From neighborhood psychiatrist to hospital executive, APA President Steven
Sharfstein, M.D., has followed a career path over the past four decades
encompassing virtually every major development in the treatment of mentally
ill individuals and illuminates how psychiatry has been shaped by a confluence
of science, politics, and economics.
In his opening address at APA's 57th Institute on Psychiatric Services in
San Diego last month, and in a later lecture there, Sharfstein sketched the
outlines of a career from early training in the psychoanalytic tradition,
through social engagement in the pioneering days of the community mental
health movement, to president and CEO of a revered hospital that began to
transform itself in the late 1980s in the era of managed care.
Today, Sharfstein said, the ethical psychiatrist operates in a"
clinical gray zone" in which a continuum of therapies—from
intensive inpatient to partial hospitalization to day treatment and outpatient
therapy utilizing a variety of approaches—can be tailored to the
individual for the most cost-effective outcome.
"Guidelines encompass areas of treatment where there is no black or
white approach," said Sharfstein, president and CEO of Sheppard Pratt
Health System in Baltimore, Md. "Instead there is a range of treatment
approaches that are biological, psychosocial, short term, or long term. The
ability and willingness of clinicians to try new treatments and adapt to new
payment systems, and therefore shift their practice over time, depend on the
terrain of the clinical gray zone."
In opening remarks at the institute, whose theme was "Community and
Recovery," Sharfstein described his origins as a community psychiatrist
at the Massachusetts Mental Health Center in the heyday of psychoanalysts
Elvin Semrad, M.D., and Jack Ewalt, M.D.
An early "romance" with psychoanalysis evolved into an interest
in a more socially engaged psychiatry, and it was at the Massachusetts Mental
Health Center that Sharfstein helped to put into practice the concept of"
neighborhood psychiatry." As a second-year resident in a
federally funded neighborhood health center in Jamaica Plain—part of the
catchment area served by the center—Sharfstein served as both primary
care physician and psychiatrist.
"I became familiar with and excited about providing services to
deinstitutionalized and chronically ill individuals in their homes and
neighborhood," he recalled. "I worked with acutely distressed
families and individuals with a range of psychiatric problems in this
It was during this period that Sharfstein witnessed a major tipping point
in the history of psychiatry—the approval of lithium for
"I admitted a patient suffering from acute mania with numerous
previous admissions as part of his unstable bipolar illness," Sharfstein
recalled. "I presented the patient to Dr. Semrad and asked for his
permission to try lithium. I will never forget his answer: `How is it that you
cannot sit with this patient?'
"Three and a half months later, when the FDA approved lithium in
1970, I started [the patient] on lithium therapy, and his dramatic improvement
allowed me to do some psychotherapy with him," Sharfstein said. "I
became a firm convert to the efficacy of mood stabilization by pharmacological
means after this experience. The paradigm shift in American psychiatry from
psychoanalytic to psychobiological began in earnest after lithium
Steven Sharfstein, M.D., presents a lecture at APA's 2005 Institute on
Psychiatric Services. "Despite the efforts of payers and their managed
care hired guns to reduce and constrain care," he said, "there is
a sense of rising expectations in society for effective psychiatric
But 35 years later, Semrad's question—How is it that you cannot sit
with this patient?—resonates anew.
Sharfstein cited 2001 data from APA's Practice Research Network showing
that only 37 percent of bipolar patients who were in outpatient treatment with
psychiatrists and who had indications for psychotherapy were receiving it.
In the era of managed care, Sharfstein asserted, the clinical gray zone in
which psychiatrists work has been a target for manipulation. Managed care"
has played havoc... by insisting on the least costly alternative and
successfully reducing the cost of care to the payers, especially
Managed care organizations have focused on what is known in economic
circles as "efficiency risk"—the cost-benefit ratio of
treating a group or category of patients—at the expense of what might be
good for individual patients, Sharfstein observed.
He cited the example of 28-day hospital stays for substance abuse
treatment, an approach that proliferated in the 1980s with little or no
evidence for the efficacy of that "magical" timeframe. The 28-day
program was in time managed virtually out of existence—even as health
plans failed to offer less-intensive
APA President Steven Sharfstein, M.D., opens APA's Institute on
Psychiatric Services last month in San Diego with the traditional bell-ringing
ceremony. Sharfstein discussed the clinical and ethical challenges today's
"Treating all patients with substance use disorders with 28-day
programs is clearly wasteful," he said. "Having no inpatient
coverage, however, for such patients is clearly risky."
Today, Sharfstein said, modern clinicians have more options than ever for
individualizing care across the clinical gray zone.
These include combinations of medications and psychotherapy;
dialectical-behavior therapy for patients with borderline personality
disorder; cognitive-behavioral therapy for depression, anxiety, and residual
symptoms of schizophrenia; family education for patients with schizophrenia
living at home; assertive community treatment; supported employment; and
multimodal treatment of children with attention-deficit/hyperactivity
disorder. And in the era of the "recovery movement," there is a
widening recognition that treatment works.
"Despite the efforts of payers and their managed care hired guns to
reduce and constrain care, there is a sense of rising expectations in society
for effective psychiatric care," Sharfstein said. "This is a very
good time in the field. More medical students from American medical schools
are selecting psychiatry over the last few years, and they are doing so for a
reason. Patients get better with treatment, we can make a good living, and the
work has never been more interesting." ▪