50 years of the CJP
Do Psychiatric Journals Have a Future in the Age of the Internet?
Peter Tyrer1
(Can J Psychiatry 2005:50:677–679)
I write this piece as the editor of the British Journal of Psychiatry, which 2 years ago celebrated its 150th anniversary. It started its life in 1853, as the Asylum Journal of Mental Science, with fairly modest aims. Although it was originally meant to be an educational journal for architects, magistrates, and other professionals apart from psychiatrists, it rapidly became a house journal for asylum doctors, dealing not so much with the science of mental health as with all aspects of the conditions within asylums (1,2). In this form, it proved a valuable forum for the isolated doctors given the appropriate title of “alienists” and separated from the rest of the medical profession who enjoyed more constant peer review and support. Eventually, the journal escaped the asylum bond that constricted its development and became the Journal of Mental Science, surviving in this form until 1963, when it assumed its present name under the editorship of Eliot Slater.
I wish The Canadian Journal of Psychiatry all the best as it enters the second half of its centenary—the first 50 years are always the worst—and would like to offer some observations on its future in the next few years, with particular reference to the influence of the Internet and its impact.
Are Psychiatrists Computer Literate?
The average psychiatrist is conventionally alleged to be highly competent when it comes to understanding words, feelings, and behaviour but generally incompetent when it comes to mastering technology. Like many stereotypes, this view is frequently inaccurate, but the notion of the psychiatrist in his or her library, surrounded by books, is much more tied to our work than the notion of the psychiatrist in a paperless office with sentinels of winking computers. There has, however, been no escaping the introduction of the Internet, which has led to many predictions about the ways in which it will change our lives, not always for the better. What is clear is that in 20 years’ time it will be extremely rare for any individual in a well-resourced part of the world to be ignorant of the Internet. In 1996, Bill Clinton remarked that “When I took office, only high-energy physicists had ever heard of what is called the Worldwide Web. Now even my cat has its own page.” (3). If kittens of the future are computer literate, even the most uncool of psychiatrists will have to join them in padding about the Net.
Indeed, they already seem to be. At a European conference on neuropharmacology, held in October 2004, 80% of the 545 delegates who completed assessments used on-line psychiatric journals (see www.cnsforum.com), and while they may not represent all psychiatrists, they are clearly using the medium in large numbers. In November 2004, all the journals published by the Royal College of Psychiatrists changed to on-line submission, so we have been able to monitor on-line use. Advances in Psychiatric Treatment, one of the journals that the Royal College of Psychiatrists publishes for postgraduate education, has had 12 000 downloads of full-text articles since it went on-line, and I know from conversations with other psychiatric editors that this is not an exceptional finding. We have also asked our readers their opinions about our new on-line system. Two-thirds of them are highly positive; only one-third grumble. We know there will always be a few—and they are not all grumpy old men—who will be reluctant to embrace this new technology, but it seems likely that their numbers will steadily diminish.
What these data tell us is that the psychiatric fraternity is keener than might at first seem evident to embrace on-line technology and that this technology is perceived to have particular educational value. The growth of what has become known as distance learning is going to be especially important in large countries such as Canada. Simultaneously, the increasing sophistication of video and Internet conferencing, which I noted recently when I was speaking in Halifax, Nova Scotia, and St John’s, Newfoundland, is going to be an enormous boon.
Whither Psychiatric Publishing?
There is a fear that these technological developments may make conventional psychiatric publishing obsolete and that paper journals, in the words of one of my colleagues, “will be relegated to the sort of literature reserved for coffee table discourse.” This fear has been accentuated by the development of open-access publication, a worthy aim (announced in Bethesda, Maryland, in June 2003) of granting to all users a free, irrevocable, worldwide, perpetual right of access to, and a license to copy, use,
distribute, transmit and display work publicly and to make and distribute derivative works, in any digital medium for any responsible purpose, subject to proper attribution of authorship (4)
and promoting the publication’s deposition in an approved “on-line repository” (such as PubMed). Open access has now been embraced by the US National Institute of Mental Health and the UK Wellcome Trust and is likely to become general publishing policy before too long. Subscription journals will then be squeezed out of existence, because the notion of a select few having access to articles only with association membership is against the open-access principle.
All good ventures are able to recognize that a threat can be made into an opportunity, and there is good reason to think that psychiatric publishing can prosper in this new environment. The aim of any journal is to disseminate knowledge quickly and accurately, and the Internet can only promote this, when used correctly. In several ways, journals can positively harness the ready accessibility and availability of almost unlimited Web space.
First, each journal can have both a paper-based and a Web-based version. The paper version would offer the main study findings and explanation, but the Web version would have additional information about the instruments used, much fuller information about the data and analysis (both qualitative and quantitative), and possibly in the future, the raw study data for use in reanalyses, systematic reviews, and metaanalysis. Second, the space freed up in a journal by putting more information on the Web-based version could be used to publish more interesting editorials, debates, discussions about controversial issues, and stimulating correspondence. Third, more space could be devoted to systematic and other reviews concentrating on the evidence base for clinical decision making—information which is so important in clinical practice. This latter point has already been noticed as one of the major changes in The Canadian Journal of Psychiatry over its 50 years’ sojourn on the world stage (5).
Even if we assume that the open-access policy will lead to all original material being readily available to nonsubscribers, the rest will still remain available only to subscribers. It is important to remember that the impact factor, which is currently the main force driving academics in their search for publication, is only roughly related to interest and readability (6); much of what clinicians relish in a journal has nothing whatsoever to do with the impact factor of its original papers.
To give you an example of the scope of my suggestions, in the British Journal of Psychiatry, we recently published a paper by Shapiro and Teasell describing a new approach to the treatment of chronic factitious disorder, carried out in Western Ontario (7). In this fascinating study, a group of patients with chronic factitious disorder—the most difficult diagnosis in rehabilitation psychiatry and a condition that is increasing in scope and prevalence (8)—were given what was called a “strategic behavioural approach” but which Kraupl Taylor at the Maudsley Hospital in London formerly called prokaletic therapy, or challenge therapy (9). Taylor used his therapy to challenge multiple self-harming patients to get better after they demanded ECT, whereas Shapiro and Teasell allocated their patients to the strategic behavioural approach after they had failed to respond to standard behavioural treatment. However, the approach involved a degree of subterfuge to induce the challenge. The authors explained to the patients that, if their disease was physical, their treatment would go forward smoothly, progress would be rapid, and recovery complete. However, if their disease was a conversion disorder, they would not recover fully because of an unconscious need to remain disabled. Hence, they would continue to make improvements in some areas but still experience significant problems and disability.
This approach seemed to work, and two-thirds of the patients lost their symptoms. Nevertheless, the published article leaves the reader with many questions. How did the clinical team resolve the ethical dilemma of putting hypotheses that they did not believe to the patients? How was the policy maintained consistently across the whole clinical team? Was it appropriate to maintain “the script,” as it was called (that is, a partly fictitious disease explanation), at family interviews as well as with the patients? What would be the implications of patients’ reading the article if it were in an open-access form? Would they feel duped or pleased that they had participated? All these matters could be discussed, dissected, and disclosed in a clinically friendly subscriber-only part of the journal in a way that cannot be done adequately at present. Further, if the arguments continue around the coffee tables, so much the better.
The Canadian Journal of Psychiatry—the Next 50 Years
The Canadian Journal of Psychiatry is already part way along the road I have recommended. The Journal is becoming more readable while also steadily increasing its impact factor—now up to 2.071, with a rise in 34% over the past 4 years. In 2003, its immediacy impact (that is, the number of times articles were cited in the year of publication) was higher than that of any other psychiatric journal. Although a minor error may have led to its immediacy impact factor not being quoted in 2004, it is all good publicity. At the helm, the Journal has both an enthusiastic editor with a strong commitment to Canadian psychiatry and a powerful Editorial Board. So, all in all, it should have no fears regarding the advance of the Internet.
Above all, I would like the Journal to be bold. I realized several years ago that this is sometimes difficult for Canadians, who are naturally polite and cautious. In the UK, we have been fed for rather too long on a diet of RCMP Constable Benton Fraser triumphing over impossible odds, and we forget what you are really like. This was brought home to me when I read an editorial in the Vancouver Sun some years ago. The wry author wrote, “the best way to identify Canadians is to note that they are the only people who will wait for the traffic lights to change before crossing an empty road at two in the morning ” (10). It is time to work at being bold, and you will sometimes have to stand up to that big boy just to the south of you, who can be a bully at times. Develop a special identity for your journal and do not be afraid of going your own way, so that when psychiatrists across the country are singing the national anthem, “with glowing hearts we see thee rise, the True North, strong and free” they have no difficulty in aligning their journal with the theme of patriotic pride.
References
1. Tomes N. The great restraint controversy: a comparative perspective on Anglo-American psychiatry in the nineteenth century. In: Bynum WF, Porter R, Shepherd M, editors. The anatomy of madness. Volume 3. The asylum and its psychiatry. London (UK): Routledge; 1988. p 190–225.
2. Renvoize E. The Association of Medical Officers of Asylums and Hospitals for the Insane, the medico-psychological associations and their presidents, In: Berrios GE, Freeman H, editors. 150 years of British psychiatry: 1841–1991. London (UK): Gaskell Books, Royal College of Psychiatrists; 1991. p 29–78.
3. Clinton WJ. Announcement of next generation Internet Initioatives [speech]. October 1996. Available: www.quotationspage.com/quotes/Bill_clinton/Acessed 2005 Sept 13.
4. Bethesda Sstatement ov open access publisjing 2003 June 20. Availabe: www.earlham.edu/~perters/fos/bethesda.htm. Acessed 2005 Sept 21
5. Paris J. Canadian psychiatry across 5 decades: from clinical inference to evidence-based practice. Can J Psychiatry 2000;45: 34–9.
6. Jones T, Hanney S, Buxton M, Burns T. What British psychiatrists read: questionnaire survey of journal usage among clinicians. Br J Psychiatry 2004;185:251–7.
7. Shapiro AP, Teasell RW. Behavioural interventions in the rehabilitation of acute vs chronic non-organic (conversion/factitious) motor disorders. Br J Psychiatry 2004;185:140–6.
8. Tyrer P, Emmanuel J, Babidge N, Yarger N, Ranger M. Instrumental psychosis: the syndrome of the Good Soldier Svejk. J Roy Soc Med 2001;94:22–5.
9. Taylor FK. Prokaletic measures derived from psychoanalytic technique. Br J Psychiatry 1976;115:407–19.
10. Anonymous. Editorial. Vancouver Sun 1997 June 26.
Author
1. Professor of Community Psychiatry and Head of Department of Psychological Medicine, Imperial College, London, England.
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