Presidential Address: Advocacy as Leadership

What a wonderful, exciting year I have had as President of your association.

From the moment I stood before you in Atlanta to today in Toronto, I have experienced what it means to lead American psychiatry.

I found myself on the Today show defending the science of psychiatry against Tom Cruise, and then just 3 months later I was in Guantanamo Bay, Cuba, debating the values of psychiatry with our nation’s military leaders. In my writing and speeches, I drew lines in the sand in support of gay marriages and in opposition to inappropriate pharmaceutical industry influence on psychiatric practice.

In September I observed, along with all of you, the horror of the devastation of Hurricane Katrina and then heard our nation’s leaders promise that the vulnerable and poor would never be left behind again. I am incredibly proud of our members’ tireless efforts to treat the legions of traumatized survivors, just as I am outraged at a government that has contributed to and prolonged their agony and swept them under the rug. I found myself struggling again with the Administration’s failures to keep its promises about health care in January, during the disastrous implementation of Medicare part D, which has devastated many of our poorest and most vulnerable patients.

In one year, I have traveled to dozens of district branches; responded to hundreds of phone calls and e-mails; chaired multiple committee meetings; appointed nearly 1,000 members to councils, committees, and task forces, including the most recent appointment of our DSM-V Task Force; and interacted with members of Congress and the Administration on the issues of the day. My days have been full and long, beginning with answering an average of 20–25 e-mails from APA at 6:00 a.m. and ending with a conference call late at night.

For those of you who do not know this already, I have a day job. I’m the President and CEO of one of the largest nonprofit psychiatric health systems in the country. We just opened a brand-new, state-of-the-art, 192-bed psychiatric hospital with satellite programs throughout the state of Maryland, 2,000 employees, and a nearly $200 million budget. I continue to see patients and supervise residents.

It was an unforgettable year.

An exhausting year.

As the great Madeline Kahn said in Blazing Saddles, “Oy, I’m tired.”

But as I end my Presidential term, I AM NOT READY TO SLOW DOWN.

What I have learned, above all else, is how important advocacy is to the future of our profession and to the care of our patients. Last year I called on the psychiatric profession to take concrete steps to regain its credibility in order to provide leadership on issues facing our country. This year I would like to propose advocacy as the key means to this leadership. Advocacy is not just calling on others to do what we want, it is shining a light for others to follow.

Some of you may recall my first 15 minutes of fame sitting with Katie Couric on the Today show one Monday last June. The Friday before, Tom Cruise had lectured cohost Matt Lauer that he “knew the history of psychiatry” better than anyone, that psychiatric treatment is never needed, and that illnesses like postpartum depression are easily cured with vitamins and exercise.

This was not what I imagined for my first month on the job. I hadn’t spent most of my life caring for patients and running a hospital only to butt heads with Joel from Risky Business. But at the end of it all, I can only thank Mr. Cruise for giving psychiatrists across North America the opportunity to get our message out—that we are physicians who prescribe treatments that work.

In the weeks that followed the Today show, my in-box piled up with angry e-mails from the antipsychiatry movement in America, which, by the way, is alive and well. If you Google me these days, you’ll find out what a fraud and a liar Sharfstein is.

I read these e-mails, I reviewed these web sites. It is clear to me that psychiatry is part of a struggle between science and antiscience in America today.

As physicians we search for the truth based on science, producing replicable results through research. The Scientologists protesting outside this meeting in Toronto represent the opposite of the search for truth. They are joined in a general movement against science by such groups as the intelligent design advocates, abstinence-only fanatics, global warming deniers, antivaccination lobbies, gay bashers, and stem cell research rejecters. There is a conflict going on in America today, sometimes called a “culture war,” but very much a conflict between those who search for truth based on science to improve the human condition and those who are blinded by dogma and denial.

In this conflict, the one weapon used by the antiscientists against American psychiatry is our relationship with the pharmaceutical industry. This is the noise that often gets in the way of our message being heard.

As I did last year, I would like to highlight some of the issues confronting our professional identity and ethics related to drug companies.

We all know that pharmaceutical breakthroughs have transformed the outcomes for millions of psychiatric patients. The proven effectiveness of antidepressant, mood-stabilizing, and antipsychotic medications has sensitized the public to the realities of mental illness and has given hope to millions. So, my comments that follow must bear this positive impact in mind.

Psychiatry and the pharmaceutical industry abide by different ethics and values. “Big pharma” is a business governed by the motive of selling products and making money. Our profession aims to provide the highest quality of psychiatric care to persons who suffer from mental illness. Understandably, there is widespread concern about the overmedicalization of mental disorders and the overuse of some medications, especially selective serotonin reuptake inhibitors (SSRIs) and stimulants. Financial incentives of managed care have contributed to a notion of a quick fix by taking a pill. There is much evidence that over the last decade psychiatrists have been providing less and less psychotherapy. This trend persists despite the strong demonstrated effectiveness of many psychotherapies and the importance of combining talking therapy with medications to achieve the best outcome. As I said last year, we have allowed the biopsychosocial model to become the bio-bio-bio model. In a time of economic constraint, a pill and a brief appointment have dominated treatment.

Direct marketing to consumers by pharma has led to an increased demand for medications and inflates the expectations about the benefits of medications. As a profession, we need to be concerned about this advertising and the impact it has had on the potential overuse of medications. Of course, what are marketed to consumers and to us by drug representatives are the highest-cost, on-patent products, and the cost of medications is something rarely considered by prescribing clinicians. When we do not prescribe cheaper but equally effective alternative medications, these added costs prevent payers from spending on other psychiatric treatments of equal or superior effectiveness.

Beware of drug company representatives bearing gifts. The pads, the pens, and the other logo-driven gifts generate distrust from our patients. If we are seen as mere pill pushers and employees of the pharmaceutical industry, our credibility and our leadership as a profession are compromised. These enticements and thinly veiled bribes must end because patients must believe that their doctors have their best interests in mind when prescriptions are handed to them. We must reevaluate single-sponsored medical education events and phase them out. And there must be independent review of all continuing medical education (CME) to ensure its credibility.

The black box warnings for SSRIs and the recent Food and Drug Administration committee recommendation for a black box warning for stimulants unsettled many of us. But we must look into our own relationships with pharma to understand why regulatory agencies and the public are concerned and distrustful. Our advocacy in favor of effective pharmacopeia should not be seen as mere marketing on behalf of industry; it must come from a dispassionate reading of the science and our clinical experience.

We must also exercise vigilance over our other core values. When I read in the New England Journal of Medicine about psychiatrists participating in the interrogation of Guantanamo detainees, I wrote to the Assistant Secretary for Health in the Department of Defense expressing serious concern about this practice. In mid-October I found myself on a Navy jet out of Andrews Air Force Base, along with the top health leadership in the military and other leaders from medical and psychological organizations, on a 3-hour trip to Guantanamo Bay. We were given an intensive 6-hour tour of the prison and briefed thoroughly on interrogation methods and the involvement of Behavioral Science Consultation Teams, known as BSCTs (pronounced “biscuits”) in the process. We were introduced to two psychologists on these teams, and we asked pointed questions about their practice and involvement in giving advice during interrogations. We were reassured repeatedly that although there may have been various “stress techniques” used in the past on detainees, today’s interrogations focused on building rapport with detainees, as positive relationships were much more effective in gaining good information than anxiety-inducing stress that could rapidly evolve into frank torture.

Not good enough. After returning to Andrews, we began a spirited 3-hour discussion over dinner. I found myself looking eye to eye with top Pentagon brass—they are much taller than I am, but we were sitting down. I told the generals that psychiatrists will not participate in the interrogation of persons held in custody. Psychologists, by contrast, had issued a position statement allowing consultations in interrogations.

If you were ever wondering what makes us different from psychologists, here it is. This is a paramount challenge to our ethics and our Hippocratic training. Judging from the record of the actual treatment of detainees, it is the thinnest of thin lines that separates such consultation from involvement in facilitating deception and cruel and degrading treatment. Innocent people being released from Guantanamo—people who never were our enemies and had no useful information in the War on Terror—are returning to their homes and families bearing terrible internal scars. Our profession is lost if we play any role in inflicting these wounds. It was clear to me that the military was not of the same mind on the subject, although within their ranks many good doctors are struggling with conflicting ethical pressures. There has been debate within our association on this topic, but we must be uncompromising about our standards in terms of working with military authorities when we are not serving a healing role.

I urge those of you who are interested in this topic to attend a special Presidential Symposium on Wednesday, chaired by Dr. Paul Appelbaum and myself, when top psychiatric forensic psychiatrists and Army leaders will engage in a discussion with each other and the audience as we, as a profession, try to alter the debate that now rages on within the Administration.

In addition to staying true to ourselves in the War on Terror, there are other values on which we need to focus. These include confidentiality in the information age and electronic medical records revolution, health disparities in our communities, and, of course, access to care.

Our science, our values…and our patients.

It is fitting that my meeting as APA President takes place on Canadian soil, where health care is a right of citizenship. I am embarrassed that this is not true south of the border. Tens of millions of Americans have no health insurance, and millions more have much less than adequate insurance for psychiatric care.

Even those who are supposed to have adequate insurance are often left out in the cold.

The new pharmacy benefit under Medicare part D is the latest example of the failure of our health system.

Although we worked with the Administration in trying to improve the benefit and include essential psychiatric medications, we found ourselves at all kinds of loggerheads with the Congress and the Administration in the basic design of part D—the fact that certain classes of drugs (such as benzodiazepines) were not included, concerns over restricted formularies, and the complexity of the entire process. The most vexing and alarming issue was and is the transition of millions of Americans who had Medicaid with excellent pharmacy coverage to Medicare part D if they were dually eligible. We were concerned that this was a train barreling down a track toward a brick wall. But we were assured, time and again, that there would be a smooth transition with patients refilling their medications not falling through the cracks.

Then came January 1. Almost immediately we heard from psychiatrists that the seriously and persistently ill patients who had no problem obtaining essential medications through Medicaid were struggling to do so during the forced transition to Medicare part D. Frustrated pharmacists could not routinely process prescriptions to very disabled patients whose lives depended on them. The complexity of Medicare part D led to many patients not knowing which of the many private drug plans under part D they were enrolled in or if they were enrolled at all. Plans failed to flag those patients who qualified for low copayments, so many patients received high bills that led them to flee the pharmacy without their medications.

This is another national disgrace…another abandonment of the most poor and vulnerable of our patients…another shocking insight into the failure to care for the less fortunate…in some ways worse than our government’s response to Hurricane Katrina… because we saw this one coming for 2 years.

Some emergency measures to help ease this transition were instituted in states around the country. In my own city of Baltimore, the health department stepped up and began paying for medications during this transition process. But no city, state, town, or local health program can financially support these medications in the long run.

There is every reason to believe that the current crisis will get worse before it gets better. Millions of patients have not enrolled in Medicare part D, and many of the clinical consequences of abruptly discontinuing medications are not yet apparent. The inevitability of severe consequences led to a page 1 New York Times story in which I was quoted as saying, “Relapse, rehospitalization, and disruption of essential treatment are the severe consequences of this shaky transition.” On that day in January, it was the “quote of the day”—a very heady day for a New Yorker like me. Just to put it into context, the previous “quote of the day” was from Osama bin Laden. The day after, it was from Oprah.

I do not believe that modest fixes to Medicare part D will do the trick. This program allows plans to change formularies every month, permits pharmacies to move in and out of networks, and depends on the same referral systems for new enrollees that so miserably failed last year. Medicare part D as currently constructed guarantees a never-ending transition. The solution is for the federal government to establish a basic drug plan that works for those who fail in the private part D plans. This is a concept so obvious that it is easy to be pessimistic about the chance that it will ever be adopted.

But we must keep fighting. I will keep fighting.

We cannot fall for worthless promises. Remember the promises to the residents of New Orleans. First, there was an evacuation plan. Second, the residents were promised that they would be supported during their dislocation and would be relocated quickly. Third, they were promised that they would have adequate health care.

To advocate and to lead, we must say five simple words about the state of our health care system in the United States today: “The emperor has no clothes.”

It is time for a single-payer universal health reform in the United States today. Every American should have access to health care and mental health treatment—today. Every American should have that as a right, not a privilege—today.

We must tirelessly advocate this change. As the health care crisis extends and mushrooms, with more and more Americans without adequate coverage, the opportunity for such change will come at national, state, and local levels. And we must be there as advocates for our patients.

And now I hand over the reins to my outstanding colleague, Dr. Pedro Ruiz, whose life and work have been devoted to expanding access to care to all. We must keep fighting for our patients and our values. Psychiatry must advocate and lead the way to guarantee quality health care for every American. Thank you.