Presidential Address

It has been a great privilege this past year to serve as President of our American Psychiatric Association. I am grateful to you for this honor. Traveling the country, I have had the opportunity to meet many of you and witness first hand your hard work and devotion to APA’s mission. You are awesome in your energy and dedication in advocating for our patients and our profession. We can be justly proud of our organization and the devoted work of its members.

I want to thank my many colleagues who have lent their support and wise counsel during this past year. I express my appreciation especially to Leslie Horton, Bruce Spring, Todd Hutton, and Rod Burgoyne, who have kept the home fires burning during my frequent absences. Many members of the Board, the Assembly, the councils, and the components have contributed to the success of this year. No one could have worked harder, been more effective, or done more than our marvelous Medical Director, Jay Scully.

This has also been a joyous year for me in my family life. When I started as President-Elect I had enjoyed the support of two loving and creative daughters, Jessica and Suzanne. Two weddings later I now have two fine sons, William and David. Suzanne and David are currently in Thailand, a move associated with their work. Jessica and Will have joined with me here in New York to celebrate the 157th annual meeting of APA.

Psychiatry has a preeminent place in today’s scientific world. In these troubled times if we do not falter in our determination, we can look ahead to a bright future. Consider this: a superb medical scientific achievement for 2003, identified by the prestigious journal Science, lies in the ongoing research studying the complex interplay between genetic and environmental risk factors in the development of mental illness (1). This work ranks as second in all of science, just behind the cosmological research that has captured the essence of the universe.

Yes, there is great promise in the research developments that continue to unfold the mysteries of gene expression. Neuroimaging reveals the impact on the brain of mood, stress, and a plethora of human emotional reactions. Research paradigms that include affective tasks and the neurocircuitry of psychotherapy responses are all part of this broad picture.

Great strides are also being made in appreciating psychiatry as a central issue in all considerations of physical health and public health. Dr. David Satcher, the first Surgeon General to issue a report on mental illness, said it well: “Mental health is fundamental to health.… Mental disorders are real health conditions.… Stigma erodes confidence that mental disorders are valid, treatable health conditions. It leads people to avoid socializing, employing or working with, or renting to or living near persons who have a mental disorder.… Stigma deters the public from wanting to pay for care” (2). For these very reasons, erasing the stigma attached to mental illness has been a major commitment for APA’s advocacy program.

This past July I attended a conference in Cairo convened by the Mediterranean division of the World Health Organization and the World Psychiatric Association to discuss mental health and rehabilitation in Iraq. The purpose of the meeting was to assess and make recommendations for needed psychiatric services in Iraq, with recognition that mental health is a primary factor in any rehabilitation effort. Health personnel in Iraq face an acute shortage of human and medical resources, the consequence of years of prolonged conflict and violence worsened by Saddam Hussein’s diversion of oil-for-food funds into the building of huge, ostentatious palaces.

Yes, there are grave problems, including security, economic instability, power grid failures, malnutrition—especially of children—unsafe water, and a severely decimated health care delivery system. But the conference reconfirmed that mental health must be a priority public health issue in any rehabilitation effort.

During his recent visit to Iraq, Tommy Thompson, Secretary of Health and Human Services, was asked by CNN, “What will be the health priorities? You mentioned infant mortality.” Secretary Thompson responded, “Well, there’s no question that infant mortality has got to be number one. But there’s hardly any treatment whatsoever for mental illness.… We have to make sure that that is rebuilt.” It was heartening to hear that mental health was second only to infant mortality on the Secretary’s list of priorities. Mental health is no longer incorrectly viewed as a luxury; instead it is recognized as a foundation for a functional society.

As the burden of stigma for patients and their families begins to lift, the need for concealment diminishes. When people understand that mental illnesses are diagnosable and treatable, more and more are coming forward, acknowledging that psychiatric illness exists in their family. Members of Congress, preeminent citizens, and the men and women on the street are increasingly willing to testify to the importance of mental health treatment. Our advocacy message is working.

When the country reeled from the devastating attacks on New York and Washington on Sept. 11, 2001, our hearts went out to those who had lost loved ones. There were not many wounded, only many dead—but those enduring psychic trauma were countless. Our initial attention was naturally directed to the psychic trauma of those who had lost loved ones, associates, and friends and to those who had witnessed the events and survived the catastrophe. Many people with limited awareness of the emotional effects of trauma began to live with it on a daily basis. They learned that being brave, strong, and determined does not necessarily eliminate psychological vulnerability. Depression, anxiety, and posttraumatic stress syndrome took on a new reality.

Those who lost loved ones continue to suffer the effects of their loss. But they know and we know that even in the face of emotional pain, many can still work and achieve their goals. Here we are in New York, where you will visit ground zero, relive the tragic events, and grieve. Take heart at our resilience in overcoming the effects of this massive assault.

While research developments are uplifting and presage our bright future, and stigma is decreasing, we continue to be plagued by serious problems in delivery of adequate patient care. State funding of important delivery systems has fallen victim to budget deficits in almost every state. Witness the tragedy of the relentless erosion of resources available for public psychiatry and the care of the severely mentally ill. Hospital closures, reduced services in outpatient clinics and crowded emergency rooms, a resurgence in the numbers of homeless, and a flood of mentally ill in jails and prisons have resulted from serial budget cuts. Too often the body politic has been willing to abdicate responsibility for the health consequences of impoverishment and violence.

This past year the President’s Freedom Commission on Mental Health issued a report on its year-long study of the nation’s mental health system. The report described it as in a shambles. The system is fragmented and needs complete restructuring. How did we arrive here?

The degrading of the mental health system is strongly related to the deinstitutionalization that took place almost 30 years ago. Deinstitutionalization was a planned response to concerns that psychiatric patients, especially the severely mentally ill, were being “warehoused,” deprived of their civil rights, and denied the best available treatment. The primary rationale was to provide more effective care, not to save money. This was a well-meaning patient care advocacy plan that went terribly wrong.

What went wrong? The most important failures were that government did not mobilize the necessary community resources and that preexisting assets were underfunded.

Where did all the patients go?

While deinstitutionalization succeeded in decreasing hospital beds, an unforeseen consequence was the proportional increase in the mentally ill housed in the criminal justice system. Following deinstitutionalization the number of state hospital beds decreased from 339 per 100,000 population to fewer than 20. Meanwhile, the number of mentally ill persons in jail has increased geometrically. Untreated and without access to long-term care, many mentally ill patients ended up with symptoms and behavior that led to their incarceration.

The Los Angeles County jail is now considered to be the largest psychiatric hospital in the country. Approximately 2,500 of its inmates are being treated for mental disorders at any one time. Fortunately, in the late 1990s a grand jury investigation resulted in the upgrading of psychiatric care in the county jail, and it is now considered one of the best psychiatric hospitals in the country. Following my visits to the jail, I remain haunted by memories of the mentally ill inmates in the holding area: a young woman screaming at unseen visions, a middle-aged man cringing in terror from paranoid delusions, young and old, male and female visibly suffering in their mental distress. Is jail really our nation’s preferred institutional treatment of choice?

You can understand why I chose to spotlight the plight of these patients in our mental health system. In 2002 I established the Committee on Jails and Prisons. The members have been hard at work, in conjunction with the APA Division of Health Care Systems and Financing, gathering data, making presentations, and building the case for reversing this trend. In February a group of dedicated experts joined together at the APA central office to brainstorm strategies and future directions for reform. The meeting focused on the fiscal implications of the involvement of people with mental illness in the criminal justice system, and it brought together many leaders in the field.

Why were we focused on the fiscal implications? The reality is that money often drives the engines of change. Our major concerns are humanitarian. However, in this day and age of severe budget constraints, attention must be paid to fiscal projections in order to redirect resources to achieve the needed results. We now have a major advocacy tool in the recently developed APA resource document “Mental Illness and the Criminal Justice System: Redirecting Resources Toward Treatment, Not Containment.” Look for it on the APA web site (http://www.psych.org/edu/other_res/lib_archives/archives/200401.pdf).

These efforts are parallel to those used in the APA business initiative. In order to increase funding of mental health insurance we have taught employers, who are responsible for funding 50% of health care, that untreated depression costs them $24 billion per year in disability, reduced work productivity, and lost days at work. We are also making our case for change in the criminal justice system by using an economic model.

What other major advocacy items are on our agenda? We certainly need nondiscriminatory access to mental health care, universal access to care, and a continuous fight to protect confidentiality. What we do not need are score cards for doctors that identify their cost-efficiency and cost-effectiveness, a faux scientific plan underway by the insurance industry. Health care cannot be bartered, advertised, or measured by the same parameters that are used to measure outcome in a production line. What is medically responsible is providing the necessary time for a complete psychiatric evaluation as described in the APA guidelines.

We must strongly support an increase in the budget for the National Institute of Mental Health (NIMH). An estimated 20% of American youth have serious emotional or behavioral disorders. An estimated two-thirds of all such youth are not receiving the treatment they need. NIMH must be provided sufficient funding to address this blight on our society.

Clinical neuroscience must be supported. As the article in Science articulated (1), because of the advances in genetics, functional imaging, pharmacology, and neuropsychology, the field of mental health research is at the threshold of major breakthroughs in pathophysiology and etiology, leading to better treatments for some of our most disabling disorders.

None of these goals can be achieved without long-range budget planning. Surgeon General Satcher’s mental health report (2) observed that there is great difficulty in improving conditions without long-range planning. Too often, budgets are written and implemented by those in the political arena, who are uncertain whether they are long-term or short-term players. Those with fiscal and humane responsibilities must think long-term regardless of their future political prospects.

The planners must also stay centered on the importance of patient care and the critical value of psychotherapy. PET scans, MRIs, and gene studies are important. But when it comes to understanding who the person is who is experiencing the illness, what is stressful for one person and different for another, the personal interactions and therapeutic alliances are imperative. Emotions affect gene expression, and what is emotionally stressful for one person is not the same for another. There is no question now about whether the patients’ problems and strengths arise from nature or nurture. We have learned in the past decade that it is clearly both. Childhood experiences in concert with the genetic characteristics of an individual shape the adult person. Psychiatric education and funding must remain focused on these agendas.

Thus, we remain determined to fight to preserve our ability to spend time with patients. There is no other way to understand their constellation of symptoms in the context of their life histories, genetic background, family interactions, cultural influences, intrinsic intelligence, education, work histories, and past psychiatric interventions. This is not an extravagance; it is a diagnostic and therapeutic imperative.

The current generation of psychiatric residents is determined and excited about the field and filled with humanitarian visions for the future. I regularly hear it when I ask applicants for psychiatric residency, “How did you become interested in psychiatry?” The answers continue to be on the same compassionate continuum: “I want to make a difference in people’s lives. Mental illness is a painful disease, and I want to be able to help change a downward course into a positive future.” Hearing these optimistic, humane, deeply felt statements confirms the imperative that we work to secure a bright future—a legacy for those who will succeed us—in the delivery of mental health care.

No one can take away our pride in our profession or the ethics of being professional. Despite rough patches in the road, we will remain united and committed to our patients in need and to each other.

Again I want to express my appreciation for being granted the extraordinary opportunity to lead our Association.