At the NEI Fall Congress, Leading Faculty Reflect on the Evolution of Psychiatry and What the Future May Hold

The first day of the 2024 Neuroscience Education Institute (NEI) Fall Congress commenced on Thursday, November 7, with opening remarks from Andrew J. Cutler, MD, Chairman, and the highly anticipated keynote address from Stephen M. Stahl, MD, PhD, DSc (Hon.), Chairman Emeritus.

The 2024 fall meeting holds special significance for NEI and Dr Stahl, marking 20 years since he created the unique learning model which defines the conference: “high-quality, visually engaging, and evidence-based” psychiatric and neurological education designed to “help increase the competence of health care professionals” in the field.

Stahl’s keynote, “PsychopharmacoloJourney: A Look at How Far We Have Come and Where We Might Go”, took attendees on a tour through the “generations” of psychopharmacology, ranging from the embrace of stimulants, first-generation antipsychotics, and benzodiazepines during the 1950s, to the advent of SSRIs in the early 2000s.

The advent of the “third generation of psychopharmacology” may be considered a new era of innovation in the psychiatric field, Stahl proposed, “targeting the inefficient information processing in brain circuits that mediate psychiatric symptoms” which manifest across numerous mental health disorders. The best-known product of that innovation may be xanomeline and tropsium chloride tablets (marketed under the name Cobenfy) that target the muscarinic system to treat schizophrenia, but also includes GABAA neurosteroid positive allosteric modulators, like brexanolone for postpartum depression.

This theme of innovation carried through to Stahl’s second talk later in the day, “Breaking the Cycle: Optimizing Treatment Strategies For Serious Mental Illness in Order to Prevent Criminal Institutionalization.” “This is a bit of an unusual lecture for me to give,” Stahl shared as he took the stage.

Based on his recent experience working within the California state psychiatric hospitals system, Stahl expressed his concern that despite novel FDA-approved drugs for serious mental illness (SMI), many incarcerated patients living with SMI can refuse treatment. Best estimates suggest that at least 25% of the US prison population are living with SMI. Further, a common feature of SMI is anosognosia, or a brain condition that blocks patients from recognizing their illness and enables resistance to the idea that treatment may be beneficial.

Stahl proposed several approaches to improving quality of life for these patients, as well as reducing the economic and social burden that untreated SMI can introduce into the communities where patients’ live.

First, though potentially controversial, Stahl suggested that in some cases of SMI, involuntary treatment may be a beneficial solution in the long-term. Recognizing the significant ethical questions that this approach raises, Stahl has sought discussion and feedback from a neuroethicist within The Vatican in Rome. This neuroethicist, who is also a priest, observed that “when you have schizophrenia, you lose some of your free will. If you don’t treat people [with SMI], that could be considered unethical.”

Stahl then explored the possibilities that getting more criminalized patients with SMI into treatment would enable: “I would like to propose that best practice will seek outcomes that include housing, treatment, and meaningful life.” By increasing treatment adherence in SMI through medications like long-acting injectables, patients would be more likely to hold down consistent housing and employment, thus interrupting the “revolving door phenomenon” that leads to further criminalization, institutionalization, and stigmatization of this patient population.

To make this vision come to life, Stahl listed additional aspects that will need to become standard practice, including greater interprofessional and interdisciplinary cooperation, community-based strategies to reduce criminalization and stigma, and trauma-informed training for members of the judicial and law enforcement systems.

This policy-centered talk from Dr Stahl was certainly a unique offering among the general sessions offered on the first day. Other sessions discussed advancements in early detection of Alzheimer disease; metabolic factors that influence mood disorders; atypical antipsychotics for depressive episodes; and strategies for treating adult ADHD.

The 2024 NEI Fall Congress will continue through Sunday, November 10. For more news and insights direction from the session rooms, visit our NEI newsroom right here on Psychiatry and Behavioral Health Learning Network.

References

Stahl, S. Breaking the Cycle: Optimizing Treatment Strategies For Serious Mental Illness in Order to Prevent Criminal Institutionalization. Presented at: NEI Fall Congress; November 7-10, 2024; Colorado Springs, Colorado.

Stahl, S. PsychopharacoloJouney: A look at how far we have come and where we might go. Presented at: NEI Fall Congress; November 7-10, 2024; Colorado Springs, Colorado.