Presidential Address: Bridging the Millennia: Mind Meets Brain

Aware of the incredible scientific achievements of the 20th century, especially during the 1990s Decade of the Brain, I selected “Mind Meets Brain” as the theme for the 2001 APA Annual Meeting. The theme recognizes that daily, new discoveries are helping us to understand how our personal interactions, including psychotherapy, influence brain development and function. Psychiatry, psychoanalysis, and neuroscience have overlapping areas of interest, such as perception, affect, dreaming, and memory, that will help elucidate relationships between mind and brain.

During the first decade of the 21st century, neuroscience and clinical research, including psychotherapy, neuroimaging, and psychopharmacology studies, will lead to scientific explanations for how our minds work. These findings will unify the major branches of knowledge under the banner of science. In particular, biology will explain our highest cognitive functions in terms of genetic programming. This era will be the Decade of the Mind. Now that the human genome has been mapped, additional research will disclose how specific genetic expressions lead to psychiatric illnesses. The 2001 Annual Meeting brings together experts from psychiatry, psychoanalysis, and neuroscience to teach us about their latest discoveries and how they are beginning to integrate findings from basic neuroscience with clinical research and practice. We are on the frontier of better understanding the treatment and prevention of psychiatric disorders.

The 2000–2001 Year in Review

My presidential year began with a working Board retreat focused on “Maintaining Professional Values in the New Millennium.” Two topics were elaborated: our business relations initiative and fresh developments in the realm of patient privacy and the confidentiality of psychiatric records. We met with a vice-president for heath services and a manager of an employee assistance plan from Fortune 500 companies and have continued to work with them. We also learned from an expert in electronic databases and medical record privacy, who subsequently became a consultant to our Committee on Confidentiality.

Institute on Psychiatric Services

The theme I selected for the 52nd Institute on Psychiatric Services in October 2000 was “Psychodynamic Psychotherapy.” The meeting had the second highest attendance in the Institute’s history. When attendees were surveyed as to what they would like to hear at the next meeting, the most frequent request was for more psychotherapy presentations.

Psychiatric trainees have been asking for more psychotherapy training, and their residency training directors have demonstrated an interest in providing it. Moreover, the Accreditation Council for Graduate Medical Education and its Residency Review Committees recognized the need for additional emphasis on psychotherapy training by adding requirements for five competencies in psychotherapy for psychiatric residents in addition to the six general competencies required of all residents beginning January 1, 2001. Residents must demonstrate competence in brief, cognitive behavior, psychodynamic, and supportive psychotherapies and in combined psychotherapy and psychopharmacology. This requirement will help return balance to training programs that had become excessively biologically oriented. I am gratified by these events, since psychotherapy is the centerpiece of our interactions with patients.

Corporate Reorganization

APA has undergone a sweeping reorganization. Seven months of my presidency were served in the 20th century as leader of the old APA and five months in the 21st century as President of the new APA. On January 1, 2001, the APA transitioned from a 501(c)(3) nonprofit tax status common for charitable organizations to the more usual 501(c)(6) nonprofit tax status for professional organizations. This change took one and a half years to accomplish. The shift permits APA to provide more financial assistance to District Branch and state organizations and to commit more of its resources to legislative and public relations activities, including a new political action committee. APA’s three subsidiary organizations—American Psychiatric Publishing, Inc., the American Psychiatric Foundation, and the American Psychiatric Institute for Research and Education—retain their 501(c)(3) tax status. Publishing activities for books, journals, and the newsletter were consolidated into the new publishing entity.

Helping District Branches and State Associations

In 2001, APA provided $700,000 in revenue-sharing funds to District Branches and state associations through asset reallocation, as promised. An additional $150,000 was made available to District Branches to support lowered dues for early career psychiatrists. Upon the recommendation of the Commission on Judicial Action, another $20,000 was provided for amicus briefs in support of successful lawsuits in California and New York.

During its first year, the Commission on Public Policy, Litigation, and Advocacy evaluated requests for assistance from District Branches and state associations. In response, the Commission recommended and the Board approved over $300,000 for assistance with scope-of-practice issues. When the Commission was formed, I asked that it develop action plans in three areas: psychologist prescribing, parity of mental health benefits in relation to other medical benefits, and psychiatric confidentiality and privacy issues. I also envisioned the development of a $1–2 million “public education fund” from voluntary contributions to support this and other high-priority activities. I am pleased to report that 32 states have enacted some form of parity legislation, that a proactive plan to deal with the efforts of psychologists to obtain prescribing privileges is well underway, and that we have begun building a sizable fund to support advocacy and litigation.

State Legislation on Psychologist Prescribing

I’d like to take a moment to acknowledge the outstanding leadership and commitment of our colleagues who have been and those who still are in the forefront of our legislative battles being fought state by state with nonphysician providers. Adversaries want to prescribe medications through legislative fiat, without the background of medical education and supervised residency training. Our members raised their voices in the legislative arena, protecting our patients’ quality of medical treatment from assault by self-serving psychologists. Our colleagues deserve not only our recognition but also our gratitude.

This year psychiatry defeated bills in six states. Currently, bills to permit psychologists to prescribe are still pending in four states (Illinois, Louisiana, Tennessee, and Texas). Our grassroots leadership, District Branch Presidents, Legislative Representatives, and lobbyists are in the legislative arena, striving tirelessly on behalf of patients to ensure that persons with mental illnesses are not subjected to deeply flawed health care by psychologists who believe prescribing medication is, to quote one of their former presidents, “no big deal.”

Let me call the roll of some heroes and heroines:

California: Ron Thurston, M.D., Legislative Representative; Bill Callahan, M.D., and Tim Murphy, M.D., District Branch Presidents; Barbara Gard, executive director; Conni Barker, lobbyist.

Georgia: Elizabeth Howell, M.D., President; Patrice Harris, M.D., Board of Trustees; Lasa Joiner, lobbyist.

Illinois: Shastri Swaminathan, M.D., President; Sid Weissman, M.D., Assembly Representative.

Louisiana: Dudley Stewart, M.D., Legislative and Assembly Representative; Aretta Rathnell, M.D., Assembly Representative; Vera Olds, lobbyist.

Tennessee: Lloyd Elam, M.D., District Branch member; Greg Kyser, M.D., Legislative Representative; Estie Harris and Anne Carr, lobbyists.

Texas: John Bush, executive director.

Connecticut: Jackie Coleman, executive director.

Hawaii: Jeff Akaka, M.D., member, Joint Commission on Government Affairs; Lydia Hardie, executive director; Robert Toyofuku, lobbyist.

Missouri: Lynne Moritz, M.D., Legislative Representative.

New Mexico: Neil Arnet, M.D., President; George Greer, M.D., Legislative Representative; Al Vogel, M.D., member, Board of Trustees; Roberta Stellman, M.D., Assembly Representative; John Anderson, lobbyist.

Maryland: Robin Weiss, M.D., President-Elect; Steven Daviss, M.D., Legislative Representative.

Thank you for all of your efforts on behalf of our patients and their families, your fellow psychiatrists, and APA.

Business Relations Initiative

The APA Business Relations Initiative to improve employee access to psychiatric treatment began during the second half of 2000. Soon thereafter, it became clear that all of the Fortune 500 companies we contacted wanted to talk to us and learn what we had to offer. The main contacts have been with Union Pacific Railroad, Hughes Electronics, Delta Airlines, a major financial services organization, the Pacific Business Group on Health, Constellation Energy, and General Telephone, which is now Verizon. Additional discussions occurred with representatives from Bank One, Sears, General Electric, American Airlines, AT&T, Dow Corning, Anheuser-Busch, Texaco, Conoco, and Pacific Gas and Electric. I am disappointed that we have not yet been able to begin pilot projects with several corporations. The unavoidable delays are attributable to the complexities of the business world. I am most gratified by the work of the Business Relations Committee and its partnership with the Carter Center in presenting “The Business Case for Mental Health Care,” an invitational forum for corporate health care decision-makers in June.

Communications

We have not solved all of our database and electronic communications problems. Mohamoud Jibrell, APA’s new Director of Information Systems, was recently hired to help resolve remaining difficulties. He is working closely with members, staff, and District Branch executives to provide what the members, District Branches, and state organizations need and want. An overarching plan for the development of a comprehensive, integrated system that will meet our needs will be presented in June. APA’s multiple membership categories and differing District Branch dues structures have contributed to the enormous complexity of our information system. APA’s recently enhanced Web site provides a members’-only section, where members can search for staff, components, and other members. Members can also revise their own address data. This is an important step in moving toward an organization-wide database.

Research

With the guidance of Darrel Regier, M.D., executive director of our research activities, APA has received research grants totaling $3.6 million for 2001. Approximately 66% of the funds are from government agencies, 26% from pharmaceutical companies, and 8% from other sources. Eighty-five percent of the government grants, and all of the pharmaceutical funds support the current 132 research training and educational fellowship awards. One of the current major research projects is an evaluation of the costs and quality of psychiatric care in the Federal Employees Health Benefits Program, covering 9 million federal employees, in which parity is mandated but the care is managed. Another highly significant research activity is beginning work on the development of DSM-V, which we hope will lead to a uniform international diagnostic nomenclature. Dr. Regier also participates in the Global Burden of Disease studies, which predict that depression will be the second leading cause of disability worldwide by 2020.

New Initiatives

In an effort to build stronger bridges with allied psychiatric organizations, I initiated a leadership summit meeting with the presidents and executive directors of the 14 groups that are currently represented in the APA Assembly. These leaders represent 20,000 psychiatrists. The initial meeting demonstrated our common interests. The special concerns of the allied organizations were highlighted. A subsequent meeting led to a trial appointment of representatives from the allied organizations to components in which they were interested.

Similar meetings with representatives of minority and ethnic organizations were planned, but adequate funding will not be available until next year.

Another initiative I am particularly satisfied with is the appointment of APA’s first Committee on the Prevention of Psychiatric Disorders and the Promotion of Mental Health. The psychiatric profession and our academic institutions have largely ceded promotion of health and prevention efforts to others in the pediatric, mental health, and social sciences fields. We have focused successfully on patients who need psychiatric treatment. However, our prevention efforts with vulnerable populations have been meager, and we must do more.

Our relationship with pharmaceutical companies has created unease among many members, stimulated by industry activities at APA’s scientific meetings. I had hoped to work with the companies to help them identify matters that hurt their image with our members and to encourage additional constructive activities. I presented this idea to company representatives on several occasions but did not receive a response. Subsequently, I appointed a task force to develop guidelines for APA’s entire relationship with pharmaceutical companies. It will report its recommendations in June.

The Future

Federal Legislation and Regulations

The 107th Congress will be considering significant legislation of interest to APA, including:

The APA’s Division of Government Relations, under the sagacious direction of Jay Cutler, J.D., will be working to revise inpatient seclusion and restraint regulations and inappropriate provisions of the Health and Human Services privacy regulations, while endeavoring to preserve the special privacy protections in the regulations applicable to psychiatric records and psychotherapy.

APA’s Place in a Changing World

APA must transform itself to maintain psychiatry’s leadership in a rapidly changing world. Organizations that are flexible, nimble, and able to change rapidly will survive. Organizations that are slow to recognize needed changes and have difficulty overcoming their own inertia will fail. Tom Peters opines that organizations have to be “lean, linked, electronic, and malleable.”

Keeping up is not sufficient. Will Rogers reminds us, “Even if you’re on the right track, you’ll get run over if you just sit there.” We must devote time to creative thinking. We must recognize the intense appetite our society has for technology and learn from our younger members and employees who are less inhibited by life’s experiences.

Currently, APA has a limited number of revenue sources. Although we may be able to increase our income from these sources, we would be on far more stable ground if we can create new funding streams. Our American Psychiatric Foundation will help to meet this challenge.

The business community is beginning to focus on what is referred to as “customer relations management” in recognition that success depends upon customer satisfaction and loyalty. This business strategy uses current technology to enable employees to provide optimal, personalized service to its valued customers. Employees recognize that they are in the customer-service business and are evaluated on that basis. The American Marketing Association reports that “65% of business comes from existing, satisfied customers and that customer acquisition costs six times the amount of customer retention.” The same principles apply to organizations whose existence depends upon maintaining a satisfied membership. We must redouble our efforts to provide our members with what they need and to give them the service they deserve.

Acknowledgments

The demands of the APA presidency have been much easier to manage with the wonderful support I received from my family, colleagues, friends, and APA staff. My wife, Bonnie, has been my understanding, patient, considerate, and loving partner. Her support, encouragement, and practical approach to life have been of enormous help to me throughout my career, but especially during the past 2 years. Our son, Jay, keeps me up to date on the latest e-world developments and has accepted my frequent absences and missed family occasions with equanimity. Thank you Bonnie and Jay.

I am delighted to have my special friends Dr. and Mrs. K.C. Yeh and my medical school classmates Mel Belding and Ray Betson with us today. K.C. recently retired from his work as an economist for the Rand Corporation. Mel is an internist specializing in the treatment of infectious diseases. Ray is a plastic surgeon. It is an honor to have you here for this event.

I also want to thank my many psychiatric colleagues and their spouses from the Los Angeles area who have joined us today and the members of the Board of Trustees and Assembly for their hard work this year. In particular, I want to thank Herb Sacks, Marcia Goin, and Drew Clemens for their friendship, assistance, and thoughtful advice.

Phil Muskin and the program committee put together an outstanding scientific program. Our members, including international members, apparently agree with my assessment. This annual meeting has the highest number of premeeting registrations in our history. Thanks also to Michelle Riba and the Institute on Psychiatric Services program committee for the highly successful meeting last October. In addition, I want to acknowledge the consistently, highly efficient job Cathy Nash and her staff and the Meetings Management staff have done for all of our scientific meetings.

It has been a pleasure to work closely with Richard Harding, President-Elect, and Mike Pearce, Speaker of the Assembly. This year, I have enjoyed regular communications and collaboration with Steve Mirin, our talented Medical Director, in addressing a range of projects. Steve’s expert negotiating skills and ability to quickly analyze complex issues has been extraordinary. I also want to thank Jay Cutler and John Blamphin for keeping APA’s messages before politicians and the public. Finally, I want to thank the staff in the Governance Office for their support and assistance. Margaret Dewar, Yoshie Satake, Laurie McQueen, and Carol Lewis have been especially helpful.

Closing Thoughts

Serving as APA President has been a wonderful and exciting experience. I was privileged to have served at a time when there is a growing public and government awareness of the plight of those members of society who suffer from the stigma of mental illness; when the U.S. Surgeon General has recognized for the first time that psychiatric patients have real disorders that are diagnosable and treatable; when psychiatric illnesses are being accepted in the same way as other medical illnesses; when our science reveals profound, new discoveries every day; when psychotherapy is regaining its prominence as an essential component of our treatments; and when special protections for our patients’ private communications are becoming more prevalent.

Our future is bright. Your American Psychiatric Association is here to represent your interests in research, education, and clinical advances, which together, safeguard our work with patients in need. My year as President ends at the close of the 2001 APA Annual Meeting. I offer Richard Harding, our incoming President, and Paul Appelbaum, our new President-Elect, my best wishes and support in furthering APA’s goals. The APA is in good hands. I am honored to have served as your President. It was a great year.

Presented at the 154th annual meeting of the American Psychiatric Association, New Orleans, May 5–10, 2001. Dr. Borenstein, 129th President of the American Psychiatric Association, is in private practice and is clinical professor in the Department of Psychiatry and Biobehavioral Sciences at the University of California, Los Angeles. Address reprint requests to Dr. Borenstein, 151 N. Canyon View Dr., Los Angeles, CA 90049-2721; [email protected] (e-mail).