Response to Presidential Address

President Bernstein, Speaker Hershfield, members of the Board of Trustees and the Assembly, colleagues, and guests: It is an honor and a privilege to join you today and, after this meeting, to assume the presidency of this wonderful organization, the American Psychiatric Association. Carol Bernstein will be a hard act to follow! In my opinion, she has done an outstanding job, and Carol and I have worked closely together to foster continuity of the many strategic goals that she has promoted.

While I was preparing these remarks at home in Houston, I noticed a cherished keepsake on the wall, a framed license to practice medicine and surgery issued to my grandfather, Ira Brown Oldham, M.D., by the Creek Medical Board of Examiners of the Creek Indian Nation. The date was 1903, shortly before Oklahoma achieved statehood, and the town was Muskogee. Merle Haggard fans in the audience may not have known that I'm an Okie from Muskogee, but that was my father's birthplace as well as my own. In Muskogee's horse-and-buggy days, my grandfather was one of the few doctors in town, and in those days doctors did it all—from measles and mumps to broken bones to appendectomies, and, of course, to compassionate round-the-clock reassurance and advice.

How the world has changed! Carol Bernstein has eloquently described the amazing capacity of the developing human brain to absorb new knowledge and to master new technology that is exploding at warp speed. Our children and grandchildren are savvy navigators of the blogosphere, where the operant languages are instant communication and immediate information retrieval, and they have networks of friends, many of whom they have never seen except on a screen. Multitasking is the name of the game, and the quiet contemplation of the 50-minute psychoanalytic hour probably seems to many like a curious relic from the past. On the whole, these are fascinating and exciting changes in our world, and our challenge is to embrace them and to harness new technology to do our job better. I wonder, though, if one part of that challenge is figuring out how to turn the clock back a bit, meaning how to bring help to the neighbor down the street who may not have a family doctor, since there aren't many of them around anymore, or to the great aunt who can't figure out how to navigate the complex health care system, or to the young college graduate who doesn't have insurance or a job.

How will we do this? Certainly, it won't be easy, and certainly we can't do it by ourselves. But in the march of progress, we have become so superspecialized that we may have lost our way—and here when I say “we,” I mean all of medicine. Ask each other or ask any of our colleagues, “Who is your doctor,” and the answers are all over the map. Many times, we as patients become family doctors to ourselves. This may not be altogether bad. We should, after all, be active participants in our own health care. But in my opinion, it is a problem if we are the only ones managing our own health care home page.

You may recall that during the 2010 election cycle, I emphasized four important priorities that I believe are of central importance to the APA and its members. These priorities are:

1) Psychiatry is part of the House of Medicine;

2) Our patients have a right to quality treatment;

3) Fragmented care is not quality care; and

4) Research and education provide the best blueprint for our future.

Let me say a few words about each. My first priority is that psychiatry is part of the House of Medicine. In my view, there is no controversy here. Evidence for the mainstream medical nature of brain disorders is abundant and persuasive. We know, for example, that depression is a complex medical illness that involves not only loss of hope, impaired occupational and social functioning, and potential risk of suicide. It also derives in part from heritable risk factors, constitutes an independent risk factor for cardiac death, and involves other types of pathophysiology, such as immunosuppression and elevated stress hormones. Every day we are learning more about the neurobiological changes associated with depression at the molecular, cellular, and structural levels in the brain. Furthermore, patients with major depressive disorder frequently have co-occurring psychiatric disorders, such as an alcohol or other substance use disorder or a personality disorder. Further complicating the picture is the frequent presence of cardiac disease, hypertension, or diabetes. It is critical that we partner effectively with our colleagues in primary care and family medicine and with colleagues in other specialties. Our patients do not neatly line up with stand-alone illnesses, and even if they do, those illnesses almost always cross a number of specialty lines.

How can we partner with our colleagues in medicine? This is clearly not an easy task, but doing it right should result in more collaborative care, with a central medical home base for patient care. Whether medical homes or accountable care organizations will be effective systems of care that help us recapture the art of patient-centered care, or person-centered medicine, remains to be seen. But we must be at the health care table as active participants as new models of care are hammered out. We must not be the only ones recognizing that there is no health without mental health.

My second priority is that our patients have a right to quality treatment. In the world of health care, patients have many rights that must be carefully respected, monitored, and protected: the right to be heard, to receive full access to culturally sensitive and unbiased care, and to be treated with dignity and respect, and the right to choose whether to accept or decline recommended treatment. But we don't as often hear advocates arguing in support of a patient's right to receive quality treatment. In extreme situations, however—and these are fortunately relatively rare—we must not shy away from active intervention when clearly indicated. I have always remembered an occasion when I was a major in the Air Force evaluating a colonel who was depressed and suicidal. He had a loaded shotgun at home and planned to kill himself after finalizing one more bank transfer of assets to his wife. I told him that he was going to be admitted to the hospital, which he then refused. I can still recall my relief at having the military structure at my back when I said, “Colonel, that's an order.” Though he outranked me in all other circumstances, I was the ranking officer in charge when he was my patient within the walls of the medical center. He knew the rules. He was hospitalized, and he recovered and returned to active duty. Of course, we have all had such clinical emergencies, and we do our best to deal with them appropriately. But there are other times when bureaucratic obstacles, inadequate resources, or even legal constraints tilt decisions in the wrong direction. Just read, for example, the court papers from the tragedy at Virginia Tech, and I think you would agree that the judicial decision to “commit” the patient to outpatient treatment (which, of course, is usually unenforceable), instead of to issue an order for the patient to be hospitalized, inappropriately overvalued his right to personal freedom above his right to quality treatment. Many lives were lost as a result, and, of course, the patient's life was ruined. I realize that this is a slippery slope, with many compelling, valid, and sometimes competing interests. We do not hesitate, however, to intervene actively when a brain disorder called epilepsy leads to a grand mal seizure or when a toxic delirium produces combative behavior. I also believe that there are many situations that are not so extreme as the Virginia Tech example, where the brain disorders that we call psychiatric disorders are not recognized, and patients are blamed for “behaving badly” instead of being guided to appropriate treatment to help them overcome disruptive or distressing illness-driven behavior.

The third priority is that fragmented care is not quality care. Here too, we have a lot of work to do. When the average length of stay in most acute psychiatric hospitals is 5 or 6 days, or even less, the goals of inpatient treatment are to keep patients safe, to adjust their medications, and, perhaps, give them a breather from stressful home or work circumstances. All too often, however, communication is spotty, and information is sketchy or incomplete. Just last month in The New England Journal of Medicine, Don Berwick referred to the fragmented nature of U.S. health care and that “no single group takes full responsibility for guiding the health of a patient.” He added that too many patients “have suffered at the hands of wasteful, ineffective, and poorly coordinated systems of care” and that “the era of fragmented care delivery should draw to a close.” Patients encounter one new treating clinician after another, and even if continuity of some kind of care is accomplished, continuity of meaningful treatment may not be. While we do our best to make the system we've got do its best for our patients, we need to lobby hard in support of quality, evidence-based, integrated treatment.

And this brings me to my fourth and last priority, that research and education provide the best blueprint for a strong future. We are witnessing an explosion of knowledge about the brain, generating new ways to prevent and treat brain disorders. We must be eloquent ambassadors, bringing this information to our patients and their families, to our medical colleagues, to third-party payers, and to our legislators and policymakers. If we believe that for some patients a longer stay in the hospital will be more helpful and cost-effective in the long run—and I for one do believe that—then we need to marshal the evidence and get on a soapbox. And if the evidence is missing, we need to lobby for funding to carry out the needed research. We need strong partnerships between practicing clinicians and academic clinical and basic science researchers. We know a lot about psychiatric treatments that work, thanks to our research progress, the strength of our academic departments of psychiatry and neuroscience, and the support of NIH and other funding sources. But when the economy falters and money gets tighter, clinicians and researchers must stand side by side to defend continued support for the very research that will not only save us money in the long run but will continue to improve the lot of our patients in need.

A few years ago, representing the American Psychoanalytic Association, I attended an annual meeting at NIMH, with representatives from other mental health organizations. The latest research findings were summarized, which included some exciting neuroimaging studies showing changes in the brain after a course of psychotherapy. Responding to my question about increased funding for psychotherapy research, Tom Insel made an interesting observation. He pointed out that for years, psychoanalysts and psychotherapists have emphasized the limits of randomized controlled trials when it comes to designing the best treatment for any individual patient in the real clinical world. He stated that, ironically, brain science is now taking us right back to the consulting room, with the promise that genomics, brain imaging, and other technologies may soon help us identify which specific treatments will be of greatest benefit for each individual patient. These strategies may not quite be ready for prime time, but this is what translational research is all about.

I think that by now you can see why it seemed fitting to me to select “integrated care” as the theme for my presidential year and for next year's annual meeting in Philadelphia. To me, integrated care has many important meanings: integrating our work with the rest of medicine; integrating education and teaching and the latest research findings into our clinical work; and integrating the stages of a patient's treatment into a coherent, progressive plan.

Let me close my remarks with a brief clinical vignette. A few years ago, when I was in South Carolina, I was amazed to get an e-mail out of the blue from a man who had been my patient when I was a resident at Columbia. He said that he found me on Google, that I probably didn't remember him, but that he had often wanted to contact me during the almost 35 years since we last saw each other. What he wanted to tell me was that he had done okay in life, which he thought would surprise me. He remembered me as arrogant, distant, pessimistic about his future, and not very helpful. I was stunned, since he was one of those patients we can all recall from our training years, who had made a profound impression on me and was indelibly fixed in my memory.

“Mr. R” was a student at the time and the son of an orthodox Jewish father. He was in love with a woman from a different faith, but his father had said to him, “If you marry her, it will be the death of me.” Mr. R was in anguish about the situation, but his love prevailed, and he married his sweetheart. The father did not attend the wedding but instead dropped dead of a heart attack on the day of the wedding. I first met Mr. R shortly thereafter, when he was hospitalized in an acute psychotic state.

What I remember from those days was how concerned I was for Mr. R. I was, after all, a student too at the time. I didn't know enough yet to appreciate the power of human resilience and the recovery potential within us all. What Mr. R saw as coldness or arrogance was, in hindsight, a defensive formality that I needed to hide my anxiety and uncertainty about how I could help him. What I also had trouble seeing at the time was the person behind the psychosis, though he was there watching me and wanting to connect with me all the time.

After mulling it over for a while, I decided to reply. I told Mr. R how glad I was to hear from him and to learn how well things had turned out for him. I said that in the context of being young and inexperienced at the time, even though I had been very concerned about him, I hadn't been sure I knew how to help him, and I clearly had kept my distance far more than I had been aware of. I told him that his message was valuable to me. I apologized for having been so unavailable to him, and I wished him well. A few days later, he e-mailed me again saying how pleased he was that I had replied and not to worry, that “all was forgiven.” I haven't heard from him since.

Why do I tell you this story? It was certainly a humbling experience for me, but I think it conveys important messages for us all, reminding us of the power of hope, the potential for recovery, and that we must never lose sight of the whole person who, for the time being, is not only our patient but also our partner in the treatment enterprise. I was appalled, as I'm sure many of you were, by the recent piece in The New York Times, where a psychiatrist contended that to sustain his income, he provides only 15-minute sessions and that he had to train himself “not to get too interested” in his patients' problems. Well, the day I choose to disregard my patients' problems is the day I should take down my shingle or, to use a Texas metaphor, hang up my spurs.

I am fortunate to work at the Menninger Clinic, a landmark institution founded decades ago by some of the leading visionaries of our field. In 1953, those founders, C.F. Menninger, Karl Menninger, and Will Menninger, prepared a document they called “Some Statements for the Counsel and Guidance of the Trustees and Medical Council of the Menninger Clinic…in Future Years.” They advocated that “only scientific medicine of the highest standards should be practiced” and that “two heads are better than one, and perhaps three better than two,” and that “teamwork is essential to the best practice of the complicated science of medicine.” They added that the work “has been and…always should be 'patient-centered.'” These words of advice are as fresh and vital today as they were almost 60 years ago. I believe that the American Psychiatric Association is one of the greatest teams in the world of medicine. We need the best integrated teamwork we can muster in order to make progress together for our field, for our profession, but most of all, for the patients we care for. I look forward to the coming year, and I believe that if we work together, there is much that we can do. Thank you very much.