Presidential Address: Our Voice in Action: Advancing Science, Care, and Our Profession

President-Elect, Dr. Stotland; Speaker, Mr. Akaka; members of the Board and Assembly; past presidents; distinguished guests; colleagues; family; and friends. It is my honor and pleasure to welcome you to Washington, D.C., my hometown, as well as to the 161st annual meeting. It has been a privilege to serve you and our Association this year. I have been fortunate to work with such a wonderful team of leaders, particularly our energetic and active Immediate Past President, mi hermano, Pedro Ruiz; our creative and focused President-Elect, Nada Stotland; and our Speaker, Jeff Akaka, who defines, lives, and breathes advocacy.

My special thanks to my dear colleague and other professional brother, Paul Fink, for the warm introduction. Paul was a leader and mentor to me in the mid-seventies, when I began to work for APA, and he was the wonderful and productive chair of our then-Council on Medical Education and Career Development. It seems as if it was yesterday that he and I duplicated materials in the basement of the very old (18th and R Streets) APA building as we worked to strengthen APA’s leadership in education and advocacy. I had the privilege of introducing him almost two decades ago at the completion of his presidential term. His leadership as President and his advocacy working to eliminate stigma, as well as his major contributions to prevention of violence and understanding its impact on individuals and families, continue to be models for me and I hope I can follow his example of a highly productive past presidency.

Last year in San Diego, I was honored by the presence of our son, David, who is completing training as a pediatric anesthesiologist, his beloved wife, Chiara, and our three wonderful grandchildren—my special loves—Helena, Andrea, and Alessandro. This year, school and schedule conflicts, as well as distance, have prevented their attendance (although one granddaughter e-mailed me that she is looking forward to the parties in San Francisco next year). Additionally, our son Mark’s untiring efforts to protect and rejuvenate our environment have had to take precedence over his travel this weekend. I miss sharing the excitement and pleasure of this meeting with them.

I am delighted to recognize my supportive, generous, and loving husband, Max, who has been the best of companions and an enthusiastic and vital partner in all my endeavors for nearly half a century.

This wonderful meeting program has been chaired by David Baron, whom I have known and admired for many years. The program reflects David’s expertise in adult education and science, as well as the diligence of the Scientific Program Committee in developing outstanding sessions in a multitude of learning formats designed to help psychiatrists help patients. I also want to express special gratitude to Dr. Thomas Insel, Director of NIMH, and his staff, especially Dr. Akil, for terrific leadership in creating the NIMH track, translating scientific insights into clinical care, and ensuring the participation of marvelous scientists throughout the program.

I appreciate the support and assistance of so many colleagues and friends, particularly Mel Sabshin, who fostered my love of APA, and Daniel X. Freedman and George Tarjan, who were exceptional mentors; time does not permit my naming them all. I especially want to recognize three psychiatrists whose back-up availability for me and my patients has allowed me to participate in APA activities so fully: Drs. Brian Doyle and Fred Hilkert and my on-call partner, Dr. Susan Lazar, who has been a wise, thoughtful, and caring consultant.

I have been touched and gratified this year by so many members’ response to my theme and my passion—putting their voice into action for our profession and our patients. This is not an easy task, but it has paid off. Their/your willingness to put the energy into advocacy brings positive results for our profession and our patients.

The Washington Post recently published the column “What Does a President Do?” Although the Post was referring to the President of the United States, the question deserves a response here. Since last year’s annual meeting, I have spent hours away from the office on APA business, attending meetings and visiting local, as well as national, psychiatric groups. This tally does not include the average of 150 e-mails daily (the highest number in one day was 280), the telephone and conference calls, or the reading, writing, and preparation needed. So it is a very full-time job.

At the same time, the position is heavily symbolic, since the President alone does not set policy or priorities or determine their execution. Our elected Board of Trustees establishes the policies and priorities which are implemented by our experienced and dedicated staff, for whom caring for APA and its members is a full-time day (and evening and weekend) job. In that vein, much credit goes to Jay Scully, the effective conductor of this symphony orchestra, who leads the staff in fulfilling the Association’s mission with energy, on key, in time, and with minimal cacophony.

I am grateful for so much staff assistance, especially for those staff who were on my “speed dial,” whom I contacted frequently and from whom I always received a thoughtful, timely, and helpful response.

It has been a tradition for the retiring President to refer to his or her theme and to enumerate the many accomplishments of the presidential term. Rather than presenting an extensive list, I would like to highlight some areas and activities that reflect important aspects of our current advocacy and future directions. They include: organizational development, public information, legislation, diagnosis and treatment, and alliances.

In keeping with my considerable interest in administration and organizational development, I began my term with a focus on strengthening APA’s organizational function. As Treasurer, I had worked with the Finance and Budget Committee and staff to ensure a strong, open, and transparent financial base to plan for the future and build reserves. As President, I wanted to give attention not only to policies and priorities but to how we could be the most effective organization possible. At our retreat last summer, the Board, assisted by staff, reviewed the book Seven Measures of Success: What Remarkable Organizations Do That Others Do Not . This small volume is the result of a study of organizations (including the American College of Cardiology, American Dental Association, and American Association of Retired Persons) which identified measures (approaches and behaviors) separating the “good” from the “great” or remarkable organizations. These seven measures were grouped into three categories and seven subcategories and are worth mentioning. The first is commitment to purpose, which can be demonstrated through a customer service culture and an alignment of products and services with the mission. Second, commitment to analysis and feedback demands that data drive strategies and planning and that the CEO becomes a broker of ideas, facilitating visionary thinking throughout the association. Finally, a commitment to action demands organizational adaptability and building alliances.

It is clear that members and mission are the heart of successful associations. We also recognized APA’s dual focus—we are a membership organization for all psychiatrists, regardless of their background or subspecialty interest—promoting science, education, ethics, and professionalism. But APA is also concerned with patients and their need for access to appropriate care.

We agreed that we needed to have greater information underlying our decisions as to directions and priorities. In that regard, we have begun a process of member surveys and focus groups to ascertain member needs and expectations. We also are tracking the wider environment to determine what is on the horizon and what we should do to incorporate that information into our strategic and operational planning. Thus, we are invested in continued cycles of gathering, analyzing, and making changes because of what was learned. Such knowledge goes beyond personal vision or interests and is vital for our long-range relevance to our profession and our community.

Last year, I recalled the words of Charles Dickens in describing the environment of our profession: “the best of times, the worst of times.” This statement certainly holds in considering public understanding of psychiatry. Although people have become more knowledgeable about the reality of psychiatric disorders and the effectiveness of our treatments, as well as their economic benefit, there still are many who are uninformed about the remarkable growth of our science, who view illness as weakness of will, who fear patients as potentially violent, or who ascribe to other outmoded concepts.

Eighteen months ago, APA initiated an expansion of our public affairs and communication efforts. Our work with patient and advocacy groups has helped enrich our scientific understanding of mental illness, adding a real practical look at the impact of illness and of treatment to policy makers, the business community, and the public at large. It was, of course, gratifying to collect my theoretical 15 minutes of fame in 30-second sound bites and a personal thrill to see my letter to the editor published in The New York Times, but even more satisfying was the large number of letters by many psychiatrists and op-eds that have been printed, not just in the Times, but throughout the media world. APA is set up to help psychiatrists and district branches improve these communication skills (invite us and we will come).

I began my presidency in the near aftermath of the Virginia Tech tragedy—one that affected all Americans but had even more painful connections in the Washington metropolitan area, which was home to many of its students. Although there was much opportunity for media overreaction and blaming, I was struck and consoled by the many media reports and politicians’ comments that demonstrated a greater understanding of psychiatric issues: the importance of psychiatric treatment (and its role in preventing violence), the complex issues of confidentiality, culture, and stigma, and the importance of adequate funding for a public mental health system, as well as for care of college students away from their home environment. Our own committee on college student mental health took on this challenge and has begun a number of important national efforts and alliances to educate the public and improve mental health care (including prevention and early intervention) available for college students. Our ongoing response preparedness is coordinated through our Office of Communication and Public Affairs and allows APA to provide assistance and support to district branches when needed in response to other tragic events. While our focus has been on helping victims and their families and dear ones, we have also been able to educate and increase public understanding about psychiatric issues in general.

Last year, I spoke of the need for care for returning military and their families and that this issue could be a model for public education and understanding of mental disorders. Since then, multiple studies have documented the frequency and intensity of the signature injuries of this military conflict: traumatic brain injuries and posttraumatic stress disorder, in addition to depression and anxiety disorders. The unique nature of the combat zone, with “24/7” danger for all personnel (also described as “360/365” for its constant, every-day nature), has produced an even more stressful combat environment and we are aware of the impact of deployments (and especially multiple deployments), not only on military personnel (and their repeated exposure to trauma), but also on families—spouses and children and the ripple effect on communities. We have made the mental health needs of returning military and their families a priority, devoting our “May is Mental Health Month” focus to this topic. APA commissioned a survey of military members and their spouses to examine these perceived needs and presented the results in collaboration with the National Alliance on Mental Illness (NAMI) and the National Military Family Association at a press conference recently. I was struck by the extent of stigma related to seeking mental health care still perceived by the respondents, as well as the voiced need for more information about warning signs, resources, and treatment. Media response has been outstanding. From CNN to The Wall Street Journal, reporters highlighted the expressed concerns about access to care, the impact of stigma, and the perception that psychiatric treatment can harm career advancement, as well as issues affecting reservists and guard members, and recognized with praise APA’s efforts in advocacy and providing information through our public information web site, www.healthyminds.org, as well as our role in providing care. We were gratified at the announcement by Defense Secretary Gates that same day amending the discriminatory language in the U.S. government security/clearance application and by his positive statement about mental health care.

The VA system is flooded with patients who need mental health care, as is the military, and both systems are in need of more mental health professionals, especially psychiatrists (the shortage exists even on military bases, as so many of the mental health professionals have been deployed to be resources in theater). I have encouraged residents finishing training to consider spending a year or more as civilian employees of the Department of Defense, working with active-duty military or in the VA system. Both offer marvelous opportunities to learn as well as do good. Perhaps we can promote a concept of loan forgiveness for those who choose to work in these most needy settings, just as exists in other physician shortage areas.

APA has joined other groups in promoting “Give an Hour,” a private, not-for-profit mental health organization that encourages mental health professionals to provide one hour’s care a week to returning military and/or their families and that has encouraged APA members to add this to their list of community volunteer efforts. I have joined and will participate actively upon the end of my presidential term.

We also have surveyed APA members about their experiences with TRICARE, the military insurance program for active-duty military and dependents. Psychiatrists voiced concerns about the administrative hurdles, which have prevented many of our members from participating. Here, too, we can put APA’s voice into action, working with leaders in the military health system to find ways to make TRICARE more administratively user-friendly. Meanwhile, I am putting my own voice into action and signing up to be a TRICARE provider. I also am keeping a diary of the process and will report back on my experiences.

In the legislative arena, APA has dealt with Congressional discussions about parity with a mature sensitivity to the political process, understanding the importance of the “win-win” (and living to fight or negotiate another day). While the provisions of the initial Senate parity legislation left much to be desired, especially in those states where parity was already enacted, we could not walk away from the collaborative efforts of the business community and the advocacy groups on parity—whatever the limitations—after years of effort without possibly losing credibility. In fact, we continued publicly to support the Senate bill, while constantly working to improve it, and also supported the House proposal, with its stronger provisions that were more patient-friendly. Now, some 9 months later, we are seeing a potential plan for compromise and eventual passage of a stronger bill. Of course, we must view whatever the final product is as a beginning, and a floor, not a ceiling.

Our work as a member of a coalition of organizations representing professionals and advocates to achieve elimination of the discriminatory co-payment for psychiatric care under Medicare is another example of successful alliance building. This Medicare provision, which implies that psychiatric services are a choice, not a necessity, is not only morally costly and negatively affecting health and quality of life, but also financially costly, with the unintended consequence of pushing many of the elderly into more expensive inpatient treatment. In keeping with our emphasis on disclosure and transparency, I do want to note that as a member of the Medicare generation, these changes would affect me!

These are two examples of patient advocacy in the legislative arena that not only are the right thing to do but that will engender cost offsets or minimal cost to remedy—pennies for parity—benefiting our patients and indirectly negating the myths and stereotypes that have been rampant about psychiatric care. Of course, there are others: privacy, confidentiality, and the electronic health record and the sustained growth rate Medicare “fix,” to name a few.

Our successes in government affairs could not have happened without a focused and disciplined partnership of members and staff working together to address ambiguities and conflicts. Also noteworthy has been the immense energy and input of our younger members—residents and early career psychiatrists. They have been active participants in Advocacy Day and related advocacy activities, as well as leaders in contributions to APA’s Political Action Committee. At times, they have put their elders to shame in the amount and intensity of their efforts. They clearly realize that their successful advocacy will determine the shape of their professional lives for years to come.

Accuracy and consistency of diagnosis is key to clinical practice and appropriate treatment depends on the correct diagnosis. Preparation of the fifth edition of APA’s Diagnostic and Statistical Manual is well under way under the superb leadership of David Kupfer, with an anticipated completion date of 2012. This complex process involves hundreds of leaders in psychiatric diagnosis, including world-renowned scientific researchers and clinicians with expertise in neuroscience, biology, genetics, statistics, epidemiology, public health, pediatrics, endocrinology, nursing, and social work.

DSM is the resource for psychiatric diagnosis used throughout the world. As such, it must be clearly science-based and without bias. Recognizing the concerns of many about undue influence of industry on medical care, APA set stringent principles to be followed for contributors to the process, including extensive disclosure of potentially competing interests and divestiture of industry support. These standards represent a new level of openness, going beyond previously published rules in other medical specialties or those set for consultants to government agencies. While some members have voiced concerns that any relationship with industry is suspect, others have seen APA’s standards as too strict. In recognition of the importance of transparency, disclosures of workgroup and task force members have been posted on the DSM web site. I want to express particular gratitude to those who have made personal sacrifices in addition to volunteering their time and expertise to ensure that we produce the very best scientifically based, clinically useful diagnostic system.

We have focused on strategic and practical alliances, working with colleagues to further our vision and joint goals. You have heard of some of our activities with NAMI and Mental Health America, both important advocacy groups. Our relationship with the American Medical Association (AMA) and the house of medicine, particularly through our section council, also has been outstanding, addressing issues of mutual concern related to scope of practice, standards of care, education, professionalism and ethics, science, and public health. We have also worked with individual medical specialties, as we did this year in developing a report in concert with the American College of Obstetricians and Gynecologists on the management of depression during pregnancy.

Internal alliances with subspecialties are also important; examples are the session sponsored by the American Academy of Child and Adolescent Psychiatry on treatment of children, the contributions of the American Association of Chairmen of Departments of Psychiatry to the academic consortium and its advocacy for funding of psychiatric research, and the pilot joint membership initiative with geriatric psychiatrists.

We have come a long way in understanding the important links between mind, brain, and body and the relation of psychiatric disorders to general health. One of my initiatives, which I anticipate continuing after my presidency, involves the link between depression and heart disease—the number one killer in the United States. We know that persons with major depression are far more likely to die after a myocardial infarction than patients with similar cardiac status who are not depressed and that treating depression has a positive impact on these findings. But there is increasing evidence that depression is an independent risk factor for cardiovascular disease, as important as tobacco use. Time precludes my listing extensive data. Suffice it to say that research findings document many physical dysfunctions in depression, including defects in platelet clotting, alterations in immune functions, especially inflammation, and decreased heart rate variability—all of which have a role in cardiovascular disease. As psychiatrist-clinicians, we need to be aware of our depressed patients’ heightened vulnerability to cardiovascular disease, but we also must alert nonpsychiatric physicians to the importance of screening for and treating depression as a key action in the prevention and care of persons with cardiovascular disease. We have initiated a process of meetings with scientists at the American Heart Association (AHA), the organization which addresses both science and public information, with the goal of formally adding depression to the list of AHA risk factors (along with smoking and hyperlipidemia) and linking their consumer-oriented Internet resources to www.healthyminds.org, APA’s public information web site. I have chosen to pursue this topic after my presidency because of its dual impact—not only in treatment of depression and in potential impact on the morbidity and mortality of heart disease, but also because it negates the myths and stereotypes about mind-body dichotomies and is a demonstration of the importance of addressing medical care in a unified whole—as well as the opportunity to model an important alliance for our profession. Here, too, relationships take time to nurture and demand a flexible willingness to meet the goals of both groups.

We have had a good year and we have been highly effective, but our success in advocacy poses a constant challenge and we must not become complacent, as there is still much to do. In closing, I am asking two things of everyone here. The first is communication with members.

Our association exists for members and our strength comes from their membership. At the same time, all psychiatrists, members or not, benefit from APA’s advocacy efforts (some do get free lunches). We need a robust membership base to inform our directions and actions, as well as provide through dues the resources to do our work. Spread the news and tell what has been one of the best-kept secrets: how much APA does for our profession and for our patients. Tell your colleagues; tell even one colleague! If you have contact with potential physicians or medical students, tell them about psychiatry. In spite of many challenges, ours is a terrific profession. We are the only specialty that integrates mind, brain, and body and our understanding of these functions in health and illness continues to expand. We have highly effective treatments and we are a tremendous resource to our colleagues in other medical specialties. The impact of our work saves and improves so many lives.

Second, pledge to engage in at least one, or even just one, advocacy activity—no, you do not have to come back to Washington to visit Congress (although that would be wonderful); there are many other ways to communicate. Call or write your legislators (there are templates and links on our web site), meet with them or their staff at home, write a letter to the editor or online to a radio show or blog, speak to clergy or other religious groups, join and become active in AMA and/or your local or state medical society, work to educate other health professionals, volunteer with “Give an Hour” or another community service organization, or, as the ad goes, “just do it.” It will feel good, as well as do good.

Each of you is important to this effort. As a practicing clinician, I know how limited time is and of the many competing priorities we all face. But we must make the time; our efforts now shape the future for us and for the next generations, as well as for their and our patients.

Two years ago, as President Steven Sharfstein completed his presidential term, he noted that he was not ready to slow down, and indeed that we as a profession cannot slow down. Past President Ruiz has demonstrated his own energy and contributions in the international arena with the World Psychiatric Association. I, too, although getting ready to celebrate my 70th birthday, am not ready to slow down or walk away. There is too much to be done.

Fortunately, our leadership is composed of highly energetic advocates, and I know that incoming President Nada Stotland will be an even more vigorous leader and that Alan Schatzberg (our incoming President-Elect) has wonderful vision and force of conviction. Both will partner effectively with our staff. So our Association is in very good hands. But it works best when you—we—put our voices into action for science, our profession, and our patients.