Steven Rasmussen first put down roots at Brown more than 50 years ago, but he sustains a sense of curiosity and wonder.
To see Brown, its medical school, and the field of psychiatry itself through the eyes of Steven Rasmussen ’74 MMSc’77 MD’77, P’13MD’17, is a rare gift. It’s not often that one’s career and life can be so intertwined with one place, marked in personal milestones—young adulthood, marriage, a daughter following in one’s own academic footsteps—and in institutional ones—being part of a team that breathed The Warren Alpert Medical School into being, and then celebrating its 50th anniversary as chair of its Department of Psychiatry and Human Behavior. That’s all in addition to leading some of the therapeutic advances of the late 20th and early 21st century that for the first time offered hope to people with obsessivecompulsive disorder.
In this interview, Rasmussen traces his growth from his undergraduate years at Brown, to a life-changing stint as a psychiatrist in rural Vermont, to a career at Brown and Butler Hospital in research, administration, and training an entire generation of clinicians.
You completed your undergraduate and medical degrees at Brown and later returned as faculty. What’s kept you so connected to this place?
I met my wife [Frances Rowe Rasmussen ’74, P’13MD’17] here when we were both undergrads. Brown is a place you can wrap your arms around—outstanding faculty, highly interdisciplinary, and just the right size. Also, when I first decided to come back to academics, I looked at a half-dozen places on the East Coast: Yale was mostly concrete and the other places were, you know, 13 stories tall. The Butler Hospital grounds were planted by Frederick Law Olmsted. Maybe it was looking up at all those magnificent trees that sold me.
As an undergraduate in 1972, you served on a committee that designed the curriculum for Brown’s new medical school. What was most important to you in shaping the medical school then? Do you see those values in The Warren Alpert Medical School of today?
I was part of the [Medical Education Program], a seven-year program that conferred a master’s in medical science in addition to an MD degree. We were taking English courses in medical school and medical classes as undergrads. That integrated experience was important to me. After all, who you become as a person is perhaps more important than what you know, particularly for a psychiatrist.
I was just reading a Brown Alumni Magazine article on a medical faculty-led course that talks about themes of mortality. That’s a great example of the original concept: How do you think about medicine in relationship to what makes us human?
What initially drew you to psychiatry?
I did my master’s degree in immune function, but what really intrigued me was behavior. I was always interested in the big questions: Why are we here? What is important to do in one’s life? The rest of medicine didn’t seem as interesting from that perspective. You don’t learn as much about yourself or others from studying your liver. What other specialty allows you to observe others, and through them, yourself?
And what about your interest in OCD?
In 1977, when I started residency at Yale, OCD was considered to be a neurotic disorder with a poor prognosis—and a rare one at that. No one was interested in it.
When I worked as a psychiatrist in the Northeast Kingdom [of Vermont], I was the only psychiatrist in the northeast quarter of the state. I saw everything. And to my surprise, I was seeing all these patients with OCD.
It so happened that there was a drug for OCD available then in Canada but not the US. One of my patients was a border guard with severe OCD. I told him about the drug, which he bought in a pharmacy in Quebec and walked across the border. He became the first person I tried on the drug and he had an amazing response. Then I tried other patients on it, and I saw it working. Remember that the only treatment for OCD then was psychodynamic psychotherapy.
Just as I was leaving Vermont to start my research career, I spoke with Myrna Weissman, a psychiatric epidemiologist who was leading a study on the prevalence of various mental disorders across the US. She said, “You know, OCD is 10,000 times more common than we thought.” So here was a disorder I was really interested in, that had a new drug treatment, and that was a lot more common than people ever thought. I decided that I wanted to set up a program in translational psychiatry for OCD.
Did Brown or Butler have an OCD research program underway?
No, nothing. When I arrived at Butler, I thought, “Where am I going to find OCD patients?” I went through old medical records to try to find some. I made a big list of people with diagnoses of anxiety, obsessive-compulsive neuroses, and personality disorder, then started contacting them. My other idea was that since some people with OCD compulsively wash their hands, they probably see dermatologists. I went to the guy who ran the dermatology department and described who I was looking for. He said, “We have zillions of those patients!”
The other problem was that we didn’t have any infrastructure at Butler for doing research. I had this connection with Yale, where I’d done my residency and where they were doing a lot of translational research. So I used to take people in a van on Saturday mornings to do infusions of psychotropic drugs there. We’d hit Pepe’s pizza afterwards and then drive home. I learned a lot about OCD during those drives.
One of your early achievements was the codevelopment of the Y-BOCS scale in 1985 to assess the severity of OCD. How did that come about?
Necessity is the mother of invention. After we began running people through these treatment studies, we realized we needed a scale to measure clinical outcome. Larry Price [now a professor of psychiatry and human behavior], Wayne Goodman, and I developed the Y-BOCS in a very short timespan, probably eight to 12 weeks, because we were under pressure going into a meeting with [pharmaceutical company]Ciba-Geigy. We had to convince them to develop a drug for OCD. We did, and we led the clinical trial for what would become the first FDA-approved treatment for OCD in the US.
What led you to your subsequent discoveries in OCD treatment?
Somewhere early on, I got hooked on the idea that we can make a difference in the lives of people who are suffering. That’s always been the primary motivation. We started doing more exposure-based treatment, which wasn’t widely available—and still isn’t. We used to send people down to Edna Foa, who was then the only person doing OCD exposure treatment in the country. Then we started doing it ourselves. We found that, combined with a serotonergic antidepressant, it helped about 85 percent of the people we saw. That left 15 percent who had a serious illness and were not getting better. We started looking into the gamma knife and DBS [deep brain stimulation]to help those patients.
You started the first gamma knife treatment program for OCD in the United States in 1993. How does the gamma knife work and what did you find?
The gamma knife was developed by a neurosurgeon in Sweden and initially used for deep-seated brain tumors. It works like a magnifying glass. You focus 201 beams of cobalt-60 on a single spot in the brain. The spot where the beams cross is where you get the energy to form a lesion.
I saw data suggesting the gamma knife could help in psychiatric surgeries, but there were still a lot of translational questions—where to put the lesion and why. I gave up reading about OCD and switched to reading about basic neuroscience. The goal was to develop a target in the connections between the orbitofrontal cortex and deeper parts of the brain. The drug side of our research had involved serendipity, but the surgical side was all hypothesis-driven.
We started seeing the gamma knife working—in some cases, dramatically. Our first patient had such severe OCD that it took him 45 minutes just to tie his shoes because of all his rituals. It got so bad, he didn’t talk, couldn’t eat, and dropped to 80 pounds. The gamma knife procedure was a great success for him. He went on to graduate first in his class in college and became a physician. We’re still following him 35 years later.
We no longer conduct gamma knife procedures, though, because a small minority of patients can get radionecrosis. The importance of the gamma knife was that it showed that creating lesions in the brain—which today, can be achieved with ultrasound and MRI-guided laser procedures—can be an effective treatment for severe OCD. It also led the way to DBS.
You led the development of Brown’s program in DBS for psychiatric disorders— the first in the country. What did it take to get that effort off the ground?
DBS involves surgically inserting electrodes into the brain that you can turn on and off to target specific pathways. Initially, I’d known DBS was being used for patients with Parkinson’s, but then I heard from a neurosurgical colleague at Brown that they had implanted the first OCD patient in Europe. He invited me to attend a neurosurgery meeting in New York to show my gamma knife data and talk to world leaders in DBS. Immediately afterward, I was connected with Bart Nuttin, a neurosurgeon in Belgium who did the first DBS procedure for OCD. We helped guide him where to put the electrode based on what we knew about the gamma knife procedure.
After that, we started developing a DBS indication for OCD in the US and had to go through the FDA to start trials. I said, “I don’t have time to do this.” I was the medical director at Butler and had a lot of clinical and administrative responsibilities at that time. I met a young scientist who was just starting out—Ben Greenberg [now a professor of psychiatry and human behavior]—and recruited him from NIH to lead the DBS study.
How is OCD understood now versus when you first began?
It used to be considered a rare neurotic disorder with a poor prognosis. Now we know it’s a common neuropsychiatric condition. Eighty-five percent of people can be effectively treated for OCD with exposure therapy or pharmacotherapy. We have surgical procedures, either DBS or lesions, that can help about 60 percent of the remainder. In many ways, it’s a success story compared to the lack of progress in schizophrenia and depression.
Your research career has been a story of collaboration, and in the 14 years you chaired the Brown Department of Psychiatry and Human Behavior, you established a reputation as a collaborator. Why is collaboration so important to you?
Brown is a unique place in terms of being more collaborative and less competitive. There’s a neurosurgeon we’re currently working with who said he experienced more collaboration in his first month at Brown than in the six to seven years he’d spent at MGH [Massachusetts General Hospital]. I think Brown attracts people who are interested in learning and innovation. It’s always most interesting to talk with people who know something you don’t.
A shining example of that collaborative energy is the Carney Institute for Brain Science. What role did you play in its creation? And what are its unique benefits?
The bridge between psychiatry and neuroscience was formed mostly out of the relationship between myself and John Donoghue, then the head of brain science at Brown. He had brought a lot of smart faculty together to focus on how math could help us understand the brain. He said, “We could really do something here combining the basic science we’re doing on campus with the work you guys are doing at the hospitals.” Around the time the Carneys gave their gift for the institute, John left to head up a center in Geneva, and I had the good fortune of chairing the search for the new director, Diane Lipscombe.
The collaborative effort between the clinical neurosciences and the Brown campus serves as a model for what could happen in other domains. They’re attempting to do that now in cancer, for example, but brain science was 15 to 20 years ahead of the curve. These days most of the innovative discoveries in our field are made by people working collaboratively across science and clinical neuroscience.
On the clinical side of things, you started as a psychiatrist at Butler in 1983 and eventually became medical director. What changes in psychiatric care have you seen in that span, for better or worse?
From about 1940 to 1970, people used to stay in institutions for years. Butler Hospital was an early adopter of short-stay treatment, so now hospitals are seen as places where patients can get acute care. But one of the tragedies, in Rhode Island in particular, is that outpatient psychiatry has been underfunded for years. Hospitalization rates are high because there’s no other place to be treated. Try to find a psychiatrist who has an opening to take someone with Blue Cross Blue Shield or some other insurance. You can’t.
There’s been an explosion of people seeking psychiatric services as mental health awareness has spread over the last 20 years, but the money to treat those people has not increased. There are more people to treat and no more resources than in 1980. My hope is that we will begin to implement some forms of treatment using new technologies. There will be an emerging role for AI in monitoring people outside the hospital setting, which should reduce cost and improve access.
You mentioned that Butler’s natural beauty was part of what drew you here. Since then, you’ve become an advocate for the grounds—saving a centuries-old beech tree from the axe and leading an effort to plant 10,000 daffodils on campus. Is your passion for plant life connected to your professional work?
There’s something healing about the natural world. In Germany, instead of sending people to a psychiatric institution, they would give them a month’s vacation in nature. When I was a psychiatrist in Vermont, we sent some of our OCD patients to a place in Rutland where they did maple sugaring and sold wood. We never hospitalized anybody.
One thing you take away from learning about the brain and its cells and circuits is how amazing it is that life evolved the way it did. The layers of complexity are astounding: 165 million synapses in a cubic millimeter of the human brain, 200,000 neurons in the fly brain. Go out to a dark-sky preserve where you can see the Milky Way and think of how many worlds there are out there. Think of those scales and how you fit in. There’s a connection between plants, the environment around us, and our own behavior. Many of our patients lack connection, yet connection to others and the natural world is waiting to be found. Everything is connected. When you see it, it can change your life.
