Presidential Address: Transforming Mental Health Through Leadership, Discovery, and Collaboration

Thank you so very much, Carolyn, for this and all your advice and mentorship. Last year, when I stood before you, I told you how honored and grateful I was for the opportunity to represent the Association and the principles and values for which it stands. My experiences as your president have confirmed these feelings in multiple ways and have reinforced my conviction that leadership is not possible without the help and support of many talented individuals. This has been a year of challenges and opportunities, of remarkable collaboration, and of a learning curve that has been exponential. I hope that the Association has benefitted from my leadership, but there has been no question that this has been a special experience for me. Therefore, it is with mixed emotions that I will turn the reins over to John Oldham, who has been a trusted colleague, friend, and advisor throughout this year. Although John and I have known each other for several decades, this opportunity to work together so closely has been rewarding, enjoyable, and educational. I am convinced that the interests of the APA are served best when we work together as a team and can benefit from the talent and creativity that such collaboration brings. I also want to thank the members of the Board of Trustees, the Assembly and its leadership, as well as district branch presidents and executive directors who truly keep “the home fires burning.” And of course, I must acknowledge the dedication, commitment, and support of Dr. Jay Scully and the outstanding staff he leads in Washington, without whom there truly would be no APA. Finally, to my family, especially Arthur and Samantha, without your love, support, and guidance—and your willingness to put up with my distractibility and my travel—I could not stand before you today. I would also like to acknowledge two very special people in my life who were taken from me in the past few months and so could not be here to share in this celebration: Dr. Tana Grady-Weliky, the program chair for this meeting and my dear friend, and Dr. Stanley H. Bernstein, my physician father, both of whom fought courageous battles with cancer in much the same way that so many of our patients fight to overcome the challenges as well as the stigma of psychiatric illness.

My theme has been “transforming mental health through leadership, discovery, and collaboration.” I would like to provide you with an update on the progress we have made in these areas over the past year as well as to share my thoughts about the future of the Association and American psychiatry.

New “discoveries” in our field continue to excite and tantalize us with the promise that some day we will more fully understand the interface between the mind and the brain. The 1990s were the decade of the brain; the 21st century may well turn out to be the century of the brain. As we continue to make advances in our exploration of brain chemistry, physiology, and structure, as we discover more about how our environment and life experiences interact with our biology and physiology, we will be better able to develop treatments that will help our patients lead fuller, richer lives while continuing to live productively with chronic illness. Our treatment armamentarium will become more nuanced and individualized as we incorporate genetics and genomics, culture, and development into psychiatric nosology, epidemiology, etiology, and treatment. As you know, the DSM-5 is well on its way toward an anticipated publication date of 2013. The 13 work groups have completed their initial reviews of potential changes to the DSM, which, thanks to extraordinary advances in technology, will be a “living document,” one that we will have the capacity to update on a regular basis as we discover more about the causes and treatments of psychiatric disorders. Preliminary recommendations of the task force and the work groups were posted on the web a little over a year ago. Comments on the proposed criteria from all over the world were reviewed extensively by the work groups and incorporated into our ongoing decision making. In addition, to further enhance scientific oversight, at my direction, the Board of Trustees established a Scientific Review Committee, chaired by Drs. Kenneth Kendler and Robert Freedman, to evaluate the science that has informed the new proposals in much the same way that study sections evaluate proposals for new research funding at the NIMH, NIDA, NIAAA, and other research institutions. The assessments of the SRC are being provided to the work groups and the Board to continue to ensure that the highest levels of rigor and assessment are used in DSM development. Field trials have begun across the country in 11 academic centers to study the reliability and clinical utility of potential changes in diagnosis. Furthermore, more than 3,000 clinicians from a variety of mental health disciplines are participating in additional field trials that will focus extensively on the clinical utility of proposed changes. By the end of August of this year, these trials will be complete, and the results will be forwarded to the work groups for incorporation into the next iteration of diagnostic proposals.

As you know, another major change in the DSM process has been the incorporation of public feedback. The response to the posting of draft criteria last April included nearly 9,000 comments and 50 million hits on the web site. We have just initiated a second public comment period that will last until June 15, 2011, focused on proposed changes to chapter organization and structure. A third period for such commentary will take place at the conclusion of the field trials in the fall, with the potential for additional comments in 2012. Our efforts to incorporate feedback in such an open and transparent way are unprecedented in the history of the DSM. The manual will serve multiple purposes for different audiences. Fundamentally, it is a nosological text that is used by clinicians throughout the world to diagnose those suffering from psychiatric disorders. In some areas, we are closer to understanding the etiology of the conditions affecting our patients, and in other areas we are limited to identifying symptom clusters that track together and where similar clinically useful techniques can be applied in treatment. Secondarily, the DSM provides a research framework for the scientific community so that we can continue to study psychiatric conditions in order to elucidate our understanding of etiology and clinical course in order to advance the development of new and more effective treatments.

We also face challenges to future discoveries. The volatile and difficult financial environment has curtailed our nation's capacity to continue its robust financial investment in our national medical research institutes, including the National Institute of Mental Health. Funds to support new research in our academic communities have been cut back, and concerns about potential conflicts of interest with the pharmaceutical industry have limited other sources of support for research. As an association, it is incumbent upon each of us to continue our efforts to educate our legislators and public officials so that this critical support does not continue to erode while simultaneously remaining mindful of the need to be fiscally prudent in the current economic climate, particularly with regard to health care. We must also develop new approaches to collaboration between academia and industry that will facilitate research and development without compromising scientific integrity, particularly since no other entities currently fund research into new pharmacological approaches to treatment.

Collaboration has been another key element of my theme: collaboration with our colleagues in the House of Medicine, collaboration with our patients and the rest of the mental health community, and collaboration across generations. With the passage of national health care reform, we are uniquely poised to collaborate with the rest of medicine in implementing integrated care for our patients. Patient-centered care has become the watchword of 21st-century health care delivery in the United States. This philosophy represents a fundamental shift from the individually driven, more hierarchical doctor-patient interactions of the last century to a more team-based, patient-focused alliance involving all medical professionals: physicians, nurses, social workers, psychologists, and other members of the health care team. This shift represents a particularly exciting opportunity for psychiatry. In many ways until now, both we and our patients have been isolated from our medical counterparts. Our patients' psychiatric records have been segregated from the full medical chart and from most electronic medical records, and the psychiatric problems of patients suffering from acute and chronic medical conditions have been overlooked, neglected, and undertreated. As we continue our efforts to combat stigma, new health care delivery systems, such as accountable care organizations and the medical home, may provide new venues for psychiatry and psychiatric patients to be fully integrated into the medical community. Regardless of the system of care in which we work, each of us must advocate for the necessity to include psychiatrists and psychiatric services in these new entities as they are created. For those of us who grew up practicing medicine when the relationship was strictly between the doctor and the patient, the movement toward such team-based care may be threatening and anxiety producing. We must figure out how to maintain our individual ethical and professional responsibilities for the care of our patients and assure appropriate confidentiality while simultaneously collaborating with others in the management of our patients' care. We must unite to bring the patient into the center rather than the periphery of the health care delivery process. We will also have enhanced prospects for collaboration with internists, pediatricians, and family physicians to improve the care received by those who do not regularly seek out psychiatric services. You will have the opportunity at this meeting to learn about some exciting new initiatives in these areas.

With the implementation of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, we finally have a legislative mandate to begin to ensure that our patients receive both access to treatment and the insurance coverage they have long deserved. The staff of the Office of Government Relations has been working diligently, in close collaboration with psychiatrists around the country, to monitor the implementation process and to make sure that our patients are aware of the benefits the new law provides. We have successfully fought off efforts by the insurance industry and managed care companies to mitigate the intent of the legislation by subjecting physicians and patients to onerous and unfair discriminatory requirements for reporting. I urge all of you to continue to inform local district branch executives as well as our national government relations staff when your patients encounter problems in parity implementation so we can continue to guarantee that they benefit from this landmark legislation.

The final aspect of my theme has been leadership. Development of leadership remains the most powerful way for us to influence the future of psychiatric practice in all of these arenas. As many of you know, I have devoted my career to the education and training of the next generation. If our science is to continue to advance, if our patients are to continue to benefit from psychiatric treatment, if our organization is to continue to survive, it is imperative that we nurture and cultivate our medical students, residents, and early-career psychiatrists. Over the past 2 years, I have held a series of “town hall” meetings in an effort to reach out to these groups so that together we can approach the future.

This has always been an important mission for the APA. Why do I believe that it is especially critical now? For the first time, there are many generational cohorts in the workplace. Our patients are living longer with chronic illness, and our treatments are focused on recovery and rehabilitation rather than simply episodes of illness. The younger generations of psychiatrists and patients have fundamentally different approaches to authority, to change, to work-life balance, and to communication than those of us currently in leadership positions in the APA as well as those of us who are leading other efforts in education, in the clinical setting, and in research. In speaking around the country to many different audiences, I have become persuaded that understanding the sociological context of generational differences is essential as we move forward into the 21st century. Some have commented that these generational differences will dissipate as the Generation Xers and the Millennials age—that the “disconnect” between the Baby Boomer and World War II generations and the two subsequent cohorts has more to do with differences between youth and age and experience than fundamental shifts in perspective. I would counter that the changes in communication styles and modalities that we have seen and are continuing to see will dramatically alter our perspectives on work-life balance and will revolutionize how we take care of our patients. As you already know, social media technology has contributed to the downfall of governments and transformed the global dissemination of information. There is no doubt that this “brave new world” will have a profound impact on all of us in ways that we can only begin to imagine.

At a recent meeting of the American College of Psychiatrists, a packed room discussed and debated the impact of new technology on education and training, doctor-patient boundaries, and the ways in which we conduct treatment. Some argued that e-mail should only be used for changing appointments and refilling prescriptions and nothing else. Others countered that e-mail provided enhanced opportunities for communication with patients who might otherwise be unable to do so in a face-to-face situation. Residents spoke about social networking sites—about the potential need to change privacy settings if you are a physician; about whether it is ethical to “google” patients; about what constitutes ethical treatment if you learn something about your patient from “googling,” such as discovering that a patient who insisted he or she was abstinent was pictured drinking, and what to do if patients “google” you. In the past, privacy was under individual control. Today, information about each of us is widely available to anyone on the Internet.

The new technologies make it easier than ever to work from home. Telecommuting is increasingly common, and I suspect that telepsychiatry will move rapidly from the institutional to the individual practitioner level. But how will we determine when work should “end” and one's personal life “begin”? And how will we define “work-life balance”? These questions and others will require ongoing conversations and debate. Solutions will require that we think creatively “outside the box” and that we collaborate closely across the generations to do so.

Our residents and early-career psychiatrists are the future leaders of our field. Their novel approaches to communication (we have so much to learn from them!), their insistence on the need to balance their work lives with their home lives, and their focus on deliverables and outcomes can provide unique perspectives to assist us in helping psychiatry move forward to be more efficient, effective, and relevant. At the same time, those of us born before 1980 have seen many of our values and practices in medicine turned upside down. We worry about the future of the doctor-patient relationship and how our ethical and humanitarian values will be maintained in a professional environment where regulation seems out of control. While we have applauded our hard-fought victory for parity, we are concerned that the economic climate will preclude our patients from its benefits. We express dismay that the public call for accountability may erode the confidential nature of our work with patients.

As you all know, pleasing all of the people all of the time is an impossibility. I came into my presidency with high hopes about our capacity to communicate effectively about the issues that matter to us and about our ability to come together as an organization to advocate for outstanding science, exceptional treatments, access to care, and high-quality educational opportunities for our members. While I am still a believer in these possibilities, I have also seen firsthand how easy it is for information to be distorted and misrepresented and how difficult it is to communicate with each other in an accurate, effective, and productive way.

I have long believed that our organization must function well at the grassroots level to move forward. We must use new technologies and media to transmit information, but our methods must be more personal and direct. While posting stories, guidelines, and strategies on our website and publishing them in Psychiatric News and DB and area newsletters is essential, it is no substitute for the personal connection. I believe our national leaders must reach out to mentor and cultivate our recent graduates. To be truly generative, I believe that our leadership, our past presidents, Board members, and Component and Assembly members must take the initiative in the development and implementation of mentorship programs for our trainees and young psychiatrists in their own communities. I have also recommended that every academic department consider devoting one grand rounds program each year to informing faculty and residents about the strategic agenda for the Association and ways to become involved in advocacy, education, and outreach in our hometowns. Such presentations would provide an annual opportunity to link the academic world with the clinical community that it serves. Local and national APA leaders could be invited to meet with young psychiatrists, and these events would provide additional forums to discuss precisely how to bring research from the bench to the bedside and how to partner successfully in our new environment.

I view the close of my tenure as President not as an end but as a beginning. You have my pledge that I will continue to work to advance the mission and the potential of the American Psychiatric Association. I look forward to our ongoing partnership on behalf of all those who suffer from psychiatric disorders, to assisting Drs. Oldham and Jeste in their leadership initiatives, and to passing the baton to the next generation, who hold the promise of the future in their hearts and minds. Our Association and our specialty are indeed in good hands. Thank you once again for this extraordinary opportunity.