Response to the Presidential Address

It is a great honor to stand here today assuming the responsibilities of your APA President. This past year our organization has had the great good fortune of having a strong, dedicated leader, Paul Appelbaum. Working closely with Paul has been a privilege, sharing with him the same vision for our profession and our organization.

I want also to acknowledge some of the many people who have helped and inspired me. Dr. Joe Yamamoto, psychiatrist, educator, and humanitarian, has been the most influential figure in my academic career. His encouragement and expectations in academia, research, and public psychiatry propelled me forward into unexpected and rewarding terrain. I am indebted to many good friends and advisors within APA: Carol Nadelson, Carolyn Robinowitz, Dan Borenstein, Herb Sacks, Martha Kirkpatrick, Drew Clemens, Herb Peyser, Sherwyn Woods, and Rod Burgoyne. My department chairperson, George Simpson, has provided thoughtful counsel and patiently suffered my many absences. John Goin, my late husband, a charismatic physician, believed I could do anything I put my mind to. Jessica and Suzanne, my creative daughters, offer me love and warmth, which makes all things possible.

A few weeks ago in meeting with a group of first-year medical students, I was asked why I had chosen to become a psychiatrist. I launched into a description of some of the remarkable discoveries of the last few decades: demonstration on fMRI of the neurocircuitry involving the anterofrontal cortex, the limbic system, and hippocampal activity; Kandel’s extraordinary findings about neuroplasticity; the integration and interrelationship of neurogenomics; and the mapping of the brain that shows with increasing clarity the neurobiological effects of attachment, attunement, and psychopharmacology.

I was holding forth with passion when I realized that their eyes were beginning to glaze over and some were nodding off. They had lost their bearings in a territory that was familiar to me but that at this point in their education was only a complicated maze of names, connections, and neuroanatomy they were struggling to memorize.

Seeing their soporific reaction, I stopped and then backtracked in time to when I was a first-year Yale medical student, in order to recall what offered real meaning for me. Why had I chosen to become a psychiatrist?

Yale’s Department of Psychiatry was the national leader in psychiatric research, teaching, and clinical investigation. The department was eclectic, not trapped in dogma. Remarkable mentors lectured to the medical students and convened small seminar groups. Most important, we met and talked with psychiatric patients. One of the first patients I got to know was Bill, a college student. He was in physical restraints when I saw him in the emergency room. He looked terrified, and his voice quavered when he spoke. Unseen voices were telling him he was evil and were threatening to rip out his heart if he didn’t repent. Listening, I was struck by how frightening and terrifying psychiatric illness can be!

As I met more patients and listened to their stories, I realized that in certain respects these patients’ symptoms were clearly less tolerable than physical pain and the suffering qualitatively different from and often worse than that of patients with physical pain. People with depression, struggling to shake off the inertia of their illness, try to work and take care of their families while weighed down by inexplicable heaviness and suicidal thoughts. The paranoid person, tormented day and night, is frightened by unseen and unexplained dangerous plots and by menacing voices that are unheard by others.

Listening to stories about real people, my medical students came alive. It was a new discovery for them to realize that these illnesses are diagnosable and treatable. They could hear the tragedy of the illnesses that if untreated spread from the patient to his or her family and friends. Many students began to realize the relevance and importance of our work and to explore the prospect of becoming psychiatrists.

This story is important, not just for medical students, but for society. We must attract the best and brightest to our specialty; our work and its potential must become known to others. The American Psychiatric Association must continue to expand its programs to increase public awareness, press for access to care, battle for destigmatization, and assure the recruitment and training of researchers and clinicians to improve patient care and safeguard the future of psychiatry.

Currently, we are in the best of times when we look at contemporary research. But, paradoxically, we are in the worst of times in not being able to deliver the benefits of new learning. Federal and state budget deficits are draining necessary resources from every aspect of society. Our patients are the most vulnerable because of the blindness of decision makers to the harsh consequences of mental illnesses.

Newspapers are rife with tragic stories resulting from funding cuts in essential services. On May 4, 2003, The Oregonian reported the following story about Farrah Russell (1):

The closing of psychiatric hospitals, the subsequent crowding in psychiatric emergency rooms, and the elimination of community mental health resources speak to the abandonment of our nation’s health and social responsibilities. We must vigorously address the root causes and the consequences of this political folly. Some consequences include homelessness, family disintegration, loss of work productivity, and a geometric increase in the mentally ill in jails and prisons. Our children, our future are at risk. There is a rising tide of abuse and neglect cases in the juvenile court system, a paucity of residential treatment centers for juveniles with demonstrable mental illness, and elimination of after-school programs, which serve the important function of providing a hot meal for poor children—the only one of their day.

There are other, more subtle, consequences of problems in the health care delivery system. The large amount of time required for administrative activities diminishes markedly time spent in patient care. This intolerable development spurred by the managed care industry and the depletion of government funding is ultimately wasteful and contrary to patients’ needs, and it distorts the training model. There is a myth among decision makers that there is a pill, a cost-effective panacea, that will cure psychiatric illnesses, and this fantasy is contributing to the diminished role of the psychiatrist.

APA’s outreach to business continues to inform decision makers in the corporate arena about the enormous costs, both human and financial, when psychiatric illness goes untreated or insufficiently treated. In February 2003, Mercer Human Resource Consulting and Marsh, Inc., an insurance broker, reported that 70% of 723 employers found that stress or depression had markedly increased as a disability condition. This figure is much higher than that of other health problems, including cancer, repetitive trauma, and cardiovascular illness.

In the United States, $24 billion a year is lost in disability, absenteeism, and decreased productivity. Employees represent 50% of the insured population in the private sector, and chief executive officers are alert to the fiscal consequences of failing to provide adequate mental health benefits.

The fight for parity must be fought on many different battlegrounds. Proposed legislation would apply only to employers who already offer mental health coverage, and then only to those with 50 or more employees. There is talk of restricting disorders, excluding, for example, posttraumatic stress disorder, anorexia nervosa, and autism. Under such fiscal constraint, employers may well drop their mental health coverage or circumvent the legislation by requiring higher copayments and deductibles.

What about our patients who are in the jails and prisons? A few years ago I was at a meeting held at the Los Angeles County Jail with representatives from the National Alliance for the Mentally Ill, the mental health staff, and the court system. A mental health worker described the dilemma posed by successfully treating an inmate with psychiatric illness but then having the results disappear after discharge with the absence of continuing treatment. He asked the judge, “Isn’t there some way to have the prisoners stay longer?” What does this say about our society when the jail system is seen as the principal treating system! The Los Angeles County Jail, as mandated by the courts, has a 50-bed, well-staffed psychiatric hospital and 2,300 other inmates in a special section where they receive psychiatric medications and ongoing evaluations.

I am working closely with the APA Corresponding Committee on Jails and Prisons and the excellent staff in the APA Office of Healthcare Systems and Financing to analyze data from ongoing studies across the country. These data identify the rising costs of the criminal justice system, to both the states and the federal government, because of the massive influx of untreated psychiatric patients in jails and prisons. Untreated psychiatric patients don’t disappear. They sit in overburdened emergency rooms, often live on the streets, and ultimately may wind up in jail. Long-range planning imperatives must meet the needs of the psychiatric patient community in these hard economic times.

The health care delivery system’s serious problems have been daunting to economists for the past two decades. With urgency, APA must assemble a group of scholarly advisors to explore the impact of current policies on psychiatric care and to construct politically viable recommendations to improve health outcomes for the mentally ill, the disadvantaged, and children and their families.

I have pointed to the external challenges, but what about our internal ones? I think, for example, about the divide that has occurred in our field since the 1960s between the biological psychiatrists and the psychologically committed psychiatrists. In the 21st century, this polarization is contrary to the best interests of patient care and is not supported by modern neurobiological research. We have gone far beyond the search for the single gene or neurotransmitter to explain psychiatric illness, to an understanding that the biological processes are far more complex and involve both facilitating and protective elements, which in turn are highly influenced by environmental and developmental factors. It is folly to separate nature from nurture and see them as independent of one another. In both research and clinical practice we must strive for an integration of these complex factors that will lead to greater depth in understanding our patients and, therefore, to better treatment. The journey from Kandel’s studies of learning in the simple Aplysia to an increasingly complex understanding of how neurobiology is shaped by external influences should become a paradigm for our goals in clinical practice and research. APA must continue a strong advocacy role in encouraging and facilitating an integration of the biological and psychological in education and research as well as in clinical practice.

APA will continue to influence the clinical practice of psychiatry through the medium of the practice guidelines and continuing medical education. In many ways the practice guidelines serve as an ideal model for education as long as they are not used as a cookbook.

We are fortunate that in this time of national and state fiscal vulnerability we have a strong organization with many members who are devoted to fighting the good fight. This past year in my visits to the Bronx, Alabama, Texas, Hawaii, Illinois, New Jersey, Washington state, and, most recently, Minnesota I have met many of our talented colleagues and have been impressed with their dedication and their work.

We must remain firmly committed to the best in psychiatric education and research. If we don’t advocate for our patients, there will be neither time nor money to use that education to provide quality care. It is moving to see the rapidly increasing awareness of our young psychiatrists. They know that we must be front and center in the battle for our patients and our profession or our patients’ needs will go unheeded and our profession diminished.

Our capacity to do better has never been greater. This nation has always been a work in progress, and it will always be. This national view is mirrored in the values of our APA. We have it in our power to take our organization to new heights of accomplishment. That is our challenge. Your APA is there to meet that challenge, and I am proud to be a part of it. We need your help and involvement in the years ahead, and from the look of the crowds gathered here in San Francisco I see that we can count on it.

Thank you.