JAMA Psychiatry is the American Medical Association's Journal for and about the medical specialty of Psychiatry. It's as psychiatrically orthodox as any media source is likely to be. I subscribe because I want to know, and I consider it my job to know, what orthodox psychiatrists are thinking.
This morning I received an email copy of the September, 2025 on-line issue (Vol. 82, No. 9) of JAMA Psychiatry, which includes an opinion article entitled, "Ethical Dilemmas of Antipsychotic Medication Discontinuation," by Helene Speyer, Ph.D., John Lysaker, Ph.D., and David Roe, Ph.D. The authors hail from (respectively) the Mental Health Center of Copenhagen Hospital, the Center for Ethics at Emory University in Atlanta, and the Department of Community Mental Health at the University of Haifa.
The opening statement of fact in this article is:
Individuals diagnosed with psychotic conditions frequently attempt to discontinue antipsychotic medication, with varying levels of professional support. Between 2 and 5 years after a first episode of psychosis, 90% either discontinue antipsychotic medications entirely or receive very low maintenance doses, and over a 20-year treatment period, they make an average of 9 attempts to discontinue medication.
The authors argue that the framework for the therapeutic relationship in treating psychosis should perhaps evolve away from the current "shared decision-making (SDM)" model to one of "shared deliberation." They say this would show respect for patient autonomy and well being, and for sharing the risks and responsibilities of treatment decisions. Surely, anyone might surmise that when 90% of patients avoid treatment or attempt to discontinue medications, some soul-searching is appropriate.
In 24 years of advocacy and legal representation of involuntary psychiatric patients, I have never known anyone who actually wanted the treatment they were receiving at the hands of the State of Illinois. They frequently say they know it's necessary, but they desperately want a future when it won't be required. In fact, they only understand that their treatment helps in terms of avoiding more, or more severe, incarceration or punishment.
Well silly me. I naively expected that the editors at JAMA Psychiatry might be interested in my perceptions from my own years of close professional involvement in this system. I wrote a comment on the article by Speyer, et al., saying in part that mental health is probably the most fundamental profession that exists, and that healing and control are both legitimate (although different) activities in complex human communities. I did honestly believe that the authors' suggestion for "shared deliberation" was constructive for purposes of ethical analysis. I don't think I belittled anything the authors of the article had written. I basically agreed with them, and said so.
Nevertheless, I received a brief email very quickly (before 8:00 AM), saying the editors had decided not to publish my comment, and referring me to their on-line commenting policy. I thanked them for such an expeditious decision, but asked whether they might elaborate or suggest how my comment might have conflicted with the policy they referred me to. So far they have not been as quick to explain as they were to just say forget it, we don't want your thoughts in our publication.
Perhaps the only reason my comments conflicted with the on-line commenting policy of JAMA Psychiatry was by my disclosure of a potential conflict of interest: I told them that I am a lifelong Scientologist, and I don't believe the study of mind and the healing of mentally caused ills ought to be condoned in nonreligious fields (e.g., medicine). But the article I was commenting about was overtly, or perhaps even ostentatiously, about "ethical dilemmas." One might think views from disparate religious orientations could be relevant.
One doesn't have to be a Scientologist to intelligently consider ethics in a context of mental health, although I would say it certainly helps.
Maybe the editors of JAMA Psychiatry just aren't very good at it.
