Psychiatry Is No Longer the 'Runt of the Litter'

Drew Ramsey, MD; Jeffrey A. Lieberman, MD


December 18, 2019

Editorial Collaboration

Medscape &

This transcript has been edited for clarity.

Drew Ramsey, MD: I'm Dr Drew Ramsey with Medscape and Columbia Psychiatry. I'm here with our department chairman, Dr Jeffrey Lieberman, who has been the president of the American Psychiatric Association (APA). A lot of you know Dr Lieberman through his work on the CATIE trial.[1] We wanted to check in with you. It's the 175th anniversary of the APA and you call this a watershed moment for our field.

Jeffrey A. Lieberman, MD: It is because of the fact that psychiatry, over its 200-year history and 175 years of the APA, has really struggled in the sense that it was the "runt of the litter" of the disciplines of medicine.

Ramsey: We never felt like we were really in the house of medicine. Is that changing, in your opinion?

Lieberman: It's definitely changed. We were in and then we were out when we were in the asylums. Then we journeyed down the garden path of Freudian psychoanalytic theory, and now we're back in terms of trying to be a pluralistic discipline which integrates different modalities to treat mental illness, such as psychosocial, pharmacologic, neuromodulatory. And the momentum is growing. What makes this a true opportunity and unique moment in this history is the fact that there is a convergence of awareness on the importance of the discipline because of the population frequency of mental disorders and their manifesting in a way that is problematic for society. Homelessness, addiction, suicide, incarceration, and mass violence have gotten the attention of the public, the media, and the government.

Ramsey: People are paying attention, and more than ever we're answering and we're involved. People consider psychiatry and mental health in a way like never before.

Lieberman: It's never been like this in terms of awareness and appreciation. If you have cancer, if you have cardiovascular disease, the limitation of what can cure you or restore you is the level of knowledge and effectiveness of the treatments. In mental health care, it's a systemic limitation of not having the services available. We have the knowledge, but we're just not using it. Because there is an awareness of how many people are affected, what the economic consequence of that is, and these social pathologies that are the tips of the iceberg of a failed policy, they now are saying, "Oh, I get it—we have to do something." This is really the low-hanging fruit for the politicians.

Ramsey: Let's talk a little bit about some of the science. Before you became a chairman, you were a great researcher. Are there scientific breakthroughs that excite you at this meeting and that all of the psychiatrists watching can be inspired by?

Lieberman: Absolutely. First of all, psychiatry gets criticized because we have not deconstructed the brain to understand where the lesion is or where the dysfunction is.

Ramsey: I saw some presentations; it feels like we're getting closer. There were some complex diagrams where I felt like I needed to go back and do a residency again.

Lieberman: You can apply.

Ramsey: You'll let me back?

Lieberman: You can do a double residency.

Somebody would say in cardiology, "It's taken you 175 years; what took you so long?" The answer to that is, the brain is not the heart.

Ramsey: It's a little more complex than a pump—no offense to our cardiology colleagues. But it seems like we're getting closer to understanding.

Lieberman: It's the most complex organ in the animal kingdom, maybe even in the universe. Our territory, our real estate, as opposed to neurology and neurosurgery or otolaryngology, is the most highly evolved portions of the brain. We didn't have the technology to be able to characterize the dysfunction of circuits unlike [those treating] a lesion produced by a stroke or tumor. But now with noninvasive imaging techniques, the use of electrophysiologic measures, and the use of genomics, which allows us to then grow through reprogramming pluripotent stem cells into organoids (which are, in effect, little brains that are personalized), we have the capacity to do so. The opportunity before us is probably greater than in any other discipline right now. Cancer has made tremendous strides but psychiatry is poised to do the same, and even exceed it, because the number of people affected is so much more.

Ramsey: It's been such a pleasure to speak with you and to hear that there is great hope for the field. It's a watershed moment. We're making "baby" brains and we're researching in a way that we never have before, and we're understanding the mind and the brain. It's been a pleasure to catch up with you and hear about how our field is really poised to launch into the next decades.

Everyone, please tune back into the Columbia Psychiatry channel here on Medscape, where we will be talking with experts and sharing the latest and greatest in research and clinical care. Thanks, Dr Lieberman.

Lieberman: My pleasure. Thanks, Drew.

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