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3 Collaboration Improves Lives of hen Max Fink, MD, accepts the Thomas W. Salmon Award from the New York Academy of Medicine on November 29 he will join Adolf Meyer, Karl People with Alzheimer’s Disease W Menninger, John Bowbly, Julius Axelrod and other psychiatric luminaries who have received the award in recognition of their outstanding contributions in psychiatry 4 Attachment Theory: An Interview and neurology. with Professor Judith Crowell, MD “I don’t know why I was chosen,” Dr. Fink said. “I am not a mover and shaker like 6 Mandating Treatment, most people on the list. This is very distinguished company.” Offering Hope: Marsha Karant, “Dr. Fink was chosen because of his immense service to medicine and psychiatry,” MD, and the AOT Program said Robert Michels, MD, University Professor and former Chairman of Psychiatry and Dean of Medicine at Cornell University, and Chairman of the Salmon Award Selection 7 Chief Resident: Committee. “Max Fink has had an extraordinary career, promoting high quality science Michael Rosen, MD based on empirical research and focused on patient treatment. He has been a mentor to major researchers who have gone on to make significant contributions of their own. 8 Psychiatric Diagnoses He has published hundreds of original papers and a dozen books.” Shift Over Time By his own account, Dr. Fink has “an unusual record” as a clinical researcher. His scientific career dates back 65 years, when as a medical trainee, he demonstrated that penicillin, then an experimental drug, was more effective than sulfa for patients JUST A CLICK AWAY with empyema. His study was published in the 1948 edition of Rubin’s Diseases of the Chest. To learn more about the Department of In 1954 Dr. Fink became Director of the newly created Department of Experimental Psychiatry and Psychiatry at Hillside Hospital when he received a grant from the National Institute Behavioral Science of Mental Health (NIMH) to study the electroencephalograms (EEGs) of patients at Stony Brook University, visit receiving convulsive therapy. It was among the first thousand grants awarded by StonyBrookMedicalCenter.org/ the federal agency. psychiatry. There you will find detailed information about our In 1959 Donald F. Klein, MD, came to work in Dr. faculty, clinical services, educational Fink’s lab as a research associate. “Max Fink programs and scientific activities. kicked me into orbit with the study of patients Click on “Updates” to see an and medications,” Dr. Klein said. Today Dr. Klein electronic version of Headlines and is Professor of Psychiatry Emeritus at Columbia latest news about the Department. University and the recipient of more than a dozen awards, including the Salmon Award. Dr. Klein recalled that when he came to Hillside patients were hospitalized for months and years at a time. He and Dr. Fink were at the forefront of the movement to test and use a new generation of medications—including Thorazine® and Tofranil®—that made it possible for patients to live outside the hospital. “We conducted Max Fink, MD, Professor Emeritus of Psychiatry and the first large placebo-controlled study of the new Neurology continued on page 2 1064 SBU HeadlinesNewsletter_FALL2011_layout one 9/8/11 3:00 PM Page 2

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MESSAGE FROM THE CHAIRMAN continued from cover drugs in the United States,” Dr. he presentation of the Klein said. “We divided them into Thomas W. Salmon Award antipsychotics and antidepressants.” by the New York Academy T Dr. Fink was also a pioneer in the of Medicine to Max Fink, MD, is a study of drugs of abuse. He began tribute to his distinguished career. testing LSD in 1953. He reported Dr. Fink was one of a small cadre that he had little problem finding of investigators who developed the volunteers among his residents. In medications that revolutionized the 1960’s he turned his attention to psychiatry in the 1960s. He was opioids and marijuana. In 1968 he instrumental in the application published an article on the “neuro- of digital computing to the interpre- physiology of the phantastica” and in tation of EEG. His courageous lead- the 1970s, he compared the effects ership in defending ECT has rescued of marijuana grown in Mississippi countless patients from the brink of to hashish made in Greece. One Mark J. Sedler, MD, MPH suicide. We are honored to have Dr. outcome of his studies was the Fink as a member of our faculty. recognition that naloxone and cycla- In this issue, we look back too on the contributions made by Professor of zocine could be used in the treatment Psychiatry and Psychology, Judith Crowell, MD, to our understanding of the of opioid overdose and dependence. role of attachment across the life span and across generations. Dr. Crowell is Many of Dr. Fink’s scientific currently conducting an important study of social and psychological factors contributions resulted from his use that increase the risk of diabetes and heart disease in adults. of EEG. When he set up his first EEG A look at Dr. Marsha Karant’s work in the Assisted Outpatient Treatment (AOT) lab in 1954, results were interpreted program highlights our Department’s role in the public mental health system. by flipping through pages of squiggles. The collaboration between our Comprehensive Psychiatric Emergency Program Dr. Fink was determined to use more and the Suffolk County AOT program helps make our county safer by ensuring rigorous methods, even if it meant that people receive the psychiatric treatment they need. using calipers and rulers to measure Another collaboration—this one between our Alzheimer’s Disease Assistance tracings by hand. In 1958, Dr. Fink Center (ADAC) and the Long Island Museum—improves the quality of life for met Turan M. Itil, MD, at a conference people with dementia, including the residents of the Long Island State in Rome. Both were there to present Veterans Home. We recently received a five-year contract from the New York papers on the effect of psychotropic State Department of Health to continue the ADAC. drugs on the human EEG. When they discovered that their findings were In our next issue, we will feature the Suffolk County Mental Health Project. almost identical, they formed what In July we received a major grant to continue this unique study for another Dr. Itil recently described as a three years. In this issue we take a brief look at one notable finding from the “wonderful and fruitful scientific project—that significant shifts occur in psychiatric diagnoses over time. collaboration.” “Dr. Fink was the sole The training of residents in psychiatry is a central mission of the Department. reason for my leaving Germany to We are pleased to introduce our new Chief Resident, Michael Rosen, MD, who come the United States,” Dr. Itil said. has already distinguished himself as a physician and medical journalist. “Our collaboration allowed me to The faculty and staff of the Department of Psychiatry and Behavioral Science continue my research in a most have made, and will continue to make, significant contributions to science, productive manner.” Dr. Itil is the medical education and community mental health services. We congratulate author of more than 550 scientific them on their fine work. articles and seven books. Dr. Itil and Dr. Fink pioneered the use of IBM computer technology to convert EEG MARK J. SEDLER, MD, MPH from analog to digital, transforming it into a quantitative and objective research tool. 1064 SBU HeadlinesNewsletter_FALL2011_layout one 9/8/11 3:00 PM Page 3

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Dr. Fink came to Stony Brook in 1972 when the Health Sciences Center was Collaboration Improves “nothing but a hole in the ground.” He was recruited by the department’s Lives of People with first chairman, Dr. Stanley Yolles, who Alzheimer’s Disease encouraged him to pursue his studies of psychoactive substances. By the time they were finished, Dr. Fink and hen Jackie Day, President and CEO his colleagues had identified EEG of the Long Island Museum, read about the Museum of Modern Art’s profiles for over 60 compounds, W (MoMa) program for people with Alzheimer’s facilitating the introduction of several disease she immediately wanted to bring it new medications. to Stony Brook. “It was such an interesting When the Hospital opened in 1980, idea,” she said, “and it fit perfectly with our Dr. Fink set up the ECT service. He educational mission.” had practiced ECT at Hillside and the She knew that she and her staff could not New York Medical College. He served create the program on their own. “It was on the American Psychiatric obvious we needed to collaborate with some- Association’s ECT Task Force when one who knows about memory impairment,” ECT was under attack in the mid- she said. Soon after, she met Darlene Jyringi, seventies. In 1979 he published Program Director of the Alzheimer’s Disease Assistance Center. When she mentioned what Edward Shorter and David the program, Ms. Jyringi enthusiastically Healy called “the definitive medical welcomed the idea of a collaboration and text on electroconvulsive shock.” suggested they include Lee Grace Cannella, Director of Therapeutic Recreation For the past 40 years, Dr. Fink at the Long Island State Veterans Home (LISVH). has been the world’s leading “We invited Darlene to the museum to talk with our educators,” Ms. Day said. expert and defender of ECT. “She helped us understand what dementia means and how to deal with it.” Recently, Dr. Fink has been leading a The team spent months sketching out the program with the help of movement to preserve catatonia and MoMA staff. In June they invited a group of veterans who are memory melancholia as independent entities impaired from the LISVH to the museum. Betsy Radecki, the Museum’s in the system of scientific classifica- Director of Education, engaged them in discussions of two iconic carriages— tion, arguing that the current scheme a stagecoach and a luxury coach once owned by William K. Vanderbilt. “I of burying them under schizophrenia asked them open-ended questions that have no wrong answers: What do and major depression is not good for you see? What do you think these were used for?” “The presentation was science or patients. excellent,” Ms. Cannella said, “stimulating yet relaxed. The residents loved it. It connected with their lives.” While he may not consider himself “a mover and a shaker,” Dr. Fink The museum plans a has created a few waves of his own. formal launch of the program in the fall. His friend and colleague, Dr. Donald Ms. Day’s principal Klein, described him as “a scientific concern now is how to skeptic who bucks the tide by refus- satisfy demand in a ing to accept conventional wisdom,” sustainable way. “We adding that Dr. Fink is “a world leader will continue to work in experimental design.” with the Alzheimer’s Disease Assistance “It is an honor to have him as a Center to identify peo- friend and colleague,” Dr. Robert ple who will derive the Michels said. “No one deserves the most benefit from it,” Salmon Award more than Max Fink.” Vanderbilt carriage in the Long Island Museum she said. 1064 SBU HeadlinesNewsletter_FALL2011_layout one 9/8/11 3:00 PM Page 4

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Attachment Theory: An Interview with Professor Judith Crowell, MD

t the end of the Second —is easy to observe in very young World War, the World Health children. Researchers can categorize A Organization commissioned attachment patterns as secure or psychiatrist John Bowlby to study insecure by observing children’s the mental health of children who behavior with their parents after had been separated from their they are exposed to a strange or parents. His investigations led to mildly threatening situation. the conclusion that a secure caring Studying attachment in older relationship with a parent or parent children and adults is less straight- substitute in early childhood is an forward because it is less easily important key to mental health in observed in daily life. We have some later life. The development of tools—structured observational Bowlby’s idea over the next 60 years assessments, questionnaires, and is known as attachment theory. structured interviews, including some Judith Crowell, MD, Professor of we developed ourselves—to study Psychiatry and Psychology at Stony and categorize adult attachments Brook University and Senior Scientist and understand their implications. at the Judge Baker Children’s Center Judith Crowell, MD, Professor of The attachment system has obvious of Harvard Medical School, has been Psychiatry and Psychology at Stony benefits. Does it have a down side? contributing to attachment theory Brook University Not really, because close and research since she was a relationships are such a valuable evolutionarily adaptive propensity to post-doctoral fellow at Stanford in and vital aspect of our lives. attach to individuals who care for the 1980s. Early in her career, she Nevertheless, the loss of an them most—typically their mothers, explored how maternal attachment attachment figure can be a huge although fathers or other caregivers patterns and parent-child relation- blow, as we see when a parent dies. also serve as important attachment ships were associated with We also see disorganized patterns figures. Parents have a correspon- emotional and behavioral disorders of attachment develop, for example, ding propensity to respond to the in young children. After coming to when children are abused. Such needs of children for protection Stony Brook, she studied attachment patterns can be detrimental to func- and support of their exploration. patterns and the development of tioning, especially in relationships. young adults’ marriages. Today, Attachments are important Are patterns of relationship she is the principal investigator of throughout life, and in some ways, permanent or can they change? a study that examines the ways in the parent-infant relationship is With my colleagues, Everett Waters, which attachment patterns are prototypical of all close relationships. PhD, in the Department of associated with adult physical and People who have experienced secure Psychology and Dominique Treboux, mental health. Dr. Crowell shares her and responsive attachments typically PhD, now at St. Joseph’s College, insights about attachment theory. are able to explore the world more we have shown that attachment freely, knowing they have a secure First, what is attachment theory? classifications tend to stay stable base to return to. We are currently Attachment theory began with the from childhood, but can change in seeing evidence that attachment study of relationships between either direction. When we looked at patterns affect physical and children and their caregivers. Babies adults whom Dr. Waters had studied mental health. and children are highly vulnerable. as babies, we found that about 75 They are not well armed and not very How is attachment theory studied? percent retained the same patterns sensible. They need the sustained The attachment “dance”—children as adults. Change was associated protection of caregivers to survive going out to explore and coming back with either positive or negative and develop. Infants have an to parents for comfort or protection change in their caregiving relation- 1064 SBU HeadlinesNewsletter_FALL2011_layout one 9/8/11 3:00 PM Page 5

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ships. We also studied young adults more capable and they are assessed attachment patterns across the transition to marriage. developing closer relationships and social functioning. I joined the Although most people did not to friends and romantic partners. project as participants became change their classification, there However, most remain close to partners and parents, allowing us were some who had been classified their parents and return to them to study attachment systems as insecure before marriage who for support with important issues. across generations and adding a were reclassified as secure after A colleague, Joseph Allen, PhD, mental health component. Now the marriage. These individuals were has identified autonomy and participants are in their 40s and we more likely to have moved away relatedness—independence and are looking at how the attachment from their families of origin, to have connectedness—as key concepts system and relationship functioning gone on to higher education, and in attachment theory as it relates affects vulnerability to adult-onset to be happier in their relationships to adolescents. diabetes and heart disease in that with partners. sample and in newly recruited Early in your career, you explored African American adults. the possibility that attachment We are seeing theory might contribute to an evidence that How can attachment theory help to understanding of psychological understand diabetes? disorders in children. What did attachment We know that some people are your research uncover? more likely to develop diabetes and Attachment can play a role in the patterns affect heart disease. For example, there development of behavioral and are health disparities among ethnic emotional problems in young physical and groups and that the higher rate of children. There is a correlation mental health. adult-onset diabetes among African between insecure types of parental Americans is not fully explained attachment and the risk of by genetic differences or economic psychological problems in their You have made a special study of factors. We suspect that attachment- children, both in terms of type of adult attachments. What are you related factors play an important and severity of pathology. finding? role—things like early trauma, This does not mean, of course, My current project is a longitudinal including racism, as well as past that all problem behaviors in children study started by Stuart Hauser, MD, and current close relationships. can be traced to problems with PhD, at the Judge Baker Children’s attachment or that all insecure Center in Boston. When Dr. Hauser How can such factors affect health? attachment patterns produce died in 2008, I took over as People with attachment systems that psychopathology, only that a deeper principal investigator. We are trying function flexibly and adaptively may understanding of how attachment to understand how people overcome manage stress more effectively. works may help us prevent or treat the impact of difficult childhood They are better able to seek help psychiatric disorders. experiences; for example, to reduce when it is needed, which helps the impact of trauma and adversity them achieve psychological and What happens to attachments that often passes from generation physiological homeostasis more during adolescence? Are childhood to generation. attachments broken off? readily, decreasing their risk of Attachments in adolescence are no Dr. Hauser and colleagues began disease and premature aging. There different from attachments in infancy by looking at the psychosocial is also a social aspect. People with and childhood. Older children and development of a cohort of secure close relationships have teens may rely less on their parents adolescents. When these partici- somebody helping them figure out for day-to-day events and in coping pants became young adults, the what is going on, someone to with mild stresses because they are team contacted them again and comfort them when things go wrong. 1064 SBU HeadlinesNewsletter_FALL2011_layout one 9/8/11 3:00 PM Page 6

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Mandating Treatment, Offering Hope: Marsha Karant, MD, and the AOT Program

ednesday, July 20, 2011: Suffolk County District W Court Judge Paul Hensley takes his seat on the bench, “In God We Trust” emblazoned on the wall behind him. A county attorney faces him from one side of the courtroom, a Mental Hygiene Legal Services attorney with her first client of the day from the other. Between them sits Marsha Tanenberg Karant, MD, JD, Clinical Associate Professor of Psychiatry at Stony Brook University. She is there as a qualified expert in psychiatry.

Seven “Kendra cases” will be heard today—petitions by the County of Suffolk to require ‘respondents’ with mental illness to receive assisted out- Marsha Karant, MD, Clinical Associate Professor of Psychiatry patient treatment (AOT). Since none of today’s cases will be contested, petition and issues an order for six psychiatrist. She was an ideal they will be dealt with routinely. months of outpatient treatment. candidate for the position. After In response to questions from the graduating with a law degree from the The basis for these proceedings is county attorney, Dr. Karant testifies University of Wisconsin and practicing Kendra’s Law, enacted in 1999 after that the young man before her is as a criminal defense attorney in New Andrew Goldstein, a man with mental over 18 and has a history of hospital- York City, she became fascinated with illness, pushed Kendra Webdale, ization for psychiatric disorders, that medicine and started taking courses a promising young writer, under a she has personally examined him and in biology. “I fell in love with learning subway train. Mr. Goldstein’s lawyer “formed an opinion with a reasonable science,” she said. She completed argued that his client was legally degree of medical certainty” that he medical school and a residency in insane and blamed the mental has a mental illness. She reviews the psychiatry at Stony Brook University, health system for failing to treat Mr. components of his treatment plan: and began treating patients in the Goldstein’s violent impulses. In the case management, a place to live, department’s outpatient service. wake of the death, advocates for medications, therapy, and drug and individuals with mental illness joined In the eleven years that followed, alcohol treatment. She swears that Ms. Webdale’s family in demanding a Dr. Karant has testified in more than the plan is in the respondent’s best law to prevent similar incidents. interest, that without it he is likely to 2,000 AOT cases. “Most are clear cut,” Dr. Karant said, “though a few harm himself or others, that he will Soon after, the Stony Brook University are contested. Each patient gets his probably not comply voluntarily, and Department of Psychiatry and or her day in court.” that it is the least restrictive plan Behavioral Science contracted with the possible. The judge finds Dr. Karant’s county to help implement the law and While the judicial process can be for- testimony credible, accepts the Dr. Karant was appointed consulting mulaic, even ritualistic, Dr. Karant’s 1064 SBU HeadlinesNewsletter_FALL2011_layout one 9/8/11 3:00 PM Page 7

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Chief Resident: Michael Rosen, MD ichael Rosen, approach is intensely personal and deliberative. Every Thursday MD, the morning she meets with the AOT Clinical Review Panel to discuss new M department’s Chief referrals and to assess the progress of the 170 people currently in Resident, has already the program. The team examines each case individually. On Thursday enjoyed a career that afternoons, she interviews patients who have been newly referred for would be the envy of treatment or whose court order is due to expire. On Fridays, she most physicians. He reviews the cases and writes treatment plans. has practiced as a board-certified physi- Ann Marie Csorny, who worked with Dr. Karant as the Director of the cian in internal medi- Suffolk County AOT Program for 11 years, credits Dr. Karant with Michael Rosen, MD cine, been appointed making the process as humanistic as possible. “People who receive to the faculty of Emory University and worked AOT are very much people for Dr. Karant—not clients, not cases, but as a nationally syndicated medical journalist. people,” Ms. Csorny said. Now he is completing his residency and Keeping people on medications and ‘in the system’ are the mainstays looking forward to a new career in psychiatry. of AOT. Art Flescher, LCSW, CASAC, Director of the Suffolk County A graduate of Duke University in psychology, Division of Community Mental Health Services, observed that one of Dr. Rosen completed his medical degree and the great advantages of the AOT Program is that it holds the mental residency at Emory and was board certified health system accountable for coordinating care around the individual. in internal medicine. He opened a private “Dr. Karant is a key part of the team,” he said. “She is an intense practice but soon became interested in broadcast medical journalism. He advanced patient advocate who balances her concern for individual liberties a step at a time: a regular guest on Good with the safety of the community. And she believes in the value of Day Atlanta, medical editor for WPXI, the the program.” NBC affiliate in Pittsburgh, senior medical “I think about the value of AOT all the time,” Dr. Karant said. “It may correspondent for WCBS-TV in New York, then not work for everyone, but it is especially useful for young patients managing editor and correspondent for a who are new to their illness and still in shock over what is happening nationally syndicated nightly medical report. to them. They are vulnerable to doing something that will ruin the rest After 10 years in television, he returned to of their lives. We try to help people make gains they can see for medicine. “I missed the intellectual rigors of themselves so that when AOT is discontinued they will continue clinical practice and I missed being with other treatment on their own.” medical professionals,” he said. “I felt a need to fulfill my altruistic mission.” One of the keys to success, she said, is understanding why patients resist taking medications. “It is rare that the problem is purely side A specialty practice in eating disorders brought him into contact with social workers effects,” she observed. “More often it is some aspect of the illness. and psychiatrists. “I became jealous of Some deny they have a mental illness. Many don’t like to lead their them,” Dr. Rosen said. “They were performing lives as mentally ill persons. They simply want to be free of the illness valuable work in psychodynamics. and its treatment.” Realizing how little he knew about human “Dr. Karant works with people who have lost faith in themselves, behavior, he came to Stony Brook for a people the system treats as failures,” Ms. Csorny said. “She helps residency in psychiatry. “Working in the them stay engaged long enough to turn their lives around. She looks outpatient department has been the most for goals they can achieve and helps create structures to make them fulfilling clinical experience I’ve had in my life,” possible. She has faith that people can do more than they think they Dr. Rosen said. “For the first time I began to can. She gives them hope.” see the full picture.” 1064 SBU HeadlinesNewsletter_FALL2011_layout one 9/8/11 3:00 PM Page 8

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For more information, please call the PSYCHIATRIC DIAGNOSES SHIFT OVER TIME Department of Psychiatry and Behavioral Science at (631) 444-2990 or visit StonyBrookMedicalCenter.org/Psychiatry. team of researchers led by Distinguished Professor Evelyn Bromet, Headlines is produced by the Stony Brook PhD, has shown that psychiatric diagnoses involving psychosis shift University Department of Psychiatry and A significantly over time, raising concerns about the quality of patient Behavioral Science, in conjunction with the Office of Communications. treatment and research outcomes based solely on initial diagnoses. The study was published in June 2011 by the American Journal of Psychiatry. Written by Michael L. McClain, Director of Communications, Department of The findings are based on four diagnostic assessments over 10 years with Psychiatry and Behavioral Science 470 participants in the Suffolk County Mental Health Project. Even though the Design by Agapito Design Studio assessments were made by experienced psychiatrists using all the information Etchings courtesy of Frank Melville, Jr. Memorial Library, Special Collections that accumulated over time, fewer than half the participants were given the same diagnosis at each point in time. Masthead Illustration: Stephen Foster Photos: Jeanne Neville, Media Services. The authors note that while some shifts in diagnosis are to be expected, the Carriage image courtesy of the Long Island fact that half of the study population was misclassified at baseline using strict Museum Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria is “a very concerning finding,” especially if the initial diagnosis is used as the sole basis for treatment or research. The authors conclude that reassessing diagnoses over the long term is essential for clinical care and research.

Roman Kotov, PhD, Laura Fochtmann, MD, Gabrielle Carlson, MD, and Marsha Stony Brook University/SUNY is an affirmative Karant, MD, were among the article’s coauthors. Dr. Bromet notes that many action, equal opportunity educator and employer. This publication can be made available in colleagues, both in the department and outside it, contributed to the study. alternate format upon request.