Response to the Presidential Address

When I chose psychiatry during my last year of medical school, several of my professors tried to talk me out of it. “Why would you waste a perfectly good medical education?,” they said to me. Fortunately, I ignored them.

I chose psychiatry, like many of us here in this room—because I was fascinated by the brain and behavior, and I was drawn to the challenge of helping people least able to help themselves. I wanted to be part of what John F. Kennedy described and demanded for people who were mentally ill, like his sister Rosemary, in announcing the Community Mental Health Act, a time when “reliance on the cold mercy of custodial isolation will be supplanted by the open warmth of community concern and capability.” He spoke those words 50 years ago in 1963, just weeks before he was killed.

In 1976, when I began my residency training in psychiatry, the new era that he predicted while introducing the Community Mental Health Act finally seemed at hand, and I wanted to be part of it. That same year I saw a movie called Network. It was about a television news anchor who had reached the end of his rope. His ratings were bad, his wife had left him, and he had lost his passion for his work and life. Consequently, he had what we would call a psychotic break and declared that he would commit suicide on the show’s next broadcast. Faced with this crisis, Network executives cynically decided to exploit his mental illness. Instead of getting him psychiatric treatment, they put him back on the air hoping that his mad antics and the prospect of his suicide would increase ratings. Kind of reminds you of cable news programs today, doesn’t it?

They turn out to be right. He is a hit, and his ratings soar. A few nights later during a show, he departs from his script and rails against the declining conditions in our society. The government is broken; bankers are corrupt; crime is rampant; war can break out at any time; and the world is going to hell in a hand basket, he decries, while the viewing audience nod their heads in agreement. Then, abruptly, he stops his rant and exhorts the viewers to get up, open their windows, stick their heads out, and shout as loud as they can, “I’m mad as hell and I’m not going to take this anymore.” The scene ends with people all over the city shouting their frustration in a kind of mass group therapy.

Although I saw this movie 37 years ago, I have recently thought about that scene in Network because as I view what is happening to the field of psychiatry and all of mental health care, I feel “mad as hell,” and I don’t want to take it anymore. The truth be told, that is why I ran for APA president—because I felt mad and wanted to use all of the power and influence of the APA to speak up and stick up for our profession and our patients.

Throughout my career, I have been acutely sensitive to the stigma associated with mental illness, the disparities in mental health care, and the lack of respect toward psychiatry as a medical specialty. I suppose there might have been a time when psychiatry wasn’t as scientifically based as it should have been. But that was then, and now is now. For such attitudes and practices to persist in the 21st century is nothing short of discriminatory and prejudicial. But persist they do.

The Mental Health Parity bill passed in 2008 and has still not been implemented. The Great Recession of 2008 has gutted public mental health systems and encouraged private and voluntary hospitals to cut psychiatric services—witness Cedars Sinai Hospital in Los Angeles closing its psychiatry department virtually overnight. The pharmaceutical industry has all but abandoned the development of novel psychotropic drugs. And DSM-5 has become a lightning rod for self-styled critics and the antipsychiatry movement. Mental illness is alternatively feared too much, or not taken seriously enough, and psychiatry continues to be a punch-line for jokes.

You would think that along with being mad about these dismal and discouraging developments that I would be pessimistic about the future of psychiatry. On the contrary, I believe that the future of our profession is bright. The great American poet Theodore Roethke, who suffered from mental illness himself and died in 1963 just weeks before the signing of the Community Mental Health Act, once said, “In a dark time, the eye begins to see.” I believe what he was saying was that sometimes it is only when we are confronted with the greatest challenges that we muster the will and the means to overcome them. We now face such a test of our courage and capacity, and I firmly believe that we can and will prevail for our profession and our patients. Because this is our time. Let me repeat that: this is our time.

You may be wondering how I can be mad as hell at the present and optimistic about the future. But I am and can. Based on my 30 years as a clinician, researcher, and teacher, I can tell you that my outrage at the indignities we suffer is now outweighed by my confidence in the prospects for our future. Even our little dust-up with the NIMH last week over my good friend Tom Insel’s critical blog about the DSM actually gives me hope. And here’s why.

From a public health perspective, people and policy makers alike have finally started to realize that brain diseases and mental disorders are among the most important causes of disability in our society. Even the most conservative estimates indicate that at least a third of the population will suffer from a major mental disorder in their lifetime. And with medical progress reducing the morbidity and mortality associated with what have historically been viewed as the most burdensome illnesses to humanity—infectious disease, cardiovascular disease, and cancer—brain disorders are fast becoming the leading public health issue. In fact, the World Bank projects that depression will be the most disabling and costly disorder on the planet by 2020.

From an economic perspective, in order to contain the explosion in health care costs, it is essential to properly treat mental illness. There is no way around it. I recently heard a famous economist speaking about health care reform. After describing the unsustainable rate of increasing expenditures, he said that the “secret sauce” of health care reform was mental health care. I would add that the ingredients of that sauce, which we need to stop keeping a secret, are managing the so-called “SPMI population,” those with serious and persistent mental illness, effectively treating patients with comorbidities—medical, psychiatric, and substance use—and using behavioral approaches to control obesity, substance use, and stress.

And then there’s the amazing science. The scientific foundation of psychiatric medicine has grown by leaps and bounds in the last 50 years. The emergence of psychopharmacology, neuroimaging, molecular genetics, and biology and the disciplines of neuroscience and cognitive psychology have launched us into the mainstream of medicine and on a course for future growth and success. Though not everyone, including ourselves, is satisfied with the rate of our field’s progress, no one can argue with one simple fact: if you or a loved-one suffers from a mental illness, your ability to receive effective treatment, recover, and lead a productive life is better now than ever in human history. Moreover, we have every reason to believe that there will continue to be unprecedented scientific progress, which will enhance our clinical capacity and benefit our patients.

It is for these reasons that despite the lingering effects of stigma and inequity, I say that this is our time, and our time is within our professional lifetimes. However, it is not going to just come to us; we will have to reach out and take it. Each of us individually and collectively must fight for the rights of our patients and respect for our profession. The American Psychiatric Association has a key role to play in this process. The APA is our best weapon in the fight for respect and equality both for our patients and our profession. Therefore, I am calling on the APA to redouble its efforts in representing our profession, both inside the beltway and across the country at the grassroots level of the membership and district branches. This is the time for us to seize the moment, for mental illness to step out of the shadows, for mental health care to be made accessible and fairly reimbursed, and for psychiatry to take its rightful role in the field of medicine. In the coming year, and thereafter, the APA will forcefully participate in the health care reform debate, launch an initiative to educate the public and media about the nature of mental illness and the capability of psychiatric medicine, and more actively engage its members while enhancing the value of membership.

So to borrow another phrase from President Kennedy, “On this day, let the word go forth from this time and place,” to consumers and clinicians, to policy makers and providers, to advocates and stakeholders, and to all the members of the APA—that for the field of psychiatry and the patients that we serve, our time has come.

Thank you very much for your attention and for you.