On a beautiful autumn day in New England, the Department of Psychiatry of Brigham and Women’s Hospital celebrated the Blueprint Centennial Event marked by a CME portion of the day, followed by a celebratory dinner. Close to 80 participants joined us at the Renaissance Boston Waterfront Hotel while we learned about the cutting edge work being undertaken at Brigham and Women’s Hospital in the areas of medical psychiatry, psychooncology, women’s mental health, neuropsychiatry and geriatric psychiatry. A lively panel discussion followed each group of lectures allowing for interactive participation. The day ended with a sentimental dinner involving an inspiring talk by our chairman, Dr. David Silbersweig, as well as a journey through the history of the BWH Department of Psychiatry by Dr. Jonathan Borus.
As we celebrated our history of transforming the future, the Department of Psychiatry looks forward to the next 100 years of advancement in brain science.
One hundred years ago, at the Peter Bent Brigham Hospital/Harvard Medical School, were Harvey Cushing and Walter B. Cannon, towering figures in the history of medicine. Cushing, the father of modern neurosurgery, described mood changes associated with endocrine abnormalities. Cannon, the pioneering physiologist/physician who developed to concept of homeostasis, realized the simultaneous and mechanistic relationship between autonomic physiology and emotion, and coined the term “fight or flight response.” Psychiatry originated at the PBBH as a Division within the Department of Medicine.
1939—Dr. John Romano, trained in both Psychology and Neuropsychiatry, established a small psychiatry service focused on providing inpatient consultations and on the study of delirium and of unusual presentations of neurological and psychiatric disorders. He recruited Dr. George Engel, who initiated his pioneering work on the biospsychosocial model of disease and treatment here.
1946—Dr. Henry Fox assumed the direction of the Psychiatry Service, expanding its clinical and educational missions, and undertaking important research on the psychiatric aspects of cardiac, endocrine, and immune disorders.
1970—by Dr. Peter Reich, during whose tenure the division gained national prominence for its consultation-liaison service and became a key site for the education of Harvard medical students.
1990—Dr. Jonathan Borus, a leading clinical educator, took the helm in and oversaw a major expansion of the educational, clinical and research missions. The service gained independent departmental status within the BWH and became a full member of its Physicians Organization, and gained appointing status at Harvard Medical School. An adult psychiatry residency training program was established in collaboration with the Beth Israel Hospital and the Massachusetts Mental Health Center, and a post-residency fellowship in consultation liaison psychiatry was established. There was a substantial growth in the number of trainees as well as in the size of the faculty.
In this year, the BWH Department also successfully merged with the Department of Psychiatry at the Faulkner Hospital. This was the first such integrated clinical and academic merger resulting from the 1998 BWH-FH corporate merger. Dr. Borus oversaw a dramatic increase in the volume of clinical services, including addiction services, inpatient and emergency consultations, and outpatient clinic visits. Finally, the department’s research portfolio grew substantially in size and scope during his tenure. Major investigators were recruited in psychiatric neuroscience, and in clinical and psychosocial research, with corresponding dramatic increases in extramural funding for research.
2008—Dr. David Silbersweig, a pioneering neuropsychiatrist and brain imaging scientist, was recruited to lead the department as well as the BWH Institute for the Neurosciences. The BWH Department of Psychiatry is now at the leading edge of a transformation in the field—one in which underlying mechanisms of mind-brain disorders are being identified, while associated, evidence-based treatments are being enhanced. This reduces the misunderstandings regarding mental illnesses, and increases hope for the large numbers of patients and families who suffer with difficulties in thought, feelings and behavior.
The Department's particular focus in this context concerns psychiatric problems associated with medical illness. This is consistent with the tradition of medical psychiatry that has permeated the Department's evolution. The Department is now deepening and extending its mission, growing sub-specialty programs, with specific emphases and clinical research-educational integration across sites and services. These developments are coordinated by Dr. Laura Miller, Vice Chair for Academic Clinical Services, and Dr. Arthur Barsky, Vice Chair for Research. They are focused in six key areas:
The Medical Psychiatry (Consultation-Liaison) Division, directed by Dr. David Gitlin, is renowned for its contributions to the diagnosis and management of the psychiatric problems that occur in the context of medical and surgical illnesses. These include the co-occurrence of psychiatric and medical illness, the psychiatric co-morbidity associated with the pathophysiology of the medical conditions, and the psychological reactions to medical illness in general and its associated stressors. A new Complex Medical Psychiatric Diagnostic Clinic has been established by Dr. Michael Mufson, to tease these aspects apart in the most difficult cases. The Division provides award-winning emergency psychiatry services in the emergency departments of both BWH and Faulkner Hospital. The Medical Psychiatry consultation service has a major fellowship program and is a key site for medical student education and residency training.
The Ambulatory (Outpatient) Division, directed by Dr. Jay Baer, has recently been re-structured to offer contemporary, evidence-based psychiatric evaluations and treatments for patients with psychiatric difficulties in the context of medical illness and care. It is also a hub of residency training. A multidisciplinary team including psychiatry, psychology, nursing and social work provides balanced, patient-centered care, with psychopharmacology and psychotherapy (including cognitive-behavioral, skills-based, mindfulness, psychodynamic, and group modalities). In this context, Dr. Jane Erb is directing the development of the BWH Center for Depression in Medical Illness.
BWH is a charter member of the National Network of Depression Centers, and is leading a national task group addressing the overlap of depression and medical illness. The department is also developing and implementing new models of psychiatric care that are seamlessly embedded in primary and medical subspecialty care. Such work, detecting and treating mental illness as well as promoting healthy behaviors, will be even more critical as health care shifts towards longitudinal, coordinated population management, and integrated, team-based approaches for comprehensive care.
The Neuropsychiatry Division has grown substantially with the arrival of Dr. Silbersweig and other dual-trained psychiatrists/neurologists and neuropsychiatrists, and is now integrated with the Cognitive and Behavioral Neurology Division of the Department of Neurology, as well as the Neuropsychology program. This multidisciplinary, highly expert team is now known as the Brigham and Women's Center for Brain Mind Medicine (CBBM). The Center, directed by Dr. Kirk Daffner, performs comprehensive evaluations of complex diagnostic dilemmas at the interface of psychiatry and neurology.
The Center also provides multidisciplinary treatment for psychiatric aspects of neurologic disorders. It has a vibrant educational program for trainees at all levels, including a neuropsychiatry/behavioral neurology fellowship. It is also a critical part of the “buck stops here,” “one stop shopping” approach that the BWH Institute for the Neurosciences is taking to patient-centered care-- providing simultaneous, coordinated, co-localized evaluations of neuropsychiatric conditions by close colleagues who are world experts in the fields of psychiatry, neurology, neurosurgery, neuroradiology, neuropathology, sleep medicine, pain medicine and neuroanesthesia.
The Women's Mental Health Program is directed by Dr. Laura Miller, a nationally-recognized leader in women's mental health. Dr. Miller's focus on peri-natal psychiatry is proving to be an extraordinary combination with BWH's Ob-Gyn department. Expertise regarding peri-menopausal and geriatric conditions across the reproductive lifespan has also been added. A women's mental health service at BWH's Fish Center for Women's Health has been established, and women's mental health services in our Outpatient Division and at Faulkner Hospital have been expanded. A Women's Mental Health fellowship, as well as the opportunity to focus on Ob-Gyn liaison within the Medical Psychiatry (C-L), provide exciting subspecialty training opportunities.
This program, led by Dr. Susan Block, Chair of Psychosocial Oncology and Palliative Care at the BWH-Dana Farber Cancer Institute, is a leader in clinical, educational and research aspects of psycho-oncology (directed by Dr. liana Braun) and palliative care (a field that Dr. Block has pioneered). In this manner, the psychiatric conditions and needs of cancer patients, survivors and supporters are elucidated and addressed.
Addictions alone, or in combination with psychiatric and/or medical illness, constitute a prevalent and difficult clinical problem. The department provides a comprehensive spectrum of addictions services, ranging from an inpatient consultation service within the Medical Psychiatry Division at BWH directed by Dr. Joji Suzuki, to inpatient detoxification, partial (day) hospital, and day and evening outpatient continuity of care at Faulkner Hospital, led by Drs. Erica Veguilla (psychiatry) and Carol Garner (medicine).
Patients with primary mood, psychotic and anxiety disorders receive care in the outpatient settings of BWH and FH, particularly in the context of concurrent medical illness and treatment. At FH, there is an adult inpatient psychiatry clinical/teaching unit, directed by Dr. K.C. Potts, providing sophisticated care for acutely and severely ill psychiatric patients. There is also a partial (day) hospital that provides associated intensive care for those who are significantly ill and/or in crisis but who do not require inpatient hospitalization.
BWH psychiatric investigators are making substantial contributions toward advancing the understanding of mental illness and its treatment. These investigations have generally been concentrated in three areas: psychiatric neurosciences; population-based, mental health services and treatment research; and longitudinal studies of adult development.
Three major laboratory groups have been working on brain circuitry and brain development in psychiatric disorders. The Functional Neuroimaging Laboratory, directed by Drs. Emily Stern and David Silbersweig, has performed ground-breaking work localizing the fronto-limbic dysfunction in brain circuitry that underlies the core features of several psychiatric disorders, including psychosis in schizophrenia, anhedonia in major depression, and emotional dyscontrol in borderline personality disorder. They are developing systems-level biomarkers that can provide a foundation for new diagnostic approaches and therapeutic targets in psychiatry. They are also studying the role of neuroinflammation in neuropsychiatric disorders.
Dr. Martha Shenton, director of the BWH Psychiatric Neuroimaging Laboratory, has performed widely-cited work utilizing structural MRI techniques to study of schizophrenia, demonstrating a reduction in volume and disruptions of connectivity among several limbic and cerebral structures. Dr. Jill Goldstein, also Director of Research for the Connors Women's Health Center, has led numerous pioneering studies focusing on fetal antecedents to sex differences in normal brain, and fetal antecedents to sex differences in schizophrenia and depression in adulthood.
Dr. Arielle Stanford is testing new targets for non-invasive brain circuit modulation with transcranial magnetic stimulation in schizophrenia and Alzheimer's disease patients with disordered volition. She and Dr. Silbersweig are working closely with Dr. Travis Tierney ,in the Department of Neurosurgery, to identify and test novel targets for deep brain stimulation in patients with severe, refractory psychiatric illness.
Dr. David Wolfe is implementing clinical trials of novel neuroprotective agents in depression and other neuropsychiatric disorders, based upon pathophysiological (not just neurotransmitter) models. Drs. Philip DeJager and Tracy Young-Pearce (also with primary appointments in the Department of Neurology) are pursuing studies of genetics and epigenomics to identify mechanism-based sub-types of illness, and of neural stem cells and neurogenesis to develop methods of neural repair, respectively.
Dr. Daniel Herrera performed studies clarifying neurochemical and pathophysiological factors disrupting hippocampal neurogenesis, and identifying neuroprotective agents to block such damage. Dr. Gabriel DeErasquin performed population molecular studies defining genetic signatures of schizophrenia. Dr. Elizabeth Sajdel-Sulkowska examined the role, and underlying mechanisms, of toxic and endocrine disruption of brain development implicated in neurodevelopmental disorders.
Other investigators in psychiatry have made significant contributions in the areas of population-based research, psychiatric epidemiology, and mental health treatment and services research. Arthur J. Barsky, M.D., a world leader in the study of somatoform disorders, established and expanded the concept of somatosensory amplification. He delineated its mechanistic role in the generation of medically unexplained symptoms, and in contributing to the wide inter-individual variability in symptoms among patients with the same serious medical disorder. He has developed cognitive-behavioral techniques to ameliorate the distress and discomfort accompanying somatic symptoms in the medically ill, and demonstrated their efficacy is several medical populations.
Susan Block, M.D. has been a national leader in creating the field of palliative care medicine and has been responsible for major advances of national and international impact in this field. She has studied the training in, and conduct of, end-of-life care as it currently occurs, and has conceptualized and developed major training programs in palliative care. Holly G. Prigerson, Ph.D., at the Dana Farber Cancer Institute, has completed a series of groundbreaking investigations of the interpersonal and intrapersonal reactions to loss and trauma. Her studies, performed with Dr. Paul Maciejewski, have illuminated the process of normal bereavement and distinguished it from prolonged or complicated grief, and from major depression. Dr. John Peteet has advanced the understanding of the role of spirituality in this context.
Grace Chang, M.D., M.P.H., made significant contributions in the description, detection, and treatment of problem drinking and alcohol abuse in pregnancy. She developed screening instruments for use in medical settings and successfully developed and tested brief interventions for problem drinking in pregnancy. Sarah L. Minden, M.D. has conducted a series of epidemiological studies of patients with multiple sclerosis. She has described the psychiatric co-morbidity, quality of life and disability, and the utilization of mental health and general health services that accompany this illness.
Most recently, she has examined the stress on the care-givers of patients with this disorder. Her work has led to the development of policy standards for mental health care for multiple sclerosis patients. Dr. Olivia Okereke has conducted leading epidemiological research concerning geriatric depression, biomarkers and modifiable risk-factors.
Dr. Megan Oser is developing and testing novel forms of acceptance-based behavioral therapy for co-morbid psychiatric and medical illness and testing strategies to improve patient engagement in medical care. Dr. Joji Suzuki is developing and testing new approaches to the treatment of opiate addiction in medically ill patients. Dr. David Gitlin and his team of hospital-based medical psychiatrists have made a number of important observations and advances in the realm of psychosomatic medicine and consultation-liaison psychiatry.
Drs. Jonathan Borus and Michael Mufson are senior faculty with many high-level contributions in this area. Dr. Laura Miller has performed leading work in the area of women's mental health service creation, particularly associated with the peri-natal period. This work has informed state-level programs. Dr. Janis Anderson has conducted a series of treatment studies that have increased the use and understanding of light therapy for seasonal affective disorder.
In the Center for Brain-Mind Medicine (partnering with the Department of Neurology), Drs. Kirk Daffner, Aaron Nelson, Dorothy Rentz and Nancy Donnovan are involved in work enhancing the early neuropsychological detection of Alzheimer's disease and explicating the role of psychosocial factors, and the nature of executive dysfunction in dementias, in the context of neuroimaging and biomarker work performed by Dr. Reisa Sperling.
Dr. David Ahern has led national efforts in e-health, concentrating on its role in shaping health-related behaviors and in self-management of chronic disease. Dr. James Cartreine has developed computerized, individualized interventions for psychiatric conditions and conflict in outer-space and work settings. Dr. John Winkelman, working in the BWH division of sleep medicine, has performed studies shedding light on restless leg syndrome and its treatment. Drs. Robert Jamison and Ajay Wasan have long conducted leading work at the intersection of psychiatric disorders and pain medicine.
George E. Vaillant, M.D., continued his landmark, prospective study of adult development while in the department. This long-term study examined the psychological and physical health of 268 male college students, first studied between 1939 and 1942, and followed regularly and continuously thereafter. The findings have fundamentally shaped our understanding of adult development and mental health throughout the life course, and of the psychological factors that contribute to successful aging and longevity. Dr. Robert Waldinger also participated in this work, and extended it into the areas of interpersonal development and psychophysiology.
Dr. Philip Wang (now Deputy Director at the National Institute of Mental Health) performed seminal studies in psychopharmacoepidemiology. Dr. Sue Levkoff developed and tested programs for the integration of mental health in primary care, and for the incorporation of an enhanced understanding of ethnic and minority factors in dementia care. Dr. James Sabin has made substantial contributions to the integration of ethics in healthcare, both nationally and internationally.
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