In this episode of Mental Health Pathfinders, host Erin Connors speaks with APA President Mark H. Rapaport, M.D., about his vision for the year ahead and the role members can play in advancing psychiatry. Dr. Rapaport discusses APA’s strategic priorities, the future of the DSM, and the importance of medical leadership, member engagement, and stronger communication throughout the organization. The conversation also examines urgent challenges facing psychiatrists and their patients, including scope creep, ghost panels, mental health parity, stigma, misinformation, and the effects of social media. Drawing on examples from crisis care and health economics, Dr. Rapaport explains how psychiatrists can demonstrate the value of their work and turn their experiences into effective advocacy for patients, communities, and the profession.

Transcript

Erin Connors (00:08) Welcome to Mental Health Pathfinders. I'm your host, Erin Connors. Today I'm joined by APA's new president, Dr. Mark Rappaport, for a conversation about his vision for the year ahead and the role APA members can play in shaping the future of psychiatry. Dr. Rappaport is founding CEO emeritus of the Huntsman Mental Health Institute at the University of Utah and an adjunct professor in the Department of Psychiatry and Behavioral Sciences at Stanford University. Throughout his career, is focused on advancing research and education, patient care, and public understanding of mental health. Dr. Rappaport, it's a pleasure to have you here today.

Mark Rapaport (00:47) Thank you very much, Aaron. It's pleasure to be with you and I'm excited about the forthcoming year.

Erin Connors (00:53) Absolutely. And as you step into the year as APA president, what do you most want members to know about your vision for this year ahead?

Mark Rapaport (01:03) Well, I'd like members to understand the tremendous need for continuity with the wonderful work that was done by Dr. Misman Rivera. We're going to be moving ahead with the strategic plan and the objectives of the strategic plan. And thanks to the great leadership of Dr. Wills, what we're doing is creating dashboards so that members can be looking, you know, at the... our APA website and following the progress that we're making. You know, the strategic plan is so exciting. Focusing on medical leadership, focusing on members value and the quality ⁓ of life for our members, as well as one APA and being a strong and efficient organization. So I'm absolutely thrilled to continue that work and drive it forward. You know, there's so many critical short, intermediate, and long-term projects related to those three sort of pillars of our strategic plan.

Erin Connors (02:15) And you know, in your remarks at the APA Annual Meeting, you emphasized two ideas. We hear you and we need you. What have you been hearing most and clearly from members and where do you need them most to step forward?

Mark Rapaport (02:30) Sure. Well, what we've heard from members is very clear. They want an organization that is flexible and responsive to major issues as they come up in mental health and psychiatry. Our members have also told us that they want the American Psychiatric Association to demonstrate leadership and to demonstrate and help them demonstrate that psychiatrists are the medical leaders when it comes to studies of the brain, when it becomes a developing new treatments or creating policies that are important for our patients and for ourselves. ⁓ We really understand that and we really have heard that. And that's why the exciting work that's going to be going on with the future of DSM ⁓ is going to be so important. The way that Dr. Aquindo and Dr. Alpert and Dr. Gatoi are conceptualizing the future of DSM is really transformative. It allows us to conceive of what's going on with our patients in four ways, in terms of their social determinants of health and developmental history and trauma history, in terms of understanding the biology of ⁓ these syndromes that we treat, these complex brain syndromes, as well as understanding that there are certain types of features that cut across all of our current nosology, things like anxiety, sleep disturbance, cognitive disturbances, and that as we holistically treat our patients, treating them in terms of their needs, in terms of social determinants, treating them in terms of their past history of trauma and developmental history, as we look at treating them in terms of their presenting conditions, we need to keep in mind this holistic approach where the treatment of anxiety or the treatment of sleep disturbance is a component of every single diagnosis we're going to be looking at. The other thing that is really exciting to me is the idea that as we assess a patient for the first time, instead of boxing them in initially into a fixed diagnosis, we're going to have larger diagnostic clusters like psychosis and mania or substance use disorders or mood disorders in general, and then create a model where over time, as we know that patient better, we'll have a much more specific singular diagnosis. So we won't have the problems we've had with somebody having schizophrenia, schizoaffective disorder and bipolar disorder at the same time, which makes no sense. What we'll have is an approach that allows us to over time shape the diagnosis appropriately, measure the severity of the illness and distress someone's under and take into account in that diagnosis quality of life and functioning. So we're looking at a completely new conceptualization and future for the DSM that to me is exciting and a great example of the APA taking true medical leadership. So that's one of the things I'm very excited about, but there are a host of other ones. Just ask a whale. Fill your entire day with conversation.

Erin Connors (06:31) I love that. But I think maybe we should get into some issues as well, because I know you talked about scope creep, ghost panels, parity, as things that directly affect patient care, obviously. So talk about why these are such urgent issues for psychiatrists and their patients right now.

Mark Rapaport (06:35) Yep. Yes, you know, it is absolutely correct that ⁓ we as a field, in order to really help our patients, must gather data and advocate when it comes to issues like scope creep. we need to really understand the extent of scope creep and we need our members to be communicating what's going on in their communities to our DBs and our DBs communicating that up through the assembly to the rest of the APA because If we understand the extent of scope creep, if we understand what is going on. We can work together to advocate for the appropriate coordinated care. But that's a care where the psychiatrist is leading the team. We also...

Erin Connors (07:55) And we're still talking about parity after all these years. Still talking about it.

Mark Rapaport (08:00) ⁓ well, parity is a longstanding challenge. And part of the reason for that is that ignorance and prejudice and shame associated with psychiatric disorders, the stigma that somehow has minimized the importance of disorders of the most wonderful organ in the body, the brain. You know, you can't... You you can't live, you can't smile, you can't have memories, you can't create without the brain. Yet, when we look at the reimbursement rates, even within our medical brethren for the same activity, psychiatrists are being paid less. And that is just wrong. And so we have to continue to our work on a national level, but even more importantly, again, we have to work on a local level to get parity. have to inform our health systems of the value of what we do. And in fact, one of the things that I've done over the last four years is work with the Sorenson Impact Institute and the Health Economics Court at the University of Utah, and we have actually developed the first monetization of the social impact of what we do in psychiatry. And we can show that our work as psychiatrists, whether we're looking at an individual level, a family level, a systems level in terms of health systems or employers, as well as a societal level, looking at the impact that we have on cities, counties, and states, we can demonstrate the value and how what we do is an investment and not a cost. So let me just make one point about that. ⁓ We prototyped ⁓ a crisis care model when I was at the University of Utah. In what we showed is in our crisis care prototype, 4,000 individuals were seen. We decreased the number of all-cause emergency department admissions for those individuals by 2.7 emergency department visits per person after they were seen in our crisis care center. So what does that tell you? That tells you that those people were functioning better. That tells you that they were more adherent with that, whatever their treatment had been. It tells you that there was a huge savings to the health system. We were decreasing the number of people going to emergency rooms significantly. We were shifting the types of patients that were going to the emergency rooms. And there is a tremendous cost savings there. The other aspect of that cost savings, looking at it at a societal level, is that when people were brought to emergency rooms in Utah or many other states, if they're brought by law enforcement, law enforcement has to wait until this position. And as you know, our patients have the longest length of stay of any group of patients in the ED. Well, with our model, There's a five minute handle. So we go from a circumstance where law enforcement may be waiting six, seven, eight hours for disposition to five minutes. Think of the savings. Think of the redistribution of law enforcement out in the community to take care of the needs of the community rather than sitting in the hospital waiting for a disposition.

Erin Connors (12:22) So how can APA members turn what they're seeing in their own practices, their health systems and their communities into like really strong advocacy?

Mark Rapaport (12:34) Well, that's exactly what we need people to do. And there are a variety of aspects to it. So one aspect of it is whether we're talking about cases of scopecrete or whether we're talking the presence of ghost panels or lack of parity. What we need is for our members to be communicating this, giving these examples to our district branches so that they can give us the data that we need to nationally advocate for it. But actually, the most important work is going to be in the health systems and in the cities and in the states that our members live in. And what we need our members to do is to get involved in advocating for appropriate limitations on scope and We're willing at the APA Central to help do that, but they need to be the ones talking to their city council people, to their county representatives, to their state representatives, and to their federal representatives about their concerns. One of the things I learned years ago when I was working at the NIH was that when congressional individuals get letters or of concern from members, particularly letters where they say, and I want a response. The representatives hear that because they calculate that each one of those letters represents a certain block of voters. And so they take that very seriously. And they actually, when I was at the NIH, one of my jobs was to respond to those requests from ⁓ constituents and send back to the Congress people the information that they needed to respond to their constituencies. So by advocating, by actually contacting your representatives when it comes to mental health issues, whether it's scope creep, whether it is the presence of ghost panels, whether it is a lack of parity, we can make changes together. but that's going to be very, very important work for us. You know, another thing, Aaron, I'd like for us to be sure and talk with our colleagues about today ⁓ is the wonderful work and really important work that's going to have to happen this year in terms of the APA responding to and working with Health and Human Services, SAMHSA. and others around some of the at times misinformation that's going on and initiatives that really require the expertise at the APA. So for example, two members of the APA have been now asked to serve on the SAMSHA working group that's going to look into the appropriate use of medication and the appropriate steps necessary to discontinue medication. And that's an example of the APA taking medical leadership, but more importantly, providing important value to all of our members. Now, we know that The work we do is very important. We know that we prescribe medications appropriately. And there needs to be a strong voice in Washington around issues like this. And I'm pleased to say that the APA is respected and being asked to be at this table, which I think is really, really important at this time.

Erin Connors (16:53) It is, it's an unprecedented time and you said there is a lot of misinformation out there. So it is important for the APA to be a voice that is able to give the correct information when it's necessary.

Mark Rapaport (17:05) Well, you know, that reminds me, I need to call out you and Jim, James, the press releases that the APA has been putting out, and I hope that our members are actually looking at them and reading them, are really thoughtfully done, but to the point and are very, very clear about our feelings that no, there is not over medicalization. of psychiatric disorders that yes, we certainly want to do what's best for our patients, but that does not mean that ⁓ we're going to abandon what we know works and helps our patients and their families. And you and James and ⁓ our advocacy groups, have just done a spectacular job with those press releases. And I hope that people do stop and read them and use them in your local communities.

Erin Connors (18:17) Thank you very much for that. mean, we do have a, communications department is very active and we do want to educate and assist in educating as well. It's a big part of what we do. Yes. Well.

Mark Rapaport (18:27) Yes, an important part.

Erin Connors (18:30) And I want to get back to you though. You know, you've long been involved in the work to reduce stigma around mental illness and substance use disorders. In some ways, it seems like things are getting better. ⁓ But what do you still think needs to be done to change the public conversation?

Mark Rapaport (18:52) Well, thank you for your optimism. And you're right. Things are getting better. One of the reasons they're getting better is younger people do not have the stigma and the same types of concerns about talking about disorders of the brain. But there's a lot of work we have to do. ⁓ The work of Bernice Pescalito and others that are looking at the The GSS survey around mental health shows that we still have a huge amount of work to do in terms of the way society perceives people with brain diseases. They still tend to feel that people with brain diseases, be it substance use disorder or be it depression or psychosis, that somehow that these disorders are still the fault of the individual. And that absolutely is not the case. So we have to do a lot more education there. We also have to do a lot more education when it comes to ⁓ helping people realize that mental health is an asset and that it's not reaching out and getting help is not something that someone should feel ashamed of. But it's a sign of, hey, I'm taking control of my life. I'm doing the things that need to be done so that I can live as rich and full a life as I possibly can. And so I can contribute and help others. That's what.

Erin Connors (20:39) kind of role does social media play here? Because I feel like there's so much out there right now and there's so many different on TikTok, there's people giving advice. What is your hope or your concern right now when it comes to social media and mental health?

Mark Rapaport (20:57) Social media, I think, is a double-edged sword. The good news about social media is that for some individuals, particularly people in rural settings or people that have felt somehow marginalized, it's possible to find certain groups that are supportive of one another. And that in itself is good. However, I think that Social media, the way it's currently being used, particularly by young people, is problematic. One of the problems with social media for many people is bullying is now something that's 24 hours a day. In the old days, when I was in school, if one were bullied, you usually weren't bullied at school, but that was it. It wasn't something that... was incessant. And also if you were being bullied, it was usually by a discreet person or persons that you knew and were acquainted with. Unfortunately, now with social media, there are some people that are getting bullied by absolute strangers, which is horrific to think about that folks will do that. Another problem with social media is this fantasy that everyone's life is wonderful. You know, if one goes on social media, you know, it certainly is perceived that everyone's world is absolutely wonderful and rosy and carefree, successful without problems. And we know that's not the case. Everyone's life.

Erin Connors (22:28) Yes, it's true.

Mark Rapaport (22:51) is full of twists and turns. Everyone's life is full of obstacles and sadness, as well as periods of joy. But unfortunately, the way social media is constructed today, that isn't the case.

Erin Connors (23:08) Well, before we let you go today, I just maybe put you on the spot a little bit. What is your biggest hope for the year ahead in this new role?

Mark Rapaport (23:17) my biggest hope is that we use this year to move forward with this concept of one APA. We use this year so that our members feel and are more engaged that we're gathering, gathering the data from our members that will allow us one to know what their needs are, but two more importantly, that they're helping the APA with the strategic goals that were developed because of the feedback that we got from our members. So if at the end of my year as president, we were able to determine that more members were involved in giving information to the DBs and that they were getting back from the DBs more information about what we're doing in terms of our annual goals related to the strategic plan in terms of the work that we're doing that you and James and others have done such a great job with the press releases are where we are really standing up for our patients and for our members with Congress, with Health and Human Services, with our peer associations and you know, with other powers that be, if that bi-directional communication and bi-directional engagement were increased, then you know what? I would feel like all of us together have done something that really is important in contributing to our organization, our patients, and the field.

Erin Connors (25:12) Dr. Mark Rappaport, thank you for joining us today and I look forward to working with you during your presidential year.

Mark Rapaport (25:18) Thank you very much, Aaron. I look very much forward to working with you.

Erin Connors (25:23) And to our listeners, can find more episodes like this one on a range of mental health topics on APA's Medical Mind Channel, available on all major podcasting platforms.