collaboration looks fairly mundane: regular communication between psychiatrist and therapist, and enough clarity about our roles so that we are not duplicating or undermining each other.
That clarity depends on the psychiatrist understanding how ERP works. Learning this has changed how I practice from the first interview on, and I have learned to question whether a patient has been seeking reassurance from me without either of us naming it. I now get to know my patients with more depth and compassion. We should advocate for restoring comprehensive ERP training to psychiatry residency — not so psychiatrists can take OCD back from the therapists who treat it so well, but so we can hold up our end of a shared responsibility.
OCD is highly treatable. Whether we treat it well remains largely a matter of how we choose to organize ourselves and how well we can interact with our colleagues.