Prof. Jerrold F. Rosenbaum: mental health care is a critical part of the medical system and the ecology of healthcare
Editor’s note
The term ‘insane or psychotic’ is widely used as ridicule by people in their daily life. It is also said the person with the mental problem is in another world outside of the world of normal people. With the fast development and awareness of the mental problems which may due to the stress and relationship from the society, we are able to get more and more understanding on psychiatry. While psychiatry may remain as a mysterious field to many of the public, mental health is an important part of health care, part of medical system, part of the ecology of healthcare. Here we are honored to invite Dr. Jerrold F. Rosenbaum, the Psychiatrist-in-Chief, Massachusetts General Hospital, Trustee, Partners Healthcare, Stanley Cobb Professor of Psychiatry, Harvard Medical School to unveil myths about psychiatry and share with us his precious experience and stories in practicing psychiatry.
Expert introduction
Dr. Jerrold F. Rosenbaum (Figure 1), Psychiatrist-in-Chief at the Massachusetts General Hospital and Stanley Cobb Professor of Psychiatry at Harvard Medical School, is recognized as one of the world’s authorities on mood and anxiety disorders, with a special emphasis on pharmacotherapy of those conditions. His research contributions include extensive leadership in the development of new therapies, the design and implementation of trials to develop innovative treatments for major depression, treatment resistant depression, and panic disorder, studies of psychopathology including comorbidity and subtypes, and studies of longitudinal course and outcomes of those disorders.
Dr. Rosenbaum has authored more than 400 original articles and reviews and has authored or edited 20 books. He currently serves on 12 editorial boards of professional journals or newsletters. A particular research focus has been ongoing studies of children at risk for anxiety disorders and depression, which examine behavioral differences, risk factors, longitudinal outcomes, treatment, genetics, and brain structure and function of children of parents with mood and anxiety disorders.
At Mass General, Dr. Rosenbaum directs a department of more than 600 clinicians, researchers, and trainees, named by U.S. News and World Report as the #1 Department of Psychiatry in the United States in 2017 and for 19 of the last 23 years. Also at Mass General—the largest hospital based research institution in the world, with over 900 million dollars per year of research funding—he served as chair of the hospital’s Executive Committee on Research. His clinical and consulting practice specializes in treatment resistant mood and anxiety disorders, and he consults extensively to colleagues on management of these conditions.
Dr. Rosenbaum led the development of the Mass General outpatient service into a world leading clinical and clinical research center, with 60 specialty clinical and clinical research programs and over $60 million of annual external research funding. Dr. Rosenbaum was the 2007 recipient of the C. Charles Burlingame Award given annually for lifetime achievement in psychiatric research and education by the Institute of Living in Hartford, CT, the 2011 Massachusetts Association of Mental Health Friend and Leader Award, the 2016 recipient of the Joseph B. Martin Dean’s Leadership Award for the Advancement of Women Faculty, and a 2018 recipient of the Ellis Island Medal of Honor. He served as president and the chairman of the Board of the Anxiety and Depression Association of America and is president and on the Board of Directors for the American Foundation for Suicide Prevention, as well as on the MGH Board of Trustees and Partners Healthcare System Board of Trustees. He currently serves as a co-Chair of Development at MGH. He and colleagues have recently founded a venture, Psy Therapeutics LLC, for the discovery and development of novel therapeutics for psychiatric disorders.
Dr. Rosenbaum received his undergraduate degree from Yale College and his medical degree from Yale School of Medicine. He completed his residency and fellowship in Psychiatry at Mass General, Harvard Medical School.
Interview
ATM: October 10 is the World Mental Health Day. Last year, the theme is ‘mental health in the workplace’. Could you please explain your understanding on the theme from your experience?
Dr. Rosenbaum: I think it’s important to begin with the understanding that a psychiatric disorder is a mental health condition reflecting brain function. The brain is a very complicated organ and under many influences. Psychiatric disorders (e.g., such as depression, bipolar disorder, various forms of anxiety disorders, OCD and related disorders, eating disorders, substance use disorders and psychotic disorders) are extremely prevalent. We say here that no family goes unattached; the prevalence of psychiatric disorders in any one-year is probably 30–40% of the population one in six of which would be considered serious. So, the impact of these disorders is quite extensive, and is felt in many different settings including schools, families and workplaces. In the workplaces, typically, there are two issues: impact on the individual and impact on the company. One source of loss of productivity is called “absenteeism.” When people miss work because of their illness, the suffering of the individual has an impact on a company. The second concept is “presenteeism,” when employees with severe psychiatric disorders do show up at the workplaces but are not able to be productive and not able to be effective. So, these two issues, absenteeism and presenteeism, reflect the fact that psychiatric disorders are major concerns for the workplace. Also, since adults spend a considerable part of their lives in the workplace, just as children spend important parts of their lives in schools, these settings offer opportunity to identify those who need help. In the US, the health care system is largely funded by employers. And since there is financial impact on the company from these conditions, it’s important to keep people healthy in general and psychiatrically in particular.
ATM: Unlike other specialties, people may hardly know about the specialty and psychiatric hospital in reality but from movies like ‘One Flew Over the Cuckoo’s Nest’ and ‘Shutter island’. Is there any misunderstanding on the mental illness or the whole specialty?
Dr. Rosenbaum: The issue that you are addressing is covered by the term “stigma.” Stigma is less often seen in other medical conditions, illness and diseases whose causes are more easily understood and thus people tend not to blame the person who is ill. Psychiatric disorders have been slow to be understood by the general population. Now in many countries and across many cultures, stigma is lessening. This change may be understood in part by research on the genetics of psychiatric disorders, on biologic factors associated with psychiatric disorders, and new successful treatments of psychiatric disorders. Also, more people talk about their experience with conditions like depression and anxiety disorders. This evolution to understanding and destigmatization has occurred before in medicine. I remember in the 1950s, as a child in a medical family and with a mother a cancer survivor, the word “cancer” was unspoken due to stigma. People would not say the word because it was feared and they were embarrassed that they had cancer. But now it is OK. Therefore, stigma disappears with understanding. In many countries, going back to the dark ages, psychiatric patients were assigned to asylums and isolated from the general medical population. Today I work at Massachusetts General Hospital, one of the best-known medical and surgical hospital in the world. Here we see psychiatric disorders as a part of overall health care, part of the medical system, part of the ecology of healthcare. I think over time, as we get more and more understanding of how the brain works, solve some of the mystery, I believe will continue to decrease.
ATM: If you were asked to use a word (professional title) to describe a psychiatrist, what would that be?
Dr. Rosenbaum: A psychiatrist is a medical doctor, a specialist who has the knowledge, tools and skills to treats these special disorders of brain function that influence how people think, feel and behave.
ATM: Have you encountered any setback or challenge in your clinical practice?
Dr. Rosenbaum: For most of my career, we have not had a good understanding of the biology of these diseases. Our treatments were mainly developed by serendipity, a word we use to describe the main source of novel treatments. There remain many people, who do not get adequate treatment, many for whom we have not yet found an effective treatment, a condition we refer to as treatment resistance, about 10% of depressed patients for example are treatment resistant. I describe my specialty, my expertise, is in trying to solve treatment resistant depression. And at times we have success when we can help people whom nobody else has been able to help. There still are many patients who continue to suffer.
ATM: Is there any specific story for example one patient that you would like to share with us or any cases that impressed you most?
Dr. Rosenbaum: It is hard to pick one. Recently I have been working with a couple from the United State. The husband is a physician and his wife has a longstanding depression. She was a very happy person and her life was joyful; she has beautiful children; her husband was successful. Despite her positive circumstances, she developed a depression lasting 4 years and her life changed. She couldn’t get out of bed. She suffered depressive rumination. Before I saw her, the couple sought care everywhere but nothing really helped. I recommended several new approaches which reduced distress minimally. Finally, we explored an alternative medicine path that had shown some promise in early studies in animal models, and she remitted. So my watchword is to never give up. These conditions are heterogeneous. One person who gets depression is not the same as another. We know that no two people are identical so we have to be flexible until we can match treatment with people uniquely. In a sense, until we can personalize psychiatry, we have to be unrelenting, to keep pressing on and trying new things, because eventually we can find something that would help an individual.
ATM: What do you think is the strength of psychiatry in MGH?
Dr. Rosenbaum: Massachusetts General Hospital is a very large hospital. It has thirty-one thousand employees. Psychiatry is the second largest department after Medicine. Our department has numerous staff who hold professor and teaching positions at Harvard Medical School. We have three hundred psychiatrists and three hundred psychologists, so it’s a very large department. We are organized by subspecialties. Our department became so strong because we have an outstanding training program. We recruit residents and fellows.
ATM: As the Chief of Psychiatry for Massachusetts General Hospital Inc., how would you comment on the future development of the psychiatry in general?
Dr. Rosenbaum: I think society has started to recognize how psychiatry disorders are prevalent and their burden is costly, especially as we pay more attention to population health. It has become apparent that if you don’t address psychiatry disorders, you are going to pay for it in the long run in terms of increased health costs. Increasingly, what we call behavior health integration is a big force in western medicine in building into routine health care early screening and detection of psychiatry disorders. Early identification and intervention for children and adolescents at risks is also a critical priority. We have a saying here that the train to adulthood only leaves the station once, so if you miss this opportunity to intervene early and help children and adolescents, they will not only lose a big part of their development experience, and an important part of their intellectual and emotional growth, but also they risk a path of life-long disability and health problems.
ATM: Is there any challenge in the cultivation and training of psychiatrist?
Dr. Rosenbaum: Psychiatry as a specialty is growing more and more popular. We have a training program, where we admit 16 residents into the adult psychiatry training program every year. The number of people wanting to go on into psychiatry is substantial and growing, and the problem is we can’t keep up with the demand. The challenge is meeting the demand for adult and child psychiatrists in the country. Over 1,000 applicants are received each year for these 16 slots.
ATM: How would you comment on the working environment of psychiatrist? How would they influence a psychiatrist’s choice of obtaining their employment?
Dr. Rosenbaum: In contrast to other medical specialties, the working environment of a psychiatrist doesn’t require expensive technology, equipment, and space. So there is great flexibility as to where a psychiatrist can practice. You can work at a general hospital, psychiatric hospital, primary care setting, or private office. All in all, there’s tremendous flexibility of our work environment. You can take your skill and work anywhere. The most important tool you need is yourself.
ATM: What would be your advice for the young generation who are ready to pursue in psychiatry?
Dr. Rosenbaum: The next generation to pursue psychiatry will know much more about the mystery of how the brain gives rise to the mind, emotion, motivation, cognition and behavior. All of these secrets are starting to be revealed. The journey of translating this knowledge into psychiatric practice is exciting.
Acknowledgements
None.
Footnote
Conflicts of Interest: The authors have no conflicts of interest to declare.
(Science Editors: Grace S. Li, Hailing Lian, ATM, editor@atmjournal.org)
