Friday, August 5, 2005

Report to the Board of Trustees of the APA

Puerto Rico Psychiatric Society

A Chapter of the American Psychiatric Association

POB 33113

San Juan, Puerto Rico 00933

Report to the Board of Trustees of the

American Psychiatric Association

July 30, 2005

The Puerto Rico Psychiatric Society directs its efforts to contribute to the five Board-adopted Strategic Goals of the APA (1)(2)(3)

1) Advocating for patients,

2) Advocating for the profession;

3) Supporting education, training, and career development,

4) Defining and supporting professional values, and

5) Enhancing the scientific basis of psychiatric care

I will address each goal in turn.

1) To promote the rights and best interest of patients and those who use or might use psychiatric services we have published a statement on the death penalty supporting APA’s 1969 statement against it. (4) We have begun collaboration with the Puerto Rico Bar Association on this issue and invited Dr. Abraham Halpern to address it at the Annual Meeting of Puerto Rican Psychiatry in November. He accepted the invitation. A recent Federal case in Puerto Rico almost ended up in a death penalty sentence. Not since the 1800; s has a person been put to death by the state in this island.

To contribute to improving access to and quality of psychiatric services we testified before the Health Commission and urged the Health Department to support an important amendment to the Mental Health law. When the new Mental Health Law was passed in 2000 patients with substance abuse disorders were not granted the rights and responsibilities that other patients with mental disorders had. So the law must be amended. In our statement before the Health Commission we also recommended specific quality indicators for use by the Health Reform of Puerto Rico. These Quality indicators were discussed at length in a 1998 DB sponsored Quality Summit of psychiatrists, social workers and policy makers. . The State funded Reform has been riddled with poor anticipation of the day to day problems brought up by the managed care paradigm and access to care has been the main issue, while monitoring quality of care was left behind.

c) Recently we published a letter in El Nuevo Dia - a respected local newspaper - addressing Tom Cruises attack on the world of Psychiatry. Our letter paraphrased, in Spanish, the joint statement made by APA, NAMI and NMHA on this subject and added our fiery Hispanic style.

d) In August we will start a weekly radio program to orient patients on mental health issues, including their rights and responsibilities. We have funding for the first six months and expect to extend the program to a year with educational grants from several pharmaceutical companies.

e) In early July we signed an agreement with the Government’s Patient Advocate to collaborate on policy making and in advocating for patients in the island.

(2) In advocating for the profession; supporting education and career development, the second goal,

a) We have increased public exposure of our APA Chapter by designing and maintaining the webpage of the Puerto Rico Psychiatric Society since 1997, the third one published by any DB. (5)(6). Media exposure has reached as far as the web has.

b) And taking this valuable opportunity at this forum with the BOT, we are recommending that the dues of APA members in Puerto Rico be revised down on the grounds of higher cost of living, lower income from third parties in private care, the compulsory membership dues of the College of Physicians and Surgeons and the fact the APA sponsored Psychiatrists Program does no cover us in Puerto Rico. According to the APA office of membership member loss in Puerto Rico is at 10% while the national average is 4%.

There were 200 of us when I ended my first turn as president in 2000. Last count in April was down to 150 members; that is a 25% loss in five years.

What is members’ number one complaint? “Dues are too high”.

So within the next two weeks the PPRS will be sending the APA a detailed set of factors that justify downward revision of member dues for APA members in Puerto Rico. We will recommend a specific rate system.

c) Within the goal of advocating for the psychiatric profession, in Puerto Rico we are anticipating an effort by organized psychology to promote a bill allowing psychologists to prescribe psychotropic medications to their scope of care. We want to avoid that. We have emphasized and will continue to make emphasis on quality of care issues before the Health Commission, the Commonwealth Senate and the House of Representatives. This is part of a proactive and preemptive approach while we also collaborate with psychologists on issues that affect the community. We do not want a copy of what happened in Guam, in New Mexico and Louisiana

(3) To support the training, and career development goal

A) We have requested support from the APA to train and certify a larger number of MD´s to prescribe buprenorphine for treatment of opioid dependence. First training occurred in December 2004 n the island. To date only 97 physicians are certified in Puerto Rico. We are not proud that this island paradise is also the mecca for heroin dependence.

b) We are managing an electronic network among local APA members, to discuss professional issues and increase esprit de corps.

c) The theme of the Annual Meeting of Puerto Rican Psychiatry: Quality and Results will cover topics such as management of medically-compromised substance dependent patients, psychiatric ethics and the death penalty, psychopharmacology and quality of care indicators.

d) On July 22 we held a “class reunion”, of all psychiatric residents of the two accredited programs, a recruitment effort geared towards countering member losses the last five years. Recalling members is a frequent activity of mine since I was elected DB president in March 2005.

e) Some DB members teach and supervise psychiatric residents at the two ACGME-accredited schools of medicine and their affiliated mental health facilities. Ironically one of the two training director is not a member of the APA. Part of our recruitment strategy includes e mail and personal contact with each training directors.

4) To define and support professional values

a) the Puerto Rico Psychiatric Society collaborates with the Academia de Psiquiatria, the Association of Child and Adolescent Psychiatrists and the Puerto Rico Medical Association, Psychiatric Section. These organizations have lower member dues and are in fact competing for our members. They provide significant CME benefits to members with pharmaceutical company sponsorship but no other significant benefits.

b) We included a panel of local experts in psychiatric ethics at our November Meeting.

c) We invited Dr. Pedro Ruiz and Dr. Michael First and Abraham Halpern to speak at the Annual Meeting in November.

d) In June we made a significant social impact in a press conference with the Association of Psychologists, Association of School Psychologists and the Teachers Association when we questioned the less than acceptable social manners and self-centered behavior of some members of the Puerto Rico Senate.

5) To enhance the scientific basis of psychiatric care

We are promoting the inclusion of Puerto Rican patients in clinical research. At least two members of the APA are now working on psychopharmacology research in the island.

On this issue, let me quote from a recent Washington Post article; (7)

“When UCLA researchers reviewed the best available studies of psychiatric drugs for depression, bipolar disorder, schizophrenia and attention deficit disorder, they found that the trials had involved 9,327 patients over the years. When the team looked to see how many patients were Native Americans, the answer was Zero.

“Native Americans are not the only group for whom psychiatrists write prescriptions with fingers crossed, the researchers at the University of California at Los Angeles found as they reviewed the data for a U.S. surgeon general's report: Of 3,980 patients in antidepressant studies, only two were Hispanic. Of 2,865 schizophrenia patients, three were Asian. Among 825 patients in bipolar disorder or manic depression studies, there were no Hispanics or Asians. Blacks were better represented, but even their numbers in any one study were too small to tell doctors anything meaningful.

In all, just 8 percent of the patients studied were minorities.

It is but one example of a larger pattern: Scientists have broadly played down the role of cultural factors in the diagnosis, treatment and outcome of mental disorders. In part, this is because modern psychiatry is based on the idea that mental illnesses are primarily organic disorders of the brain. This medical zed approach suggests that the symptoms, course and treatment of disorders ought to be the same whether patients are from the Caribbean, Canada or Cambodia.

“Unlike anti-psychiatry groups that wish to do away altogether with drugs and doctors, advocates for cultural competence argue only against one-size-fits-all thinking. Genetic vulnerabilities and brain chemistry are undoubtedly important, said Lewis-Fernandez, but (not all problems) can be reduced to brain chemistry.

"Sure, after a certain amount of suffering for a certain amount of time, your brain reacts," he said. "The idea of mainstream psychiatry is that the pill will correct the chemical imbalance in the brain. Yes, but the imbalance keeps happening because of the situation (the patient) is in, and the pill can't correct the situation”

Finally, let me quote Dale Walker, past speaker of the Assembly on the APA mission in 1998:¨“APA is an organization of psychiatrists working together to ensure humane care and effective treatment for all persons with mental illnesses, including substance use disorders. It is the voice and conscience of modern psychiatry. Its vision is a society that has available, accessible quality psychiatric diagnosis and treatment [as well as] prevention services”. The Puerto Rico Psychiatric Society is now prepared to become that voice and conscience in this territory of the United States of America……and we are doing it with your support.

1. “Board Endorses Latest Phase of APA’s Strategic Planning Process”, Psychiatric news
2. APA Work Plan to Translate Strategies Into Action, Psychiatric News, March 02, 2001

3. Minutes of the Puerto Rico Psychiatric Society February to July 2005

4. 1969 Resolution of the Board of Trustees of the APA on the Death Sentence.

5 Webpage of the Puerto Rico Psychiatric Society, celebrating its 8th anniversary.

6. Analysis of Mental Health in Puerto Rico. Enrique Rivera Mass et al. 2005. Webpage of the Puerto Rico Psychiatric Society.

7 Patients' Diversity Is Often Discounted, Alternatives to Mainstream Medical Treatment Call for Recognizing Ethnic, Social Differences, Shankar Vedantam, Washington Post Staff Writer, Sunday, June 26, 2005.