While Hermiticity of a time-independent Hamiltonian leads to unitary time evolution, in and of itself, the requirement of Hermiticity is only sufficient for unitary time evolution. In this paper, we provide conditions that are both necessary and sufficient. We show that
symmetry of a time-independent Hamiltonian, or equivalently, reality of the secular equation that determines its eigenvalues, is both necessary and sufficient for unitary time evolution. For any
-symmetric Hamiltonian
H
, there always exists an operator
V
that relates
H
to its Hermitian adjoint according to
V
HV
−1
=
H
†
. When the energy spectrum of
H
is complete, Hilbert space norms 〈
ψ
1
|
V
|
ψ
2
〉 constructed with this
V
are always preserved in time. With the energy eigenvalues of a real secular equation being either real or appearing in complex conjugate pairs, we thus establish the unitarity of time evolution in both cases. We also establish the unitarity of time evolution for Hamiltonians whose energy spectra are not complete. We show that when the energy eigenvalues of a Hamiltonian are real and complete, the operator
V
is a positive Hermitian operator, which has an associated square root operator that can be used to bring the Hamiltonian to a Hermitian form. We show that systems with
-symmetric Hamiltonians obey causality. We note that Hermitian theories are ordinarily associated with a path integral quantization prescription in which the path integral measure is real, while in contrast, non-Hermitian but
-symmetric theories are ordinarily associated with path integrals in which the measure needs to be complex, but in which the Euclidean time continuation of the path integral is nonetheless real. Just as the second-order Klein–Gordon theory is stabilized against transitions to negative frequencies because its Hamiltonian is positive-definite, through
symmetry, the fourth-order derivative Pais–Uhlenbeck theory can equally be stabilized.