Response to the Presidential Address

President Stotland, Past-President Sharfstein, former presidents, Medical Director Scully, Board members, APA members, and distinguished guests, I am humbled by the distinct honor you have bestowed on me and am most appreciative of being given the opportunity to serve all of you and this great organization.

First, let me personally thank Dr. Stotland, not only for her kind words but, moreover, for her superb year as our President. We are all greatly indebted to her for her tireless work in support of the specialty and the organization. Nada has taken on the most challenging of problems with the greatest aplomb. She has been available 24/7, not only to staff and Board members but to the entire membership. She has taken over at a time of diminishing funds and misleading attacks and led us through both economic and political crises. Personally, I am deeply appreciative of her teaching me about APA structures, policies, procedures, and, most importantly, politics. I only hope I can contribute a small percentage of what she has given the organization.

Second, let me thank Steve Sharfstein for his kind and generous introduction. Almost 40 years ago, we met as first-year residents at Massachusetts Mental Health Center (MMHC) and Harvard Medical School. My wife and I have been good friends of the Sharfsteins over that time. Since then, our careers have taken different paths, sometimes overlapping in the running of hospitals and at other times assuming rather different roles in our profession. And that is one of the gifts of psychiatry: the rich variety of experiences that are offered to those who choose to train in our specialty. Indeed, it is the great variety that psychiatry offered that attracted me to it in the late 60s—psychoanalytic theories and psychodynamic and analytic therapies, a blending of the humanities and medicine, and an emerging biological science of the brain and its attendant set of pharmacological therapies.

Today, many of these still are in play, but there has been considerable erosion in our own self-image, in part because of antipsychiatry movements but also in part to some of the developments within our field. It is really time to take stock of where we are in 2009 and to right the craft. I am reminded of an adage that a cardiologist, with whom I shared a program over 20 years ago, said when he likened psychiatry to Noah’s ark: a rickety craft made of balsa wood, listing from side to side, leaking in lots of spots but on the whole a lot better than being in the water. With all our detractors, we need to keep our pride in what we do and remind ourselves how difficult and stressful it is to be a psychiatrist and how much we have to offer.

At this point in my career, I have had many mentors who have given me great guidance and taught me much, and I want to thank them for all their help. Jack Ewalt, Joe Schildkraut, and Carl Salzman at MMHC; Shervert Frazier and Jonathan Cole at McLean Hospital; Jack Barchas, Stewart Agras, and David Hamburg at Stanford. Of course, my wife and daughters and son-in-law and granddaughter have been great supporters as well. Last, my sister, late brother-in-law, and niece, all of whom have or had been long-standing members of the APA, have taught me so much about both life and psychiatry.

As I thought of what I wanted to accomplish over the next year, I sorted my priorities into four areas: re-establishing pride in our profession, continuing to improve the annual meeting, establishing new ways to interact with industry, and facing our economic realities.

First, we need to re-establish our pride in the profession. When Steve and I started years ago, the training was largely influenced by the psychoanalysts who had considerable verve in their beliefs of their practice and considerable pride in what they did. Their long training and sacrifice led them, ultimately, I believe, to be both proud of their practice and comfortable with the opportunities and lifestyle their work afforded. They thought becoming an analyst took a great deal of time, effort, and devotion that deserved to be rewarded. They saw their craft as complex and were proud of their efforts. While the practice may have been supplanted by other approaches or subspecialties, a potentially greater loss resides in our practices and identities: the dedication to intellectual challenge and hard efforts and commensurate intellectual and financial rewards. There are many reasons for this, and hopefully one of you will track and record the various trends better than I can. But here are a few influences that have led to a loss of pride.

One issue is that while we rightly became the defenders and voices of our patients who had largely been discriminated against in days before parity, we perhaps blurred our professional practices and identity with a social work/advocacy approach to the disadvantaged with chronic mental illness. We trained other mental health professionals and often espoused an egalitarianism that reduced the importance of our own roles and suggested that perhaps a medical degree was not necessary. Our zeal for social betterment perhaps also led to an overbroadening of syndrome criteria and to an oversimplification of psychiatric diagnosis. DSM-III and subsequent editions were major steps forward in diagnosis and classification, but reducing the diagnosis of major depression to meeting five of nine criteria for at least 2 weeks reflected an oversimplification of the assessment of patients with a complex disorder.

So too, as psychopharmacology became easier, in some senses, to practice with the advent of the selective serotonin reuptake inhibitors (SSRIs), we fooled ourselves into thinking treating depression or bipolar disorder was not difficult. In the 1980s, I remember talking with Gerry Klerman, a pioneer in our field. I was concerned then that in spite of tricyclic antidepressants, monoamine oxidase inhibitors, and lithium, I had a lot of refractory depressed patients who were experiencing chronic depression. It bothered me. The textbooks said the illness lasted 6 months, and surely I could get my patients better in that time frame. Some of us began to talk about refractory or chronic depression. Twenty-five years later, we have the landmark Sequenced Treatment Alternatives to Relieve Depression study that tells us, again, we have lots of patients who do not readily respond to a single SSRI. My colleagues, treating depression is clearly more complex than prescribing 20 mg of fluoxetine. I find it tough and challenging work that gives me great satisfaction and pride. Can any of us adequately describe that feeling the first time we made a breakthrough with or saw improvement in one of our patients? That is what we need to restore to the specialty, a sense of pride in our caring for patients, many of whom have complex comorbidities and whose treatment requires tremendous skill in both psychosocial and somatic therapeutic arenas.

As the recent attacks on the APA and leaders of the profession have occurred, it has struck me that some of the detractors in the press have voiced concern that some folks have earned too good a living, often by doing presentations. I have heard from colleagues and directly from one reporter asking me about one of my colleagues having too high an annual income. I can assure you these detractors would not ask the same question of a surgeon or radiologist earning 10 times the amount paid our colleagues.

None of us do what we do for money. Yet, it is also time for us to realize that our members and residents have never taken vows of poverty and the complexity of the work deserves to be recognized. We need to ask ourselves how we have contributed to our own devaluation with which others seem to resonate, and we need to reverse the course. The rewards for our dedication should not be limited to a sense of pride, but we are also entitled to be paid commensurate to the challenge. The time has come to be proud of what we do and to advocate for what we and our patients justly deserve.

The second area that I will focus on is continuing to improve our annual meeting. Our past two presidents have done yeomen’s work in this regard, and working with the APA staff of Debbie Hales, Cathy Nash, and their folks, we have an exciting program. But we need to do more. The APA was once where we all went for the newest information, but other more specialized meetings have grown and perhaps eroded our platform. Julio Licinio of the University of Miami will serve as my Scientific Program Committee Chair, and Don Hilty of the University of California at Davis will be the Vice Chair. We have already been meeting and are implementing a number of changes in the planning and evaluation of proposals that will, in the end, strengthen the program. We will provide more content in key areas that you, the membership, tell us you want to know more about. Whether you are interested in psychopharmacology or psychotherapy, we will provide sessions that are informative and useful. We will have tracks in those areas as well as child, geriatrics, consultation-liaison, etc. These will be color-coded for you to make it easier to see what is being offered and when. We will encourage leaders in the field to organize symposia covering the latest information in an intelligible and applicable fashion. We all need to understand better brain imaging, brain circuitry, and genetics if we are going to keep up with the rapidly emerging science of our profession.

As many of you know, the Board of Trustees has decided to phase out industry-supported symposia. These have been well done and very popular, and our APA committees and staff have done superb work in ensuring they have been free of bias. Often, these sessions have been the best attended parts of the program. We now need to bring up the quality of the entire scientific program to the highest level possible. Debbie Hales and her folks have already done a great job in improving the courses that are offered. We will expand on her efforts and ask the leaders of our field to teach us the skills we need to practice: CBT, brain stimulatory devices, psychopharmacology, etc. In keeping with my priority to restore pride in our profession, the theme of our next annual meeting will be “Pride and Promise: Toward a New Psychiatry,” and I look forward to greeting you all in New Orleans 1 year hence.

Let me remind you, we have another meeting the first week in October in New York City. Jill Gruber has chaired the Institute on Psychiatric Services (IPS) Program Committee. Working with Steve Goldfinger, the APA has added some terrific new sessions. We will have a Psychopharm course on Saturday with Charles DeBattista, Terry Ketter, Jeffrey Lieberman, Jeremy Copland, and other leaders. We will have a special session on repetitive-transcranial magnetic stimulation, taught by Johnny O’Reardon, and a CBT for psychosis course. Mark it on your calendars. In keeping up with the theme of the annual meeting, this upcoming IPS meeting will be called “Pride and Practice: Bringing Innovation Into Our Treatments.”

My third area of focus will be finding optimal ways of interacting with the pharmaceutical industry. There has been much spleen and rhetoric regarding industry, and often this has distorted and blurred the facts and demeaned our members, our leaders, APA, and industry. Some believe we should have no contact with industry. As someone who has worked in psychopharmacology for years, this makes little sense to me for many reasons. First, we do not learn how to deal with others or teach our students how to interact with others by segregating people. It has never worked. Second, industry has much to teach us. They do, perhaps, more research than do our national institutes or our philanthropic foundations, and so excluding their voice will only deprive us of new knowledge. Third, we cannot develop new somatic therapies without industry. Think how we or our patients would feel if we didn’t have hope for new treatments. Fourth, we do not want to have industry unaffected by the experienced voice of academia. Think how poorly development would go. Ignoring industry will not make it go away. It will just mean we have less influence and input. Last, we have many members who work with or for industry, and these are dedicated, hardworking, and honorable people who pay their dues to the APA and contribute in so many ways. We need to sit down with industry and come up with ways of interacting that are acceptable to both sides and fit with future guidelines. I have pledged to follow-up on recent initiatives and work with Dr. Scully and our Board of Trustees to affect a new partnership, a partnership we can be proud of for what it contributes to the well-being of our patients and our profession.

Fourth, the overall economy and a loss of funding specifically for the APA have led to a relative shortfall in revenues during this past year. Our reserves have been affected by the stock market crash but still remain strong. We are fortunate to have had the expert skill and leadership of Jay Scully and our CFO Terri Swetnam, who managed to cut costs in midyear and give us a positive bottom line by year’s end. In addition, the Board also markedly has cut costs in governance and approved a governance reorganization plan to not only meet the new budget but also to improve efficiency. Dr. Stotland began working on this early in her presidency and asked me to lead a task force that consisted of past presidents and other leaders. We proposed a reduction in the number of components from 14 councils and 73 nonaward committees to nine councils and 14 committees, and we are in the process of implementing the plan. Although the seeming majority of members have been strongly in favor of these efforts, we recognize the concerns expressed by some. However, the new structure is more efficient and far, far less costly. The Board voted to cut other aspects of governance as well. We have eliminated one of our four Board meetings per year, drastically reduced by 70% the Joint Reference Committee budget, and approved cuts in the Assembly budget. We need to continue to work together to streamline our governance and live within a reduced budget. My friends, dues in many of our district branches, including my own, are very high, and we all need to economize. This will continue to be a focus for me during my presidency and for the Board.

Colleagues, let me again express my deepest thanks for your vote of confidence and for entrusting the leadership of our great association to me. Together, we can strengthen the APA and psychiatry and bring them both to greater heights. I appreciate all your involvement and support. Have a great meeting.