NIMH during the tenure of Director Herbert Pardes, M.D. (1978-1984): The President's Commission on Mental Health and the reemergence of NIMH's scientific mission

To summarize these 5-1/2 years, I would offer the following. NIMH--which, like the mental health field in general, has focused principally on services and broad social issues in the 1960s and 1970s--was modified to be a more scientific institute focused on basic biology and behavioral science, major clinical disorders, diagnosis, treatment, and epidemiology. NIMH in its entirety regained a high level of respect in the general NIH community and won increasing support from Congress and the Administration. Increasingly positive perceptions of NIMH may have had a positive effect on the recruitment issue in psychiatry; the numbers of U.S. recruits started to turn back upward. After the early assault by the OMB and the Reagan Administration on the NIMH budget, the year 1982 and 1983 led to a more supportive attitude, and so the threat to the vitality of NIMH and to its overall fiscal support relented. Programs in research training and mental health clinical training and the intramural program were sustained along with the preeminent focus on building extramural support. We recognized that support of the intramural program accounted for an unduly high proportion of overall NIMH research expenditures. In response, we set firm policies designed to build the extramural program while maintaining the strength of the intramural program without expanding it. I might note parenthetically that I had the opportunity to chair an Intramural Research Program Planning Committee convened by NIMH. Without anticipating Dr. Hyman's comments regarding this effort, I will say that we found the intramural research program to be a national resource that, with continued emphasis on scientific quality, should contribute greatly to the nation's mental health and scientific goals in the years ahead. Perhaps in the most global terms the era can be remembered as one in which NIMH shifted toward becoming a predominantly research institute with related education programs. On the one hand, we drew some limits regarding what was considered the purview of NIMH, and we focused much more on illness. On the other hand, we retained much of the richness of NIMH and its focus on the relationships between various disciplines, while catalyzing the extraordinary explosion of the capacity to understand brain and behavior and thereby bring greater promise to the effort to control psychiatric disorders. The excitement of the research and the greater enthusiasm of the government, along with NIMH's encouragement of citizen group activity, contributed to destigmatization and set the groundwork for a much stronger overall advocacy effort on behalf of NIMH, which has continued over the last 10 to 15 years. Simultaneously, attempts were made to secure more data regarding the usefulness of psychiatric treatments and their effectiveness. This too would serve us well in terms of a more favorable attitude toward improving insurance through Medicare and through other areas of mental health care reimbursement. It is an honor to have worked at NIMH. The staff members there are superb, and I want to express my thanks to them. The dedication of outstanding federal leaders is one of the powerful assets of this nation and has been central to the many accomplishments of NIMH.

NARSAD: a decade of support for psychiatric research. Interview by John A Talbott

The National Alliance for Research on Schizophrenia and Depression (NARSAD) celebrated its tenth anniversary this year. The organization raises and distributes funds for scientific research on brain disorders. As a member of NARSAD's scientific council since the organization was founded, I have been greatly impressed by the energy and commitment of NARSAD's leaders and staff and the many individuals who volunteer as members of the board of directors and the scientific council. I asked Constance E. Lieber, president of the board of directors, and Herbert Pardes, M.D., president of the scientific council, both of whom have been deeply involved with NARSAD since its inception, to agree to an interview with Psychiatric Services. The following is an edited transcript of the interview.

Herbert Pardes, MD

Though mergers, affiliations, and financial challenges pervade all of academic medicine, New York City exhibits in microcosm the changes taking place throughout the country. At the helm of Columbia University College of Physicians and Surgeons is Herbert Pardes, MD, who came to Columbia in 1984 from the NIH and has served as dean since 1989. Since becoming dean, Pardes has received high marks for re-invigorating the academic strengths of Columbia while skillfully managing the financial issues faced by an inner-city medical center. Interviewed in his office in upper Manhattan, Pardes candidly discussed life and times in the big city and the difficulties of maintaining an emphasis on research in an era when money talks.

The future of medical schools and teaching hospitals in the era of managed care

At the 125 U.S. medical schools and their affiliated teaching hospitals, most of the nation's basic and clinical research advances are made, and these translate into topflight medical care and great reductions in health care costs (e.g., $30 billion a year for polio). But these medical schools and teaching hospitals and their capacities to provide critical education and research are threatened by escalating erosion of their infrastructure, the declining academic workforce, the diminishing of quality and access as a result of growing marketplace forces, and shrinking funds. The author provides details about the forces threatening academic medical centers (i.e., medical schools and their affiliated teaching hospitals) and then presents a variety of strategies that individual academic medical centers can carry out to more efficiently use their resources. But sufficient resources ae still needed if centers are to function as they should. What is to save them? The author indicates that centers should not overly depend on managed care, the pharmaceutical industry, or foundations to provide the necessary support, and that centers' internal strategies can go only so far. He proposes that the importance of centers and the dangers they face must be communicated convincingly to the nation's citizens, business leaders, government representatives, and purchasers of health care. The message must be repeated frequently so it will sink in, and must be given in terms that are relevant to individuals and their families. He also advises that certain types of partnerships may be helpful. But most critical is the need to persuade the government to mandate separate revenue streams for research, education, and care for the underserved. As hard as this will be to achieve, there are many allies of academic medicine, from the president to numerous legislators; the author discusses what they have said and done to help. He concludes by urging everyone in academic medicine to do their parts to make a powerful case for the value of academic medical centers to society, and affirms his belief that American society will sustain these centers.

Genetics and psychiatry: past discoveries, current dilemmas, and future directions

Family, twin, and adoption studies have suggested an important role for hereditary factors in the etiology and pathogenesis of several psychiatric disorders. Advances in molecular and statistical genetics may very well reveal the identity of these factors, which may include single genes. Linked markers, critical to the discovery of abnormal genes in several medical conditions, have been reported for Huntington's disease, Alzheimer's disease, bipolar disorder, and schizophrenia. Psychiatric disorders pose particular problems (etiologic heterogeneity, incomplete penetrance, variable expressivity) for genetic research. New practical and ethical questions also arise. Nevertheless, knowledge may emerge that will suggest new approaches to diagnosis, prevention, and treatment.

Neuroscience and psychiatry: marriage or coexistence?

Psychiatry, which has experienced the influence of many thrusts in its history, is currently experiencing the impact of neuroscience. Clinicians view the impact with excitement and with apprehension. The author reviews examples of the excitement of scientific developments related to psychiatry. He traces the coexisting evolution of a more differentiated clinical psychiatry and deals with questions of reconciling neuroscience and behavioral approaches. The author's contention is that neuroscience will strengthen psychiatry and that biological and psychological integration will thus be enhanced.

The clinician-researcher in psychiatry

As clinical research in psychiatry has grown in importance and promise in the past decade, the need for a growing pool of skilled clinician-researchers has been increasingly recognized. Compared with physicians in other specialties, psychiatrists in academic positions have less training in research and devote less time to it, which is reflected in the growing concentration of research funds from the National Institute of Mental Health in just a few of the strongest medical school departments. To focus attention on the need for developing the role of clinician-researchers, the authors examine four major tasks faced by clinician-researchers and present a developmental perspective on the transition to research.

Psychiatric research: the role of the state

Psychiatric research is as exciting as any field in health science today. But it will require support from a variety of sources if it is to achieve its potential. Two main points bear emphasizing in any overview of current mental health research. First, of course, is the vitality and significance of the work itself, and second is the multifaceted issue of support. This presentation will review briefly the various component parts on which this country's mental health research establishment is based: funding from the federal government; the crucial role of the individual state; and contributions of various other sections of our society to the overall research effort. This overview will also consider some of the secondary results of research support within the state.

Haloperidol concentrations elevated in Chinese patients

After 6 weeks of fixed dose oral haloperidol treatment. Chinese schizophrenic patients (in the People's Republic of China) had 52% higher plasma haloperidol concentrations than U.S. non-Asian schizophrenic patients. Chinese and U.S. patients were matched for sex and body weight. The difference in plasma drug concentrations may explain why Asians are reported to require smaller dosages of neuroleptic drugs than non-Asians, and why they may be more sensitive to neuroleptic-induced side effects. When prescribing haloperidol to persons of Asian ancestry, physicians should consider that higher than expected plasma haloperidol concentrations and an increased sensitivity to haloperidol may occur.

Survival strategies for community mental health services in the 1980s

Widespread reduction of financial resources has created a growing concern about the survival of community mental health services and their inherent concepts and ideals. To survive and, in some ways, grow, community mental health centers have used strategies such as incorporation, alternative services, innovative funding, and political activities. The authors discuss strategies that focus on the program management aspects of mental health. They theorize that if CMHCs can employ business techniques but retain the values of community mental health, a more efficient, yet still highly principled, system of mental health services can result.

Challenges to academic psychiatry

Economic constraints, effects of retrenchments in federal health policy, and increased competition for resources are challenging all sectors of academic medicine. Departments of psychiatry are at particular risk during this era for reasons including the lack of a sound research and research training base in many psychiatry departments; the small number of students entering the field and implications therein for the availability of residency slots in psychiatry; and patterns of allocating resources within academic medical centers which, combined with biases in reimbursement policy toward cognitively based specialties, threaten the economic strength of psychiatric departments. A conceptual model based on marketing principles is proposed to aid in identifying and capitalizing on the unique strengths of the field.

Introduction: research at the interface of medicine and psychiatry

Linkages between psychiatry and other medical specialties have become increasingly evident over the past decade. Reinstatement of the medical internship for psychiatric trainees, expansion of psychiatric liaison services, growth of general hospital psychiatric units, determination of the extensive role served by nonpsychiatric physicians in providing mental health care, and research evidence of the economic benefits of incorporating mental health services in general health settings all have served to break down artificial boundaries between mental health and general health concerns. The psychiatric consultation-liaison service initiated in 1981 by the NIMH at the NIH Clinical Center in Bethesda has afforded opportunity for numerous collaborative research projects with clinical investigators of various categorical disease programs. In addition to offering new etiological insights into psychiatric and general medical illnesses, the work described in this symposium promises to move clinical practice closer toward the Engel model of biopsychosocial medicine.

Report of the Graduate Medical Education National Advisory Committee and health manpower development

The federally chartered Graduate Medical Education National Advisory Committee projected a shortage of approximately 12,000 general and child psychiatrists by 1990. The committee's methods of analysis and recommendations have been criticized on grounds ranging from the accuracy of its data to the appropriateness of federal involvement in free-market issues. Yet the GMENAC report appears to have contributed to a recent reversal of psychiatric recruitment trends, and psychiatrists should be aware of its further implications for clinical and academic psychiatry. We analyzed the GMENAC process as one element among many that will determine future health care personnel development trends.