Maryland's Long Commitment to Patient Care Chronicled

Family caregivers of people with severe chronic mental illnesses reported improvements in family life, more effective problem-solving, enhanced self-empowerment, and lower stress after participating in a consumer-run family educational program, psychiatrists at the University of Maryland School of Medicine in Baltimore found.

Lisa Dixon, M.D, Ph.D., a professor of psychiatry and director of health services research in psychiatry at Maryland, led a team of researchers who collaborated with the National Alliance on Mental Illness (NAMI) to assess the efficacy of NAMI's 12-week Family to Family program.

About 250,000 family caregivers have taken part in this free program since its inception in 1991, and about 18,000 people enroll in it annually nationwide, according to Joyce Burland, Ph.D., who directs NAMI's Education, Training, and Peer Support Center.

The Family to Family course had not been systematically evaluated, however, Dixon said. With funding from the National Institute of Mental Health (NIMH), Dixon and her staff screened more than 1,500 family members seeking to participate in five counties in Maryland from March 2006 to October 2009.

The researchers recruited 318 caregivers for their randomized, controlled trial, assigning about half to the classes and the rest to a wait list. They assessed subjects prior to randomization and three months after sessions concluded or would have concluded for those in the control group. They used a variety of scales—some novel—to assess changes in attitudes and behavior.

“NAMI took a risk in agreeing to this study,” Dixon told Psychiatric News. “There was a potential here for a collision between a self-help advocacy group and the academic model of evidence-based medicine, which relies on randomized trials.

“We had to deal with NAMI members' concerns that people assigned to the wait list were being deprived of a helpful service,” Dixon said. “But we didn't know at the outset that it was helpful. That's why we had to do the study.” Full results will be published this year.

Dixon's study exemplifies the Maryland Department of Psychiatry's long-standing commitment to improving the lives of people with severe chronic mental illnesses in partnership with their families and communities, Anthony Lehman, M.D., M.S.P.H., professor and chair of psychiatry at Maryland, told Psychiatric News.

Changing Times, Changing Minds, 100 Years of Psychiatry at the University of Maryland School of Medicine, published in December 2010, traces the department's history. The nearly 600-page book also provides a window on advances in psychiatry in the United States over the past century, focusing particularly on community psychiatry. The book, written by veteran journalist Pat McNees, includes 200 photographs.

In 1910, medical students at Maryland received only a few hours of lectures on “nervous and mental diseases” and observed severely mentally ill patients at the Bay View Asylum across the city.

“The place reeked with terrible odors, the patients yelling, soiling, untidy, locked in ‘strong rooms,’ tied up or down with restraints of various kinds, herded together in wards and under the domination of guards who were untrained for the job. This was my introduction to the field of public care of the insane, and it was not unusual elsewhere,” Ralph Truitt, M.D., a 1910 graduate of Maryland's medical school, wrote in an unpublished journal covering 50 years of psychiatric practice.

Truitt later became psychiatrist in chief of the Bay View Asylum, where he removed patients from restraints and instituted other reforms. He went on to become a professor of psychiatry at Maryland. His niece, Virginia Truitt Sherr, M.D., a psychiatrist practicing in Holland, Pa., offered his memoir as a resource for the departmental history.

Federal funding for training of psychiatrists and psychiatric services increased dramatically after World War II, thanks to passage of the National Mental Health Act in 1946. In 1948, the field of neuropsychiatry split into neurology and psychiatry. In 1949, the NIMH was established, one of the first four components of the National Institutes of Health.

Also in 1949, the Baltimore Sun published “Maryland's Shame,” a series of articles exposing overcrowding and understaffing at dilapidated state public mental hospitals, not then affiliated with the university.

The resulting outrage prompted the Maryland General Assembly to appropriate $25 million to correct these problems, and nearly $3 million to build the Psychiatric Institute at Maryland to train psychiatrists, provide state-of-the-art care, and study the prevention and treatment of mental illness. Psychiatry then was part of the Department of Medicine; it became a separate department in 1950.

The department's first chair, Jacob Finesinger, M.D., recruited from Harvard, still is revered for his skill in teaching students and residents how to interview patients.

Residents at the Psychiatric Institute in the 1950s commonly underwent psychoanalysis and studied psychoanalytic theory. Yet they also saw the need to address chronic medical illness, violence, poverty, substance abuse, and other social issues accompanying psychiatric disorders in their patients. They worked in tandem with the Baltimore City Health Department, which had offices across the street.

In the 1970s, the psychiatry department and the state of Maryland collaborated in a novel and intensive effort to draw university-trained psychiatrists into public service. Under what they called “the Maryland Plan,” state hospitals stopped training their own residents. Russell Monroe, M.D., chair of Maryland's psychiatry department, and long-time faculty member Walter Weintraub, M.D., working with Gary Nyman, M.D., M.B.A., Alp Karahasan, M.D., Ph.D., and Henry Harbin, M.D., consecutive directors of the Maryland Mental Hygiene Administration, created a onetrack residency program, rotating all trainees through public-sector facilities. The Maryland Plan markedly increased the percentage of residents who chose to enter public-sector psychiatry.

The Maryland Plan boosted the academic environment in state hospitals and reduced the stigma of working with severely mentally ill people, Brian Hepburn, M.D., executive director of the Maryland Mental Hygiene Administration, said at a symposium last September marking the 60th anniversary of the psychiatry department's founding. He called the relationship between the university and the state “mutually beneficial and a true partnership.”

As part of the Maryland Plan, the state-run Maryland Psychiatric Research Center became a division of the university's Department of Psychiatry. The center, directed by William Carpenter, M.D., since 1977, is a leading center for research on schizophrenia and related disorders. The center publishes Schizophrenia Bulletin for which Carpenter is editor in chief.

Carpenter's work helped bring John Talbott, M.D., to Maryland. Talbott, APA's president from 1984 to 1985, chaired Maryland's psychiatry department from 1985 to 2000, deepening its focus on developing model systems for providing public psychiatry. Talbott chaired an APA program funded by Pew, which brought aspects of these model programs to medical centers nationally. They fostered collaboration between state mental health systems and university departments of psychiatry.

Lehman, who has chaired the department since 2000, is a long-term investigator of health services delivery and outcomes. He led the Schizophrenia Patient Outcomes Research Team, which, in a series of studies over two decades, has assessed efficacy of treatment interventions for people with schizophrenia. “Evidence-based practices are where the odds are,” Lehman said. “They increase the likelihood that initial treatment choices will be effective and safe for each person.”

More information about the University of Maryland's Department of Psychiatry and Changing Times, Changing Minds is posted at <http://medschool.umaryland.edu/psychiatry/History.asp>.