Asynchronous patient portal messaging has become a routine part of psychiatric practice, yet its impact on the therapeutic frame remains poorly defined. Unlike telephone calls or e-mail, portal-based communication is embedded into the electronic health record, extending care beyond scheduled visits. Although patient portals may improve access, transparency, and satisfaction, concerns have been raised about their effects on therapeutic boundaries, the therapeutic alliance, and clinician workload. The authors introduce the concept of the asynchronous frame to describe the explicit and implicit expectations governing between-session communication. Defining this frame collaboratively may preserve therapeutic integrity, support clinicians, and promote safe, patient-centered psychiatric care.

The 25th Amendment to the U.S. Constitution offers procedures to address presidential disability. However, it omits a standard and process by which inability to discharge the duties of the office should be judged. Formulation of a standard and an approach to evaluation should begin by recognizing the similarities with workplace fitness-for-duty evaluations. Thus, operationalizing the 25th Amendment would involve developing a job description, considering the degree of impairment that would render a president unable to function, and clarifying an approach to evaluation. Establishing an independent work group could mitigate the intensely political environment in which this process would unfold.

The DSM's loss of a diagnostic hierarchy has contributed to widespread diagnostic proliferation and a misunderstanding of comorbidity. The original concept of comorbidity referred to the co-occurrence of two distinct disease entities, each with its own etiology and pathology. In psychiatry, by contrast, comorbidity has come to mean the accumulation of multiple DSM diagnoses, many of which have overlapping criteria and limited construct validity. This shift accelerated after DSM-III, which emphasized reliability over parsimony and encouraged clinicians to treat symptom clusters as separate disorders. The authors argue that DSM-6 should restore a diagnostic hierarchy grounded in construct validity. Such a hierarchy would privilege disorders with strong empirical validators, distinguish true from false comorbidity, reduce diagnostic inflation, clarify etiological relationships, and improve treatment selection. Drawing on the original intentions of the concept of comorbidity, the historical contrast between DSM-II and DSM-III, and contemporary work, the authors outline a path toward a more coherent and scientific psychiatric classification.

In light of the dramatic rise in Medicare Advantage (MA) enrollment over the past 20 years and the negative impacts of certain MA plans on accessibility, affordability, and equity in mental health care, the authors analyzed literature and publicly available data to explore the impacts of the expansion of MA on psychiatric care. A comprehensive search was conducted in PubMed between December 2025 and January 2026, and data from KFF published between 2021 and 2025 were analyzed to examine trends in MA with a particular focus on mental health. This analysis revealed that increased penetration of MA into the Medicare-eligible population worsened existing strains on psychiatric care through managed care practices that limited access, increased out-of-pocket costs, perpetuated inequity, and may have contributed to lower psychiatrist participation in the Medicare program. To better understand the consequences of MA's emerging predominance on psychiatric care, studies of care quality and outcomes must correct for diagnosis upcoding and selective enrollment in MA, which limit comparisons between MA and traditional Medicare. Efforts to address accessibility, affordability, and equity in MA must address narrow networks, high out-of-pocket costs, and prior authorization requirements in MA plans, which create barriers to accessing mental health care, especially for vulnerable populations.

Discontinuation of the U.S. Food and Drug Administration's clozapine risk evaluation and mitigation strategy program led to a package insert (PI) revision in June 2025. However, that PI update retained many elements that are inconsistent with modern clozapine prescribing, including rapid titration, twice-daily dosing at the start of therapy, and titration without regard to patient factors (e.g., ancestry, sex and gender, or smoking status). The revision also provided no guidance on monitoring for myocarditis or mitigating the primary causes of mortality-pneumonia and ileus. This discrepancy between the clozapine PI and evidence-based practices has caused clinicians to consider whether deviation from the PI presents a medicolegal risk and how to cope with outdated PI information for clozapine and other medications. This article reviews the relative weight of different forms of medical evidence in establishing the standard of care, illustrates through case law that a PI does not define the standard of care and is inadmissible in malpractice litigation without expert testimony, and provides guidance for clinicians on how to navigate outdated, non-evidence-based PI recommendations. The information in this article should reassure clinicians that using modern evidence-based care-not archaic PI recommendations-is the optimal choice when treating patients.