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Q & A WITH SERIES ADVISOR JEFFREY LIEBERMAN, M.D.

Where does the term “psychiatry” come from?

The term psychiatry translates to “healer of the soul.”

 

What is mental illness?

Mental illness is a disturbance in someone's mental functioning or behavior, which is outside of the range of what would normatively occur and is causing them great distress. It may be impairing their function and is disproportionate to the circumstances they're in. For example, if somebody is depressed because somebody died, or they lost their job, or they didn't win the game, it's understandable to be depressed. But if you're profoundly sad, crying every day, can't get out of bed and there's nothing in your life that really seems to be responsible for that, then that's disproportionate. 

So, we define mental illness based on distress, based on if it's enduring as opposed to transient, and whether it's proportionate to an individual's circumstances.

 

How do you diagnose mental illness?

We do it by defining the symptoms and the course. 

There is still no objective biologic test by radiology, EKG, blood test, or by measurement of the vital sign that can be used as a diagnostic test for the mental disorder. We’d like to have them. We desperately seek them. It's the Holy Grail to have a diagnostic test.

 

Is there a cure today for mental illness?

We have the ability not to cure, necessarily, not to know the definitive causes of all the mental illnesses, but we have the ability to effectively treat the majority of mental illnesses, which collectively affect about a fifth of the world's population. It means changing people's lives for the better, and in the best cases, allowing them to live pretty much normal lives, albeit with treatment, just as if they were being treated for high blood pressure or for diabetes or for asthma.

 

What medical breakthroughs allowed doctors to begin treating mental illness effectively?

1950 marked the beginning of the decade that changed the field of psychiatry and the history of mental illness because the first genuinely therapeutic treatment for mental disorders was discovered. It was discovered by a French surgeon working in Algeria, trying to develop a treatment to treat surgical shock, but in the process synthesized a molecule called chlorpromazine. It turned out to be ineffective for his purposes, but extremely effective for schizophrenia and alleviating the psychotic symptoms.

By the early 1960s, there were 40 million people around the world who were on Thorazine. Today, virtually any person that has a diagnosis of schizophrenia is on a Thorazine derivative or Thorazine-like medication. 

The first antidepressant, Imipramine, was discovered by a Swiss psychiatrist.

 

Moving forward, what should doctors focus on to more effectively treat mental illness?

It's going to take a sustained commitment in terms of the scientists, the clinicians, the government funding agencies, and the advocacy groups in patient populations. Genes are key to determining who we are, and we thought if we could sequence the genome, we would know everything that we need to know. But when that was completed, we found out that was only the beginning.

Even though we had the blueprint, we didn't know how the parts of the blueprint interacted with each other to produce the diversity of expression that creates, you know, the panoply of features in the human population. It's a complicated problem and we're going to get there, but it's not going to happen immediately.

 

Why are there more people with mental illness in jail than ever before?

Going back millennia, mental illness was viewed as a supernatural phenomenon: You were either cursed and the work of the devil, or you may have been a Saint and enlightened. Then it became moral deviance and religious heresy, and then we had the notion that these were naturally-occurring conditions. They're illnesses that affect people. And we don't want them running amuck and hurting themselves or getting into trouble. So we want to put them somewhere where they're going to be safe and cared for.

That was the asylums. Unfortunately, the asylums turned into snake pits, and there was a social movement to treat people more humanely by allowing them to be living in the community and treated in the community with resources, medication, and social support services. But those resources never materialized, so that grand vision went awry. 

As a result, jails have become the largest site for people with mental illness of any institutional system in our society. There are more people in jail with mental illness than there are in state mental hospitals or any type of community residential program. 

The effort has not been expended to enable them to be diverted from being put in jail if they do come in contact with the law. As a result of that, they get taken to a jail, get a court sentence, and end up in jail. Basically, it hasn't risen to the level of importance enough for our society to readdress this.

 

How is the state of mental health treatment today? 

We know more than we ever have in history. But at the same time, far less is being done than could be done, and it really has to do with the second class status, the prejudicial policies that govern how mental health care is provided in our country, and in many other countries as well. It reflects what the stigma, prejudice, and biases are, which are historical and continue. It’s the continuation of a long history.

 

How have doctors raised awareness in communities that stigmatize mental health and mental illness?

The challenge for psychiatry was first to acquire that knowledge through scientific methodology and technology. But the other challenge is, how do you implement it? How do you provide it to people and get the most bang for your buck in terms of improving the quality of life and extending the longevity of humanity? 

We have to think about each community individually in terms of its characteristics. So each group—whether it's Hispanics, whether it's African-Americans, whether it's LGBTQ people—has their own way of perceiving and interacting with healthcare providers. And in the case of the African-American community, which has historically been very wary of white institutional authority, one of our faculty has gone to the churches, which is a point of social congregation of African-Americans. Instead of giving a sermon, he gives a lecture. Afterwards, he is able to do assessments like in the clinic. That’s been extended to another place where people traditionally congregate, the barbershops. 

With this kind of cultural sensitivity and tailoring the delivery of healthcare, mental health care services actually achieve greater impact in terms of benefiting the health of people than some scientific discoveries.

 

How has COVID affected the state of mental health in America?

The first way it's affected it is in terms of people being susceptible to the illness and having lost loved ones.

The next biggest consequence will likely be the effect that this experience, and the social and economic disruption that it's causing, will have on the collective human psyche. Apart from people having had their lives disrupted, potentially having been sick and in the hospital, or having lost loved ones, it's changed their lives in that the whole social fabric and network has been disrupted.

The majority of people, even though it's been unpleasant and difficult for them to go through, can weather it because people are resilient. There's also information that's been put out as mental health first aid for ways to cope with isolation in terms of ways to maintain a routine through this.

But for people who have pre-existing conditions, psychiatric conditions, or have constitutional or genetic vulnerabilities, particularly to conditions like anxiety disorders, mood disorders, substance abuse disorders, obsessional disorders, phobic disorders, this is going to tip them over the edge, and prompt them to become symptomatic. We'd be much better off if we were proactively taking steps to mitigate that effect through a proactive, public mental health initiative to try and preempt or mitigate the psychological consequences of COVID.

ABOUT DR LIEBERMAN

Jeffrey A. Lieberman, M.D., is Chair of Columbia University College of Physicians and Surgeons, the largest and leading Department of Psychiatry in the U.S.; the Director of the New York State Psychiatric Institute, a research institute on brain disorders; and Psychiatrist-in-Chief of the New York Presbyterian Hospital-Columbia University Medical Center.

Over his nearly four-decade career, Dr. Lieberman has cared for thousands of patients with serious mental illness, and published more than 700 academic articles and 16 books, including the textbook Psychiatry (John Wiley & Sons Ltd); Comprehensive Care of Schizophrenia (Oxford University Press); and the critically acclaimed Shrinks: The Untold Story of Psychiatry (Little Brown, 2015). 

His research in neurobiology, pharmacology and the treatment of schizophrenia and other psychotic disorders has been recognized by the National Academy of Sciences Institute of Medicine; Fellowship in the American Association for the Advancement of Science (AAAS); and the National Alliance of the Mentally Ill (NAMI)’s Exemplary Psychiatrist and Scientific Research Awards. Dr. Lieberman also served as President of the American Psychiatric Association in 2013 and 2014. More recently, Dr. Lieberman's work has extended into public policy and advocacy for enhancing awareness of mental illness and improving mental health care, as well as reducing the stigma associated with mental illness.  

To learn more about Dr. Lieberman visit his website.

Jeffrey	Lieberman - Professor and Chairman, Department of Psychiatry, Columbia University College of Physicians and Surgeons

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