Redefining phenotypes to advance psychiatric genetics: Implications from hierarchical taxonomy of psychopathology

Genetic discovery in psychiatry and clinical psychology is hindered by suboptimal phenotypic definitions. We argue that the hierarchical, dimensional, and data-driven classification system proposed by the Hierarchical Taxonomy of Psychopathology (HiTOP) consortium provides a more effective approach to identifying genes that underlie mental disorders, and to studying psychiatric etiology, than current diagnostic categories. Specifically, genes are expected to operate at different levels of the HiTOP hierarchy, with some highly pleiotropic genes influencing higher order psychopathology (e.g., the general factor), whereas other genes conferring more specific risk for individual spectra (e.g., internalizing), subfactors (e.g., fear disorders), or narrow symptoms (e.g., mood instability). We propose that the HiTOP model aligns well with the current understanding of the higher order genetic structure of psychopathology that has emerged from a large body of family and twin studies. We also discuss the convergence between the HiTOP model and findings from recent molecular studies of psychopathology indicating broad genetic pleiotropy, such as cross-disorder SNP-based shared genetic covariance and polygenic risk scores, and we highlight molecular genetic studies that have successfully redefined phenotypes to enhance precision and statistical power. Finally, we suggest how to integrate a HiTOP approach into future molecular genetic research, including quantitative and hierarchical assessment tools for future data-collection and recommendations concerning phenotypic analyses. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

[Historical Development of Symptomatology in Psychosis with Reference to Pathogenesis]

The role of mental symptomatology is to describe various clinical symptoms without refer- ring to their pathogenesis. This may be because of the influence of K. Jasper's General Psycho- pathology. However, from the mid-19th to early 20th century, when modern psychiatry was estab- lished, some excellent hypotheses concerning the pathogenesis of mental symptoms were pro- posed, although it was difficult to verify these hypotheses because of technical limitations. The purpose of this article was to review the historical development of symptomatology in psycho- sis with reference to the pathogenesis. W. Griesinger (1845, 1861) distinguished between the etiology and pathogenesis of a disease, and stated that every mental disease is a manifestation of brain disease. Subsequent investigators elaborated on this view : C. Wernicke (1894, 1906) proposed the disconnection of the association tracts, and P. Flechsig (1894, 1920) regarded the late myelinating "association areas"' (this term was from Flechsig) as the field of the mind. J. H. Jackson (1895) proposed the evolutionary and hierarchical organization of the nervous system. E. Kraepelin (1913) speculated on the hypoactivity of the frontal cortex-the highest cerebral centers according to Jackson's terminology-and hyperactivity of the temporal speech cortex as the pathogenesis of psychotic symptoms in dementia praecox, which were found to be the case based on neuroimaging methods over sixty years later. Currently, the pathogenesis of mental symptoms is being investigated from the viewpoint of the dysfunctions of neural cir- cuits, such as cortico-limbic, cortico-thalamic, or cortico-striatal circuitry.

Identification and validation of mixed anxiety-depression

BACKGROUND

Mixed anxiety-depression (MAD) has been under scrutiny to determine its potential place in psychiatric nosology. The current study sought to investigate its prevalence, clinical characteristics, course and potential validators.

METHOD

Restricted latent-class analyses were fit to 12-month self-reports of depression and anxiety symptom criteria in a large population-based sample of twins. Classes were examined across an array of relevant indicators (demographics, co-morbidity, adverse life events, clinical significance and twin concordance). Longitudinal analyses investigated the stability of, and transitions between, these classes for two time periods approximately 1.5 years apart.

RESULTS

In all analyses, a class exhibiting levels of MAD symptomatology distinctly above the unaffected subjects yet having low prevalence of either major depression (MD) or generalized anxiety disorder (GAD) was identified. A restricted four-class model, constraining two classes to have no prior disorder history to distinguish residual or recurrent symptoms from new onsets in the last year, provided an interpretable classification: two groups with no prior history that were unaffected or had MAD and two with prior history having relatively low or high symptom levels. Prevalence of MAD was substantial (9-11%), and subjects with MAD differed quantitatively but not qualitatively from those with lifetime MD or GAD across the clinical validators examined.

CONCLUSIONS

Our findings suggest that MAD is a commonly occurring, identifiable syndromal subtype that warrants further study and consideration for inclusion in future nosologic systems.

Psychodynamics and psychopharmacotherapy in the treatment of difficult patients with personality and eating disorders

The complex inter-relationship between external and internal reality, a source of interest and controversy in psychiatry, has come to the foreground more prominently in the context of more integrative understanding of psychopharmacotherapy. This paper discusses the meaning and clinical applications of the psychodynamic related to psychopharmacotherapy for difficult personality and eating disorders patients. The one of the psychodynamic explanations for patients' being difficult is related to their perceived lack of mentalizing (reflective) capacities. Lack of mentalizing capacity implies disturbed view of psychopharmacotherapy. Therapeutic relationship and optimal alliance offers the frame for acceptance of psychiatric drugs as positive and useful for personality and eating disorder patients. Mentalization and intersubjectivity theories have direct implications for clinical practice, and that the notion of the third is particularly useful in understanding what happens in the patient-doctor relationship.

Is treatment-resistance in psychiatric disorders a trap for polypharmacy?

BACKGROUND

Nowadays, more and more mental health professionals manage patients who fail treatment for major psychiatric disorders. There is not a consensus on how to deal with treatment-resistance patients, but usually psychiatrists result to polypharmacy.

METHOD

In reviewing the evidence based clinical research we will try to answer some questions about treatment-resistant psychiatric disorders. Treatment-resistant symptoms complicate the clinical course of all psychiatric disorders especially schizophrenia, causing the patients not to reach the therapeutical goal and enter remission. In consequence, polypharmacy is used to try to deal with the remaining symptoms, raising other issues.

SUMMARY

We will try to deal with this problematic issue through clinical studies and major research done to try and answer the question posed.

A Korean survey on qualities and definition of a good psychiatrist

The definition of a "good" psychiatrist has varied over the past decades due to changing roles of psychiatrists. Studies on the qualities of "good" psychiatrists have been completed in many countries. However, no such study has been undertaken in Korea. In Korea, recent growing interest in psychiatry demands the identification of qualities for a good psychiatrist. The purpose of this study was to define the qualities of a good psychiatrist in Korea, subsequently facilitating the improvement of psychiatric training programs. The questionnaire was based on a Singaporean survey with the permission from the original authors. Respondents were divided into patient group and psychiatrist group. The 40-item questionnaire contained items grouped into four themes: Professional, Personal Values, Academic Executive and Relationship. Of the four themes, both patient and psychiatrist groups considered Professional as the most important, whereas Academic Executive as the least important. The mean scores for all items of each theme in the patient group were higher than those in the psychiatrist group, reflecting higher expectations for good psychiatrist in the patient group. Patients emphasized Relationship more than psychiatrists did. It is concluded that a good psychiatrist in Korea can be defined as "a good communicator and listener with a professional manner, who respects confidentiality and has good doctor-patient relationships."

Enrich classifications in psychiatry with textual data: an ontology for psychiatry including social concepts

We propose a modular approach to develop an ontology of psychiatry, ONTOPSYCHIA, based on Patient Discharges Summaries (PDS) and divided into three modules (i.e. social, mental disorders and treatments). We decided to take into account the social aspects of the patient life described in PDS to consider information such as family history, social environment or education.

Towards Constructing a New Taxonomy for Psychiatry Using Self-reported Symptoms

The Diagnostic and Statistical Manual (DSM) has served as the gold standard for psychiatric diagnosis for the past several decades in the USA, and DSM diagnoses mirror mental health and substance abuse diagnoses in ICD-9 and ICD-10. However, DSM diagnoses have severe limitations when used as phenotypes for studies of the pathophysiology underlying mental disorders, as well as for clinical treatment and research. In this paper, we use a novel approach of deconstructing DSM diagnostic criteria, and using expert knowledge to inform feature selection for unsupervised machine learning. We are able to identify clusters of symptoms that stratify subjects with the same DSM disorders into cohorts with increased clinical and biological homogeneity. These findings suggest that itemized self-report symptom data should inform a new taxonomy for psychiatry, and will enhance the bi-directional translation of knowledge from the bench to the clinic through a common terminology.

[The dubious 'reality' of a psychiatric classification]

BACKGROUND

The latest edition of the Diagnostic and Statistical Manual of Mental Disorders, DSM-5, incorporates many new classifications, but some of the classifications that appeared in earlier editions have been dropped. The article comments on and clarifies some of the items that have caused controversy.

AIM

To investigate whether a psychiatric classification can ever depict reality of whether it is in fact a social construct.

METHOD

The article is based on a review of the literature and provides a conceptual analysis of articles and manuals.

RESULTS

An attempt has been made to distinguish between different kinds of psychiatric classifications; the 'kinds' can range from natural to artificial and can be practical , interactive or indifferent. This part of the study has led to the conclusion that the way in which we view the type of psychiatric disorders is determined by our entrenched 'subject-object' way of thinking.

CONCLUSION

The dichotomy between natural (object) and artificial (subject) should be abandoned and the 'reality' of a psychiatric classification should be seen as a continuum and evolutionary process.

Impact of destruction of classic moral principles on ethical questions in psychiatry

Society's treatment of psychiatric patients was always a reflection of social development and social awareness, as well as of ethical principles dominating a certain time period in that society. Over the last two and a half millennia, during which principles of Hippocratic ethics applied, attitudes towards psychiatric patients, from an ethical and practical standpoint, were and still are controversial to say the least. During this period thousands of people with mental disorders were abused, tortured, or killed, all of this in accordance to the existing ethical and legislative norms (Malleus Maleficarum, eugenic laws of totalitarian regimes...). In the last forty years many international organizations and associations brought forth a number of resolutions and declarations warning of the position and of the rights of psychiatric patients and giving instructions on the humane, that is to say ethical, treatment of this category of patients. In almost all the western countries laws are passed to protect the rights of people with mental disorders. Thanks to this and maybe even more to the development of psychiatry as a medical and scientific profession, the position of those with mental disorders is improving. However, at the same time over the last 40 years we are witnesses to the destruction of the classic moral principles and the establishment of certain "new" ethics which put psychiatric patients at a disadvantage, only in a more subtle way then before. This is why it is important to reexamine many of the ethical questions in psychiatry in the context of present ethical controversy.

Characteristics of practitioners in a private managed behavioral health plan

BACKGROUND

Little is known about the practitioners in managed behavioral healthcare organization (MBHO) networks who are treating mental and substance use disorders among privately insured patients in the United States. It is likely that the role of the private sector in treating behavioral health will increase due to the recent implementation of federal parity legislation and the inclusion of behavioral health as a required service in the insurance exchange plans created under healthcare reform. Further, the healthcare reform legislation has highlighted the need to ensure a qualified workforce in order to improve access to quality healthcare, and provides an additional focus on the behavioral health workforce. To expand understanding of treatment of mental and substance use disorders among privately insured patients, this study examines practitioner types, experience, specialized expertise, and demographics of in-network practitioners providing outpatient care in one large national MBHO.

METHODS

Descriptive analyses used 2004 practitioner credentialing and other administrative data for one MBHO. The sample included 28,897 practitioners who submitted at least one outpatient claim in 2004. Chi-square and t-tests were used to compare findings across types of practitioners.

RESULTS

About half of practitioners were female, 12% were bilingual, and mean age was 53, with significant variation by practitioner type. On average, practitioners report 15.3 years of experience (SD = 9.4), also with significant variation by practitioner type. Many practitioners reported specialized expertise, with about 40% reporting expertise for treating children and about 60% for treating adolescents.

CONCLUSIONS

Overall, these results based on self-report indicate that the practitioner network in this large MBHO is experienced and has specialized training, but echo concerns about the aging of this workforce. These data should provide us with a baseline of practitioner characteristics as we enter an era that anticipates great change in the behavioral health workforce.

[Subject and basic definitions of the addictive medicine: the notion of addictive disorders]

The definition and classification of psychoactive substances are presented. The basic clinical notions related to non-medical use of drugs are defined and characterized. The criteria of drug dependences are listed. The description of phasic states of addictive diseases is presented. The relationship between addictive disorders and abnormal activity of cerebral reward system is emphasized. The problem of treatment resistance of addictive disorders and low treatment efficacy in addictive medicine is designated.

The work of Emil Kraepelin and his research group in München

Emil Kraepelin is well known due to his development of the psychiatric classification. The ICD-10 and DSM-IV classification is based on the dichotomy of endogenous psychoses into affective psychoses and schizophrenia as early as 1899. Moreover, beside his classification system he put enormous impact on the development of psychiatry to an empirical field of science. The research activities of Kraepelin and his coworkers show that he was not only the most active researcher in the field of psychiatry in his time but also that his research activities included a lot of clinical and experimental work in different disciplines of psychiatry, including psychology, pharmacology and natural sciences as 'Hilfswissenschaften'. Due to his extraordinary position also in his time he brought together important researchers of this time, in particular after the foundation of a psychiatric research institute. Alois Alzheimer, Franz Nissl, Robert Gaupp, or Korbinian Brodman are only a few of his well known coworkers. Kraepelin tried to bring foreward the empirical knowledge in psychiatry, he did not want to have cessation in psychiatry in general and in the classification of psychiatric disorders in particular. He discussed and partly revisted his view and his theoretical approach in the different editions of his textbook according to the state of his empirical knowledge. This is also true for the dichotomy. More than twenty years after the 6th edition of his textbook, he wrote in an essay 'Die Erscheinungsformen des Irreseins' ('The manifestations of insanity') regarding the dichotomy: "No experienced diagnostician would deny that cases where it seems impossible to arrive to a clear decision, despite extremely careful observation, are unpleasantly frequent." and "....therefore, the increasingly obvious impossibility to separate the two respective illnesses satisfactorily should raise the suspicion that our question is wrong". This contribution shows that Kraepelin himself questioned his dichotomy of dementia praecox and manic depressive insanity, a discussion which is lively still today--more than 80 years later.

Diagnosis and course of affective psychoses: was Kraepelin right?

Kraepelin's basic attitude to the classification of psychoses was data-oriented and flexible. In his latter years he was close to revising his own celebrated dichotomy between manic-depressive insanity and dementia praecox in order to take account of a large group of intermediate psychoses, which today are called schizo-affective. His concept of a continuum from healthy to ill has stood the test of time and corresponds to modern epidemiological findings. Kraepelin's unitarian concept of manic-depressive insanity did not survive. It was differentiated and broken down into several subgroups, and a proportional diagnostic spectrum with a continuum from mania via bipolar disorders to depression has recently even been proposed. Bipolar disorders would in that case be comorbid disorders of mania plus depression. In contrast to Kraepelin's unitarian view the long-term prognosis of subgroups of mood disorders varies considerably. Overall it is nevertheless astonishing how much of Kraepelin's legacy has survived.

Historical overview: Kraepelin's impact on psychiatry

This paper reviews the importance Emil Kraepelin put on disease course as a classificatory principle. It then outlines the academic reception of Kraepelin's disease entities outside Germany, charts the uptake of his diagnostic concepts within clinical practice in Britain, and compares data on admissions for bipolar disorders, involutional melancholia and postpartum psychoses to the North Wales asylum during the period Kraepelin was working to data on contemporary admissions in an effort to shed further light on the validity of his diagnostic concepts.

[The psychopathology of Karl Jaspers: then and now]

The book entitled 'Allgemeine Psychopathologie' by the German psychiatrist-philosopher Karl Jaspers, first published in 1913, has had a lasting influence on the way in which psychiatry defines subjective psychiatric symptoms--phenomena. His psychopathology of meaningful connections, however, which purports to provide an empathic 'understanding' of the causes of mental disorders, is more controversial, particularly now that neurobiology claims it can explain all material causes. This article presents an enthusiastic summary of Jaspers' original work and culminates with a plea for a re-appraisal and revaluation of Jaspers phenomenology and methodological dualism. Jaspers' view on this subject is particularly important in our days of DSM-criteria, neuro-imaging and molecular biology.

Two registers of madness in Enlightenment Britain. Part 1

Part 1 of this essay argues that in Augustan and Georgian England it was widely understood that madness could have two more-or-less distinct meanings. 'Moral' madness was the subject's own fault, and he/she remained accountable for actions commissioned under its effects. The delusional ideas arose in the mind, and by definition remained within the moral province of the individual. By contrast, in 'real' madness, the sufferer was the passive recipient of body-based sickness, and he/she was understood to be innocent, but paid for this exculpation of moral accountability by surrendering full personhood. Part 2 of the essay examines how Georgian churchmen viewed madness, and then returns to psychiatry proper for a closer look at how certain theories of madness were inflected by the problematics of insanity's conflicting meanings. Finally, a previously unrecognized Georgian psychiatric therapy, 'classical moral treatment', is described and put in the context of the better-known Tukean 'moral treatment'.

Diagnoses of patients treated with ECT: a comparison of evidence-based standards with reported use

OBJECTIVE

This study assessed the extent to which patients treated with electroconvulsive therapy (ECT) had diagnoses for which ECT is an efficacious treatment according to evidence-based standards.

METHODS

ECT use among all beneficiaries of a large New England insurance company in 1994 and 1995 was examined using a retrospective cohort design. Associations between provider characteristics and ECT use for diagnoses outside the standards were determined using logistic regression analysis.

RESULTS

A total of 996 individuals among approximately 1.2 million beneficiaries were treated with ECT. They received a total of 1,532 ECT courses. For 86.5 percent of the courses, the diagnosis was within evidence-based indications; for 13.5 percent, the diagnosis was outside the indications. In more than half of the 13.5 percent of cases, conditions were depressive disorders for which no studies have been conducted or disorders that likely had associated depressive symptoms. Patients receiving ECT for diagnoses outside evidence-based indications were more likely to have been treated by psychiatrists who graduated from medical school between 1940 and 1960 and between 1961 and 1980 than by those who graduated between 1981 and 1990. These patients were also less likely to have been treated by psychiatrists who received their medical education outside the U.S.

CONCLUSIONS

Diagnoses of patients treated with ECT were mostly within evidence-based indications. The results provide reassurance to those concerned that ECT may be used indiscriminately. If confirmed by further research, the finding that psychiatrists trained in earlier eras were more likely to use ECT for diagnoses outside evidence-based indications may offer an opportunity for targeted quality improvement.

Classifications in psychiatry: a conceptual history

BACKGROUND

Historical accounts of psychiatric classifications have hitherto been written in terms of a 'received view'. This contains two assumptions, that: (i) the activity of classifying is inherent to the human mind; and (ii) psychiatric 'phenomena' are stable natural objects.

OBJECTIVES

The aim of this article is to provide an outline of the evolution of psychiatric classifications from the perspective of conceptual history. This is defined as a theoretical and empirical inquiry into the principles, sortal techniques and contexts in which alienists carried out their task. It assumes that all psychiatric classifications are cultural products, and endeavours to answer the question of whether classificatory models imported from the natural sciences can be applied to man-made constructs (such as mental illness) definitionally based on 'personalised semantics'.

METHODS

Exemplars of classificatory activity are first mapped and contextualised. Then, it is suggested that in each historical period crafting classifications has been like playing a game of chess with each move being governed by rules. This is illustrated by offering an analysis of the 1860-1861 French debate on classification.

RESULTS AND CONCLUSIONS

(1) Medicine is not a contemplative but a modificatory activity and hence classifications are only valuable if they can release new information about the object classified. (2) It should not be inferred from the fact that psychiatric classifications are not working well (i.e. that they only behave as actuarial devices) that they must be given up. Conceptual work needs to continue to identify 'invariants' (i.e. stable elements that anchor classifications to 'nature'. (3) Because mental disorders are more than unstable behavioural epiphenomena wrapped around stable molecular changes, 'neurobiological' invariants may not do. Stability depends upon time frames. Furthermore, it is unlikely that gene-based classifications will ever be considered as classifications of mental disorders. For once, they would have low predictive power because of their lack of information about the defining codes of mental illness. 'Social' and 'psychological' invariants have problems of their own.

Treatment orientation and associated characteristics of North American academic psychiatrists

We present data showing the degree to which a "biological-psychotherapeutic" division persists in American psychiatry, and how psychiatrists' treatment orientation is associated with personal and professional characteristics. Almost two thirds of academic psychiatrists who responded to our survey (N = 435) could be classified as either biological (27%) or psychotherapeutic (37%) in orientation, according to the proportion of their caseload to which they provided psychotherapy (< or = 25% vs. > 75%). There appears to have been an increase over the last 35 years in the proportion of psychiatrists who can be classified as biologically oriented and a decrease in the proportion who can be classified as psychotherapeutically oriented, as well as the emergence of a large class of intermediate or "eclectic" practitioners (36%). Several personal and professional attributes were distributed differentially according to treatment orientation. Psychotherapeutically oriented respondents more frequently reported personal histories of psychiatric disorders than did biologically oriented respondents (64% vs. 39%) as well as greater satisfaction with clinical work (81% vs. 53% "very satisfied"). Differences were also found in age, gender, history of personal psychotherapy, family history of psychiatric disorder, history of marijuana use, degrees of involvement in research, teaching and clinical care of patients, and overall work satisfaction, as well as other characteristics.

[Classification in actual psychiatry]

The importance of diagnosis in psychiatry is relevant for therapeutic, research and public health questions. During the '70s, operational criteria improved ways for developing reliability and the basis of validity of psychiatric diagnosis. However, the possibility of a common language in psychiatry has been in doubt because of the proliferation of operational systems. There are also reductionist trends that could be dangerous for psychopathology and pedagogy.

Measuring the determinants of work values for psychiatrists' services in the resource-based relative value scale study

OBJECTIVE

As part of the Harvard resource-based relative value scale study, the authors investigated how well the codes in the Physician's Current Procedural Terminology, 4th edition, or CPT-4, match psychiatric services to the work involved in evaluating and managing patients and how patient care characteristics affect different levels of psychiatric work.

METHOD

A random sample of over 200 psychiatrists and subspecialists was asked to use 68 typical clinical examples or vignettes to evaluate services described by CPT codes. Data were analyzed by multivariate statistical methods.

RESULTS

The survey showed that the existing coding system does not adequately describe the work that psychiatrists do. Within a single code (e.g., 90844, individual medical psychotherapy), there was wide (more than twofold) variation in the estimates, from multiple measurements based on different vignettes, of the amount of work represented. Estimates of work values varied significantly according to treatment setting and patient characteristics: psychiatric services in the hospital showed an average work value 25% greater than that for office services; treating new patients involved 18% more effort than treating established patients; and treating patients described as at risk of harming self or others increased the psychiatrists' work effort by 36%.

CONCLUSIONS

Revisions in coding evaluation and management services in the new Medicare fee schedule for psychiatric services should be further refined and then implemented. These revisions would bring the coding system into line with psychiatric practice, making it a better way of accounting for the relative work involved in treating patients of varying difficulty.

Current procedural terminology codes for psychiatric services

Physicians' Current Procedural Terminology (CPT) is the system most commonly recognized by third-party payers for describing medical services in numerical codes for subsequent reimbursement. Adequate description of psychiatric services using CPT codes is an ongoing challenge. Psychiatrists have responded to the demands of third-party payers and peer review organizations for documentation and accountability by billing for specific services rather than by designating all care as psychotherapy. The authors present guidelines for using CPT codes to describe inpatient and outpatient psychiatric services and consultation. They also discuss continuing controversies, including regional diversity in the interpretation of codes by third-party payers, the risks of "gaming" the coding process, and the use of CPT codes by non-physician providers and the consequent mixing of data on service charges.

[Systematic psychiatry or 35 years of hospital clinical research]

In an ere in which man is beginning to master and make his way into the various systems which surround him (atom, cosmic exploration, organ transplant, genetic manipulations...), a clinical practice which would remain centered on the various forms and apparent characteristics of psychic dysfunctioning, has become anachronical. Since 35 years, the author has been trying to introduce gradually within psychiatry, specific processes which would confer to it more scientific status. The disentanglement from traditional clinical practice, made easier by the fact of working in the open department of a general hospital as well as the perfecting of an adequate method structurating observation with modern logical-mathematic notions, enabled him to elaborate a new clinical psychiatry, open to present techniques and more strict interdisciplinary research. The chronological account of the steps which have been taken allows a simplified synthesis of this new psychiatry.

Reading about ... Liaison psychiatry

In 1929, George W. Henry published a paper on ‘Some Modern Aspects of Psychiatry in General Hospital Practice’ and thus became the founder of what later came to be known as liaison psychiatry. He described his work as a psychiatric consultant at Cornell Medical School and advised that ‘On the staff of every general hospital there should be a psychiatrist who would make regular visits to the wards, who would direct a psychiatric out-patient clinic, who would continue the instruction and organize the psychiatric work of interns and who would attend staff conferences so that there might be a mutual exchange of medical experience and a frank discussion of the more complicated cases'. This quotation spells out the essence of psychiatric liaison with medicine. The work of Henry and a few other pioneers bore fruit: psychiatry was at last brought into general hospitals and the mainstream of twentieth century medicine. This was a development of far-reaching consequence for both clinical disciplines, and a major landmark in the history of modern psychiatry.