Southern California PSYCHIATRIST August 2025

President’s Column – A Call to Action

by Patrick Kelly, MD

For many of us, summer can be a time of rest and reflection, as schools empty and businesses slow their pace. We take time off to spend with loved ones or pursue activities outside of work, giving us a chance to recharge and return to fall renewed and reinvigorated.

However, summer is not always a time of inactivity—far from it. For some, it can be a flurry of movement. In medicine generally, summer is a time of change. Residents graduate from training, while new interns hear themselves called “doctor” for the first time. Training directors begin the process of welcoming new future colleagues into the field, and surgeons perform their very first operations (hence the tongue-in-cheek saying among physicians: “never have surgery in July”).

This summer in particular has seen significant legislative activity. On a positive note, the US House of Representatives passed the SUPPORT for Patients and Communities Reauthorization Act of 2025 (H.R. 2483). This bipartisan bill aims to reauthorize and expand funding for substance use disorder prevention, treatment, and recovery programs.

On the other hand, the House and Senate passed H.R. 1, a highly impactful and controversial measure that will, among other things, drastically reduce access to essential healthcare resources for 3.4 million Californians, almost 1 million of whom are located in Los Angeles County.

As psychiatrists and scientists, our mission is never to restrict access to mental health care and services. While the broader political and economic implications of this bill are beyond the scope of this discussion, its harmful effects on our field and our patients have been and remain a focus of this organization. Advocating for the well-being of our profession and our patients is one of SCPS’s most essential functions, and we pledge to continue advocating in the strongest possible terms to ensure that the voices of those actually delivering this care are heard.

And so, for some of us, summer becomes a time of planning—a time for your representatives within SCPS to reflect on our past successes and challenges, and to gather our strength for the work ahead. As we would counsel our patients, we can remain mindfully focused on the positive aspects of our own lives to shore up our strength for future action.

So, if you are vacationing, truly try to disconnect and enjoy your time away. If you are just beginning or ending your training, endeavor make it the best possible experience you can. If you are working, devote yourself to caring for those in your charge (including, most importantly, yourself). And If you find yourself frustrated or disappointed by events beyond your control, know that you are among sympathetic friends and colleagues who share your feelings. We are stronger together, sharing both our joys and our sorrows—and when we channel that collective strength into action, we become a powerful force for positive change.

But our work cannot be done alone—we need your voice and your expertise. Whether you’re a seasoned practitioner or just beginning your career, there are meaningful ways to contribute to our advocacy efforts. Our Government Affairs Committee is actively seeking new members to help craft position statements and engage with policymakers. Our Communications Committee needs volunteers to help amplify our message through social media and community outreach. And our Academic Liaison Committee is working to create resources that support our members and trainees through these challenging times.

Your participation matters. Even if you can only contribute an hour or two a month, your perspective as a practicing psychiatrist adds invaluable weight to our efforts. We particularly encourage our early-career members to get involved—your fresh insights and energy are exactly what we need to build a stronger future for our profession.

Have a wonderful summer—restful, productive, or rejuvenating, as suits you and your needs best—and know that SCPS is doing the same, preparing ourselves for a successful and impactful fall.  Together, we can ensure that the voices of psychiatrists and the needs of our patients are never overlooked.

The Dangers of Legislating Medical Guidelines: Why Clinical Practice Should Remain in Clinical Hands

by Emily Wood, MD, PhD

This year, CSAP co-sponsored bill SB 331 (SB 331 Substance Abuse – AMENDED, 2025) with Senator Caroline Menjivar (SD 20, San Fernando Valley & Burbank) to make several procedural and definitional changes to LPS law and the CARE Act with the goal of improving access to care for individuals with mental illness. For now, the bill has been put on the back-burner of the 2-year legislative cycle to be discussed again in 2026. Opposition to the bill focused on adding this line to LPS code: ““Mental health disorder” means a condition outlined in the current edition of the Diagnostic and Statistical Manual of Mental Disorders.” Their argument is that the DSM is too broad and includes diagnoses such as “caffeine use disorder, gender dysphoria, and restless leg syndrome.” And, their answer is for the legislature to pick and choose the diagnoses that should be considered under LPS law.

Medicine is a dynamic field where scientific understanding evolves continuously, treatment protocols adapt to new evidence, and clinical judgment must navigate complex individual circumstances. Yet, legislators attempt to codify medical practice through rigid statutory definitions and prescribed protocols. This trend represents a fundamental misunderstanding of how medical knowledge develops and threatens to undermine the very foundations of evidence-based care.

Static Legal Definitions in Dynamic Fields

Since the Diagnostic and Statistical Manual of Mental Disorders (DSM) was first introduced in 1952, it has undergone 5 major revisions (and a couple minor) to reflect advances in neuroscience, psychology, and clinical experience. Conditions once considered distinct have been combined, new disorders have been recognized, and diagnostic criteria have been refined based on research findings. When legislators attempt to create static definitions of what constitutes a “qualifying” mental health disorder, they freeze medical practice at a particular moment in time, preventing clinicians from incorporating new scientific understanding. The DSM-5, published in 2013, introduced significant changes from its predecessor. Conditions were reclassified, new disorders were added, and diagnostic criteria were modified based on accumulated research. When DSM-6 eventually arrives, it will undoubtedly bring further changes. Legal statutes, however, cannot be updated as readily as clinical guidelines. The result is an inevitable mismatch between current medical understanding and outdated legal requirements.

A fundamental flaw in legislating based on specific diagnoses lies in misunderstanding how mental health conditions actually manifest in practice. Mental illness doesn’t respect neat categorical boundaries. A person with gender dysphoria who becomes suicidal presents the same immediate safety concerns as someone with major depression who becomes suicidal. The relevant clinical question isn’t whether their underlying diagnosis appears on a legislative approved list—it’s whether they meet functional criteria for intervention, such as being a danger to themselves, others, or unable to care for their basic needs.

When legislators attempt to create hierarchies of “serious” versus “minor” mental health conditions, they reveal a profound misunderstanding of psychiatric illness. Gender dysphoria, often cited by opponents of comprehensive mental health legislation as an example of diagnostic overreach, is associated with significantly elevated suicide risk. Should emergency clinicians be forced to discharge a suicidal transgender youth because their underlying condition doesn’t appear on a legislatively approved list? Such scenarios highlight the absurdity of substituting legislative judgment for clinical assessment.

Grave Disability is Legally Defined

While it is not reasonable for the legislature to codify constantly changing scientific and medical guidelines, the legislature is the voice of the people and should broadly define our current societal understanding of what is considered grave disability. In 2023, California made the first revision to “grave disability” since the inception of LPS law in 1967. The updated definition now reads: “A condition in which a person, as a result of a mental health disorder, a severe substance use disorder, chronic alcoholism, or a co-occurring mental health disorder and a severe substance use disorder, is unable to provide for their basic personal needs for food, clothing, shelter, personal safety, or necessary medical care.”

This language is generally accepted to mean that we, as a society, should step in to provide care for a person who is unable to manage their insulin-dependent diabetes due to their mental health disorder. On the one hand, an individual with schizophrenia who is too disorganized and/or paranoid to understand their diabetes, why the meds are necessary, or how to manage their meds, leading to near weekly emergency department visits for hyperglycemia, we can agree that the individual is gravely disabled and not making a rational choice about how to spend their time and resources. On the other hand, consider a person with ADHD who occasionally misses some insulin doses leading to an increased rate of trips to the emergency department and secondary disorders (neuropathy and vision changes). It has been noted that they are more likely to miss doses of insulin on days when they also missed their morning ADHD meds. While their MH disorder is certainly related to their poor medical self-care, we would not determine that they are “unable to provide for their necessary medical care” and therefore should be put on a hold and then conserved if this keeps happening. The reason that they would not be held and conserved is not because they have a non-qualifying MH disorder but because they are not gravely disabled.

Without question, the relationships between mental health diagnoses and danger to self, danger to others, and grave disability are not evenly distributed. Certain disorders are associated with acute DTS and hardly at all with GD. And, some are far more likely to be associated with GD and conservatorship due to their symptoms, chronicity, typical level of insight, and treatment options. The appropriate role for legislation is to establish broad functional criteria—such as defining grave disability as inability to provide for basic personal needs—while leaving specific clinical determinations to trained professionals. When a person with diabetes and psychosis becomes too disorganized to manage their insulin, the relevant question isn’t whether their underlying psychiatric condition appears on an approved list, but whether they can safely care for themselves.

Mental and Behavioral Healthcare Fragmentation

For a multitude of reasons, our system of supporting individuals who are disabled due to dysfunction or atypical functioning of their central nervous system is highly fragmented. Within medicine, “structural” issues, especially those that impact the motor or sensory systems, are the purview of neurologists. Under California laws, irreversible neurodevelopmental changes that occur very early (intellectual developmental disability) or very late (neurocognitive disorder, dementia) and prevent a person from being able to care for themselves are conserved under Probate law. Whereas those who are unable to care for themselves (gravely disabled) due to other mental health disorders are conserved through LPS law. Individuals with certain neurodevelopmental disorders presenting in childhood can receive services for the rest of their lives through the Regional Centers. But, individuals who experience prodromal symptoms during adolescence and then have their first psychotic episode at age 18, have no such services available. Until recently, substance use was long considered a disorder of willpower and hedonia alone which led to its treatment centers and professionals being certified under an entirely different regulatory agency than other mental health issues.

In the current system, this fragmentation is a chief excuse for denying access to services. Co-occurring diagnoses are used as weapons by various agencies to point the finger at other agencies to provide necessary care. Real-world clinical scenarios rarely fit neatly into legal categories. Consider a patient with major neurocognitive disorder (dementia) who becomes aggressive and poses safety risks to themselves and others. Current interpretations in some jurisdictions exclude such individuals from psychiatric hospitalization if their primary diagnosis is dementia rather than a “traditional” psychiatric condition. This creates an absurd situation where vulnerable individuals are denied appropriate care based on diagnostic technicalities rather than clinical need.

Comparing to Other Specialities

The parallel to obstetrics is striking and instructive. Critics argue that psychiatrists inappropriately “lock people up” based on questionable diagnoses, yet we don’t see similar legislative attempts to restrict obstetric practice despite well-documented problems with unnecessary cesarean sections. Cesarean rates have risen dramatically—from 23% to over 30% nationally—with significant variation between hospitals that cannot be explained by patient risk factors alone. Some facilities perform cesareans at rates exceeding 60%, while others maintain rates below 15% for similar patient populations. This suggests substantial overuse of a surgical procedure that carries real risks for both mothers and babies.

If we applied the same logic used against psychiatry to obstetrics, legislators would be creating approved lists of ICD-10 codes justifying cesarean delivery. They might mandate that women with prior cesareans must attempt vaginal birth after cesarean (VBAC) regardless of clinical circumstances, arguing that “prior cesarean section” isn’t sufficient justification for repeat surgery. Or they might take the opposite extreme and ban cesarean sections entirely, accepting that some women will die in childbirth as “the price of freedom” from surgical overreach. Both approaches would be absurd, yet this is precisely the type of diagnostic discrimination being proposed for mental health practice. The clinical question should not be whether a patient’s condition appears on a legislative list, but whether they meet functional criteria requiring intervention—grave disability, danger to self or others—regardless of the underlying psychiatric diagnosis.

Keeping Medical Practice in Professional Hands

The practice of medicine should remain where it belongs: in the hands of trained clinicians guided by evolving scientific evidence, not constrained by the static language of legal code. This will happen in psychiatry only if we stay involved in supporting legislation that ensures this remains the case.

SB 331, the bill highlighted earlier, sponsored by organized psychiatry to define mental health disorders by what is in the current DSM, will again be heard in 2026, and each of us can play important roles in taking it across the finish line. These roles include 1) supporting organized advocacy work through our yearly dues contributions, 2) following CSAP,s weekly email updates and writing letters to our legislators at key points in the process. For those of us with additional time or interest, other key roles are rolling up our sleeves and working in SCPS committees to develop amendments and counterproposals that increase support and lessen opposition, and even–when necessary–being available to testify at legislative hearings. Working in our favor is the fact that our medical voices are highly respected by both the public and the legislature, which makes our advocacy–when we engage in it–extremely effective, working through SCPS to write letters of support to our legislators.

The Open Window: Gray Skies On The Horizon

by Reba Bindra, MD

Satori is a term derived from Zen Buddhism and loosely translates as an “awakening,” “understanding,” or “comprehension.” It can be a profound shift in perception that transcends ordinary thought. A moment of clarity where an individual perceives the true nature of reality.

I love being a psychiatrist with my soul and spending the last 2 decades working with the most severely mentally ill has been both fulfilling and harrowing. Day in and day out I am knee deep in the fantastical, paranoid, hallucinogenic, tortured worlds of my patients. I know them as soon as I see them, maybe not their specific story, but certainly their journey.

For many years I managed the disappointment and frustration of a revolving door of “care” of psychiatric inpatient hospitals. I convinced myself that if for just one day (in some cases, one hour) I could provide respite to a patient who was tormented by their paranoia and inescapable voices, that I was “doing something”. Small acts of kindness to ease their mental burden, often as simple as listening and respecting their reality. This served as my anchor, the reason I ultimately found meaning working in a jail setting.

As a reminder, jails are for those who are “innocent until proven guilty” (though if we are being honest, everyone  thinks if someone is in jail, they must be guilty of something.  Makes you wonder why we need a system of justice at all) and prisons are those who have been convicted and serving time.  Jails are the new de facto mental health facilities and there is none bigger than the LA County jail system.

Then, without warning, mental illness showed up on my family’s doorstep.  The unmistakable paranoia, delusions, and self-contained, altered reality. Suddenly the boundaries between my personal and professional lives were blurred. I should know how to handle this, right? I should “do something”. It did not take long for reality to set in—none of my experience or skills were going to help. In that moment, I had no special powers to make it better. Thousands and thousands of families try to navigate through the labyrinth that is our mental health system for their loved ones but to no avail. My family was now part of the thousands, the barrier between my ecosystems broken.

The feeling of helplessness that took over was unlike anything I have ever experienced. It’s irrational for me to think that I could have altered the course of a relentless disease that asserts itself loudly and at times is stronger than any tools we have to fight it. And yet, I started to question my sense of purpose and value as a psychiatrist. What was I really doing for these patients? What is my ultimate purpose? What. Am. I. Doing? Do something.

I thought I might be having an existential crisis, a mid-life crisis or this was a bad case of burn out. (Maybe all 3?). In the midst of this internal chaos, my good friend sent me an NY Times article about Ocean Vuong, a writer, poet and professor of creative writing who articulates the concept of satori through the profound moments in his life. He says “…satori is a brief window, and the idea for Buddhists is to allow the understanding in that brief window to alter your life”.

Fleeting moments of profound illumination and introspection–it’s an uncomfortable feeling in this mental space. I have no regrets about what I have accomplished as a psychiatrist up to this point and I will never give up on performing the small acts of kindness that can have such a large impact on the lives of the most vulnerable human beings.  But these are short-term, temporary acts, what about more meaningful and lasting ones?

My soul-searching journey is complicated by the fact that in the jail, the goal is not patient care–it is to cater to the legal system. The system expects efficiency and treatment, but those two ideas are almost mutually exclusive. In the name of efficiency, there is often a “one size fits all” approach in terms of treatment which disregards the individual needs of the patient further erasing what makes them unique human beings. They are forever defined by their illness alone.  Quick stabilization of psychiatric symptoms so patients can cycle through the carceral system during their “lucid” moments and then be released into the community with no illusions of continuity of care is the accepted practice.   It is a virtual basket of ethical challenges that are in my head constantly.  Many days my heart is heavy with the knowledge of how powerless I really am in a complex, impersonal bubble which is largely devoid of empathy.  Apparently, it must be to minimally function (so I am told).

I know what you are thinking, why not work somewhere else? Maybe I will find enlightenment elsewhere? Not likely. Wherever I may end up, it will be with this population of patients. I have tried to deviate from this pattern, but I always circle back to them.  Whether in an ER, a psychiatric hospital, the state hospital or jail, the plight is the same. My angst would be the same. And as strange as it sounds, I find myself irrationally drawn to the patients in the jail system.  I have yet to fully dive into that one.

I am hoping that the brief window of satori that has opened for me stays open long enough for me to get some clarity and direction. My defenses are down and I am going to take it as an opportunity to “do something” but maybe do it differently. I will sit with my discomfort and acknowledge that there are no black and white answers, it’s all pretty gray.  That’s not a bad thing though.  Gray is complex with infinite shades and its propensity to negotiate between the extremes.  It’s where contradictions can co-exist and lead to opportunities for understanding and compromise.

I don’t know if I will find a clear path out of this maze, but I am embracing this open window with my whole heart.  I will breathe in the unfamiliar air and appreciate the fleeting illumination hoping for clarity and grace not just as a physician but as a human being.  Ultimately, how long the window stays open is up to me.

Dan Marchese and Lulu Garcia-Navarro. “ ‘The Interview’: Ocean Vuong was Ready to Kill. Then a Moment of Grace Changed His Life” .  New York Times.  03 May 2025

California’s MIST Reform: A Case Study in Unintended Consequences

by Michael Dodge, MD

The Challenge

The United States faces a “competency services crisis” driven largely by defendants with low-level charges and severe mental illness. In California, Incompetent to Stand Trial (IST) cases increased 72% from 1999-2014, creating overwhelming pressure on state hospital systems and extending carceral contact for vulnerable populations.

Legislative Response and Reality

California’s ambitious attempt to address this crisis through Senate Bill 317 (2022) offers important lessons for psychiatrists and policy makers nationwide. The bill eliminated competency restoration for most Misdemeanor Incompetent to Stand Trial (MIST) defendants, instead mandating community referrals, Assisted Outpatient Treatment, or charge dismissal.

While well-intentioned, this sudden shift created significant challenges:

• Community infrastructure couldn’t absorb the increased referrals
• Many MIST defendants were released without treatment linkage
• Public mental health infrastructure continues to fail those with the most severe mental illness

Course Corrections

Recognizing these gaps, California passed SB 1400 (2024), requiring courts to hold hearings assessing diversion eligibility for all MIST defendants. Despite these reforms, Los Angeles Sheriff’s Department data shows year-over-year increases in average daily MIST jail populations, suggesting the most treatment-resistant individuals remain incarcerated longest.

The latest response, SB 820 (2025), proposes reinstating involuntary medication orders for MIST defendants who refuse treatment while jailed, acknowledging that clinical deterioration in custody creates additional harms.

Clinical Implications

This legislative cycle highlights several key points for practicing psychiatrists:

Criminalization is not the answer: Despite the issues outlined above, we must continue to move individuals with severe mental illness out of our county jails.

Early Intervention Matters: The Sequential Intercept Model suggests focusing on earlier intervention points may be more effective than post-arrest diversion.

Coordination is Key: Appropriate resource allocation and coordination is needed to ensure that our public mental health systems provide high-quality, community-based care.  Those with more severe mental illness will require innovative interventions to avoid further institutionalization.

Moving Forward

California’s experience demonstrates that criminal justice reform requires careful coordination between legal, medical, and social service systems. For psychiatrists, this underscores the importance of:

• Advocating for robust community mental health infrastructure
• Developing expertise in treating individuals who refuse care
• Maintaining a firm stance that low-level offenders should be diverted as early as possible

A project is currently underway that will look at specific outcomes for the MIST population in Los Angeles county in the aftermath of the legislative changes discussed above. I hope to be able to identify factors that contribute to successful diversion of MIST individuals and highlight issues that must be addressed in order to prevent recidivism. Findings will be presented in an update to this publication in the Spring of 2026.

Antidepressant Discontinuation: Balancing Evidence, Patient Experience, and Clinical Practice

by Emily Wood, MD, PhD

Recent public discourse around antidepressant discontinuation has brought important questions to the forefront of psychiatric practice. During his confirmation hearing for Secretary of Health and Human Services on January 29, 2025, Robert F. Kennedy Jr. claimed: “I know people, including members of my family, who’ve had a much worse time getting off of SSRIs than they have getting off of heroin.”¹ High-profile media coverage, including multiple pieces in The New York Times about prolonged discontinuation effects,²^,³ has further amplified patient concerns. As psychiatrists, we have an opportunity—and responsibility—to address these concerns with nuance, empathy, and evidence-based perspective.

Understanding Withdrawal and Discontinuation: Terminology and Neurobiology

The terms “withdrawal symptoms” and “discontinuation symptoms” refer to the same phenomenon: physical and psychological symptoms that occur when stopping, missing, or reducing doses of a medication. While “discontinuation syndrome” was originally coined for antidepressants to minimize concerns, the more pharmacologically accurate term is “withdrawal symptoms,” now widely adopted by professional bodies like the Royal College of Psychiatrists and NICE.⁴

Withdrawal effects are a predictable aspect of any drug that is eliminated from the body more quickly than physiological adaptations take to resolve. During long-term medication use, the brain undergoes homeostatic adaptations to maintain equilibrium. When medication is reduced or stopped, this disrupts the adapted state, leading to withdrawal symptoms as the system reestablishes balance.⁴

Importantly, symptom duration is determined by the time required for these adaptations to resolve, not solely by the drug’s elimination half-life. This explains why some patients experience symptoms longer than predicted based on how quickly medication clears the body.

The Reality of Discontinuation Effects

The scientific literature clearly establishes that antidepressant discontinuation symptoms are real and common. Recent comprehensive meta-analyses provide important context: a 2025 systematic review of 49 randomized controlled trials found that participants who stopped antidepressants experienced, on average, one additional symptom compared to those who discontinued placebo or continued treatment.⁵ This effect, while statistically significant, fell below the threshold typically considered clinically significant discontinuation syndrome.

Earlier research by Henssler and colleagues found that when directly comparing antidepressant discontinuation with placebo, the difference in symptom incidence was approximately 8%.⁶ These studies confirm that discontinuation effects exist but suggest their magnitude may be more modest than previously reported. The most common symptoms include dizziness (affecting about 6% more patients than placebo), nausea, vertigo, and nervousness.⁵

What’s crucial to understand is that these symptoms reflect the expected physiological process of readaptation. When we discontinue a medication that has been modulating neurotransmitter systems for months or years, the body requires time to recalibrate. This process is fundamentally different from ongoing drug presence—it’s about change and adaptation, not toxicity.

The Information Gap: A Systems Problem

A significant factor driving patient concerns is the perceived lack of informed consent about discontinuation effects. This concern deserves serious attention, but we must examine it within the broader context of antidepressant prescribing patterns. Approximately 75-79% of antidepressants are prescribed by primary care physicians, rather than psychiatrists or mental health specialists.⁷^,⁸ This pattern has remained consistent over the past two decades. Research has shown that shared decision-making about antidepressants is less robust in primary care settings compared to specialty mental health care.⁹

This isn’t a criticism of our primary care colleagues—it’s a recognition of system limitations. Primary care providers manage an enormous breadth of conditions within constrained time frames. Detailed discussions about psychiatric medication risks, benefits, side effects, and discontinuation effects may not be part of their standard training or practice protocols. As psychiatrists, we have both the expertise and responsibility to fill this knowledge gap, particularly for complex cases.

Validation and Communication: Core Clinical Skills

One of the most damaging aspects of current practice is the tendency to dismiss or minimize patient experiences with side effects and discontinuation symptoms. When patients report withdrawal effects weeks or months after stopping medication, responding with skepticism (“that medication should be out of your system by now”) is both scientifically inaccurate and therapeutically harmful.

Discontinuation symptoms aren’t about drug presence—they’re about physiological adaptation. Just as we expect adjustment periods when starting medications, we should anticipate and validate adjustment periods when stopping them. This process can take months, and individual variation is substantial.

Effective communication requires acknowledging the reality of patient experiences while providing accurate context. When patients describe difficult discontinuation symptoms, our response should validate their experience while explaining the underlying biology of readaptation.

Evidence-Based Perspective on Long-Term Effects

While we must take discontinuation symptoms seriously, the concept of “prolonged withdrawal” lasting years requires careful scrutiny. The term “withdrawal” implies ongoing effects from medication removal, but symptoms persisting years after discontinuation likely represent a more complex phenomenon.

It’s worth noting that individuals with depression demonstrate high placebo response rates and low placebo dropout rates compared to other medical conditions,¹⁰ highlighting the complex interplay between expectation, biology, and symptom reporting in this population. And, depression is associated with poor memory, especially for periods of low mood. When symptoms return months or years after discontinuation, attributing them solely to “prolonged withdrawal” may overlook the possibility of recurring mental health conditions that originally prompted treatment.

In discussing the potential risks of a medication, we are always comparing it with other medications and not taking medication. For instance, many studies have demonstrated that untreated depression is associated with cognitive decline, and recurrent depressive episodes correlate with progressive cognitive changes.¹¹ Furthermore, research suggests that antidepressants don’t cause long-term cognitive impairment. (11) This doesn’t mean medications are risk-free, but it provides important context for risk-benefit discussions.

This isn’t to dismiss patient experiences, but rather to encourage more precise understanding. Long-term medication use certainly creates lasting changes in brain and body systems. However, distinguishing between medication effects, natural illness course, aging, and life circumstances becomes increasingly difficult over extended timeframes.

Recommendations from the literature

Our approach should emphasize several key principles:

Comprehensive Informed Consent: Discuss both benefits and potential discontinuation effects before starting treatment. Patients deserve to understand what they’re choosing.

Validation Without Catastrophizing: Acknowledge discontinuation symptoms as real and potentially challenging while providing realistic timelines and expectations.

Individualized Discontinuation Planning: Develop tapering schedules based on individual factors, medication half-life, and patient preference. Rushed discontinuation often worsens symptoms.

Ongoing Risk-Benefit Assessment: Regularly revisit whether continued treatment serves the patient’s best interests. Some patients benefit from long-term treatment; others may prefer discontinuation.

Collaborative Decision-Making: Include patients as partners in treatment decisions, respecting their autonomy while providing professional guidance.

Conclusion

The current discourse around antidepressant discontinuation reflects legitimate patient concerns that deserve thoughtful response. Recent research provides a more nuanced picture: discontinuation symptoms are real but generally modest in severity, affecting a meaningful minority of patients but rarely reaching clinically significant thresholds. By improving our communication, validating patient experiences, and providing evidence-based guidance, we can address these concerns while maintaining the therapeutic benefits these medications offer many patients.

Our goal isn’t to defend medications at all costs or dismiss patient concerns, but to provide the nuanced, individualized care that psychiatry demands. This means acknowledging both the benefits and limitations of our treatments while supporting patients through whatever treatment choices serve them best.

References

1. Mann B. Antidepressants harder to quit than heroin? Fact-checking RFK Jr. NPR. https://www.npr.org/sections/shots-health-news/2025/01/30/nx-s1-5281164/antidepressants-ssris-rfk-jr-heroin. January 30, 2025. Accessed August 3, 2025.
2. Barry E. Leading a Movement Away From Psychiatric Medication. The New York Times. https://www.nytimes.com/2025/03/17/health/laura-delano-psychiatric-meds.html. March 17, 2025. Accessed August 3, 2025.
3. Barry E. New Research Questions Severity of Withdrawal From Antidepressants. The New York Times. https://www.nytimes.com/2025/07/09/health/antidepressants-withdrawal-symptoms.html. July 9, 2025. Accessed August 3, 2025.
4. Henssler J, Schmidt Y, Schmidt U, Schwarzer G, Bschor T, Baethge C. Incidence of antidepressant discontinuation symptoms: a systematic review and meta-analysis. The Lancet Psychiatry. 2024;11(7):526-535.
5. Kalfas M, Tsapekos D, Butler M, et al. Incidence and Nature of Antidepressant Discontinuation Symptoms: A Systematic Review and Meta-Analysis. JAMA Psychiatry. Published online July 9, 2025.  https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2836262
6. Leeuwen EV, Driel ML van, Horowitz MA, et al. Approaches for discontinuation versus continuation of long‐term antidepressant use for depressive and anxiety disorders in adults. Cochrane Database of Systematic Reviews. 2021;2021(4).  https://journals.sagepub.com/doi/10.1177/21501327211023871
7. Jetty A, Petterson S, Westfall JM, Jabbarpour Y. Assessing Primary Care Contributions to Behavioral Health: A Cross-sectional Study Using Medical Expenditure Panel Survey. J Prim Care Community Health. 2021;12:21501327211023871.  https://www.psychiatrist.com/jcp/national-patterns-antidepressant-treatment-psychiatrists/
8. Mojtabai R, Olfson M. National patterns in antidepressant treatment by psychiatrists and general medical providers: results from the national comorbidity survey replication. J Clin Psychiatry. 2008;69(7):1064-1074.  https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2443367
9. Bschor T, Unger J, Nagel L, Schwarzer G, Baethge C. Negative Effects During Placebo Treatment: A Systematic Review and Meta-Analysis. JAMA Psychiatry. 2025;82(6):618-621.  https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2832699
10. Semkovska M, Quinlivan L, O’Grady T, et al. Cognitive function following a major depressive episode: a systematic review and meta-analysis. The Lancet Psychiatry. 2019;6(10):851-861.  https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30291-3/abstract
11. Prado CE, Watt S, Crowe SF. A meta-analysis of the effects of antidepressants on cognitive functioning in depressed and non-depressed samples. Neuropsychol Rev. 2018;28(1):32-72.  https://link.springer.com/article/10.1007/s11065-018-9369-5

Welcome New SCPS Members!

We are proud to spotlight some of our newest members:

Jennifer Siegel, MD – General Member

Dr. Siegel specializes in treating Obsessive Compulsive Disorder (OCD), OCD-related disorders, and anxiety-spectrum disorders (i.e. Generalized Anxiety Disorder, Panic Disorder, Social Anxiety Disorder). She has additional expertise in treating college & graduate students, healthcare providers, and other working professionals.

Dr. Siegel earned her medical degree from the University of Pennsylvania Perelman School of Medicine and completed her residency training at the University of Southern California, serving as chief resident for outpatient psychiatry. She previously graduated summa cum laude from Washington University in St. Louis, where she received her bachelor’s degree in psychology with minors in graphic design and studio art. At the University of Pennsylvania, Dr. Siegel was a Bridging the Gaps Clinical Scholar, receiving an additional certificate in Community Health. Dr. Siegel received the Kenneth E. Appel Award for exceptional devotion to the care and treatment of patients in the psychiatry department at UPenn. While a resident at USC, she won resident of the year during both her PGY-3 and PGY-4 year, received the inaugural Gold Heart Award from the psychiatry department, and was awarded the SCPS PER foundation award.

She is currently accepting patients through her private practice and has accepted a faculty position as a Clinical Assistant Professor of Psychiatry & the Behavioral Sciences at Keck Medicine of USC, working specifically in student mental health.

Lynn Yudofsky, MD – General Member

Lynn Yudofsky, MD is a Yale, Baylor College of Medicine, and UCLA educated board certified psychiatrist who was previously an attending psychiatrist on the faculty at Stanford University and the Director of Behavioral Health and Medicine at an obesity medicine digital health company. She has a special interest in lifestyle and integrative psychiatry as well as weight management.

Dr. Yudofsky now has a private practice in Los Angeles, Yudofsky Psychiatry. She offers medication management, psychotherapy, and a number of integrative treatments to patients throughout California. In addition to traditional psychiatric care, she also offers various wellness services including comprehensive weight management (using behavioral strategies and medications as indicated).

Ariella Nikou, MD – Resident-Fellow Member

I am currently a rising PGY-4 psychiatry resident at the USC / LA General Medical Center program. My interests include integrated care between psychiatry and other medical fields with special interest in reproductive psychiatry.

All new SCPS members are invited to provide Membership Spotlight materials.  (Providing these materials is optional.)

April Council Highlights

by Gillian Friedman, MD

President’s Report:  Dr. Rees

CSAP Letter to California Attorney General RE: SAMSHA

• March 27^th HHS announced dramatic restructuring – Administration for Healthy America (AHA) would eliminate SAMSHA
• CSAP drafted letter to CA Attorney General outlining background (such as Congress’s legislation mandating SAMSHA) urging CA Attorney General to take appropriate action to preserve SAMSHA. (AG could decide to act now – e.g. CA has already filed lawsuits against Trump admin – or could wait and act in concert with other state attorneys general). Motion passes to have SCPS signature to the CSAP letter to AG.

NAMI Walks – motion to give same amt as in past years to Greater Los Angeles NAMI, divide same total amount among Inland Region NAMI Walks (more walks this year with new walk in San Bernardino).

-Greater Los Angeles 5/10

-San Bernardino 5/4

-Ventura Cty 5/17

-Riverside – usually in the fall — $450 donation

-Coachella Valley – usually in the fall — $100 donation

• Suggestion that we have return to sort of metric for the future in how to distribute support funds.
• Suggestion to also look into facilitating SCPS members attending some NAMI meeting in future.

Federal Legislation Task Force proposal

• Purpose to examine/address threats to the psychiatric care that we can provide to our patients in California, could work directly with APA but with California-focused advocacy. Could partner with other DBs inside or outside California, as well as other psychiatric organizations (e.g., AACAP)
• Make America Healthy Again (MAHA) anti-psychiatric medication stance
• SAMSHA elimination
• Medicaid cuts/restructuring
• Medicare cuts/restructuring
• Telehealth changes
• Research defunding

• Issues/Barriers to Federal Legislation Task Force identified by Council:

-Time involved

-No source of funding to drive legislative lobbying (as CSAP funding drives SYASL legislative advocacy for us)

-Where national task force would fit in our current structure (does it happen all in GAC?)

• Dr. Kelly suggests forming an exploratory committee to investigate possibilities for this type of workgroup.

Public Affairs Committee

-Ask from Dr. Rees for Chair and committee members to revitalize social media presence

-Want: TikTokers, Instagrammers, etc.

APA Leadership Forum

-Monthly meetings for presidents and presidents-elect

-Recent meeting discussed business side of APA

-Second part of meeting was about advocacy – APA puts out public statements, but the public statements, while read by members, are not reaching the intended audience (legislators).

Upcoming: APA Insider Session on May 8^th

SCPS Installation & Awards Ceremony Sat 5/3/25 2:30-5:30 pm, The New Center for Psychoanalysis, 2014 Sawtelle Blvd, Los Angeles

SCPS Reception 5/19/25 4-6pm, Flemings Downtown LA

Advocacy Talks – reviewed residency programs where SCPS has presents, residency programs on the radar.

Election Results presented:

President-elect: Emily Wood, M.D.

Treasurer-elect: Gillian Friedman, M.D.

Secretary: Roderick Shaner, M.D.

Early Career Psychiatrist Representative: Ruqayyah Malik, M.D.

DMURR: Austin Nguy, M.D.

Resident-Fellow Member Reps: Christopher Chamanadjian, M.D., Alexis Smith, M.D.

San Fernando Valley Councillor: Yelena Koldobskaya, M.D.

APA Assembly Representative: Mathew Goldenberg, D.O.

President Elect Report: Dr. Kelly

Reviewed April 2025 Special Advocacy Edition of SCPS Newsletter, including New Member Spotlight. Reviewed upcoming authors for May.

Committee Reports

GAC

RESOLVED: That the SCPS Council take an OPPOSE position to AB 416.

GAC presentation: This is one of a long history of legislative attempts to give private (not LPS-designated) ERs ability to place patients on 5150s and send them to LPS-designated facilities. CHANGES WHO CAN PLACE 5150s. Counties can currently choose to designate ER physicians, but then can also determine types of facilities where the patients are sent. This bill essentially gives ER physicians ability in unfunded manner to shift uninsured patients to county facilities.

RESOLVED: That the SCPS Council approve a letter of support for HR-2483 Section 104 (Support for individuals and families impacted by fetal alcohol spectrum disorder).

GAC presentation: This is a House bill providing support for a large variety of programs for substance abuse and mental health disorders. Section 104 deals specifically with supporting individuals and families affected by Fetal Alcohol Syndrome. The language in Section 104 emphasizes importance of programs for fetal alcohol spectrum disorder, and allow SCPS to add our name to a group of professional organizations supporting this specific section

SCPS APA Leadership Workgroup

Dr. Silverman and Dr. Shaner described the progress of the workgroup in elaborating potential SCPS projects to forward SCPS representation at national levels. The proposal is for the APA to have a more organized and open selection of members for APA Councils, with specified input from district branches.

AB-1429: Behavioral Health Reimbursement – CSAP to take oppose unless amended position, as previously recommended by SCPS Council

AB-384: Full Service Partnerships – CSAP took no position. GAC noted that SCPS committee members felt that , given the need for FSP in carceral systems, presumptive eligibility for released inmates made sense, even if it might decrease access for other groups, and that we should continue to follow the progress of this bill and consider recommending a position at some point.

CSAP PAC recommended contributions

Approved PAC-selected contributions for CA mental health advocates who work closely with CSAP: CA Sen. Caroline Menjivar, CA Sen. Henry Stern, CA Sen. Ben Allen, Assemblymember Sharon Quirk Silva,

PAC has formed Ad Hoc Committee to examine future PAC contribution recommendations

Membership Committee Report – Membership report was presented and ratified. Current month’s members 855/935.

Disaster Relief Committee –

-APA Sessions related to the Wildfires/Disasters presented.

-Goal-setting meeting

Child and Adolescent Committee – Separate Child/Adolescent Reception at APA

Unhoused Workgroup – Working on putting together a report for Council. Would like to have ongoing committee (was initially intended as temporary workgroup) – would like representatives from different counties. Please reach out to Danielle is interested in working with this ongoing committee.

Stimulant Taskforce – Continuing to follow resolutions/action papers put forth in last year, seeing where they go; looking to put together set of resources that doctors and patients can use to make complaints/raise alert. Taking a pause from federal actions to see how federal changes

Private Practice Committee – Finalizing program with PRMS for second half of the year (topics to include telehealth, controlled substance prescribing). Suggest action paper, etc. to push for private practice representation at APA (e.g., Private Practice Caucus).

Diversity and Culture

Co-chairs not present

Alternatives to Incarceration

Some ideas about working with Sheriff’s Dept, etc. Invitation to SCPS members to attend committee meetings – next May 1^st.

Access to Care

Met with leadership of several local NAMI affiliates – pursuing idea of survey of NAMI members to help identify needs/areas of mutual advocacy.

APA Representation Task Force – Goals for improving SCPS collaboration with APA

How to work together on timely legislative priorities

Action papers – opportunities for improvement (e.g., push for having a deadline by which board of trustees has to act)

APA components (councils, etc.) – what is the rubric? (Still under review, can’t be shared yet, according to APA – will follow). Having DB input into Area 6 representation, with transparency if DB representation declined.

Executive Director training and leadership development

Awards Committee

Diversity and Culture Committee votes on the George Mallory Award, passes to the Awards Committee – C. Freeman selected for George Mallory Award

Academic Liaison Committee

Notified program directors of residents who have won the Excellence in Psychiatric Education awards.

RFM (Resident-Fellow)

Focusing on topics of interest for next year.

Assembly Reports – in preparation for the upcoming Assembly. Reviewing action papers. Will be a chance for RFM Deputy Representative candidates to speak to the Area 6 Council this upcoming Monday meeting.

Treasurer’s Report  — Dr. Wood

November Financials and Cash on Hand Report

Dr. Wood reviewed various financial metrics, 2024 year totals and 2025 year-to-date. Overall, SCPS is in good fiscal health.

Adjournment – Dr. Rees 09:18

Next meeting is May 8, 2025

May Council Highlights

by Alex Lin, MD

President’s Report

Installation and awards Ceremony

Ceremony went well (food and location especially), many thanks to Matt and Mindi for leading and coordinating.

Presidential awards:  Victoria Huang, Elizabeth Caselegno, Laura Halpin, Ruqayyah Malik, Anita Red, Emily Wood

NAMI Walk

Sat:  05/10/25 from 09:00 -13:00 at LA Historic State Park

Galya would appreciate having other join her

APA Reception

About half of the Exec Council will be at APA

05/19/2025 from 16:00 – 18:00 at Fleming’s

Expecting 200-250 guests.  This will go over the total budget we had set but not over the SCPS contribution (b/c we took in contributions from another source); we only have 5 tickets left (so pretty much at max capacity)

Incoming pres (Mark Rappaport) is moving back to LA, transferring to our DB, and will be coming to our reception

SCPS Presentations at APA

Mental Health Advocacy:  experiences of CA legislators and psychiatrists (05/17 @ 13:30)

Mental Health Training for Judges:  how judges and psychiatrists can work together to improve diversion out of the jail setting (05/20 @ 15:45)

APA Strategic Plan

Mindi attended AM meeting (DB Exec Director specific); Rod attended afternoon session

Mindi’s take:  APA has hired consulting team to prepare a 5–10 yr strategic plan.  Met w/ DB Exec Directors.  APA will allow people to follow up w/ questions, which Mindi thinks will be important so that we can express our comments/concerns.  Our DBs are facing the same challenges (we communicate well but are not necessarily “reaching” members).  DBs doing face-to-face meetings have decreased attendance, and members seem more interested in social, not educational, meetings.  Physician burnout came up (especially the work outside of actual pt contact).

Rod’s take:  prelim planning meeting w/ consulting firm w/ multiple stages (how will they gather data, reach out, socializing the process).  APA leadership (Rachel Johnson) said we have not had a strategic plan for a long time and have had more of a scattershot approach.  They will try to narrow down to a ~5 key areas for focus.  3 areas identified in poll:  parity/payment, workforce issues (which encompasses many other issues), psychiatric leadership.

Galya’s take:  meeting was scheduled for 1 hr but only took about 30 mins and seemed to end rather abruptly.

Advocacy talk

7 programs visited completed, 6 not visited

Galya hopes we continue w/ this going forward

President-elect’s Report

Congratulations, Galya, on her term, especially in such a chaotic and fraught year.  She did much work behind the scenes, and her efforts are appreciated.

Newsletter Report

Topics in May 2025 issue discussed.  CA Advocacy Highlights.  Announcements for SCPS APA Reception and list of APA sessions related to the wildfires

Sign ups for June:  Danielle, Kayla, Anita, Rubi.  We’ll do the sign ups for the next few mos in June (and consider whatever you see/hear at APA as a potential article topic).

Reminder about Google form submission

AACAP reception follows SCPS

Committee Reports

Assembly

Assembly will begin Fri before APA.  Will meet w/ Area 6 to review action papers this coming Mon.  Will pick dep rep from Area 6 to be “second-in-command.”  This is the most exciting time of the year for Assembly reps.  We have many Assembly papers/position statements (~50).  Matt G. co-authored a paper related to addiction (position statement).  He is part of addiction council that authored another paper.  2 controversial Area 6 papers will also be coming through (neurodiversity and hospitalization funding).

Question:  what sessions are open to regular members and what should be prioritized?  In general:  Welcome reception, opening reception, plenary, and distinguished life fellows.  Assembly is open to guests and consider the various focus caucuses.

Membership 884/952

8 RFM, 10 GM

We have lost ~100 members (so down total members, but that is not unusual for May).  We may also gain some after the APA Annual Meeting (when they want to register to view sessions).

Members were ratified

APA Representation Task Force

3 areas:  (1.) Standardization for nominations and appointments to APA committees and councils; (2.) APA Governance structure including Judicial Review Committee (above Assembly, below Board of Trustees).  Some issues include how long it takes papers to be passed (so one suggestion might be to require that papers be reviewed w/i 1 yr); (3.) Area 6/DB improved communication (DB input for BOT, ECP, RFM nominations; formalize process for APA nominations).  A lot of headway has been made in this area.

Private Practice

3 updates:  regular meeting 06/17 @ 7PM (Pain and TRD); 09/13 @ 9AM (PRMS and legal talk; PRMS rep and a Board attorney) on tele-prescribing and controlled substance prescribing; longer term goal to establish an APA component on private-practice psychiatry (defined ways forward:  application process for caucus and action paper; hopefully SCPS can be one of the leaders in this area).  Mindi thinks there will be a lot of support for this because 7 other DBs at the strategic meeting have noticed an upswing in psychiatrists entering private practice.

Disaster Committee

CA coalition on disaster meeting tomorrow.  Mindi will be there.  Foundation will give donation to CA Firefighter peer-to-peer group.  There is a plan to show APA leadership in areas devastated by the fires.

C will be participating in panel talk at APA Meeting about CA wildfires.

Maybe we should have a WhatsApp group to discuss what sessions we will be going to.  Galya will send a code so that Council members can add themselves.  APA app also provides a way to communication (and might be more secure).

DFAPA

2025 applicants, 2026 convocation:  Enrico Castillo, Matt Goldenberg, J. Zeb Little, Misty Richards.

Recommendation passes

Child and Adolescent

AACAP reception (mentioned previously)

Unhoused Work Group

No report

Stimulant Issues Task Force

In a period of quiescence, given macro issues.  Working on some things locally, including a guide to assist psychiatrists and patients.

Diversity and Culture

Met this past month.  Reviewing George Mallory award selection process.  C Freeman was awardee.  Will try to extend reach to people who are not necessarily looking at our publications.

Alternatives to Incarceration

One motion to bring to council:  support position on Senate Bill 357 (Menjivar).  Does not mandate an immediate or complete transfer of all duties and functions.  Instead, it empowers the BOS to selectively determine which responsibilities are appropriate for transfer and to ensure DYD (Department of Youth Development) is prepared to assume the function while protecting public safety.  It is a good alternative to incarceration.  Questions:  none.

Motion passed.

Reba and Emily are working w/ NAMI to connect to management in Sheriff’s dept to improve situation in men’s central jail.

Access to Care

Had one meeting between ATC and NAMI.  NAMI offered to send survey about barriers to access (specifically about clinic appts).  Working on survey questions, which will take some time.  Will likely reach out to other committees for feedback.

SCPS Awards Committee

Thanks to Matt G.  Matt and Mindi will be discussing on how to improve things generally; anyone w/ feedback can reach out to them.

Academic Liaison

Exploring potential of committee to more fully engage leadership at academic centers (and/or ECP in putting together their dossiers for promotion).

RFM

2 meetings, 6 residents have shown up to at least 1.  UCLA, CDG, CMH, Harbor.  Hope to get representation from more programs.  Last meeting discussed APA Meeting events (including Reception).  Reviewed some action papers that are going to the Assembly so that RFMs can become familiar w/ action papers.  Got official approval for caucus; first meeting will be at the APA.  Will transition to Alexis and Chris.  Many thinks to Justin and So Min for revitalizing the committee.

GAC Report

Discussed general organization.  Rod thanked all of the committee members for all of their hard work, especially co-chair Emily.  Rod will rotate off; Emily become sr chair and state legislative rep.  Laura will become the co-chair and fed rep.

Action item 1:  recommend that Council discuss and possibly develop a subsequent motion to outreach to NAMI chapters in the IE, perhaps through the IE councillors, to provide to NAMI members a suggested brief but effective message to their congressional rep about Medi-Cal.  Focus on fed funding for the state.  House budget reconciliation will be meeting through May.

2 suggested alternate motions:  (1.)  outreach to our IE members to contact their congresspeople; (2.) make an effort to work collaboratively w/ NAMI.  Discussion:  maybe first step is to reach out to NAMI to see what they have already done and then 3 IE councilors and Mindi can then move forward from there.

Second motion passes.

Federal/multilevel issue:

APA national advocacy:  discussion of how the APA can interface w/ an administration that is more focused on legislative action (vs. education)

Status of congressional budget reconciliation and Medi-Cal cuts

CSAP meeting w/ AG Bonta’s staff re:  SAMHSA litigation and subsequent 05/05/2025 action by CA

Consideration of regular report to Council on key Federal legislative issues and possible recs to Council on associated positions.

CSAP GAC Update:

This is a key month for bills moving forward:  SB-331 Substance abuse (Menjivar) à Appropriations in May; SB-367 Mental Health (Allen) Appropriations in May; SB-820 à 3^rd reading; SB-823 à comes out of “Suspense” at end of May

AB-416 Involuntary commitment (SCPS’s strong opposition likely to lead to significantly amended bill); AB-1429 Behavioral health reimbursement (despite SCPS opposition unless amended, bill is moving forward); SB-751 Veterans and former first responders research pilot program (SCPS opposition but also moving through quickly).

CSAP Board issues:  upcoming issue w/ DB representation  (regarding large/small DBs) à 4 positions available and 5 DBs, so there is a chance that 1 DB might not be represented; SCPS is the only one that wants to keep the current rotation model.  All DBs have the same voting strength on the Board, regardless of size.  Because SCPS has more members, our members get fewer chances to sit on the Board, if rotation is done evenly.  We also gave up our spot during one rotation.  Maybe we can add a 5^th spot (ex-officio) to prevent further dilution.

Advocacy issues:

Scott vs. Smith:  Psychiatric mobile response team and law enforcement (Dr. Wood). Committee members discussed differing opinions regarding the viability of different solutions to help ensure appropriate law enforcement involvement in mental health emergencies.

Appreciation expressed for all of Rod’s efforts.

PAC Report

No report

Treasurer’s Report

Motion to approve report and tax return.  Motion passes.

New Business

Nothing

Old Business

Again, many thanks to Galya.  Gayla considered it an honor to lead us.  If one leaves a committee, please consider returning.

Adjournment:  9:02