Psychiatry Can Be Proud as it Marches Forward

Much of my life has been in psychiatry, and I have worked in many areas of the field. I say that because I am alert to criticism that comes from many quarters. We should always welcome criticism, but excessive and unreasonable criticism requires a response.

I think it fair to say that I know our field well. My training in psychiatry has included being a research fellow and psychoanalytic graduate. I have held many leadership positions, including the director of the National Institute of Mental Health (NIMH); chair of the American Association of Chairs of Departments of Psychiatry; president of APA; and chair of three departments at Downstate, Colorado, and Columbia. I have directed inpatient and outpatient programs as well as been a private practitioner.

I have had the great pleasure of working with marvelous colleagues and heroes such as Lyman Wynne, Floyd Bloom, Biff Bunney, Fred Goodwin, Bob Post, Dan Weinberger, Daniel X. Freedman, Steve Paul, Judy Rapoport, Richard Wyatt, Jack Barchas, and countless others. I was on the Lasker Award Committee that chose Mogen Schou for his development of lithium as a treatment.

Watching outstanding scientific leaders like Seymour Kety, Dave Hamburg, Donald and Rachel Klein, Eric Kandel, Paul Greengard, Steve Sharfstein, Myrna Weissman, and Sol Synder made me proud of our field. Later I applauded the selection of Aaron Beck and Nancy Wexler for the Lasker Award for, respectively, great work on cognitive and behavioral therapy and Huntington’s disease. There were also times when we refuted such notions as taraxein as a cause of schizophrenia, hemodialysis as a treatment for schizophrenia, and Soteria houses as a homelike treatment setting for people with schizophrenia where medication was eschewed.

Then John Kane and Herb Meltzer won approval for clozapine, and John Strauss and Will Carpenter showed the importance of negative symptoms in schizophrenia, and more recently Helen Mayberg produced outstanding work on brain stimulation. I could go on extensively to identify heroes in various walks of life to attend to people with mental illness and bring support for mental health.

I say all this because when some critics imply or state that little or anything was scientifically based before the last 10 to 15 years, I think of this as nonsense. Also, to attack simplistically the many clinicians who used the tools available at the time to help patients is irresponsible. Psychiatrists like other clinicians throughout medicine use what is available to them to help patients. There were some who did not reach the moral and ethical medical standing we expect, but they constitute small numbers.

Some observers today may fail to recognize the historical path for the development of what might be referred to as “new findings” and developments in paradigm shifts in science and practice. Some fail to recognize their roots in the efforts of people who did heroic work before them. We should learn from the good and bad as we go forward.

To seize on outlier members of the psychiatric field as representative targets to evaluate psychiatry is myopic. Every field has misguided advocates. Leeches, lobotomies, radical mastectomies for breast cancer, three-week bed rest after a coronary, and trephining to free the brain of evil spirits have been and gone. One should not critique a field on the basis of those who did what they could with what they had, simply because there were some ill-advised proponents or failed therapeutic interventions.

In looking at the evolution of psychiatry, an important development was the reaching out by leaders like Daniel Freedman and a meeting I had with families of psychiatric patients that launched the National Alliance for the Mentally Ill (NAMI, today the National Alliance on Mental Illness) in 1980 followed by NARSAD’s founding a few years later (currently the Brain & Behavior Research Foundation—BBRF), the Depression and Bipolar Support Alliance, Mental Health America, and others concerned about anxiety disorders, borderline personality disorders, obsessive-compulsive disorder, and suicide prevention—all fostered collaborations important today.

Ironically there are opportunities today in mental illness and mental health. This field has too frequently been a low priority or an inconvenience. But events, some good some bad, call for renewed and high level attention to mental health and illness. What are they?

• Disturbed individuals with all-too-easy access to guns, killing innocent people to whom they have no personal connection indiscriminately.

• Countless veterans after honorable service returning home to minimum support and bedeviled by PTSD, depression, substance abuse, and traumatic brain injury.

• Suicide rates exceeding 39,000 to 41,000 a year (this is an underestimate since many suicides are not reported). In the United States alone, over half are gun related.

• Jails and prisons filled with people whose core problem is psychiatric illness, not antisocial personality.

• The World Health Organization Declaration that mental illness is the leading health cause of disability in the life of human beings throughout the world.

• Recognition of the extraordinarily high cost of health care when mental illness is comorbid with other kinds of medical illnesses.

• Dismantling of psychiatric services throughout the country despite emergency rooms and hospital beds filled with patients with nowhere to go.

• Worldwide shock and disbelief that one airline pilot with suicidal depression whose violent tendency was not adequately detected, communicated, and managed could cause death and emotional damage to so many and terrify the world.

We must take advantage of these developments to strengthen mental illness prevention and treatment. Psychiatry should be guided by key principles. Among them:

• Ensuring the primacy of patients and families.

• Being actively involved in the overall family of medicine.

• Aggressively reacting to unreasonable policies regarding malpractice and reimbursement.

• Censoring lapses by individual psychiatrists from personal/professional integrity in relationships with patients and family and in clinical practice and public presentations.

• Securing a reasonable compromise between excessive focus on confidentiality and the need to gather data to help secure better results in treatment and research.

• Restoring the dignity and respect for the medical and psychiatric profession through our work with patients, families, and the public.

To carry these out, we have assets:

Citizen support has steadily increased. There was only modest activity by citizen advocates before 1980. Since then, NAMI and the local alliances have become stronger.

Before the 1980s, only a few occasional academic centers had strong psychiatric research programs. Today almost every academic medical center has a substantial psychiatric research effort that frequently is either number 1, 2, or 3 in level of activity in that particular medical center.

We have strong APA leaders and psychiatrists serving as medical school deans, vice presidents of health science in academic health centers, chief executive officers of general medical hospitals, and key leaders at the AMA and American Association of Medical Colleges. We have tens of thousands of responsible psychiatric clinicians, educators, researchers, and administrators in various settings working on behalf of people with mental illness.

Research is exciting and increasingly sophisticated. Stem cells, imaging, molecular biology, genetic sequencing, optogenetics, greater data aggregation, and identification of biological markers all characterizes today’s research. Environmental risks factors for psychiatric disorders have been identified and confirmed. Epigenetic mechanisms are better understood. Gene-environment interactions are seen as central to many psychopathologies. All of these have led to more widespread collaboration.

I believe too that we are seeing an increase in the readiness of private philanthropy to augment government support for psychiatric research. NARSAD/BBRF over three decades has supplied over $328 million to more than 4,000 researchers all over the world from all the relevant disciplines. A brilliant new Lieber Institute at Johns Hopkins has been established with great support from the Lieber and Maltz families to focus on the basic etiology of schizophrenia. Ted Stanley has provided huge resources to the Broad Institute for work on the genetics of severe mental illness.

Philanthropy has for years been hindered by stigma. It is astonishing and disturbing that for so long so few have contributed to supporting research on mental health and mental illness when 20 percent of the country has a psychiatric disorder or is victimized because family members are racked by these illnesses.

It is welcome that President Obama and First Lady Michelle Obama have brought attention to the fight against mental illness and for strengthening research to understanding the brain. Others too like New York City’s First Lady Chirlane McCray have chosen to focus on mental illness.

So what actions must we take? Leaders like Lloyd Sederer and Steve Sharfstein have offered suggestions.

• Expand working relationships with patients, families, legislators, policymakers, insurers, and colleagues in other disciplines to strive for real parity.

• Educate all government leaders at the local, state, and federal levels regarding the mammoth issues under the umbrella of psychiatric illness.

• Work with APA President Renȳe Binder and President-elect Maria Oquendo, along with leaders like Florida Judge Steve Leifman, to diminish the criminalization of mental illness and help police respond more effectively to psychiatrically ill individuals.

• Expand assisted outpatient treatment and court-ordered outpatient commitment to reduce inpatient hospitalization, homelessness, and incarceration.

• Establish crisis and respite services in every community.

• Push for same-day appointments and open access for patients requiring immediate care.

• More actively include families in treatment processes.

• Advocate for research on gun violence as a public health crisis.

• Optimize diagnostic concepts and clarification for maximum clinical utility while exploring alternative frameworks to guide research directed at fundamentals of etiology and pathophysiology.

• As Fuller Torrey points out, we need to deal with patients who need long-term care in protected settings where both treatment and general support can be provided along with protection for the community from severely ill psychiatric patients who may have diminished impulse control.

We should work on advancing congressional bills such as Pennsylvania Congressman Dr. Tim Murphy’s bill, the Helping Families in Mental Health Crisis Act (HR 2646). While there are other meritorious bills related to mental health that ultimately should be considered in Congress as well, the general thrust is for these provisions:

• To create a single clinical coordinator for federal services and programs related to mental health and substance use disorders.

• To increase voluntary and when necessary involuntary access to mental health services.

• To value the judgment of clinicians and families.

• To increase the participation of psychiatrists in government at every level.

• To promote public education about what to do when faced with a patient with acute mental illness.

• To increase development of integrated mental health and primary care services.

• To promote reliable and valid quality measures to encourage mental health providers to ground clinical care in evidence-based, outcome-driven models.

• To increase funding for psychiatric research and violence prevention.

• To increase the number of psychiatric beds.

Psychiatry has a long and rich history. It has been filled with conflicts, challenges, and diverse ideologies. Simultaneously, it has been graced by people in research, education, community care, clinical practice, and many other areas whose main purpose has been to help people who are struggling with mental illness.

Detractors or critics are not unusual and in fact should be heard. They play a valuable role in all areas of societal engagement. Psychiatry has been a favored target by anti-animal research activists, anti-involuntary hospitalization advocates, anti-ECT spokespersons, and misinformed ideological critics of all forms of therapy in psychiatry.

Responsible criticism can encourage more or better evidence; it can point the way to new concepts, new technology, and new interventions and can serve to educate the public about mental illness and its treatment. This is valuable. What is ill advised are attacks by leaders of psychiatry on their predecessors and their work.

Psychiatry is not alone in failing to have the answers to all its illnesses. Pancreatic cancer, glioblastoma, Lou Gehrig’s disease, and many others unfortunately await greater understanding. Advances in psychiatry, as in these other fields, generally progresses step by step with clinicians and researchers building on, revising, or even on occasion reversing the findings of those who preceded them. The fact that earlier theories are overtaken or found to be incomplete does not diminish their value as steps along the way to greater understanding and discovery. This is the essence of science.

The Huntington’s disease gene was discovered in 1993—over two decades ago. Despite that great discovery, the next 20 plus years has not brought the critical understanding to explain how that gene causes the disease or the treatment to control or eliminate it. That is no criticism of the people who did the work. It was invaluable to identify the gene. Hereditary disease researchers have produced information that ultimately should help in clarifying the basic causes and developing effective treatments.

Let’s celebrate the constructive work of our predecessors. The psychiatry profession is not perfect, but it has a proud and honorable history and does not deserve the unfair or excessive criticism directed at it. Let us take pride in what our predecessors were able to accomplish in their time to reduce the harmful effects of mental illness on individuals, families, and communities and to improve care. The World Health Organization asserts that mental illness “is the most serious and destructive of illness among all medical pathology.” Our mission calls for dealing with that challenge. Let’s focus on our primary goal. ■