COMMENTARY

A Brief History of American Psychiatry: From a Founding Father to Dr Anonymous

Drew Ramsey, MD; John M. Oldham, MD, MS

Disclosures

November 07, 2019

Editorial Collaboration

Medscape &

This transcript has been edited for clarity.

Drew Ramsey, MD: Hello, everyone. I'm Dr Drew Ramsey from Medscape Psychiatry and Columbia Psychiatry, here at the American Psychiatric Association (APA) 175th annual conference. We wanted to talk a little bit about history with Dr John Oldham, one of the leaders in our field. Dr Oldham is a professor of psychiatry at Baylor and the chief of staff at the Menninger Clinic. He is the past president of the APA and was the director of the New York State Psychiatric Institute when I was an intern and a PGY-II. John, it's really good to see you again. You helped create a remarkable tribute to the 175th-year history of the APA.

John M. Oldham, MD, MS: This was a group effort and a wonderful opportunity to celebrate the 175th anniversary of the APA.

Ramsey: Let's hop into the timeline. We wanted to focus on three or four of the most important points in the history, according to Dr Oldham. Let's get started.

Benjamin Rush: 'Father of American Psychiatry'

Ramsey: The first stop on our timeline is, of course, Dr Benjamin Rush. Who is Benjamin Rush?

Oldham: Benjamin Rush was a major, major figure in the history of psychiatry and usually is referred to as the "Father of American Psychiatry." He is widely recognized for his work. On the wall is the first real textbook of psychiatry, called Medical Inquiries and Observations, Upon Diseases of the Mind. It was the standard textbook in psychiatry for decades.

Ramsey: The first textbook [was published] in 1812.

Oldham: Rush was revered. One of his mentors was Benjamin Franklin. He had many contacts.

Ramsey: He was known as the "American Hippocrates." He was a huge figure in American medicine. I believe he had a son who had what they called a breakdown and then eventually died by suicide.

Oldham: That turned his interest onto the field of mental health and mental illness. He was widely regarded as a very revered expert and compassionate physician who really moved away from the early pre-colonial myths—demons and witchcraft—to focus in on the medical nature of the brain and the mind, and to treat it as a part of the body that we needed to understand more about.

Ramsey: I love that we had a psychiatrist sign the Declaration of Independence. It feels like it establishes from the very beginning that we were going to be a country that is achieving what we're realizing now, where mental health is considered an equal partner in our physical health.

Oldham: Exactly. He was so widely respected that he was able to get that message across in a way that I think would have been hard for many people to achieve.

St Elizabeth's Hospital and New York State Psychiatric Institute

Ramsey: Let's move on to just a little more history. History buffs always want to know about "firsts." Dr Oldham wanted to stop here and tell us about a couple of firsts in American psychiatry.

Oldham: St Elizabeth's Hospital was one of the grand major hospitals, where a lot of wonderful things were done. In 1855, this was established by the federal government as the first psychiatric hospital, in Washington, DC. This continues to be a major site for training and for care. It was a large example of the hospital system that grew throughout the country when the mentally ill were cared for in inpatient settings, way before we had the treatments that are now available. How did we get to better and better treatments? We did that through lots of things, such as education, clinical wisdom, and research.

I also wanted to talk about the first and oldest psychiatric dedicated research facility in the United States, which was the New York State Psychiatric Institute. It was founded in 1896. Enormous progress was made at this institute. It was a hospital and it also extended into a basic science and hospital research institute. More recently, people in the institute included Eric Kandel, who won the Nobel Prize for his work about learning and memory. This is the kind of important research that has helped us progress from these early days until the state of the science at this point, which is remarkable.

Ramsey: New York State Psychiatric Institute is where Josh Gordon, the current director of the National Institute of Mental Health (NIMH), trained, and I think it is one of the top-funded institutes in terms of NIMH funding year after year. I really think it sets a standard for how research and clinical care can go hand in hand in an institution and absolutely change the field.

Dr John Fryer, aka 'Dr Anonymous'

Ramsey: Let's move on to a few more moments. The APA has been focusing on trailblazers, and we wanted to stop here because 1972 is a historic moment. Dr John Fryer came in front of the APA as a psychiatrist and as a member, wearing a mask as "Dr Anonymous" and requesting that homosexuality be taken out of our diagnostic criteria. John, where were you in this moment?

Oldham: This was right after I was a resident in psychiatry at Columbia, which is where Bob Spitzer was doing work on the Diagnostic and Statistical Manual of Mental Disorders (DSM) III. I had finished my residency in 1971, so I had been very conversant with this controversy because it didn't all erupt at once. This was something that was discussed, even in the prior work that led to that 1980 publication of the DSM-III. What qualified as an actual, legitimate illness, and what didn't, was really an interesting history. Sexual disorders were classified as personality disorders in DSM-I. That is a very different way that we later thought about it when they became viewed as disorders all by themselves. But it was the progress based on the courage of this man, and many others who followed, that led to the recognition that sexual orientation was not something that should be qualified or classified as an illness.

Ramsey: Certainly, this was a moment where I think we learned something about our field and something about establishing trust with the public. This was a nice moment for everyone here to remember John Fryer, "Dr Anonymous," who helped us look at who we are, and change who we are, as an organization.

DSM and Diagnostic Criteria

Ramsey: Let's move on to some diagnostic criteria. As we begin to think about diagnostic criteria, you've been really intimately involved with the DSM, especially around personality disorders. But tell us about how diagnosis has shifted and why what we did with the DSM was so important.

Oldham: The DSM is a diagnostic manual that the APA has been the leader in developing, and it's not just used in this country; it's used worldwide. The labels in the DSM are not based on hard science alone. We use all of the research we've got, we use all of the clinical wisdom we've got. But it's a language. It's a way we can talk to each other. We know pretty much what we're talking about by using the same terms, but there is nothing specific [about it] that is absolutely gospel.

Ramsey: That frustrates the public in a certain way—that this is a "language" for us to frame up how individuals are struggling and how to understand what parts of their personality could be at play. But in some ways, how else would we do that when we don't know exactly what these disorders are, from a biological basis? What do you think Benjamin Rush would have thought about this?

Oldham: I think he would have liked it, and I think he would have wished we had gone further down this road.

Ramsey: This is some of our history. The APA has had such a rich 175 years. Along with our increasingly valid diagnostic systems, all of the brain science has changed over the 175 years to where we now think about [psychiatry] from a genetic level and a neurocircuitry level. We're combining that with better diagnosis and we are really taking on stigma.

It's been such a pleasure to learn a little bit more about our history. Dr Oldham, thank you so much for joining us. I'm Drew Ramsey for Medscape. We'll see you next time.

Drew Ramsey, MD, is an assistant clinical professor of psychiatry at Columbia University College of Physicians and Surgeons, and one of psychiatry's leading proponents of using nutritional interventions to help prevent and manage mental illness. Ramsey splits his time between New York City and his family farm in Indiana.

John M. Oldham, MD, MS, is a distinguished emeritus professor of psychiatry in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine. Previously, Dr Oldham held positions as director of the New York State Psychiatric Institute and president of the American Psychiatric Association.

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