Leo Sher, M.D.

Today, we publish an interview with an eminent American psychiatrist, attorney, and writer, Dr. Jacob Appel.

Jacob Appel, M.D., J.D. is Professor of Psychiatry and Medical Education and Director of Ethics Education in Psychiatry at the Icahn School of Medicine at Mount Sinai in New York City.

Leo Sher: What is the most important issue in contemporary psychiatry?

Jacob Appel: Although many challenges confront contemporary psychiatry, I believe the most important challenge right now is access to care.  A series of structural factors has led to a decrease in the psychiatric workforce (more retirements at an early age due to COVID, an artificial shortage of residency spots) and many psychiatrists don’t take insurance.  Others no longer take new patients.  In addition, many screen out “high risk” patients, who are those most in need of care.  The result is that in many communities, including New York City (where I work), middle- and working-class people struggle to find outpatient psychiatrists.  Nurse practitioners have not filled this gap, as many in private practice also refuse to accept insurance or high-risk patients.   Policymakers must take steps to increase the overall size of the psychiatric workforce and to incentivize providing care to those in need, including high-risk patients, such as those with a history of serious suicide attempts.

Leo Sher: How do you see the future of psychiatry?

Jacob Appel: These are very exciting times for psychiatry.  For many years, psychiatrists offered treatments with limited understanding of how they worked.  At present, most psychiatric conditions – such as schizophrenia or depression – are better thought of as syndromes, rather than diseases, just as various kidney diseases were once grouped under the term Bright’s disease a century ago.  But soon we will be able to break down these syndromes into organically-defined subtypes.  We will be able to target specific antipsychotics to specific forms of schizophrenia or to predict in advance which patients with depression will benefit more from medication or from talk therapy or from both.  In twenty years, we will look back in wonder at how little we knew and, more importantly, we will have a range of novel therapeutic options for our patients. 

Leo Sher: What needs to be done to improve psychological health and reduce suicide rates around the world?

Jacob Appel: Many factors are contributing to the current mental health crisis.  I will focus on one in the United States that might help reduce suicide.  I have written about this particular topic at length here:  https://pubmed.ncbi.nlm.nih.gov/22828046/  The short explanation is that blaming providers for suicide or holding them liable may actually increase the risk of suicide by creating invisible victims.  For instance, if psychiatrists are afraid of being sued for a completed suicide, they may be unwilling to accept patients at high risk of suicide into their practices, which protects the physicians but places these untreated individuals at even higher risk.  Another concerning phenomenon is admitting patients involuntarily who are at lower risk of suicide, out of an overabundance of caution, which may scare them away from seeking care in the future when they are at greater risk.  As I explain in my paper, psychiatrists take great pains to protect their patients and offer top-quality care.  Nobody has ever demonstrated a connection between liability for outpatient suicide and reduced suicide rates.   In fact, such liability is relatively new – the first case in NY State dates from 1982 – and suicide rates actually have risen since that time.  I do hope this offers food for thought and a potential outside-the-box contribution to suicide reduction.