Presidential Address

Psychiatry is a wonderful specialty that unlike others must face concerted and, at times, coordinated efforts of an antipsychiatry movement. Nada Stotland, in her remarks last year, eloquently articulated the challenges we face on a daily basis. And my friends, we will need to continue to work on this everyday for quite some time.

But psychiatrists should take pride in their often heroic efforts to take care of those with mental illness. Not only are we dedicated physicians, but we lobby hard on behalf of the disadvantaged. Witness the great 10-year plus struggle to enact parity for mental illnesses, to eliminate the discriminatory Medicare copay for psychiatric treatment, to cover under Medicare the prescription costs for benzodiazepines for the elderly, etc. This past year, we witnessed the passing of healthcare reform. For our patients, this means the elimination of the exclusion from coverage because of prior illness as well as universal coverage for all Americans and elimination of the doughnut in Medicare drug benefit coverage. We fought hard for all of these. We fight everyday for patients' and psychiatrists' rights with block grants, amicus briefs, and lobbying.

Our great American Psychiatric Foundation, the APF, headed by Paul Burke, supports a wonderful television series on PBS, Healthy Minds, sponsors programs to help teachers deal with emerging behavioral problems in students, and cosponsors “Give an Hour” to help returning veterans.

Psychiatrists should be proud of the great science that our academics are generating and the progress made in the neurosciences. Witness the many superb presentations at this Annual Meeting already by the best young and older minds in our field.

Our Annual Meeting this year is entitled “Pride and Promise: Toward a New Psychiatry,” and our IPS meeting was entitled “Pride and Practice: Bringing Innovation Into Our Treatment.”

We must be proud of the research of our American Psychiatric Institute for Research and Education (APIRE), led by Darrell Regier, in support of understanding our manpower needs, how we practice, and what services should be covered by third-party payers. These help each of us everyday. APIRE also provides research fellowship awards and special mentored research colloquia to young academics.

We should be proud of the great journals we publish: The American Journal of Psychiatry, Psychiatric Services, FOCUS, Psychiatric News, etc. We must take pride in the manuals, textbooks, and other books published by the leading psychiatric publisher in the world, American Psychiatric Publishing (or APPI), under Ron McMillen.

We should be proud of the guidelines we generate to help all specialists take care of patients with psychiatric disorders. We should be particularly proud of the DSM. We had a successful media launch preceding the Web posting of the proposed revisions for DSM-5, and this was handled professionally by Drs. Regier and Kupfer in collaboration with our public affairs staff and consultants. There were face-to-face meetings with several of the major newspapers and news services as well as conference calls with others and advocacy groups. Generally, the coverage in the press has been positive. Let us be proud here of several things: the seriousness of the APA's efforts to provide to the world a useful nomenclature that can unite us in our efforts to help those with mental illness and the expenditure of great amounts of time and money to develop the DSM, among others. The website generated 41 million hits and over 8,700 substantive comments—truly remarkable and a great example of transparency.

Now, there have been attacks on DSM-5. Some of these tell us much about psychiatry, stigma, our detractors' thinking, etc. Some critics understandably worry that we may be overdiagnosing individuals as having a psychiatric disorder. That is not the case, and we need to be as clear as possible in defining and emphasizing levels of impairment and distress before patients receive a diagnosis. Some of this concern, however, reflects stigmatization of the psychiatric patient; some, antipsychiatry sentiment; some, fear of the psychiatrist or the psychiatric patient.

There are many misperceptions we need to combat. First, psychiatric disorders are unfortunately common, independent of the number of psychiatrists. In fact, we have a major shortage of psychiatrists in this country. Psychiatrists do not need to look for business. Second, receiving a psychiatric diagnosis is still, unfortunately, stigmatizing to many.

One distinguished colleague argued against including binge eating disorder because these patients may not need to receive a psychiatric diagnosis. That is a sad argument: It would be okay to call binge eating a medical disorder but not a psychiatric one.

This issue is also seen in the attacks on mild neurocognitive impairment that came out of our Cognitive Disorder Work Group, led by Ronald Peterson, a distinguished neurologist at the Mayo Clinic. Are the same critics attacking the neurologists for their proposed mild cognitive impairment? No. This hypocrisy really reflects stigmatization.

Some of the attacks have been by English and history professors, and, my friends, this does present a problem we need to think about. Everyone feels emotions; everyone reads pop psychology articles or watches pop psychologists on TV; and many come to believe they are experts in psychiatry. Having been in the profession for over 40 years, I am only beginning to get a sense about the workings of the mind and the bases for psychopathology.

What can we do about it? It is nice in some sense to be in a specialty that many believe they can understand. But that is a false impression, and we contribute to it in many ways—let us remember, these professors are not attacking cardiology or hematology or, for heavens sake, otolaryngology. One major way, evident in the DSM, is our use of common language. Other medical specialties have disorders based on Latin and Greek terms that are complimented by lay terminology or descriptors. Take, for example, myocardial infarction and heart attack. When you look at psychiatry, you see disorders that are distinctly unmedical in sound in many ways—binge eating disorder, major depression, panic disorder, etc.—with no real parallel and more technical medical terminology. This may make disorders appear intelligible but also can make them seem trivial and less serious.

Binge eating can be seen as eating too much once in a while and not the out-of-control overeating that leads to morbid obesity. Wouldn't we be better off with a bulimia diagnosis than binge eating? Similarly, the proposed temper dysregulation disorder for children does not convey the out-of-control moods and behavior these children experience. We need to be more medical to be taken seriously. Still, we should be proud of what we have achieved in all the iterations of the DSM.

One of our major goals for this year has been to improve the Annual Meetings. We started with the Institute for Psychiatric Services by broadening the program beyond its traditional community bent and added special courses in psychopharmacology and other key areas. We had special lectures by a number of academic leaders in the field and a number of special workshops related to key areas of clinical practice, e.g., brain stimulation devices. Our attendance at the New York IPS set a record, and we look forward to a successful attendance and meeting in Boston.

We spent a great deal of time on improving the Annual Meeting. More of this meeting than in the past was planned prospectively. We enlisted experts in the field who served as consultants to the Scientific Program Committee and who helped evaluate outside submissions as well. Our Chairs did a great job, as did the whole committee. Deb Hales, our Associate Medical Director for Education, and Cathy Nash and their staffs have done a terrific job putting the meeting together.

This is a dynamite program, with the best people to teach all of us. It has lots on somatic and psychosocial treatments. It has a variety of sessions, including special lectures, workshops, symposia, master courses, etc. “FOCUS Live” and 13 DSM sessions should be enormously popular.

The program book is terrific, and as we promised you a year ago, we have organized the meeting into tracts based on topics and color-coded the book to make it easy for all of us to find sessions that are of interest.

We should be proud of the meeting and that we can provide a high-level meeting even without industry support. Finding optimal ways of interacting with industry-how, what, why, and when-have been fractious issues for medical societies. Last year, I gave you my views on the issue and pointed out the decision of the Board to phase out industry-supported CME. This year, we have virtually no such sessions. This is not only of our doing, but the negative attacks on industry have made them gun shy of supporting such programs. That is too bad, but that is where the field is heading.

Fortunately, as I have outlined for you, I think we can have a better and more comprehensive and less skewed meeting when we plan it ourselves. But we do need to have ways of interacting with industry if we are to stay current. There are a number of new drugs that have been recently released that many of us know little about, and that cannot be good for either us or our patients. But too often, the strident debate and attacks have obfuscated the negative impact of eliminating industry from our offices. I asked Syd Weissman of Northwestern University and a former member of the APA Board to chair a task force to help us work on ways to interact with industry. Their analysis led to their promulgating a set of resolutions to serve as a code of conduct for the APA for dealing with outside organizations and companies. This code was approved recently by the Board and can serve as the basis for developing new strategies of working with industry. I am indebted to Syd and his colleagues as well as to our staff—Paul Burke and Linda Bueno of the American Psychiatric Foundation—for their efforts. There are more details to be worked on over the summer, particularly regarding how a new board committee, chaired by our Secretary, will process and review disclosures.

My friends—in terms of revenues today, we are much smaller than we were 2 years ago. Our four corporations now have total annual revenues of around $55 million, down from $65 million a few years ago. This is due largely to the loss of ad revenues in our journals and has been experienced by other specialty societies as well. The Board, working with Jay Scully and Terri Swetnam, our CFO, did yeoman work on dealing with a sudden decrease in revenues of $8 million during the past year and reduced expenses dramatically. Remember in 2008, President Stotland led an effort to streamline our Governance to make us more efficient, and we had already cut costs in the 2009 budget. Still, in November of last year, we were faced with a $1 million shortfall for the year, and the Board voted to use reserves to cover it. Fortunately, a number of things came through for us, particularly the stock market rally meant we were not obligated to fund a shortfall in the retirement plans and we had lower publishing costs due to a lack of advertising—the silver lining to the cloud. In the end, we wound up with a surplus of $1.2 million for the C-6 core APA corporation and $2.9 million overall. A great turn around.

Now, before we go out and spend, that was 2009. This year, 2010, is not running ahead of budget, and times are still iffy. Many of the cuts we approved in 2009 were for 2010, and we still are at the margin of break-even. However, our reserves are strong, and we have excellent leadership at all levels to help us through the storm. We are making it, but it will take great care to ensure continued financial health.

A major cost saving and efficiency measure that we have been working on is the reorganization of the four corporations into two. We plan to have the so-called C-6 corporation, the APA largely as it is today, and just one C-3 foundation. The publishing will move from the C-3 to the C-6. This will be more efficient in many ways. It will require fewer audits and tax filings. It will better ally the funds flow with the member-oriented missions of the APA and allow for focused activities in the Foundation. We will all gain in the end. The three Foundation Chairs, Drs. Barchas, Roberts, and Harding, have worked with their boards and with the C-6 APA Board to affect this, and we are indebted to them for their efforts. We expect to finalize the reorganization shortly and will outline the details to all of you over the next few weeks.

One undertaking to improve member benefits and the APA itself is through our endorsing an exclusive insurance partner for providing liability or malpractice coverage. We are in the process of endorsing a new carrier, APA Partners, Inc. They have been the carrier for the American Academy of Child and Adolescent Psychiatry. This will be beneficial to all of you, to the APA overall, and the district branches. It will provide members a choice, and competition can only help. Members will be free to stay with their current provider or switch at no risk to a new APA-endorsed insurance partner. We will be releasing details soon.

As you have heard, the APA does so many great things for the members and the field, but we can do more. We had a recent meeting with Jay Scully and the leaders of the corporations to think about where we are heading and came up with a number of intriguing possibilities. The APA should be your place for education, maintenance of skills, acquisition of new techniques, and preparation for recertification. These can be coordinated via the Annual Meeting and IPS but also through the journals and online programs. Combine this with our members-in-training efforts and greater help with dealing with setting up a practice or ending one, the APA can be an even greater help to all of us throughout our professional lives. Some of these elements are already in place. We already have a practice network to help answer some questions for the field. But that could be expanded to better answer many lingering questions. We could be doing relatively quickly genetic studies of many disorders. We could be assessing outcomes and doing effectiveness studies. Why not ennoble our work by providing our selves, and the rest of the world, the answers to how best to diagnose and treat our patients? Think of the contributions each of us could make. Then, we will only be prouder of our work as psychiatrists and as members of the oldest medical specialty society in the country: the American Psychiatric Association.

My colleagues, the future is bright for our specialty. I am confident that President-Elect Bernstein, a noted educator and experienced APA officer, will provide great leadership for the upcoming year, and John Oldham will do so for the following one.

My friends, it has been an honor to serve you as your President, and I look forward to future collaborations. I wish all of you much success. Again, my thanks, and have a great meeting.