This is the last presidential column of the 20th century and, by societal acceptance if not mathematical specificity, of this millennium. I’ve pretty well resisted getting into the millennium frenzy but, hey, I’m only human.

One thousand years ago, in Western cultures, people with psychiatric illnesses were widely believed to be suffering from afflictions by evil spirits or the devil. Thanks to the Persian physician Avicenna, however, the preservation of the rational and humane treatment of the mentally ill that had been championed by the Greeks was now reintroduced by Arabic physicians and scholars. This was particularly true not only in the Arab world, but also in the areas of Europe where the Moors made their conquests.

One hundred years ago, at the turn of the 20th century, the themes that would occupy psychiatry in the coming century were already in evidence. One theme has been the emphasis on understanding brain pathology in psychiatric illness, built on the work of Bleuler and Kraepelin. Adolph Meyer suggested a psychobiological theory that attempted to integrate psychological and biological understanding of a patient’s illness. And, of course, 1900 marked the publication of Freud’s Interpretation of Dreams and the beginnings of modern psychoanalysis.

Less well known, however, is another work on which Freud was laboring at the same time. In the Project for a Scientific Psychology, Freud was attempting to understand the neural basis for psychological processes. While this work was not published until 1953, many years after his death, his century-old quest has marked one of the important preoccupations of modern American psychiatry.

As we mark the 100th anniversary of the publication of Interpretation of Dreams, I have no question that Freud would be both amazed and gratified at the progress that has been made, not only in the area of psychoanalysis and psychoanalytic thought, but in understanding the connections between brain and mind, which was the major focus of the Project. I know that I don’t need to tell you that the advances in research in psychiatry, spanning the entire spectrum of biological, psychological, and social aspects of mental processes and functions, have transformed our field.

There is little question that continued advances in neuroscience techniques, the understanding of human development and brain maturation, and elucidation of the relationship between genetic endowment and developmental experiences will continue to produce dramatic gains in our knowledge base. These gains have already been translated into more effective treatments than could have been imagined at the turn of the last century. And I have little doubt that in 100 years psychiatrists will marvel at how far they have come since 1999.

What were the preoccupations a century ago? Providing humane treatment for psychiatric disorders, understanding reasonable diagnostic classifications, overcoming substantial societal forces working against humane and rational diagnosis and treatment, and developing effective treatments were clearly at the forefront. Building on tremendous scientific advances of the late 19th century, the turn of the last century marked a time of great optimism for what 20th-century science would bring for psychiatry.

Well, we haven’t been disappointed; amazing advances have occurred. We’re still preoccupied with many of the same issues as our colleagues from a hundred years ago, but, of course, in a way transformed by a century of experience and newly discovered knowledge. We’re still concerned with how the psychiatrically ill suffer irrational discrimination in many ways. Social ostracism, stigmatization, discriminatory governmental policies and corporate policies, discriminatory limits on access to care and reimbursement for care are but a few manifestations of these ongoing concerns. And we’re still working to develop more effective treatments based on an etiologically based system of diagnosis.

But the world is different in many ways than a hundred years ago and concerns have arisen that hardly could have been foreseen.

The human genome is now almost fully mapped. This brings with it the potential for manipulation of those genes affecting brain function. How this knowledge will be used and who will control it remains very unclear. Also, while as physicians we focus on amelioration of pathology, we are all too aware of forces at work to use such manipulations to alter or enhance naturally occurring phenomena such as intelligence and cognitive abilities.

Most interesting to me are questions of how computer technology will be used to understand, and perhaps modify, mental functioning. Human brain-machine interfaces already exist. Control of such technology is likely, I believe, to become one of the critical societal decisions of the information age.

Electronic communications are transforming our society and will likely transform the practice of medicine, but we have already seen severe erosion in medical-record privacy because of this. How individual medical-privacy rights are preserved and what limits will be placed around the use of medical-record information, either with or without the individual’s permission, remains unresolved today.

We unfortunately live in a time and culture in which self-reflection and self-awareness are little valued, and at times actively denigrated. This, to me, is one of the tragic effects of the modern era and of the technological advances in medicine and psychiatry. There may be no greater task for us as psychiatrists than working to preserve the humane aspects of medical care and the human aspects of psychiatric treatment.

It’s a wonderful and difficult time in which we’re now living. There are both immense opportunities and incredible challenges as we look to the future. I hope you can take some time for reflection over the next few busy weeks as you look forward to the new year, the new century, and the new millennium.