IN THE COMPANY OF PSYCHIATRIC ELITE

I felt like a kid in the candy store, surrounded by sweet, colorful, and shiny objects. High mood, you might as well call it elation, was my new state of mind. I didn’t know where to turn first. Everything was new and attractive. I could barely believe it. Was I dreaming? Was I really here, in this place of wonder, a Disneyland where dreams come true? Was I in Hollywood of the psychiatric world, where the production of “movies” was a daily occurrence in the buildings of Ivy hospital (Butler) affiliated with Ivy university (Brown)? Was I in the place (Providence) where the history of the country was palpable everywhere? All these questions were rhetorical. There was no need for anyone to answer them. I knew it was a new reality in my life. I found myself among the stars of the psychiatric world, comfortable in my own skin, without a trace of social anxiety, as if it had vanished, erased by the imaginary gum.

Hospital

Butler Hospital is one of America's oldest psychiatric hospitals and is characterized by beautiful architecture and landscaped grounds. It was founded in 1844, in an era of “moral treatment”, a period of reform for psychiatry and the nation. Dr. Isaac Ray, the hospital’s first superintendent, believed that each patient should be treated humanely in a clean, safe environment. In fact, many physicians at the time believed that appropriate treatment required hospitalization because it was assumed that the pressures and excitement of society were the main cause of mental illness. The facilities themselves rather than the drugs or therapy were viewed as the main elements of the cure. In an ideal environment, a carefully regulated everyday routine was important to heal the disordered mind.

The land that was incorporated into Butler Hospital was originally a farm. As part of the therapeutic routine, daily farm work was carried out and vegetables and dairy products were used to prepare meals in the hospital. This historic fact reminded me of a similar work therapy program on the farm at a different hospital (in Vršac), where my psychiatric career began. These were the emerging threads of what was later developed in occupational therapy with the motto, “Sick minds, sick bodies, and sick souls may be healed through occupation” *

When I arrived in 1996, the Butler Hospital was located on 114 acres of natural lawns, woodlands, and open meadows. There were 35 buildings that housed numerous services and programs. A large number of the historical red brick buildings built in the 1800s remained standing and were still in use, with necessary upgrades. My office was located in one of those buildings with an enormous window overlooking the newly created garden full of flowers, paths, and benches where everyone can come for a walking meditation or contemplation. The tranquility and greenness of the trees and plants were soothing to the eyes and healing to the soul.

Community

Definitely, I was in good company. For the first time, I found myself in a private, free-standing psychiatric hospital with the finest group of psychiatrists and other physicians dedicated to the care of the mentally ill. I remember the first staff meeting in the room next to the cafeteria when I was introduced to the group as a new addition. It wasn't just me, but 5 other psychiatrists who joined the hospital staff at that time. I have never seen so many psychiatrists gathered in one room.

In this group of newcomers was Larry Price. Later on, he became my research and academic mentor. He came from Yale University, where he had a distinguished research career in mood disorders. Dr. Price was tasked to develop a clinical and research program in affective disorders at Butler Hospital. He hired Linda Carpenter as soon as she completed her research fellowship training at Yale. Two of them single-handedly developed the above-mentioned program. I closely worked with them and gradually became a dedicated clinician in the domain of mood disorders. It was my new interest because of my transition from predominantly inpatient work to full-time outpatient psychiatry practice where patients diagnosed with mood disorders predominated.

Dr. Price was very knowledgeable in psychopharmacology. He was editor-in-chief of the reputable Brown University Psychopharmacology Update newsletter and had many other publications testifying for his excellence. ** He knew that I had a lot of experience using novel drugs that were flooding the market at that time. I was creatively applying them in difficult-to-treat patients with mood disorders. Because of that Dr. Price invited me to be a part of the research team. As a result of our cooperation, several manuscripts were produced during this period. ***

Dr. Price was an unassuming quiet person, but a very respectable scholar, researcher, clinician, and administrator. During his tenure at Butler Hospital, he held important positions and made many contributions to our profession. I feel lucky that he was my mentor and supporter.

Coat of many colors

I use this biblical reference to the gift that Joseph received from his father to symbolically depict the rich, colorful and diverse presence and various activities of the psychiatrists I met and learned from while at Butler Hospital.

There was Linda Carpenter, a young tour de force. She was ambitious, energetic, productive, and innovative. Always with a big smile on her face, ready for anything that came her way either as a challenge or an opportunity. She was more approachable than Larry Price, so we worked closely on a number of occasions, not only as part of research projects but in many other activities, some personal and others professional. Later in her career, she became known for her work in neurostimulation, especially the use of transcranial magnetic stimulation (TMS) in the treatment of mood disorders, primarily depression. ****

Kathy Phillips was my immediate boss, head of outpatient services, internationally known for her pioneering work on body dysmorphic disorder (BDD), a common but often neglected or misdiagnosed. Many of her research studies were funded by the National Institute of Mental Health. People with BDD see themselves as abnormal, ugly, or unappealing, causing emotional distress or adversely affecting their functioning and quality of life. At the time I arrived at Butler Hospital in 1996, she published the first book ever written about BDD. ***** Thanks to the book, and many years of researching and popularizing this unusual disorder, she had a high profile in the media. I appreciated her intelligence, elegance, and knowledge of the field of psychiatry that I knew little about.

Steve Rasmussen was a medical director of Butler Hospital. He was known for his expertise in obsessive-compulsive disorder (OCD). He was one of the creators of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) used extensively in research and clinical practice to both determine the severity of OCD and to monitor improvement during treatment. Dr. Rasmussen treated the most severe cases of OCD in collaboration with neurosurgeons using a gamma knife. Gamma knife is a treatment for OCD that does not require opening the skull. Instead, multiple gamma rays pass through the skull. When gamma rays intersect, the energy level is high enough to destroy the targeted brain tissue believed to be a neural substrate for intractable OCD. About 60% of those who did not respond to behavior therapy or medicines for OCD benefited from this procedure. ****** I remember he always had his hands full. Knowing his limited time, he told the others that even if they only had five minutes with the patients, as long as they were fully present with them, it would carry a significant therapeutic value. This advice has remained in my memory, and I have put it into practice in my work and in my life, especially at times of exceptional business that characterized my life in those years. My encounters with Dr. Rasmussen were infrequent and short. But he could always find those five minutes to listen to my need and give me wise counsel. Currently, he holds a distinguished position as Chairman of the Department of Psychiatry and Human Behavior at the Alpert School of Medicine at Brown University.

There were many others that I will mention only briefly because I did not participate in a significant way in the important programs they were running. One of them was Robert Kohn, a psychiatrist originally from Brazil who launched a program for the Portuguese-speaking population. They had the highest concentration in the United States in Rhode Island and Massachusetts. This program was a great success and, consequently, the Butler Hospital opened the second “international” program for Spanish-speaking people headed by Alvaro Olivares. Dr. Olivares even had a popular radio program that helped many patients to get engaged in treatment. Dr. Kohn was also credited with establishing a geriatric psychiatric fellowship program, a necessary sub-specialty for the aging population with mental health needs.

Another name that comes to mind is Stephen Salloway, a neurologist who has dedicated his career to patients with dementia. He was a founding director of the Memory and Aging Program at Butler Hospital and has been at the forefront of the study and treatment of Alzheimer's disease and dementia. I was introduced to his work by Dr. Ross, Fargo's behavioral neurologist, even before I arrived in Providence. Dr. Salloway wrote an impactful book with his colleagues, which I studied because I have an interest in neuropsychiatric disorders. ******* This book was a valuable resource for me in the preparation for my lectures in Fargo.

Many other talented psychiatrists were contributors to the “coat of many colors.” Dawn Picotte, a child and adolescent psychiatrist joined Butler Hospital at the same time I did. Later on, she developed a residential program for the treatment of troubled adolescents. Alan Gordon and Michael Fiori were indispensable in the addiction treatment program. They were joined by Jon Grant who developed protocols for the treatment of compulsive gambling.

Finally, I would like to mention Martin Furman, the Chief of the Intensive Treatment Unit at Butler hospital for his innovative work in the use of maintenance Electroconvulsive Therapy (ECT) in the treatment of severe depression. ******** I referred some of my patients to this important treatment, which helped patients with the most serious form of depression and prevented their repeated hospitalizations, or worse.

University

Brown University is one of the oldest institutions of higher education in the country. It was founded in 1764. The main campus is located on College Hill, in the midst of colonial-era buildings with the most beautiful architecture from that period in the U.S. Brown University is well known for its undergraduate Open Curriculum, which allows students to study without any course requirements outside of their major. This has been a very appealing attribute to many students because of the intellectual freedom unmatched by any other college in the world.

Brown University Medical School was established in 1811. Nowadays it is one of the top 25 medical schools in the nation. Department of Psychiatry and Human Behavior is one of the largest departments of the medical school dedicated to providing excellence in research, education, clinical care, community service, and mental illness advocacy. Since Butler Hospital was Brown University's primary affiliated teaching hospital, many psychiatrists had academic appointments. I was one of them. The range of research areas in psychiatry and psychology was impressive. Equally impressive were the educational programs.

The leader of the department was Martin Keller, a pioneer in prospective, longitudinal, naturalistic studies and novel assessment methods. These studies have brought about a paradigm shift in understanding that mood and anxiety disorders are not short-term episodes, but rather chronic, recurring, and disabling conditions that manifest themselves over the course of a lifetime. Dr. Keller was the most powerful psychiatrist in Rhode Island for 20 years. He was heavily involved in bringing money to the department from both the pharmaceutical industry and the National Institute of Health grants. Unfortunately, he didn’t resist the “song of the siren” from “Big Pharma” and had to leave his position in 2009 after the scandal concerning one of the studies in which he participated.

My involvement with the Department of Psychiatry and Human Behavior was significant. I developed a passion for education and teaching through both traditional and innovative methods. I organized seminars for first-year residents, gave lectures, supervised and mentored trainees in their outpatient rotations, and closely instructed residents and medical students in emergency psychiatry. Other important educational activities were focused on patients, their families, and the general community. For my work in the community, I was recognized by a leading patient and family advocacy organization (the National Alliance on Mental Illness) with their yearly Exemplary Psychiatrist Award in 2004.

Libraries

My love of libraries has gone on all my life. Wherever I was, a visit to the library was not to be missed. For instance, when I lived in Fargo, other than a public library, I was often present in the libraries of four educational institutions, the Neuropsychiatric Research Institute, and Veterans Administration and MeritCare health care system libraries. It was therefore inevitable that I would pursue my passion for libraries in Providence. Let me start by mentioning the Providence Public Library, which is located in the historic building and is the recipient of the National Medal for Museum and Library Service in 2001 for outstanding service to the community. I will continue with Providence Athenaeum, where the history of 200 years of existence is overwhelming once you enter its Greek Revival building. Its collections are unmatched and were used by writers, thinkers, and members of the community “to enrich the mind, inspire the spirit, and elevate the public discourse.” ********* The Athenaeum predates the establishment of public libraries. It was my daughter Simone's favorite spot where her love of books flourished.

My preferred destination was the libraries of Brown University. There were five of them, but I visited only two: The Rockefeller Library (known as “The Rock”), and Sciences Library. The main library was named in honor of John D. Rockefeller, Jr. for his philanthropy. He was a student at Brown and praised his college experience as the culmination of his future life. The long Credo by John D. Rockefeller Jr. is exhibited in bronze letters on the wall in the main lobby of the Rockefeller Library. I cite here one of his "believes" with whom I identified most:

“I believe that love is the greatest thing in the world; that it alone can overcome hate; that right can and will triumph over might.”

The “Rock” library was the biggest of all. It was a gathering place for both staff and students. I remember going down with the elevator into its three lower floors that sunk into the slope of College Hill, “digging” rare collections of books from Yugoslavia. My interests in humanities, social sciences, and art were broadened and satisfied by visits to this unusual place that housed 1.5 million books.

Brown University was one of the first universities in the nation to combine its science collections into a single library in the interest of facilitating an interdisciplinary approach to teaching and research. A fifteen-story building, completed in 1971, was located at the end of the most popular street on the East Side of Providence, Thayer Street. I liked spending time in Sciences Library’s imposing building, not only because of its valuable materials but also because of the view of the area. The combination of beauty and science had created a state of exaltation within me. The poetry and prose of my mind’s creative side came to their full expression in this enriched environment. The knowledge built into this “tower” was my nourishment for a better understanding of the world with the help of the best scientific minds.

Author

I have known Peter Kremer through his column “Practicing” in the professional newspaper Psychiatric Times since my arrival in the United States. Month after month, I read his chronicle from the perspective of someone who practiced psychiatry every day. His narration and the inclusion of his experiences in the story was a breath of fresh air in the “room” full of dry and distant information “downloads.” He advocated the integration of therapy with prescribing medications. He believed that doctors need to spend enough time with their patients to get to know each other. That the strength of this relationship is what holds the greatest healing potential. His philosophy of care was also my own, so no wonder I was drawn to him.

In 1993, he erupted into public consciousness when he published his book, Listening to Prozac. ********** Suddenly, Dr. Kremer became the most famous psychiatrist in America and was a frequent guest on talk shows and other media. The book was written at a time when Prozac was relatively new on the market. Much of it is about how the antidepressant Prozac has revolutionized the power of psychopharmacological drugs. Dr. Kremer used the term “cosmetic psychopharmacology” to describe how Prozac and other medications can be used to make people feel “better than well” due to their ability to “transform” one's behavior, as well as the concept of self. Prozac seemed to give social confidence to the habitually timid, to make the sensitive person develop “thick skin”, and to equip the introvert with the social skills of a salesman. With this book and many others, Dr. Kremer successfully argued for the combination of two modes of treatment, psychotherapy and drug therapy. We met in the halls of the Butler Hospital during meetings of the local branch of the American Psychiatric Association. Furthermore, he sometimes referred patients to me from his busy private office.

To sum it up

The form of my psychiatric sculpture had become more and more recognizable. While I was at Butler Hospital, I was surrounded by the patina of the old and the radiance of the new. These were the proper ingredients in the environment where the story of the past and the present were merged. I felt like I was in the right place at the right time to benefit and be beneficial in the company of the psychiatric elite. Figuratively speaking, my plate was full of wonderful food that I ate and digested easily. Its nutrients became a part of me. I was nourished and flourished.

* https://www.aota.org/

** Encyclopedia of Psychopharmacology, by Ian P. Stolerman (Editor), Lawrence H. Price (Editor), Springer; 2nd ed. 2015

*** Carpenter LL, Schecter JM, Leon Z (2004). A Case Series Describing Orlistat Use In Patients On Psychotropic Medications. Medicine and Health/Rhode Island, 87 (12): 375-7

Yasmin S, Carpenter LL, Leon Z, Siniscalchi, JM Price LH (2001). Adjunctive Gabapentin treatment-Resistant Depression: A Retrospective Chart Review. J Affective Disorders, 63(1-3):243-7.

Carpenter LL, Leon Z, Yasmin S, Price LH (2002). Do obese depressed patients respond to topiramate? A retrospective chart review. J Affective Disorders, 69(1-3):251-5.

Carpenter LL, Jocic Z, Hall JM, Rasmussen SA, Price LH (1999). Mirtazapine Augmentation in the Treatment of Refractory Depression. J Clin Psychiatry, 60:45-49.

Carpenter LL, Leon Z, Yasmin S, Price LH (1999). Clinical Experience with Mirtazapine in the Treatment of Panic Disorder. Ann Clin Psychiatry, 11:81-86.

**** Carpenter LL (2006). Neurostimulation in resistant depression. J of Psychopharmacology, 20: 35-40

***** The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder, by K.A. Phillips, Oxford University Press, 1996

****** Rasmussen S, et al (2000). Neurosurgical approaches to intractable OCD, CNS Spectrums, 5:23-34.

******* The Neuropsychiatry of Limbic and Subcortical Disorders, by Salloway, Stephen, Malloy, Paul and Cummings, Jeffrey, Amer Psychiatric Pub., 1997

******** Gagne JR, Furman MJ, et al. (2000). Efficacy of continuation ECT and AD compared to AD alone in depressed patients. Am J of Psychiatry, 157: 1960-1965

********* https://providenceathenaeum.org/

********** Listening to Prozac, by Peter D. Kremer, Viking, 1993