Neglecting to consider treatment options. Consider just a few scenarios: The recurrently relapsing patient with psychosis who is not switched to a long-acting injectable formulation; the persistently psychotic patient who does not receive a trial of clozapine; the treatment-resistant depression patient who is not referred for electroconvulsive therapy or transcranial magnetic stimulation; and the patient receiving an atypical antipsychotic who is monitored inconsistently for metabolic dysregulation.
Treating patients but not vigorously advocating for them—thus allowing a broken, convoluted mental health system to delay or prevent access to care; incarcerate relapsed patients instead of hospitalizing them; permit insurance companies to discriminate against coverage of mental illness; and tie the hands of psychiatrists who want to select medication they judge best for their patients.
None of us is 'without sin'
We all aspire to help our patients in the best way we can, and to avoid errors. However, even a seasoned psychiatrist can stumble unwittingly, and that is understandable and forgivable. It is willful, recurring neglect of the patient’s welfare that can be deleterious and that, in my opinion, qualifies as a cardinal sin. Fortunately, such neglect is a low-frequency event in psychiatric practice, but even a single occurrence is one too many.