Challenging, but Interesting, Times Ahead for Incoming APA President

Caroline Cassels

May 21, 2010

May 21, 2010 — On the eve of the American Psychiatric Association's (APA's) 163rd annual meeting, APA president-elect Carol Bernstein, MD, discusses some of the key issues and challenges facing the profession in the next year and beyond.

A top priority, said Dr. Bernstein, is trying to reduce the stigma of mental illness by finding ways to integrate the practice of psychiatry across the spectrum of medical specialties into what she calls "the house of medicine."

"We have to stop viewing [mental health] as separate from overall health. Collaboration with our colleagues in other medical specialties is key," she said in an interview with Medscape Psychiatry.

Dr. Carol Bernstein

One proposed method of achieving this goal is to integrate mental health care into primary care clinics and marry physical and mental health records.

"Right now in our country we have different funding streams for community health, community mental health, for substance abuse, and for child mental health. Our system is fragmented, and we need to bring it together and be working side by side with our medical colleagues to improve patient care," she said.

Such initiatives, said Dr. Bernstein, will help advance much of what the APA has been trying to achieve with the recently passed mental health parity legislation, which, at its core, aims to end the considerable stigma and discrimination against individuals with mental illness.

20-Year Struggle

Under the legislation, it is mandatory for insurance companies offering private health insurance to provide nondiscriminatory coverage for mental illness that is equivalent to coverage for other medical illnesses, bringing the United States one step closer to ending its history of unequal coverage for persons with mental illness.

It has been a 20-year struggle to get this legislation passed, said Dr. Bernstein, and although it is a major step forward, there is still a considerable distance to go.

The government is currently looking at the implementation of the law, and the APA has submitted Interim Final Rule comments to help ensure the law is implemented the way its makers intended to ensure equal access to mental health care for individuals with mental illnesses.

"People are worried that the law isn't perfect, and it isn't. But just like the passage of the healthcare reform bill, parity legislation is a first step — one that is on par with the laws that challenged racial discrimination against the African American community in the 1950s," said Dr. Bernstein.

Time for Transparency

Another hot button issue that is expected to be tackled at this year's annual meeting is the issue of conflicts of interest between psychiatrists and the pharmaceutical industry.

In 2008 the issue of physicians' relationships with industry received wide media attention when allegations came to light that a number of high-profile psychiatrists allegedly failed to accurately disclose payments from drug companies.

Since then the APA has taken steps to reduce the association's ties with industry, including a gradual phasing out of industry-sponsored symposia along with industry-supplied meals at its annual meetings.

At last year's annual meeting a proposed set of guidelines was developed by an 11-member working group on individual psychiatrists' relationship with industry and was set to be distributed to its members for feedback.

The proposed guidelines addressed such issues as gifts from the pharmaceutical industry, receipt of medical samples, attendance at industry-sponsored events, consulting for industry, contact with pharmaceutical representatives, and disclosure of relationships with pharmaceutical companies.

The final guidelines have been passed by the board and are expected to be publicly released at the annual meeting.

Guidelines Stir Controversy

Dr. Bernstein acknowledged that the Appelbaum report created some controversy among the APA membership, with some clinicians concerned that the proposed guidelines may be encroaching on their individual rights.

However, she said, it is clear that full disclosure and transparency are principles that all physicians, including psychiatrists, must embrace.

"There is no question that the horse has left the barn. It hurts everyone's credibility if [the public] thinks that clinicians are being motivated by profit and not by science," said Dr. Bernstein.

Dr. Bernstein added that it is her personal belief that those involved in the leadership of medical organizations should be without financial conflicts and that she hopes the APA Board will ultimately move in this direction.

An APA committee chaired by Dr. Bernstein recently developed what she described as a "robust" disclosure policy to vet the potential conflicts of individuals involved in APA's governance.

"The form is quite extensive. Members are asked to disclose actual dollar amounts and [other benefits] they may have received. The forms are then vetted and reviewed," she said.

Nevertheless, she added, the relationship between drug companies and clinicians is complex and one size may not fit all. For instance, she said, although it may be relatively simple for a clinician in private practice to be free of drug company entanglements, the academic community relies on industry support, in addition to support from government agencies, to fund research, particularly in the current economic climate where funds are scarce.

"In academia it is a much more complicated issue because you want smart, intelligent people to be involved in research for new treatments. So the question is how do you do that in a way that is transparent and clear and not tainted," she said.

DSM-5 to Be a Living Document

If there is one issue that trumps the others, it may be the development of the new fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which will be tested in field trials this summer.

Still a work in progress, members of the 13 DSM-5 work groups are currently reviewing and refining the manual based on more than 9000 comments received from the public during a 2-month review phase in which the draft document was posted online. This initial review phase closed April 20. To date, said Dr. Bernstein, the DSM-5 Website has received more than 750,000 unique visits and more than 45 million hits.

The updated draft, she added, will be the focus of 12 sessions at the APA annual meeting, one of which will provide an opportunity for member feedback.

"The DSM-5 has 2 important values. One is the value to clinicians so that they can more accurately diagnose and ultimately treat patients. But it is also a research tool, and part of it is being developed so we can move forward with research and science to better understand the etiology of these disorders," said Dr. Bernstein.

She pointed out that the advent of the Internet will allow the DSM-5 to become a "living document."

"By being able to post [the DSM-5] on the Web, it will be easier to modify going forward. Future efforts at the APA will focus on how to operationalize making the DSM truly a living document," said Dr. Bernstein.

The final version of the DSM-5 is expected to be published in May 2013.

As APA president, Dr. Bernstein says one of her main goals is to prepare young psychiatrists in their roles as future leaders, educators, researchers, and clinicians.

"I hope we can develop more consistent direction and policy for the association as a whole, which means increased collaboration between the elected leadership and Dr. James Scully, who is the medical director and chief executive officer, to help move [the APA] forward.

"Towards that end we must understand the perspective of the next generation and how technology and communication are impacting young clinicians in the practice of psychiatry as well as their preferences for organizational participation. Their views and beliefs about leadership qualities are equally important," she said.

Dr. Bernstein will be delivering her address, Transforming Mental Health Through Leadership, Discovery and Collaboration, at the opening session of the APA annual meeting at 4:30 pm CT on Sunday, May 22.

Dr. Bernstein has disclosed no relevant financial relationships.


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