A Fulfilling Year of APA Presidency: From DSM-5 to Positive Psychiatry

Good afternoon. First of all, I want to thank Carolyn Robinowitz for such a kind introduction. Carolyn, your service to the APA in so many different roles has been a role model for the rest of us.

Many years ago, I migrated to the U.S. with three partners: my wife Sonali, my love for psychiatry, and my Indian accent. I am happy to report that none of these partners has deserted me so far. For someone born, raised, and educated thousands of miles away, even becoming an APA member seemed like a fantasy, let alone being its president. I still have a sense of disbelief at how lucky I have been.

This past year has been an incredibly busy but an amazing year—and a great privilege. I can summarize my feelings in three words: gratitude, pride, and contentment.

My gratitude extends to all the APA members for your trust and faith in my ability to lead this wonderful organization representing 33,000 psychiatrists. The APA is the largest psychiatric society in the world and the oldest medical organization in the U.S. The APA is truly a microcosm of our country. The country’s motto, E pluribus unum, meaning one out of many, reflects on both its diversity and unity. America is not really a melting pot; it is more like a salad bowl or a cultural mosaic, in which different groups retain their uniqueness but serve a common goal. I think the same applies to the APA too. APA members differ in age, gender, ethnicity, subspecialty, type of practice, political views, whatever, yet we all are united around the common goal of promoting the highest quality health care for people with mental illnesses.

The APA governance is a three-legged stool. The three legs are the Board of Trustees, which is chaired by the president, the Assembly, which represents grass roots democracy starting at the district branch level, and the APA staff. These three components need to work together to serve our members, who in turn serve our patients and their families. A year ago, as president-elect, I vowed to focus on unity within the APA. I am proud to say that during the past year, we have had exemplary unity among the Board of Trustees, Assembly, and staff. Without this unity, we would not have accomplished what we did. We also maintained successful partnerships with other organizations like the AMA and the NAMI. I hope and expect that this unity will continue into the future.

I want to thank several specific individuals. I’m grateful to my predecessor John Oldham and my successor Jeff Lieberman for their incredible help during the past year. They both were longtime friends and distinguished colleagues previously and have now come even closer. I owe a lot to my mentors, two of whom must be watching this function from above: the late Drs. N.S. Vahia and Richard Jed Wyatt. I also want to thank my colleagues, trainees, and staff at University of California, San Diego, for allowing me to spend time working with the APA. I want to specially acknowledge my chair, Lewis Judd. Last but not least, I want to express my appreciation for my family and friends. My wife, Sonali, is a superwoman. An accomplished child psychiatrist and a wonderful mother; she does it all. I feel lucky to be a man standing behind a successful woman; actually, make it three successful women, including our two daughters. Shafali is a child neurologist, and Neelum is completing residency in pediatrics. Between them, these three ladies have participated in four marathons and four 60-mile walks for breast cancer research. They have been my friends, philosophers, guides—and bosses. The uneven gender balance in our family has been recently corrected with the addition of Richard, Nischal, and Kiran. In addition to their day jobs, Richard and Shafali run a nonprofit called ACEing Autism, which teaches tennis to kids with autism with the goal of improving their motor skills and, more importantly, social skills. Finally, I want to mention several other members of my family and friends who are here: Vijay, Reshma, Vikram, Maya, Leena, and their spouses.

I feel proud to be a psychiatrist. While psychiatry is not the most lucrative medical discipline, studies show that psychiatrists are at or near the top of all medical specialties in terms of job satisfaction. This job satisfaction is related to caring for some of the most disenfranchised individuals in the world.

During the past year, we accomplished two major tasks with long-term impact: completion, approval, and publication of DSM-5 and selection of a new CEO/Medical Director.

Regarding the first task, I have been closely involved with the DSM-5 almost from its inception. I was a member of the original task force and chair of its neurocognitive disorders workgroup. The work on DSM-5 has involved pro bono efforts by several hundred experts from around the world. There has been unprecedented public interest and media scrutiny of DSM-5. My task, as the president, was to ensure finalization of the criteria and text and their approval by the Board of Trustees. This required coordination and collaboration involving the DSM-5 Task Force, 13 work groups, with about 10 members each, and four independent review committees, plus experts in criteria, coding, and field trials. These groups did not always agree with one another. On top of that, the APA made available online drafts of the DSM-5 criteria to the outside community for its review and received 23,000 public comments. How do you bring these diverse stakeholders to the table and reach a consensus? We formed a summit group in which representatives from the various bodies came together. We had several meetings, as well as long conference calls with 35 people on line. It was not easy. There was plenty of debate, but we all wanted the same thing: a clinical diagnostic manual reflecting the best science available today. The DSM-5 is now published. I want us to give a big hand to David Kupfer, the Chair of the DSM-5 Task Force, and also to Darrel Regier, the Vice Chair. We hope that the DSM-5 will lead to more accurate diagnoses, better access to mental health services, and improved patient outcomes. Of course, with scientific advances, it will need revisions. Science should never be stagnant, and neither should medicine.

Regarding the second task, choosing the next CEO/Medical Director of the APA, Jay Scully will be stepping down later this year after 12 years of incredible service. Jay has led the Association though the making of DSM-5, enactment of the Mental Health Parity Act, reorganization of APA and its components, and close collaboration with various other societies. Jay has done a better job of balancing the budget than our government and Congress have. Jay leaves the APA in a much stronger position than when he joined. We will miss his leadership, enthusiasm, and commitment to our members and their patients. Last year, I formed a search committee including major leaders in psychiatry and chaired by Paul Appelbaum, a distinguished past president of the APA. The selection process progressed effectively. The Board of Trustees has selected an outstanding successor to Jay: Saul Levin. Saul has a long history with the APA, having served on the APA delegation to the AMA, the Political Action Committee Board, and the Scientific Program Committee. Saul is currently the interim director of the District of Columbia Department of Health. He was previously AMA’s vice president for science, medicine, and public health. Saul’s expertise in electronic health information exchanges and implementation of the Affordable Care Act plus his proven leadership of large organizations will come in handy as we adapt to and take a leadership role in mental health care reform.

In addition to those two major tasks, APA did a remarkable job last year in many other ways too. Let me summarize just a few of these activities and accomplishments.

An important task involved fighting insurance companies which were discriminating against people with mental illnesses by downgrading their benefits. We have won several of these battles, but we will not rest until there is real mental health parity.

APA also continued to strongly advocate for better Medicare and Medicaid reimbursements for psychiatric care. We will remain vigilant as the health care reform unfolds.

We all have been deeply touched and saddened by the senseless gun violence in Tucson, Aurora, and Newtown. APA and the district branches stepped forward to provide critical help to the local communities. There has been an unfortunate tendency in some quarters to equate mental illness with violence. But we must remind others that 96% of the violent crimes are unrelated to mental illness and that people with mental illnesses are far more likely to be victims rather than perpetrators of crime. At the same time, we must improve the access to care for people with serious mental illnesses. I recently formed an APA-led coalition of physician organizations, including AMA, that will develop recommendations for enhancing mental health care as well as reducing the stigma of violence.

Along these lines, an important issue relates to identifying young people with mental illness who are at high risk for violence. The American Psychiatric Foundation has sponsored an innovative program called “Typical or Troubled?” It has trained 60,000 teachers and parents on how to recognize differences between typical teen behavior and mental illness. This program has connected with over 900,000 students across the U.S.

Another critical arena is diversity. Just as the population of the country becomes increasingly more diverse, so must the APA and its leadership. Annelle Primm has led APA’s OMNA on Tour Program to reach out to underserved rural communities. It has focused on improving access to health care for depressed women living in poverty.

Among other bragging points, the American Journal of Psychiatry, under Bob Freedman, continues to be one of the top medical journals in the world. Last year, it had four of the 10 articles on the New England Journal of Medicine list of papers with highest clinical relevance. No other journal had more than one.

The Psychiatric News has made major strides too. Its daily e-mail alerts and recent series of articles on DSM-5 have been highly successful and popular. Recently, the Psychiatric News won an excel award from the Association of Media and Publishing.

Jeff Borenstein’s Healthy Minds public television series has produced nearly 40 episodes on topics like military mental health, bipolar, autism, and suicide prevention. The series has reached 60% of U.S. households and has received two Emmy nominations and four Telly awards.

In terms of international members of APA, their numbers have increased significantly this year. Also, for the first time ever, we will have international members on some of APA’s councils and committees.

Jeff Lieberman appointed a workgroup on members in training and early-career psychiatrists that will recommend ways of expanding the involvement of these leaders of tomorrow.

This APA year is ending on a high note, with this history-making annual meeting. Not only are we celebrating the publication of DSM-5, but also, for the first time ever, a past president of the country (Bill Clinton) will be our keynote speaker. This signifies the rising stature of our organization and our field. Three Nobel laureates will also be here. The theme for this meeting is “Pursuing Wellness Across the Lifespan.” We have separate tracks for all major subspecialties in psychiatry, highlighting their special status within the APA. There are invited sessions on international medical graduates, psychiatrists in the media, and the radical caucus. That is diversity!

I would not trade this past year of APA presidency for anything else, even though it included countless hours of work and my share of sleepless nights! For any of you who may be interested in becoming an APA president, I strongly recommend this job. You won’t make much money, but the benefits are great. Sometimes people ask me, “What is the best part of APA presidency? Was it the honor of being invited to the White House to join President Obama for the announcement of the BRAIN Initiative? Will it be introducing Bill Clinton tomorrow?” While those certainly are unforgettable moments, the most rewarding part for an APA president is to hear a member say, “Thanks for what you and the APA are doing.” That is simply priceless.

Moving forward, the future of psychiatry and of the APA is bright. Sure, we will go through some difficult times, but we will come out ahead. We have succeeded in the past, and we will succeed again. I have every confidence in the leadership of Jeff Lieberman, Paul Summergrad, and Saul Levin in taking the APA to the next level during the coming years.

As I end my year of APA presidency, I am personally looking forward to returning fulltime to my own research, teaching, and clinical work at University of California, San Diego. I hope that my family and my colleagues and staff will be glad to have me back. As a geriatric psychiatrist, my work focuses on successful aging and positive psychiatry. I am convinced that life begins at age 50. Studies show that quality of well-being follows a U-shaped curve. It is pretty high in early twenties, then starts going down and hits the rock bottom around 50; that is the time of midlife crisis. But then, people change their jobs or partners or just their attitudes and behaviors, and the well-being starts going up progressively into their fifties, sixties, seventies, and eighties. Quality of life and psychosocial functioning depend less on physical health and more on positive psychological traits like resilience, optimism, social engagement, and wisdom. Successful aging is not an oxymoron but is an evidence-based scientific fact. It has a biological basis. Some of the most exciting neuroscience research during the past two decades has shown conclusive evidence of neuroplasticity of aging. New synapses and even new neurons in some brain regions can form in older age, provided there is optimal physical and psychosocial stimulation. At UCSD, we have just begun research on successful aging among people with serious mental illnesses, and our ultimate goal is to develop interventions that will make this a norm rather than an exception.

I expect that the future role of psychiatry will be much broader than treating psychiatric symptoms. It will seek to enhance well-being of people with mental or physical illnesses. That is positive psychiatry. We will learn more about brain processes responsible for these traits, and we will seek new ways to promote resilience, optimism, and wisdom through psychotherapeutic interventions.

Thank you for giving me this opportunity of a lifetime to lead our charge this past year. Robert Baden-Powell initiated the scouting movement with boy scouts and girl scouts. He wrote in his last letter to them, “Leave this world a little better than you found it.” This should apply to presidencies too. Am I leaving the APA a little better than I found it? That will be for the others to judge. However, I do know that the APA and all of you have left me much better than when you found me. For that, I will be eternally grateful.

Thank you, and best wishes to all of you.