50 years of the CJP
Editing The Canadian Journal of Psychiatry 1995–2004
Quentin Rae-Grant, MB, ChB, FRCPsych, FRCPC 1
(Can J Psychiatry 2005:50:675–676)
Over the period 1995 to 2004, I had the privilege of being the editor-in-chief of the now 50-year-old Canadian Journal of Psychiatry. These years abounded with changes and challenges. What we published in the Journal reflected what was happening in psychiatry, and in society as a whole.
My term spanned the transition from the 20th to the 21st century, which was anticipated with substantial anxiety in respect to computer systems. (Nothing happened!) Somewhat later, the dot-com bubble did burst and bring reality into this increasingly important field. The events of September 11, 2001, shocked North America with experiences suffered by many in other parts of the world but new to this region.
The pace of life in general has accelerated over these years. Similarly, there has been an acceleration of communication by e-mail, cellphones, and pagers, all of which require immediate response. The demand to increase performance each year is creating an atmosphere of increased tension and anxiety, with “stress leave” being the politically correct response to those affected. This labelling, however, is a refusal to acknowledge the high percentages who suffer mental illness over their lifetime. This also reflects the reality that stigma remains vigorous, despite commendable efforts by individuals and organizations to educate and enlighten the public. The persistence of stigma associated with mental illness also indicates that, like it or not, psychiatry is still not highly respected in the medical–hospital culture.
During my years as editor-in-chief, the practice of psychiatry changed radically. Longer-stay beds were closed or transferred to general hospitals. These financially driven requirements have led to a revolving-door syndrome characterized by repeated admissions and swamped emergency rooms. (This is not to oppose the concept of reintegration but to politely suggest that some individuals still require a longer stay, particularly since community services that have been put in place do not consistently meet the needs of the chronically ill.) Community treatment orders have addressed this issue, with considerable success reported so far.
Further, the advent of new medications with fewer immediate side effects virtually requires their use in serious mental illness. The shortage of beds has led to the use of multiple medications (and, unfortunately, to a decline in the personal aspect of treatment, as indicated by this direct quote from a psychiatrist with a long-term patient: “ If you want psychotherapy, go to a psychotherapist”).
The bottom line in today’s psychiatry is defined by more patients, fewer staff, and increased medication—to the point that medications introduced primarily for one condition are now used for many and the link between diagnosis and selected treatment has become blurred across schizophrenia, affective disorders, dementia, and the treatment of troublesome youth. If there is a problem there must be a pill! Those psychiatrists who continue to provide psychotherapy and psychoanalysis face a dilemma. The public perception of psychiatry is still that of the couch, yet the value of what we provide is demeaned by the widespread acceptance of “counsellors” (with training and practice unspecified) for any and every need for personal care.
Allied to this change has been the increasing influence of administration on clinical service provision, best demonstrated by the concept expressed in the 1991 Barer-Stoddard report (1) that doctors drive the cost of health care, so fewer doctors must equal less cost. The result of cutting back medical school places despite dire predictions of disaster is only now being fully felt by the public. Both the number of doctors and the hours they can practise have been constrained in favour of other priorities and compete with the considerable value of newer diagnostic tests. Similar are the measures of psychiatrists’ performance, such as a length-of-stay that is often shorter than needed for medication to be effective.
My term also spanned an era of diagnostic confusion that led to frequent diagnoses of comorbidities. Because most patients had not read the DSM-IV, they presented with a variety of symptoms and were inevitably labelled with several “comorbid” conditions, as required by hospital filing systems. However, as the distinctions become more blurred, so does the use of multiple labels.
The last decade has also been marked by an increased role for pharmaceutical firms, and this has had implications for publishing in the Journal. The interrelation between industry and psychiatry is immense but necessary. The companies generously fund clinical trials of new products but, in most cases, retain ultimate control over the publication of results. They heavily support publications such as the Journal, but they can also influence which ones survive (as demonstrated by the demise of the Canadian Psychiatric Associaton Bulletin). Industry provides increasing funds for meetings and presentations. In fairness, it must be acknowledged that, while paper sessions at meetings are sparsely attended, lunches and dinners with clearly defined sponsorship are packed. Advertising is now directed at the public in general (at least on American television, which is widely available to Canadians). What the companies rarely provide is funding for long-term studies of continuing effectiveness and side effects—exactly the reason that many drugs have had to be withdrawn or end up with warnings. The extent of this interaction is now recognized, and prominent journals such as the Lancet no longer prohibit using anyone who was funded by a pharmaceutical firm as a guest editor.
During my term, the Journal became available electronically. At the same time, the Internet’s increased availability has led patients to use it to reference medication (mostly in regard to diagnosis and side effects), although this process does not take the placebo effect into account. Detailed and repeated discussion of benefits and side effects has now become essential in practice to ensure compliance (a major problem for the seriously ill).
With all these changes in mind, it should not be surprising that the Journal itself has changed. For many years, it seemed to function as a school for young authors at the start of their publishing careers. Changing this practice and raising the standards of acceptance has made publication more difficult and created a higher rejection rate. Another development during my term was the regular publication of review papers solicited from experts, both in Canada and elsewhere, accompanied by guest editorials from leading clinicians and researchers. Putting these factors together, our “impact factor,” that is, the number of times an article is cited over a period of time, grew from 0.5 to 2.071 in the past 10 years. My successor, Joel Paris, is continuing on the same path, further raising the bar, and introducing a new series, entitled “In Debate,” that features divergent views on controversial topics. The Journal is in excellent hands.
I am thankful for the opportunity to have been editor-in-chief of The Canadian Journal of Psychiatry and have great confidence in its future.
References
1. Barer ML, Stoddart GL. Toward integrated medical resource policies for Canada. Prepared for the federal/provincial/territorial conference of deputy ministers of health. Ottawa (ON): Health Canada; 1991.
Author
1. Editor in-Chief 1995 to 2004; Professor Emeritus, University of Western Ontario, London, Ontario.
e-mail: qrg@idirect.com or qrg@rogers.com
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