3 Questions: Maria Oquendo, First Latina APA President

When Maria Oquendo, MD, graduated from P&S in 1984, her class was predominantly male. Today, medical schools are evenly balanced in terms of gender, and the psychiatry specialty has no shortage of women. Cultivating ethnic diversity in psychiatry, however, has remained more difficult.

As president of the American Psychiatric Association (APA), increasing diversity is one of several items on Dr. Oquendo’s agenda, “because when you have different ideas percolating, you’re going to come up with better solutions.” That same principle governs Dr. Oquendo’s other goals: increasing the links between psychiatrists and other physicians and the links among psychiatrists from different countries.

Alongside her leadership roles and clinical practice, Dr. Oquendo conducts research in mood disorders, particularly suicidal behavior.

She recently shared her thoughts about her new position as APA president and her latest research on suicide.

Q: You’re a champion for diversity in psychiatry. Could you share your perspective?

Oquendo: I think that when you have people who come from different backgrounds or have different experiences, they will have different ideas. And when you have different ideas percolating through an environment, you’re going to come up with better solutions to problems.

I worked really hard to diversify the psychiatry residency here at Columbia, and now 25 percent of our residents are from underrepresented ethnic minority groups. But you have to make a concerted effort—it doesn’t happen naturally. I thought that just by being Latina, it would be enough. But that is not enough. And even with 25 percent, residents from diverse ethnic backgrounds say they still feel a little lonesome sometimes.

It’s very important to try to move the needle so that our medical profession is as diverse as our population. In combination, Latinos and African Americans make up around 30 percent of the population, and that percentage is probably going to increase a lot more in the next 10 years. So we have a lot to do.

Q: One of your stated priorities as APA president is strengthening partnerships between psychiatrists and other physicians. Could you explain?

Oquendo: Family medicine, internal medicine, obstetrics, pediatrics—these are the specialties that are delivering a lot of mental health care. But traditionally, psychiatrists have operated in different settings than primary care physicians. We need to work more closely with other physicians to improve the care that people receive—not just providing consultations but also managing the most severe cases.

Let’s say that you have an OB/GYN who is seeing a woman with depression who is unwilling to take medication. A lot of times the OB/GYN doesn’t know that there are other treatments for depression, like cognitive behavior therapy or interpersonal therapy. If you have a psychiatrist in the practice, then the psychiatrist is right there to provide assistance, and maybe even to deliver the care.

Just recently, the Centers for Medicare & Medicaid approved payment codes for psychiatric services when the service is embedded in a primary care clinic. With the availability of these codes, I think we have a situation ripe for more collaboration with other physicians.

Q: You’ve recently published a study that identified biological markers that predict the lethality of suicidal behavior. Will this lead to a way to identify people before they attempt suicide?

Oquendo: We found that if serotonin 1A receptors are very elevated in a particular part of the brain—the dorsal raphe nucleus—then that individual is more likely to think about suicide or make suicide attempts with more medically serious outcomes than someone whose 1A receptor expression is low.

In the study, we scanned 100 people who had depression. Fifty percent of them had already made a suicide attempt, but 50 percent had not. And we followed them for two years.

What we found is a linear relationship. It’s not a perfect test because some people who have elevated serotonin 1A receptors don’t make suicide attempts at all or don't make high lethality attempts. So this can’t be used to predict what any individual will do.

But it helps us get at some of the underlying biology of what might be driving lethality in suicidal behavior. What’s probably happening is that there are changes that lead to increased suicidal ideation, and the more you think about suicide, the more likely you are to carefully plan things that are more medically damaging. We anticipate that as we understand the biology better, we will be able to develop treatments that have a specific target—which we don’t quite have yet.

Interestingly, our findings fit with what we’ve learned in treating individuals who have a lot of suicidal ideation. These patients do better if you give them an antidepressant that targets the serotonin system than if you give them an antidepressant that targets the dopaminergic system. Both types of antidepressants relieve depression at more or less the same rate, but if somebody has a lot of suicidal ideation, the SSRI brings their suicidal ideation down more quickly than the dopaminergic agent.

The research suggests that there’s an abnormality in the serotonergic system that leads to greater suicidal ideation and that we need to address the abnormality.

In 2017, after 28 years on the P&S faculty, Dr. Oquendo will join the University of Pennsylvania’s Perelman School of Medicine as chair of the psychiatry department.