Dr. Talbott is professor of psychiatry, University of Maryland School of Medicine, Baltimore, and editor emeritus of Psychiatric Services. Send correspondence to him at the Department of Psychiatry, University of Maryland School of Medicine, 701 West Pratt St., Rm. 322, Baltimore, MD 21201 (e-mail: firstname.lastname@example.org). Lisa B. Dixon, M.D., M.P.H., and Anthony F. Lehman, M.D., M.S.P.H., are editors of this column.
Academia and public mental health systems have experienced a long and varied history of relationships throughout the United States. It is critical to understand the history of these partnerships in order to have a context for current relationships and a broad view of the current state of affairs. As an introduction for this new column, I provide an overview of the evolution of these relationships and then discuss some current national trends.
The first public hospital in America was founded in 1773 in Williamsburg, Virginia, and state psychiatric hospital systems flowered in the 19th century (1). However, during this time, academic medicine and psychiatry were for the most part not involved in establishing or operating state hospitals. The College of Physicians and Surgeons, founded in 1767 and later absorbed by Columbia University, did not establish the New York Psychiatric Institute until 1896. Harvard Medical School, founded in 1782, did not establish the Boston Psychopathic Institute until 1912. However, these were "special" state hospitals, meant from the start to be different, indeed better by design, than the lumbering old facilities on huge rural tracts of land that we all think of as "traditional" state hospitals.
Those older facilities, such as the Topeka (Kansas) State Hospital, were isolated from academic influences until the mid-20th century. Even then, such relationships were often also "special"; in the case of the Menninger Hospital, for instance, the state facility was used only as a training site for psychiatric residents.
At about this same time, after World War II, the Veterans' Administration (VA) started what became the largest public-academic collaboration in the United States when it proposed that most "general" VA hospitals be affiliated with medical schools and their medical and psychiatric care guided by "Deans' Committees."
Unfortunately, there is a paucity of literature about these early efforts, especially from an administrative and systems viewpoint. Not surprisingly for those who knew him, it was not until Walter Barton, superintendent of the Boston State Hospital, authored a pioneering textbook, Administration in Psychiatry (2), in 1962 that the issue of training psychiatrists for public service at a traditional state hospital was dealt with in the psychiatric literature. Shortly thereafter, his colleague and successor as superintendent, Milton Greenblatt, published a report "University-Hospital Collaboration in Psychiatric Education" (3). Greenblatt's subsequent book, Dynamics of Institutional Change (4), dealt extensively with the advantages of state-university collaboration. The next superintendent, Jonathan Cole, another academic psychiatrist, also maximized use of this position but, in his case, to perform quality psychopharmacological research (5).
In 1975 James Shore published his work on Oregon's university-state-community psychiatry collaboration, and since then, the Oregon group has published numerous works on training in public community psychiatry, community support programs, and community mental health centers (CMHCs) (see reference 6 for an example). A few years later, in 1982, the Maryland group, led by Henry Harbin, wrote of its efforts in training, recruiting, and retaining psychiatrists in the state system (7).
During this era Larry Faulkner and his colleagues assessed the types of public-academic collaborations in CMHCs and VA and state hospitals (8). Finally, in June 1984 a national conference was held, where many of the programs mentioned above were presented. The conference resulted in both a book, Working Together: State-University Collaboration in Mental Health (9), and a national initiative known as the State-University Collaboration Project, which spurred development over the next decade of educational, service, and research (10) programs between states and universities. The results of the aforementioned programs were largely process ones, and few quantitative outcomes were published.
Shortly thereafter, in 1988, the National Institute of Mental Health (NIMH) initiated its Public-Academic Liaison Program (PAL) that rewarded investigators submitting research grants if they conducted such research as part of a public-academic collaboration. Three years later, Bevilacqua (11) summarized the program and its progress in this journal, and I summarized the program led by the American Psychiatric Association (APA) (12). Other reports, too numerous to cite here but largely published in this journal and our sister journal, the American Journal of Psychiatry, documented the results of these two national initiatives and demonstrated the power of a little money, a great deal of expertise, and the ability to convene meetings, award honors, and disseminate successful results. For instance, the NIMH PAL program resulted in more than a hundred new research grants that utilized state hospital sites and populations, and the APA-led program resulted in more than a hundred new "bridging" positions for academic psychiatrists.
In terms of publications, in this journal alone, descriptions of public-academic partnerships were published for the following states: Arkansas, California, Colorado, Connecticut, Kansas, Kentucky, Maryland, Nebraska, New York, North Carolina, Ohio, Oregon, Pennsylvania, South Carolina, Vermont, Virginia, Washington, and the District of Columbia. [A list of articles published in this journal that describe these partnerships is available as an online supplement to this column at ps.psychiatryonline.org.]
It has now been 25 years since the pioneering programs in Oregon and Maryland were initiated and almost that long since the APA- and NIMH-led initiatives were inaugurated. What is the current status of public-academic collaborations?
Just recently, Buckley, Faulkner, and I replicated Faulkner's 1983 survey (8) of involvement with the public sector of medical school departments of psychiatry (Talbott JA, Buckley P, Faulkner L: unpublished data, 2005—2006). What we found falls in the realm of good news-bad news; that is, although many programs suffered, many have thrived. Departments' activities likewise varied—about a third increased, a third decreased, and a third stayed the same. There were outstanding outliers; for example one department garnered three full-time professorships, and another lost all research funding when the state facility folded. One provocative comment from a chair of psychiatry was, "Of course things are better. Before 1980 we had nothing." Of importance as well is the fact that training has shifted from general residency training to subspecialty fellowships, in particular forensic fellowships, reflecting the change in our field.
Where do we stand now? In our survey, about half the departments envisioned no new initiatives with the public sector, while half saw opportunities for bold new initiatives. Finally, our repeat survey showed that what makes these partnerships work is not sophisticated planning and implementation but largely depends on good interpersonal relationships; that is, a good partnership is based upon mutual respect, good personal relationships, history, and trust, as well as a joint understanding of the partner's differing missions.
I recently had the opportunity to interview Robert Glover, director of the National Association of State Mental Health Program Directors, for another project. What I learned was that today's challenges and opportunities have almost no resemblance to those of yesteryear. Facilities are bursting with court-remanded patients, sexual offenders, and persons with comorbid drug and alcohol diagnoses. Staffing is once again a problem, and funding remains as critical a stress as it was a half-century ago. Commissioners and directors are looking for partners to help solve these problems, and they are looking to academic institutions.
In sum, public-academic partnerships have a very long history. In the past few decades some have blossomed, and others have withered; some have added faculty and programs and training opportunities, and others have lost important research sites. Despite these mixed results, however, I foresee a new burst of energy because of changing times, emerging challenges, and a new cast of characters.