Presidential Address

Welcome to the 162nd meeting of the American Psychiatric Association. This meeting is a celebration of psychiatry. In the midst of a worldwide economic and influenza crisis, psychiatrists and others have come from over 100 countries to learn and to be refreshed and re-inspired. Before I begin, I would like to thank my husband of 46 years, Harold Stotland, our four daughters, and the mentors—many of them from the APA—who enabled me to serve as President of our Association.

The APA is the voice of psychiatry in the United States. During the past year, I have testified on your behalf in Congress, the Food and Drug Administration, and the Institute of Medicine. I have been interviewed by reporters nearly every day. I have visited APA district branches from Seattle to Vermont and Texas to Minnesota. On behalf of the APA, I have been received with respect at meetings in China, Czechoslovakia, England, France, Italy, and India. As the richest country in the world, we need to make the contributions that entitle us to that respect. Currently, we are working with the World Psychiatric Association to bring psychiatric information to developing countries via the World Wide Web. Many of the dedicated psychiatrists practicing in the United States have brought their wisdom and expertise from other countries. I now ask our international medical graduates to stand to receive our thanks. We have much to celebrate. Our field is blossoming with new science. Most Americans recognize that psychiatric disorders are real and that treatments work. Our parity law and the elimination of the discriminatory Medicare copay are powerful statements about the legitimacy of psychiatry and the social costs of untreated psychiatric illnesses. Our Association has a balanced budget, a growing membership, and an impressive array of activities to support us and our patients.

We must learn to celebrate ourselves. Our skills are unique and precious: medical and psychological knowledge, communication and compassion—all in the service of healing some of the most devastating diseases that afflict humankind. We are brain doctors and doctors of emotion and cognition. We chose to pursue medical and mental health training. We dissected cadavers. We attended operations, births, and deaths. We spent long nights at the bedside. When we could not save our patients, we comforted their families. Let’s stop talking about “mental health” and “physical health,” “psychiatric care” and “medical care.” There is no health without mental health. Despite centuries of these artificial distinctions, our language reveals that everyone knows that. When people are alarmed, they say, “I’m going to have a heart attack.” When they are confused, they say, “I can’t see straight.” When they are struggling, they say they are “trying to hold body and soul together.”

Psychiatry is the medical discipline that compasses the body and the soul. We understand our patients’ physiology, and we share our patients’ burdens of guilt, grief, and anxiety. We recognize that we must help our patients call on those sources of strength and meaning that not only alleviate psychiatric symptoms, but make life worth living.

Health is not just a physiologic state; it is a function of social circumstances. A vision of medicine isolated from society is tunnel vision. More advances in life expectancy have come from clean water than from antibiotics that treat water-borne infections. Poverty, discrimination, and abuse are toxic. We have an obligation to use our medical expertise and our position in society to create social conditions that promote health. We can do more to improve the health of disadvantaged populations by providing safe communities, good jobs, and education than by treating the people who get sick because they are uneducated, unemployed, and unprotected. That is why we support the rights of people who are gay to marry and raise children. That is why we take the position that each woman is the best judge of whether to have an abortion or a baby. That is why we oppose participation in the interrogation of detainees. And that is why I told a reporter from Parade magazine that putting children in the adult penal system is “just plain wrong.”

The failure to provide care for returning members of the military is also wrong. No one should have to face death on the battlefield only to come home to a lifetime of nightmares. No child should suffer the absence of a parent only to have that parent come back numb, irritable, and withdrawn. Therefore, we are working with the psychiatric leadership of the armed forces to plan educational activities to help military officers recognize mental illnesses and create conditions that encourage members of the military to seek care when they need it. We will also educate our members about the particular etiologies, characteristics, and treatments of psychiatric disorders affecting active and returning members of the military.

The failure of the richest country in the world to provide medical care to everyone is wrong. Job loss, foreclosures, dislocation, and precipitous declines in the values of investments have magnified existing healthcare problems and disparities. The high costs of our fragmented system are sapping the strength of our businesses. We have educated ourselves about healthcare reform options, and we have polled our members. Of those who replied, most, but not all, preferred a single-payer system. Shall we stay out of the fray for fear of offending our minority or speak up on behalf of our majority? Let your leadership know what you think.

We have to decide how to fund medical research and education as well. Psychotherapy is the heart of psychiatry; it is essential that we maintain psychotherapy research, training, and practice. But some of our patients need somatic treatments as well. The only medications I had to offer severely depressed patients during my residency were potentially lethal. Newer medications may be better, but they are not good enough. We want pharmaceutical companies to develop better products, but we also recognize that their shareholders demand that they return a profit, in the form of increased sales, when they support education and research. That raises legitimate concerns about their influence on our science, our training, and our clinical care. The APA has been a leader in addressing conflicts of interest. We require members in elected and appointed APA positions to disclose their pharmaceutical and other relevant relationships. The APA Board of Trustees appointed a working group to address the APA’s relationships with the pharmaceutical industry before we were asked about them by a United States Senator. When the report for the Senator was completed, we simultaneously gave a copy to the New York Times . The decision to phase out industry-supported symposia and meals at our meetings has won us praise from the media and the public. Each of us can pay for our own continuing medical education. We must also remember that disclosures of pharmaceutical relationships are not sufficient to ensure scientific objectivity. We have to scrutinize research data and make independent judgments about whether the conclusions are warranted.

Another APA working group has proposed guidelines for the relationships between individual psychiatrists and industry. Our guiding principle is the welfare of our patients. Their welfare depends not only on the treatment we provide, but also on their trust that our recommendations are informed by unbiased scientific evidence. We are equally scrupulous as we develop the fifth edition of our diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders. Effective care depends on accurate diagnosis. Therefore, every medical specialty develops, promulgates, and utilizes diagnostic criteria. The APA demanded an unprecedented level of disclosure and divestiture from the broad array of clinicians, researchers, and epidemiologists working on DSM-V. They are not simply revamping the current edition; they are considering all the possible structures for psychiatric diagnoses. They have published over 100 papers and participated in many national and international conferences; they will be speaking and listening at these meetings. We have made another unprecedented decision: to post their progress reports on a dedicated public website, a website that also allows for public comment. DSM-V drafts will be widely distributed and discussed in order to encourage healthy debate. We have spared no expense, time, or trouble to make DSM-V the best possible tool for clinicians, educators, and researchers and policy makers. Our enemies will try to use doubts about the DSM as a weapon to undermine our profession. After the debates, after the decisions, we will need to come together and make peace with DSM-V.

We have enemies. No other medical specialty has an entire organization dedicated to its destruction. As I have traveled the world, I have been reminded that the Scientologists speak many languages. In Prague, they claimed that psychiatrists are “agents of death;” in Florence, that psychiatry is “the journey from which you never return.” Our enemies use allegations about conflicts of interest and the DSM process as weapons to discredit psychiatry.

I would like to introduce several colleagues who represent the genuine heart of psychiatry and the APA.

Women immigrants from Asia who are victims of domestic violence need culturally informed services. Our colleague Surinder Nand helped to found a center in Chicago for these women.

When Hurricane Katrina left tens of thousands of residents of New Orleans without medical care, our colleague Anna Holmgren left her home and practice and spent weeks providing that care.

Generations of disadvantaged children are growing up in a cycle of violence. Our colleague Carl Bell has developed a school intervention that breaks that cycle.

In Hawaii, an influential psychologist, lawyer, and congressional staffer has spent 20 years pushing psychologist prescribing legislation. Psychologists are not allowed to prescribe medication in Hawaii because Jeff Akaka has spent countless hours in the halls of the state legislature.

Wars and natural disasters have traumatized thousands of children in distant lands. Arshad Husain flies into the war zone to teach their teachers and community leaders how to minimize the psychic scars left by those horrific experiences.

When reporters want information about a controversial issue concerning sexual orientation, they call Jack Drescher for a cogent explanation of the facts.

Marshall Forstein’s APA project has trained hundreds of us to care for patients with HIV/AIDS.

Francine Cournos has devoted her career to the disenfranchised: the homeless and the frightened immigrants unfamiliar with the American system.

Every psychiatrist is a hero. You compete for funding for your research and time to teach medical students the psychiatry they will need to be good doctors. You give talks at your schools and places of worship. You testify before legislative committees. You wrangle with hospital administrators who want to replace your inpatient units with more lucrative sports medicine services, and you protest when state politicians want to slash public services. You battle managed care functionaries to fund the care your patients need, and, when they refuse, you treat your patients anyway. You come home from a hard day’s work, put your children to bed, and spend the evening reading our journals so that you can do your job better the next day.

Nevertheless, psychiatry is stigmatized. People with psychiatric illnesses do not receive the understanding that lightens the burden of other diseases. Other people do not understand that the black hole of depression or a plague of “voices” swallows up a vital person, leaving behind only a suffering shell. Friends and relatives do not send flowers when our patients are in the hospital. People tell them that they are not trying hard enough, praying hard enough, or that treatment will turn them into zombies. Stigma feeds the unrelenting criticism of psychiatry. Criticism can be healthy. We all have much to learn. That is the reason we have come to this meeting. But our critics fail-or refuse-to recognize that their criticisms apply to the entire field of medicine. Psychiatry has the same strengths and weaknesses as our sister specialties. Our critics say that we pathologize normal traits, like shyness, and bad habits, like gambling, and the unhappiness that everyone experiences in the normal course of life. The spectrum of psychiatric signs and symptoms is like that of other medical disciplines. There is no magic dividing line between normal blood pressure and hypertension, a common cold and a serious upper respiratory infection, common lower back pain and spinal arthritis. We spend billions of dollars on millions of doctor visits for those spectrum complaints.

Our critics refuse to believe that psychiatric illnesses are serious, potentially fatal, in children as well as adults. That did not help the 10-year-old boy who recently hung himself in the school bathroom.

Our critics say that conflicts of interest bias the development and prescription of psychotropic medications. Precisely the same questions apply to the medications used in every other branch of medicine.

Our critics say that psychiatric treatments are not “scientific.” An article in the February 25, 2009 Journal of the American Medical Association stated, “Just 11% of more than 2,700 recommendations approved by cardiologists for treating heart patients are supported by high-quality scientific testing.” Our critics paint a gruesome picture of electroconvulsive therapy. Oncologists treat cancer by burning with radiation, poisoning with chemotherapy, and cutting their patients’ bodies open and sewing, stapling, or gluing them back together: surgery.

Our critics say that psychiatric disorders aren’t real because we have not discovered specific etiologies for them. Diabetes is “caused” by the failure of the pancreas to produce insulin. But that failure is caused by an autoimmune process whose cause is unknown. Just like diabetes, schizophrenia is “caused” by genetics, circumstances, and behaviors.

Our critics say that we don’t cure psychiatric conditions. Where are the cures for congestive heart failure, diabetes, and arthritis?

A few years ago, we made an educational video. A woman who had been successfully treated for schizophrenia described her date with a fellow poetry lover. When she came home, she had an unfamiliar and increasingly uncomfortable feeling. Finally she called her counselor, who told her, “What you are feeling is joy.” The core value of medicine does not lie in keeping people alive. Everybody dies. The core value of medicine lies in the relief of suffering and the restoration of function. That is what we do. That is who we are. Our joy comes from helping suffering people to regain their joy. We need not, we must not, and we will not tolerate unjust, uninformed attacks that perpetuate stigma and undermine our patients’ trust.

Now the APA is preparing for changing times. We will have ever clearer images demonstrating the causes and effects of psychiatric disorders in the brain. Pharmacogenetics will become part of everyday practice. We will facilitate the newly discovered ability of the brain to repair itself. We will understand how serotonin affects both the mood and the platelets. We will identify psychiatric disorders at the early stages, before they disrupt people’s cognitive and emotional development. We will teach parents and teachers to help children develop thinking and behavioral skills that enable them to relate positively to others and avoid the clashes and miseries that can trigger psychiatric illnesses.

We will use new technologies, including electronic medical records, with all their advantages and disadvantages. They will enable the primary care and emergency physicians who treat our patients to know what we have prescribed. They will keep medication regimens and laboratory results up-to-date and generate “prompts” for us and our patients. We recognize the potential risks of electronic medical records. A list of check-off boxes cannot capture essential elements of the interaction between a patient and a doctor; the record must include narrative. Privacy is a concern for all medical care; it is as important for genetic profiles and the diagnosis of sexually transmitted diseases as for psychiatric care. It is useless to rail against electronic medical records; instead, we are participating in the discussions where those records are being designed.

We are also participating in the debates about “comparative effectiveness” and “pay for performance.” These concepts are popular with the public and our national government, but they pose dangers as well. We need head-to-head, not parallel, treatment trials to compare effectiveness. We need data about real-life patients of both genders, all ages, and all ethnicities, with common comorbidities, rather than relatively healthy and homogeneous study populations. Counting the numbers of diagnostic tests and asking patients whether they are happy with their care are interesting, but we need to identify the elements of performance that matter to our patients’ well-being. We need health data before we make health policy.

We will replace our nation’s fragmented, expensive, and wasteful nonsystem. It puts barriers between patients and the care they need. It forces us to spend our time fighting a bureaucracy instead of taking care of our patients, our students, and our research. It has put too many of our patients in prison and on the streets. It has let them die 25 years earlier than they should. We will develop a system that provides one-stop, coordinated, consistent, healthcare by a team that includes us and pays us fairly and promptly.

We have prepared for the future with an efficient and effective APA. The new central structure developed by our incoming president, Alan Schatzberg, is streamlined and nimble. It will replace duplication of effort with collaboration with our subspecialty organizations. It will allow any interested APA members to participate in our discussions.

So I leave you with a strong and stable Association, a rich tradition, and an exciting future. Thank you for your attention, your praise, and your criticism over the past year. Thank you for allowing me the extraordinary honor and privilege of serving as the President of the American Psychiatric Association. Most of all, thank you for living the cherished values that make us who we are.