An Editor’s Journey Ends, but the Journal’s Mission Continues

Three decades ago, I was offered to become the editor-in-chief of Psychotherapy and Psychosomatics. I had served in the journal as an associate editor for a few years, and for the two editors (Peter Sifneos and Hellmuth Freyberger) I was the most suitable candidate. I first thought of declining the opportunity: I was in the middle of many research projects, and I feared that the new task could hinder their accomplishment. I was also very busy running an Affective Disorders Program that involved assessing and personally treating patients who were part of clinical studies or who were referred to us for difficulties in their management. And I did not feel ready to handle the new challenge. But Peter Sifneos had a different opinion: “Becoming an editor will enlarge your horizons and vision (it will force you to read papers that you would otherwise avoid) and these insights will make your own research grow. Being a clinician you will be able to discern papers that make sense and to lead the journal to a meaningful direction.” Indeed, when I eventually accepted, I realized that being a clinician, a researcher and an editor were inextricably linked. And now that it is time for me to leave my editor’s position, I have realized that my journey as an editor reflects the many changes that have occurred in medicine and psychiatry in the past three decades, as well as my personal changes in terms of insight and attitudes. In this editorial, I will share my journey, subdividing my long editorship according to decades.

Building the Journal’s Identity (1992–2001)

As a young and relatively inexperienced editor-in-chief, I had to refer to role models. There were three main influences. One came from the editorship of the Journal of Affective Disorders by one of the most important researchers in depression of the past century, Eugene Paykel [1]. In submitting papers to his journal, I had experienced the fact that he actually read the papers (not only the abstracts) and was able to provide suggestions and directions in addition to those of the reviewers. Another important role model was Alvan Feinstein [2], the father of modern clinical epidemiology and of clinimetrics, editor of the Journal of Clinical Epidemiology. I appreciated the strong intellectual content and courage provided by the editorials and the high methodological standards of the articles. A third source of guidance came from Thomas Wise, editor of Psychosomatics. The practical implications of what he selected were an additional source of inspiration. I appointed in the editorial board outstanding clinical scientists, such as Per Bech, Massimo Biondi, Paul Emmelkamp, Maurizio Fava, Robert Kellner, Isaac Marks, and Tom Sensky. George Christodoulou, John Nemiah, and Tores Theorell were already on board.

In my opening editorial [3], I presented the new format of the journal that consisted of editorials, special articles (reviews), regular articles, clinical notes (observations that may be helpful to clinicians and stimulate more systematic research), and book reviews. There was a lucky circumstance associated with that journal issue. A teacher and mentor of mine, George Engel, had sent me a book that included his contribution “How much longer must medicine’s science be bound by a seventeenth century world view?” [4]. When I read the chapter, I immediately realized that it was one of his most important papers. I was surprised, however, it was in a book that was hard to get and was not retrievable. George Engel explained to me what happened. It was based on a presentation at a conference, and he meant to submit the paper to the New England Journal of Medicine. But, for a misunderstanding, it got published in the book of proceedings of the conference [4] and it was stuck there. I realized it was a great opportunity. I requested and got the permission of the publisher to reprint it, in an edited form, in our journal [5].

Since the flow of submitted papers was low, I decided to invite reviews on various aspects of psychosomatic medicine, having in mind an excellent collection of papers that Oscar Hill [6] edited in the seventies. Further, when I attended international conferences, I tried to recruit new submissions of original investigations. In 1992, the impact factor (IF) was pretty low (0.38) and I soon realized that the attraction potential of the journal, despite its long tradition, was limited.

In the years 1992–1995, we published a number of reviews on various aspects of psychosomatic medicine that Hellmuth Freyberger and I then collected in a volume [7]. A result of that collection of papers was the publication of the Diagnostic Criteria for Psychosomatic Research (DCPR) in 1995 [8], which translated clinical insights derived from psychosomatic research into operational tools. We attempted to do what the Washington University group did in the seventies for psychiatric diagnoses [9], producing the basis for the DSM development [10]. The DCPR [8], that were updated in 2017 [11], stimulated a large body of research, introducing clinical concepts, such as demoralization and irritable mood, that were missing in DSM [10].

I realized that the editorials could stimulate research and debate on controversial topics. In 1994, I published an editorial on the dependence potential of antidepressant drugs. The paper introduced the possibility that antidepressant medications might actually increase chronicity in mood and anxiety disorders [12]. In the paper, I referred to a literature that was scattered under different names but was nonetheless available and raised important questions. The paper strongly reflected my clinical experience with withdrawal syndromes from discontinuing antidepressants and a number of clinical phenomena (e.g., loss of clinical effect, paradoxical reactions, resistance) in the course of mood disturbances. The editorial [12] triggered a hot debate that extended over the following decades and contributed to the recognition of clinical phenomena that would have not otherwise gained sufficient attention [13]. It also opened the journal to the field of psychopharmacology. I thought that psychosomatic medicine had always been the field of pioneers who challenged current paradigms. It was important to be receptive to any aspect of clinical medicine that had innovative features and high methodological standards, and attention to psychopharmacology complemented a major area of interest of the journal, psychotherapy research. The first conceptual formulation of the sequential model in mood and anxiety disorders according to stages of development (i.e., pharmacotherapy followed by psychotherapy; psychotherapy followed by pharmacotherapy; two consecutive forms of psychotherapy or pharmacotherapy), instead of their simultaneous administration [14], exemplified the new approach.

Other new areas of attention were opened. In 1996, a review on the clinical implications of psychological well-being [15], well ahead of the advent of positive psychology, and another on the concept of recovery in affective disorders [16] were published. In 1998, there was a special issue on emotional aspects of the pituitary disease [17] that anticipated a subsequent interest for the topic of quality of life in the endocrine literature.

The level and the breadth of original studies progressively improved. In addition to classic psychosomatic investigations, there was an increasing presence of randomized controlled trials in psychotherapy, including one of the earliest papers on mindfulness meditation [18]. In 1998, we published a seminal investigation of scientific journals and their authors’ financial conflict of interest [19]. For the first time, it indicated that one out of 3 articles in major journals had at least one author with substantial conflicts of interest [19]. Three years later, the lack of effectiveness of disclosure policies in medical journals was reported [20]. Also in view of those publications [19, 20], the issue of financial conflicts of interest in medicine could no longer be ignored [21]. Once again, we were able to anticipate other journals in addressing these issues. In 10 years, the journal’s IF had progressively increased (Fig. 1) and in 2001 reached 3.43, with considerable improvements in psychiatry and psychology rankings.

Fig. 1.

IF of Psychotherapy and Psychosomatics over three decades (1992–2020).

/WebMaterial/ShowPic/1439543Fostering Innovations and Pluralism (2002–2011)

Kuhn reminds us that novelty in science emerges with difficulty, against a background of strong resistance ([22], p. 64). The intellectual capital of medicine is the creativity linking clinical practice and research. The development of models and innovations that may provide better explanations of clinical phenomena strictly depends on this interaction. Preservation of and support to pluralism are an additional key to addressing the challenges of clinical practice.

An intellectual crisis of clinical research was clearly identified in the eighties by Engel [23] and Feinstein [24]. Feinstein ([24], p. 216) attributed it to the decline of clinical medicine as the source of fundamental scientific challenges, “with investigators who often had no clinical training or responsibilities, and with results that often had no overt relationship to clinical phenomena.” At the beginning of my second decade as an editor, the crisis became more and more manifest. In psychiatry, it stemmed from a narrow concept of science which neglected clinical observation, the basic method of medicine [23], and simply applied oversimplified neurobiological models to the understanding and treatment of mental disorders [25]. With the editorial board, enriched by the presence of Antonio Barbosa, Richard Balon, Guy Chouinard, Jim Hudson, Eugene Paykel, Chiara Rafanelli, Ulrich Schnyder, Eduard Vieta, Tom Wise, and Robert Zachariae, we tried to counteract this intellectual crisis fostering innovations and pluralism.

As to the journal’s organization, Tom Sensky suggested that we added a specific section concerned with innovations. Most of the papers we published had novel features, but the new section could highlight the most significant messages. We also added a section on research letters that could accommodate more papers on pilot studies, original clinical observations, case reports, and new hypotheses.

As to the journal’s contents, we worked on several converging lines of research. A first major area involved clinimetrics, the science of clinical measurements introduced by Feinstein [2]. We published works concerned with indices, rating scales, and other expressions that are used to describe or measure symptoms, physical signs, and other distinctly clinical phenomena. Clinimetrics expands taxonomy to include patterns of symptoms, severity of illness, effects of comorbid conditions, timing and rate of illness progression, functional capacity, and other clinical features that demarcate major prognostic and therapeutic differences among patients who otherwise seem deceptively similar because they share the same diagnosis and laboratory results [2]. We thus extended the role, function, and modalities of clinical assessment of psychosocial factors, as exemplified by the integrative use of DCPR [11]. On the occasion of a special issue that was a tribute to Feinstein’s accomplishments [26], we argued that psychometric theory was an obstacle to the progress of clinical research [27] and that time had come to substitute or integrate obsolete psychometric methods with those provided by clinimetrics [27, 28].

The interest in the role of financial conflicts of interest in medicine that we had introduced in the late nineties [19-21] continued. We published a report on substantial financial ties with the pharmaceutical industry in 90% of members of clinical practice guidelines committees [29] that forced the American Psychiatric Association to address the issue. I realized that pluralism of viewpoints, an essential component of scientific and clinical progress, was threatened by corporate interests that resulted in self-selected academic oligarchies (special interest groups). Members of special interest groups, by virtue of their financial power and close ties with other members of the group, have the task of systematically preventing the dissemination of data which may be in conflict with their interests [21]. Such censorship became particularly strong in psychopharmacology. It was thus important that the journal, in a psychosomatic spirit, offered a free, but rigorously evaluated, channel for scientific communications. We received submissions and, after adequate revisions, published several investigations and critical reviews in psychopharmacology. A few examples deserve brief mention: a double-blind placebo-controlled trial on loss of clinical effects and resistance on re-challenge with antidepressant medications [30, 31], with important implications for understanding the mechanisms of tolerance [32]; an analysis on the risks of suicide with selective serotonin reuptake inhibitors (SSRI) [33] that was one of the main bases for a black-box warning of the Food and Drug Administration (FDA); a review on the unwarranted superiority of escitalopram over citalopram [34]; a re-analysis of the data of one of the largest trials in a depression that led to new insights about the efficacy and effectiveness of antidepressants [35]. In all cases, we were open to host (and did publish) dissenting views in the correspondence section of the journal.

In this decade, systematic reviews and meta-analyses started achieved wide currency in the medical literature. When we published the first systematic review of our journal [36], Sensky [37] wrote an accompanying editorial on the importance of careful critical appraisal of the literature that became our standard for evaluating subsequent submissions. Indeed, the pseudo-objectivity of systematic reviews, obtained by increasingly complicated and cumbersome procedures, where the presence of an author with clinical familiarity with the topic is optional, is often associated with intellectual poverty and the cult of mediocrity [38]. Not surprisingly, a frequent conclusion is then that the evidence is too limited and further studies are needed [39]. As to meta-analyses, our approach was extremely cautious. Feinstein [40] compared meta-analyses to the alchemy that existed before modern scientific chemistry. The analogy was the hope to convert existing things into something better (changing base metals into gold) and the work with material that was heterogeneous and poorly identified. Indeed, meta-analyses often include highly heterogeneous studies and ascribe conflicting results to random variability, whereas different outcomes may reflect different patient populations, enrollment, and protocol characteristics [40].

During this decade, the journal’s IF continued to grow (Fig. 1), reaching the value of 6.28 in 2011. The rejection rate paralleled such an increase, with a level of about 85% of submissions and became pretty stable over the years. A major determinant of selection was the clinical factor, the degree and the extent to which a paper provides information to the clinician that may improve his/her practice [41]. We thus published an increasing number of RCT concerned with psychological interventions, including in the medically ill, which should shed some light on their efficacy and indications. We also privileged clinical reports and original conceptualizations that could open new perspectives. At times, they involved a few cases, as in the first description of persistent sexual side effects after SSRI discontinuation published as a letter to the editor [42]. In other cases, clinical descriptions captured features that had been neglected until then, such as posttraumatic embitterment disorder [43], that later attracted a considerable amount of the literature [44]. New concepts were those of rehabilitation in endocrinology [45] and of innovative clinical services [46, 47].

The Making of a Counter-Culture (2012–2021)

Part of the challenge and, at the same time, fascination of being a clinician lies in applying the scientific method to the care of patients and in the understanding of disease [23]. An increased knowledge would result in significant benefits for the patients and in a sense of continued development on the part of the physician [25]. However, I had observed a progressive detachment of clinicians from research, at times accompanied by a sense of personal stagnation and tiredness [25]. Influential randomized trials were generally done by and for the benefits of the industry; guidelines served vested interests; national and federal research funds were unable to address basic clinical questions [48]. “Personalized medicine,” referred to as genomics-based knowledge, promises to approach each patient as the biological individual he/she is, yet its practical applications are still a long way to go, and neglect of psychological, behavioral, and social features could actually lead to a “depersonalized” medicine [49]. Evidence-based medicine (EBM) was (and still is) the prevailing scientific paradigm. The model of EBM was originally articulated in a way that highlighted the many sources of knowledge and how they could be integrated with judgment in the shared decisions for the care of the whole person [50]. However, in the following years, marketing strategies of the industry and lack of familiarity with clinical issues of many investigators conveyed the message that there was only one option for treatment of a specific condition. Many seasoned clinicians, in all specialties and types of practice, might have perceived there was something wrong with the approach dictated by the EBM model. However, they were reluctant to voice that the emperor had no clothes, because the scientific literature was so compact in praising the emperor’s clothes [51]. Younger physicians who adhered to guidelines were convinced to apply the best evidence and were not aware that they were simply guided to see problems in a biased way and to treat the average instead of the individual patient, degrading clinical practice.

The problem was that we were living in an age of transition: there were signs of the decline and fall of current conceptual models, such as EBM, but it was difficult to foresee alternative frameworks [51]. The journal had become the asylum of heretics (of beliefs and practice contrary to what is normally accepted and maintained). In a classic essay of my youth, Roszak [52] analyzed the development of a counter-culture that was aimed to challenging the conventional worldview and of what was called the technocratic society in the sixties. This is what we needed to develop with the journal in my third decade as an editor: to build a laboratory which may remove conceptual obstacles to the progress of clinical research, to foster alternative ways of viewing clinical problems, and to host innovations in assessment and treatment.

It was thus necessary to do what had never been attempted before: to point to the clinical inadequacy of EBM [53]. The net result of EBM is the product of guidelines, endorsed by scientific societies that are liable to conflicts of interest, where the prescribing clinician is driven by an overestimated consideration of potential benefits, paying little attention to the likelihood of responsiveness and to potential vulnerabilities in relation to the adverse effects of treatment [53].

The journal attempted to provide data that might yield a better balance between benefits and vulnerabilities. The case of antidepressant medications may serve as an example. In 2015, we published the first systematic review in the literature on withdrawal symptoms after SSRI tapering and/or discontinuation [54] and in 2018 the first systematic review on serotonin-noradrenaline reuptake inhibitor discontinuation (SNRI) [55]. Hengartner et al. [56] remarked that these systematic reviews appeared after nearly 200 meta-analyses on the benefits of new-generation antidepressants. Both reviews concluded that the disturbances that appear with tapering and discontinuing antidepressant medications should be classified as withdrawal symptoms, could be severe, and would not necessarily wane after a few weeks [54, 55]. An editorial written by Chouinard and Chouinard [57] provided diagnostic criteria for the clinician to discriminate between withdrawal, relapse, rebound, and persistent post-withdrawal disorders. We also published the first reports on the use of psychotherapy in discontinuing antidepressants [58] and in persistent post-withdrawal disorders [59]. These steps we made, in addition to subsequent contributions, yielded a change in how the problem was viewed: the term discontinuation syndrome, supported by the pharmaceutical industry, has finally been replaced by that of withdrawal syndrome [13]. It has not been a simple change in terminology: eventually, a major public health problem (one out 6 people in the general population may have problems in stopping antidepressants) was disclosed and, hopefully, could be addressed by appropriate research and changes in policies [13]. SSRI and SNRI were suggested to be better alternatives to benzodiazepines in the drug treatment of anxiety disorders. The findings of a systematic review with meta-analysis of direct comparisons [60] pointed to just the opposite (benzodiazepines are more effective and with fewer side effects than antidepressants in anxiety disorders). The unfair consideration of benzodiazepines in the recent psychiatric literature prompted the creation of an international task force [61] that led to a better appraisal of the clinical use of benzodiazepines [62].

It was then clear that we needed to develop a more comprehensive framework geared to the formulation of clinical judgment [63], to include the issues of responsiveness and vulnerability (in addition to benefits), the consideration of comorbidity and multimorbidity, and other important contextual factors [53]. Such a model relies on clinimetrics to study clinical phenomena, to assess the importance of different types of data, to create appropriate systems of taxonomy for classifying information, and to develop intellectual models and pragmatic methods that would maintain and improve the clinical art while advancing the state of clinical sciences [2, 64]. In line with this approach, we published contributions on the clinical utility of clinimetric indices [65-75], including the first position paper on clinimetric criteria for patient-reported outcome measures [76]; on staging [77, 78]; on issues that affect treatment outcome, such as illness and medication attitudes and previous therapeutic experiences [71, 79]; on iatrogenic effects [54, 55, 57, 80-83].

Another important source of innovation came from the recently developed medicine-based evidence (MBE) [84]. MBE provides the biological and biographical basis of precision medicine. It builds on the archive of patient profiles using data from all study types and data sources, including both clinical and socio-behavioral information. The clinician seeking guidance for the management of the individual patient will start with the patient’s longitudinal profile and find matches in the archive, which provides an important source of therapeutic pluralism [84]. MBE attempts to produce fine-grained profiling of subgroups of patients based on clinimetric criteria. The clinical advantages of this approach have been outlined in clinical psychology and psychiatry [85], with particular reference to the coexistence of anxiety and depression [86] and to psychotic disorders [87, 88]. In the journal, we thus introduced clinical reviews that do not refer to the average patients, but to the subgroups entailed by MBE [86-88].

In terms of meta-analyses, the differences between Psychotherapy and Psychosomatics and other medical journals became striking. At a time when meta-analyses were on the rise (from fewer than 1,000 a year in 2000 to about 11,000 in 2017) [89], our critical and selective approach [90] led to publication of very few papers using this statistical procedure and to exclusion of network and umbrella meta-analyses. I wonder whether in due course (10 or 20 years from now) we will realize that scientific journals have wasted a lot of space with clinically useless and methodologically flawed meta-analyses [90], with an endless list of authors who rotate among papers using the same databases.

Most of our journal space was taken by original investigations with innovative features. At times, they were major randomized controlled clinical trials; other times, they consisted of pilot studies or clinical observations. One may wonder, in fact, whether the answers to specific clinical questions are likely to come from larger and larger randomized controlled trials with broad inclusion criteria, or by a series a small trials, that deal with specific populations in terms of clinical characterization or treatment history [91]. Examples are provided by clinical trials concerned with psychotherapy [58, 59, 92-99]. In 2018, we published a position paper concerned with the journal’s standards for psychotherapy research that also included the use of clinimetric indices for assessing side effects and clinical deterioration [100].

In this decade, there was a marked progressive increase in the journal’s IF, from 7.23 in 2012 to 17.66 in 2020 (Fig. 1). Psychotherapy and Psychosomatics has become one of the top 5 journals in the psychiatry and psychology rankings (actually in psychology, it is the number one of those publishing original investigations). Many colleagues (including fellow editors) wondered about the reasons of this success. Indeed, there were many factors that seemed to play against our growth in the IF: the bulk of our papers consisted of original investigations, with very few reviews; we very seldom published meta-analyses, despite the fact that these papers are likely to attract citations; we had few editorials and did not publish commentaries, perspectives, insights that are used by other journals to increase citations; the journal kept its psychosomatic identity [3], at a time when this was regarded as obsolete by other journals that even changed their names. My explanation was that our focus on innovations and pluralism was the drive. Kuhn [22] remarked that scientific revolutions are initially restricted to a small segment of the scientific community, but progressively lead to a more general awareness that a certain paradigm has ceased to function adequately. The editorial board of the journal was expanded to include investigators who were able to provide important insights on the topics covered by the journal (I would like to mention here Benjamin Becker, Jianxin Cao, Andre Carvalho, Jose de Leon, Ajandek Eory, Gregor Hasler, Robin Jarrett, Kyung Koh, Hochang Lee, Silvia Schneider, Vladan Starcevic, Hong-xing Wang, Jesse Wright, Naoki Yoshinaga, and Stephan Zipfel).

Welcome to the New Editors

In the last few years, more and more the role of Fiammetta Cosci and Jenny Guidi became important in evaluating manuscripts and shaping directions, with particular reference to their function as associate editors. Now it is time for me to leave my position in Psychotherapy and Psychosomatics and to hand the baton to Fiammetta Cosci and Jenny Guidi, who, starting from July 1, 2022, become editors-in-chief. Two editors may be more effective than one, particularly with the broadening of the areas of interest of the journal. Fiammetta Cosci works at the University of Florence, where she obtained her medical degree and completed her residency in psychiatry. She then got her PhD from the University of Maastricht. She has a strong focus on psychosomatic medicine and psychopharmacology. Jenny Guidi received both her PhD and PsyD degrees from the University of Bologna, where she currently works. She has a particular interest in clinimetrics and psychotherapy research. I am convinced that their competence, clinical skills, integrity, and creativity, in addition to the energy of their young age, will lead to a further growth of Psychotherapy and Psychosomatics.

While reading the literature as a young psychiatrist, I had the feeling that improvement in my performance was a function of both expanding my knowledge with technical information and upgrading my clinical judgment by trying to capture how senior colleagues and nurses came to certain conclusions. I believe that clinical practice is the source of the fundamental scientific challenges. Having the privilege of being the editor of this journal helped me dealing with complex and difficult clinical challenges and provided important directions for my own research. And even now that I turn 70, I feel I am still growing. I will thus continue to share what I have understood and what I still have to understand as a submitting author to this and other journals. In the meanwhile, I believe that Psychotherapy and Psychosomatics is in excellent hands and will continue its mission stronger and renewed.

Acknowledgments

For the journal’s achievements of these three decades, I am indebted to a number of people. I would first like to acknowledge here the support I had in all these years from Thomas, Steven, and Gabriella Karger, who allowed me an intellectual freedom that would have been difficult to find elsewhere. Without them, there would be no Psychotherapy and Psychosomatics. Within the publishing house, over the years Thomas Nold was always ready to provide expert technical support to my ideas and initiatives, and I am grateful for that, after his retirement, Kathryn Schoefert continued in such endeavor. I would also like to acknowledge the work of the editorial board and statistical consultants (Fortunato Pesarin, Maria Zielezny, and Carmen Berrocal Montiel); the help of many external reviewers, who dedicated their time and efforts to assess and improve the quality of submitted manuscripts; the contribution of Elena Tomba who played an essential role in the transition from the paper to the online submission system; the skills of Carlotta Belaise, Emanuela Offidani, and Andrea Sabbatini who prepared the press releases of the published articles; and, last but not least, the support of our authors and readers.

Conflict of Interest Statement

The author has nothing to disclose.

Funding Sources

The author has no funding to declare.

Author Contributions

The author conceived and wrote the entire manuscript.

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