From advocates passionately fighting to destigmatize mental illness, to professionals committed to a multidisciplinary approach to mental health, psychiatry today is, in many ways, much different from three decades ago. But Stuart Yudofsky, M.D., knows there is still much more to be done. The distinguished service professor and chairman of the Menninger Department of Psychiatry and Behavioral Sciences, and Drs. Beth K. and Stuart C. Yudofsky Presidential Chair in Neuropsychiatry at Baylor College of Medicine discusses the field of neuropsychiatry and how his own challenges with dyslexia help him connect with patients and the struggles they face.
Q | Can you tell us about your formative years?
A | I was born and attended public schools in Louisville, Kentucky, where my older sister and I were blessed with devoted, kind parents. Both our mother and father worked tirelessly in a family business and were, in every way, wonderful role models. They taught us never to take for grated the opportunities that America has afforded us, and of our responsibilities to work hard and be contributing citizens.
In Kentucky, we lived at the junction of two beautiful public parks—Seneca Park and Cherokee Park—where there were acres and acres of beautiful, old-growth woods and creeks that were teeming with wildlife. Growing up, I spent much of my free time outdoors and was enthralled by the beauty, miracles and mysteries in nature. These experiences quite ‘naturally’ led to a passion for biology and other natural sciences.
My interest in medicine also blossomed in Louisville when I was very young. The principle influences of my aspiration to become a physician derived from two of my neighbors who were general surgeons and exemplary human beings. My best friend’s father, Dr. Clyde H. Foshee was born in a small town in Alabama and attended Harvard Medical School, where he also took his surgical residency at Massachusetts General Hospital. He would take me and his son, Clyde, on trips to their farm in Indiana and explain, with clarity and precision, the co-mingled life cycles of mosquitoes and dragonflies as well as how the bodies of his Hereford cows and human beings worked in similar fashions—both in health and disease.
On one occasion when I was eight years old, Dr. Foshee was driving us across a very high bridge spanning the Ohio River that separates Kentucky and Indiana. I asked him why we would feel so anxious when we looked down into the water from the bridge—even though we knew we were safe on the sturdy bridge. Dr. Foshee answered by detailing Freud’s theory of a ‘death wish’ that he had learned while a medical student in Boston. It was my first introduction to the world of the unconscious mind and how repressed conflicts manifested as fears, wishes and symptoms. I was enthralled and wanted to learn so much more about how the mind works, and to grow up to be just like Dr. Foshee.
Although it remained undiagnosed for decades, one other primary influence of my childhood is that I have a dyslexia. Letters and numbers that I see somehow lose their sequence in my brain, with the result that I could and still cannot ‘sound out syllables’ when I read. I reverse the letters of words and numbers in columns when I write them down. The net result was that I was a very poor student throughout elementary and middle schools, and for most of high school. Around the 10th grade, things started to change for me. By complete accident, I stumbled upon a new way to read and calculate. I would recognize how a whole word looked— without having to sound out the letters and syllables, as I had been taught to do. If I knew the meaning of that word, I could fly forward. So I made a big effort to learn what a lot of words mean. I also learned to solve mathematics problems in my head, where, for some reason, the numbers and columns didn’t ‘jump around’ until I tried to write them down. By college, I was no longer held back by my dyslexia.
Paradoxically, along with the abundant upset and frustrations associated with dyslexia, my self-perception of being ‘pretty stupid’ held some unexpected advantages. For example, by being a slow, labored reader, I learned to appreciate much more than the content of writing—particularly the quality of how words are expression by excellent writers. And when I began to read rapidly through my new method, I felt like a blind person who could suddenly see. My perceived ‘stupidity’ taught me how to recognize and appreciate the exceptional abilities and qualities of others: people with abilities and knowledge that I do not have.
Valuing what other people have to say about a vast array of subjects, I began to read nearly everything I could get my hands on—and still do. Thinking of myself as ‘stupid’ also taught me how to be very persistent and how to overcome my being slow by working longer and harder than many others. It taught me not to give up easily. I learned to pursue creative approaches to escape the confining box of my dyslexia. Finally, I also know how it feels to struggle and be ‘down and out,’ which affords me empathy and a credential with my patients when they say, ‘You have always had it so easy, Dr. Y. How could you possibly understand what I am going through?’ No one who is suffering wants to accept help from someone who they think is pretty close to being perfect.
Q | What were the college and medical school influences in your becoming a psychiatrist?
A | In college I had several excellent teachers who, to my great surprise, determined that I was a good writer. They went so far as to encourage me to become a writer instead of a physician. With my teachers’ encouragement and help, I was awarded the opportunity to attend Oxford in England to study English literature. Unfortunately (for so many more important reasons than my trivial personal ones), it was the time of the Vietnam War, so I wasn’t able to maintain my draft deferment while studying English literature in England. The net result was that I did not get to stay long at Oxford and returned to complete my pre-med work and apply to medical school.
Intensely interested in becoming a surgeon, I applied to Baylor University College of Medicine in mid-‘60s because physicians like Dr. DeBakey and Dr. Cooley were transforming surgery through the breakthroughs they were making in open-heart surgery. Dr. DeBakey’s picture appeared on the cover of Time magazine, and, like so many other pre-meds in the east where I went to college, I was captivated by the breakthroughs and excitement in the Texas Medical Center. Many of my colleagues and classmates also came to Baylor because of their interest in becoming surgeons. Nonetheless, we all felt deep compassion for the patients with mental illnesses whom we cared for during our medical school psychiatry rotation. Unfortunately, in that era there was often very little could be done to intervene in the most severe and disabling psychiatric illnesses.
Dr. Hilde Bruch was an eminent physician on the Baylor Psychiatry faculty at that time, and she was a pioneer in researching and understanding people with anorexia nervosa. She arranged for me to take a long elective in psychiatry at Columbia College of Physicians and Surgeons, where, to my own great surprise, I changed my lifelong goal from being a surgeon to becoming a psychiatrist. Nonetheless, after medical school, I took a straight surgical first year of residency (we called it an internship at the time), and relished the opportunity to learn under surgeons and to take care of surgical patients who were very ill. To this day I feel a great affection for surgeons and this grand and essential medical specialty.
Q | What was your residency in psychiatry like?
A | My residency in psychiatry at Columbia occurred at an exciting time in psychiatry. At that time, Columbia was (and remains) a powerhouse in psychiatry; its large faculty assumed the leadership in making major changes to how mental illnesses are diagnosed and categorized. The department’s work at that time led to the modern versions of what we call the Diagnostic and Statistical Manual of Mental Disorders (DSM). As a result, for the first time, DSM provided a common language for physicians to communicate with their colleagues and patients, to assay prognoses and to conduct valid research.
One breakthrough of the modern DSM was to make the diagnoses of mental illnesses based on objective criteria of signs and symptoms, as opposed to the theoretical speculations that predominated psychiatric diagnostics up until that time. For example, a prominent theory of the time was that the devastating illness, schizophrenia, was ‘caused’ by the patients’ parents, especially their mothers, who rewarded and punished their children indiscriminately. Mothers of people with schizophrenia were wrongly and damagingly labeled as ‘Schizophrenogenic Mothers’ in that era. Thus, these mothers were twice injured – first by having a child with a very serious mental illness; and secondly by the field of psychiatry that erroneously blamed the mother for ‘causing’ the torments of their child. There was just no good evidence that schizophrenia or most of the other serious mental illnesses could be caused in that way, and the tides of such stigmatization and misinformation were, thankfully, changed by the work that was being done at Columbia during the time of my residency.
When I took my training in the early 1970s, the field of psychiatry was out of balance, with excess emphasis being placed on the experiential and psychological ‘causes’ of severe and persistent mental illnesses. There was far too little focus on the hereditary and neurobiological influences of psychiatric disorders. The field had moved too far away from mainstream medicine, and the appreciation of the role of brain dysfunction in psychiatric disorders. Advances in the DSM and recognition of the importance of psychopharmacology in the treatment of many psychiatric disorders helped to regain the balance of our field.
Q | What did you do after you completed your residency?
A | When I completed my residency, I was asked by my Psychiatry Chairman at Columbia, Dr. Lawrence Kolb, to work on an inpatient psychiatry teaching service that was located in the Neurological Institute (NI). The NI is a specialized hospital for patients with neurological disorders that is operated by the Columbia Department of Neurology. The patients at the Neurological Institute suffer from such disorders as brain tumors, traumatic brain injury, Parkinson’s disease, multiple sclerosis, intractable seizures; and, for many years, I cared for patients with the psychiatric concomitants of these conditions. As a result, I became very interested in a field called neuropsychiatry, which focuses on the psychiatric aspects of neurological disease and the neurological aspects of psychiatric disease. For example, we treat the depression of patients with Parkinson’s disease, the psychosis associated with stroke, the aggression and irritability associated with traumatic brain injury, and the psychological, interpersonal, family and occupational life disruptions that these devastating illnesses invariably lead to. I did research associated with the impulsive aggression, violence and irritability that often is associated with brain lesions. My team and I focused on developing standardized scales to measure aggression, violence and agitation, and we have used these scales to do outcome research on the effectiveness of a broad range of medications in treating these disorders.
Q | So you were at Columbia. Did you come back here from there?
A | Not right away. Over the years that I was at Columbia, I rose in the ranks to associate professor, vice chairman of the Department of Psychiatry and was deputy director of the New York State Psychiatric Institute, which is a behavioral science research institute associated with Columbia University. The Columbia Department of Psychiatry and the New York State Psychiatric Institute are very large and active institutions, and my administrative responsibilities began to overtake my research, teaching and clinical work. To advance my work in studying pharmacological agents to treat people with traumatic brain injury, I accepted a position of chief of psychiatry at Pittsburgh’s at Allegheny General Hospital and director of psychiatric research at Allegheny/Singer Research Institute. Allegheny has an active life flight program whereby many patients in western Pennsylvania come for acute care immediately after traumatic brain injury. Thereafter, I held the position of professor and chairman of the Department of Psychiatry at the University of Chicago and chief of psychiatric services at the University of Chicago Hospital System.
My wife, Beth, who is also a psychiatrist, our three young daughters, and I enjoyed and appreciated the privilege of being in Chicago and at the University of Chicago. It is an extraordinary city and university. Nonetheless, when the opportunity arose in 1991 for me to return to Baylor and Houston Methodist Hospital, my family supported my doing so. I have held the positions of professor and chairman of Baylor College of Medicine Department of Psychiatry and Behavioral Sciences as well as chairman of psychiatry at the Houston Methodist Hospital for almost a quarter of a century. I am honored and privileged to be in these positions and to work in the Texas Medical Center. We are also proud to be Houstonians and regard it as our ‘hometown.’
Q | Did you have important mentors in your career?
A | Oh, yes! I’ve been quite blessed with outstanding mentors throughout my career. In college my mentors were, interestingly enough, my English literature professors. When I went to Baylor, Dr. Hilde Bruch, a psychoanalyst was an important mentor, as was Dr. Shervert Frazier, who was a chairman of the department of psychiatry at Baylor when I was a medical student. Both were brilliant, devoted clinicians and academicians who took time from their full schedules to shepherd my career, and those of other Baylor medical students and residents who were interested in psychiatry.
As discussed earlier, my chairman of psychiatry at Columbia at the time I was a resident was Dr. Lawrence Kolb, who was my devoted mentor. When I was about to complete my term as chief resident, Dr. Kolb invited me to his office on the 14th floor of the New York State Psychiatric Institute. He summoned me over to the window in his office from which one can see a broad vista of the Hudson River, the New Jersey Palisades and the George Washington Bridge. He then took me to another window where the vast Columbia Presbyterian Medical Center was in full view. And then he said, ‘What do you see from this view? Tell me exactly what you see.’ And I said, ‘Well, I see many beautiful buildings; lots students, doctors and nurses in white lab coats and uniforms going here and there; and a lot of traffic—cars, buses and cabs.’
Dr. Kolb then said, ‘Stuart, take special notice of all the Columbia faculty and staff, as well as our beautiful buildings. You’ve benefitted from the training you have received from those dedicated professionals, and you learned and worked in so many of these beautiful buildings, have you not?’
‘Oh, yes, sir,’ I replied! And then he said, ‘Well, Stuart, these faculty and staff did not educate themselves; nor did the buildings build themselves. At some point in your career you will have an obligation to leave Columbia to share with others what you have learned about psychiatry here. I did so when I came here after many years at Johns Hopkins in Baltimore. You must leave here to train psychiatry students and faculty in places that are not so advanced in psychiatry as we are; you must help them to build research and training buildings and programs in psychiatry. Never forget that many people did that for you, and someday you will have the responsibility to do it for others.’ I was taken aback by what Dr. Kolb was telling me. I had feared that the reason that he called me to his office was that I had done something wrong and was in deep trouble.
My wife Beth has been my most important mentor throughout our nearly 40 years of marriage. She is wonderful mother of our three daughters, partner and a fabulous academic psychiatrist. She is a consultation liaison psychiatrist who has worked in the public sector for her entire career. In Houston, she led the consultation/liaison service at Ben Taub General Hospital. This service addresses the psychiatric conditions of people who are hospitalized with medical and surgical illnesses. Psychiatry consultations/liaison services help physicians of all medical specialties and hospital staff work together as a team to consider both the complex medical and psychosocial issues of hospitalized patients. Dr. Beth has a much better sense of ‘life balance’ than do I. She has mentored me, albeit with mixed success, in understanding the importance of fun, family and relaxation in a balanced life. She also has a much better sense of the implications of life stages and the passage of time than do I.
My incredible supervisors, colleagues, residents, students and patients (and their devoted Houston families) at Baylor and Methodist have been and remain my most outstanding mentors. They teach me what I don’t know and have missed, they point me in the right directions, they provide endless encouragement and are responsible for the lion’s share of what I get credit for having accomplished during the time I have been in Houston. My appreciation to these heroes is boundless.
Q | What would you say are the proudest moments of your career?
A | My proudest moment is when a patient says, ‘I’ve been suffering for such a long time, and now I feel better. I just never thought I would feel any better.’ Patient care is at the very center of my professional identity and gratification. I had another moment of pride yesterday when I received, out of the blue, a simple, single-paged note from someone whom I taught when he was a medical student on my neuropsychiatry service at Columbia/Presbyterian, 40 years ago. He said that what he learned during that experience has helped him take better care of patients throughout his career.
For many years a dear friend and colleague, Robert E. Hales, M.D.—a West Point graduate, psychiatrist, and current chairman of the Department of Psychiatry at University of California, Davis Campus—and I have collaborated on two textbooks—‘The American Psychiatric Press Textbook of Psychiatry’; and also the ‘American Psychiatric Press Textbook of Neuropsychiatry and Behavioral Neurosciences.’ Published by the American Psychiatric Association, both will soon be in their 6th editions and are published in many languages. They are considered standard textbooks in psychiatry and neuropsychiatry for medical students, residents and practicing psychiatrists. I also take some pride in two hybrid books that I have written for both mental health professionals and the general public. Both are—to my surprise—well received and quite successful. ‘Fatal Flaws’ is a book about personality disorders—like borderline personality disorder, narcissistic personality disorder, antisocial personality disorder, obsessive compulsive personality disorder, histrionic personality disorder, etc.,—from the perspectives of people in close relationships with people with those conditions. My most recent book, ‘Fatal Pauses,’ is about people who get stuck in life and are terribly unhappy. Examples include people in dysfunctional relationships; and those with problems of overeating and obesity; with alcohol and substance abuse; with wasting time surfing the Internet or playing video games; with eating disorders; with over-pleasing others, etc.
Finally, I will probably be remembered for helping—along with many, many others—to spearhead the move of the legendary Menninger Clinic from Topeka, Kansas, to Houston. Prior to their move, Menninger had flourished in Kansas for over 75 years. However, about 15 years ago, Menninger realized that they needed to transition to a new, much larger city in order to be affiliated with a great research-oriented medical school and an outstanding teaching general hospital. Many other cities, medical schools and hospitals actively sought to recruit Menninger; but the Houston Community, Baylor College of Medicine, the Houston Methodist Hospital and the Texas Medical Center prevailed. We all believe that Menninger’s move here is working well, as the Menninger Clinic continues to offer outstanding care to patients regionally and around the nation. On this very day, Menninger Clinic’s beds are full with long waiting lists on each service. Additionally, the teaching and research at the Menninger Clinic are excellent. As a result, Menninger has returned to being ranked among the nation’s top five psychiatric hospitals, and is blessed with a beautiful new facility near the Texas Medical Center.
Q | How have you seen things change through your career in terms of patient diagnoses and treatment today versus 20 or 30 years ago?
A | Very similar to many other types of medical illnesses like hypertension, diabetes and seizure disorders, most psychiatric illnesses are chronic conditions that must be managed over a lifetime. That being said, now that psychiatry has returned to its roots in medicine and neurobiology, the advances over the past several decades in our ability to treat the symptoms and reduce the suffering of those among us with mental illnesses have been revolutionary. Accordingly, the pervasive stigma that has historically been associated with having a psychiatric disorder is also reduced. This means that people are much more willing to trust psychiatrists and other behavioral health professionals.
Over the past decades, we have been working much more effectively as multi-disciplined teams in our care for people with mental illnesses. Although we have a very long way to go in this regard, diagnosis and treatment are far more evidence-based. This will dramatically improve in the future when we discover valid and sensitive biological markers for psychiatric disorders and as we learn more about the genetic bases for these conditions. We shouldn’t guess as much as we do now when we, for example, choose a medication to treat depression. We now involve families in our care, and that’s been a change. Prior to the 1970s, there was widespread belief that parents and spouses were responsible for many mental illnesses, and that they should be excluded from the psychiatric care of their family members or loved ones who are ill. As a field, we could not have been more wrong. Most often, families are loving and want to participate in and facilitate the care and recovery of their loved ones with mental illnesses. We must work in partnership with families to provide optimal care of people with psychiatric disorders.
Another major change is the rise of advocacy groups—largely comprised of people with mental illnesses and their families—who work in tandem with mental health professionals to provide essential information about the nature and treatment of mental illnesses. Advocacy groups are now in partnership with mental health professionals in generating resources to support research, clinical services, and fighting stigma on every front. They proclaim unabashedly, ‘Yes, people in my family have mental illnesses; Yes, I have suffered from depression; Yes, I have abused substances. This condition is a brain disorder which tragically affects me and my family; and I am not a criminal nor am I ashamed of it.’
Psychiatrists are now sharing information with our patients and having them as informed as we are in all elements of their care. This did not happen in the past. If you read ‘Fatal Pauses,’ you will get a sense of how a modern psychiatrist works in partnership with his patients and their families in exploring and solving mysteries associated with mental disorders. Each holds vital clues and information requisite to solving the problems, which can’t be solved by keeping either ‘side’ in the dark. So the participation of patients in their own care in psychiatry is a major important advance, and that includes patients’ families and their communities.
Our field now embraces a bio-psycho-social-spiritual approach to understanding and helping people with mental illnesses. Each of these aspects must be integrated in care and addressed to have good therapeutic outcomes. We commonly combine treatments—cognitive behavioral therapy with medications, for example—and do not embrace a reductionistic, single theoretical model. Nonetheless, it is important to recognize that the somatic organ of all behavioral disorders is the brain. Just like the organ of a nephrologist is the kidney, and the organ of a cardiologist is the heart, the organ of a psychiatrist and other mental health professionals is the brain. We must know as much as we can about the role of the brain in every behavioral disorder. Consequently, I do not believe that it makes conceptual sense for neurology and psychiatry to be separate disciplines. (I confess to be in a small minority in this view.) I strongly believe and advocate that psychiatry and neurology they should be integrated into a single discipline, ‘the Clinical Neurosciences.’ I see very few patients with psychiatric illnesses without neurological elements. And I see very few patients with neurological illnesses who do not have psychiatric concomitants.
Q | You treat people who come from a variety of different backgrounds and income levels. Would you say that mental illness is an equalizer?
A | Yes, mental illness is an equal opportunity affliction. Using the most conservative diagnostic criteria and statistics, one in four adults and one in 10 children have a diagnosable mental disorder in any given year. Elderly people have a higher prevalence of neuropsychiatric disorders; so, with the aging of our population, mental illnesses will be even more common. When serious mental illness does occur, it has profound implications for the individual and his or her family. People have greater difficulty in school, in carrying out their responsibilities at work, and in caring for their families. The economic effects of psychiatric illness can, therefore, be profound—with lost hours at work and with the high costs of professional care. Thus with severe and persistent mental illnesses, people’s incomes and socioeconomic status tend to drift downward. The good news is that effective psychiatric care can be very helpful in mitigating the pain and suffering of our patients, as well as the long-term financial consequences of mental illness.
Q | What should we be doing to support those facing mental illness?
A | The first thing is to listen closely to what our patients and their families are telling us about their conditions. About what and how they are feeling; about what bothers them the most; about what they believe ‘caused’ their suffering; about what they believe will be helpful in alleviating such. Secondly, as caregivers, we must be available when they are suffering and call on us. Access to care and early intervention is essential to reduce the neurobiolic morbidity and patient suffering associated with all psychiatric disorders. Third, we must allocate sufficient time for our patients to communicate with us and to address their needs. Hospital lengths of stay and outpatient appointments are much too brief to provide optimal care. Much of this is a result of government and insurance reimbursement standards, and we must all work to change this abomination that is a consequence of stigmatization of the mentally ill. Fourth, we must not shame or blame people for their psychiatric disorders—such as by saying to a person with depression: ‘Shake it off; pull yourself up by your bootstraps.’ When patients tell me that’s what a family member or friend has said to them, I reply, ‘I know that your brother was well intentioned. But what if you have hypothyroidism? Can you pull your thyroid levels up by its bootstraps? Could you shake off a low thyroid level? There are neurobiological changes associated with depression that must be addressed in order for you to feel better. You will also have to do everything in your power to help out—such as with diet, exercise, pushing yourself to be with people, etc.’
Q | Do you have any upcoming projects or things you are working on that you are excited about?
A | Yes, this is such an active and exciting time in our field. Everywhere I look there is an opportunity to participate in great breakthroughs in our understanding of psychiatric disorders and in the delivery of effective psychiatric care. All of our many outstanding institutions in the Texas Medical Center already work together closely to care for people with mental illnesses, and we will continue to do so. One current project that we are working on as a community is to build a neuropsychiatric research institute on the beautiful new Mental Health Epicenter Campus of the Menninger Clinic. Our plan is to provide groundbreaking research in that facility that will be translated rapidly and directly into respectful, compassionate and effective patient care. In that proposed facility, which is a joint project of Menninger Clinic and Baylor College of Medicine, a new generation of medical students, residents and mental health professionals will be educated in behavioral health. The architectural plans for the new institute have been completed, and we have raised from the generous Houston community—and far beyond— over $12 million dollars towards the $25 million goal.
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