How American Psychiatry Can Save Itself: Part 2
How American Psychiatry Can Save Itself: Part 2
In the February 2012 issue of Psychiatric Times, I discussed and rebutted some common criticisms of psychiatry, such as its alleged lack of “objective” diagnostic criteria and its supposed tendency to “medicalize normality.”1I also suggested that most current criticism of DSM-5 misses the fundamental problem with the recent DSMs—namely, that in the absence of either a sound biological basis for the main disorders or a rich description of the patient’s experience of the disorders (phenomenology), the DSM framework has inadvertently left clinicians with “the worst of both worlds.”
Here I address what, in my estimation, are the primary reasons for the American public’s disenchantment with psychiatry; how the profession ought to address these issues; and how we need to replace the DSM’s categorical system with one that is clinically useful for both clinicians and patients.
What must be done?
So far, I have discussed problems with American psychiatry that, in my view, are largely peripheral to the central concerns of the average clinician—as well as to the average person who suffers from a serious psychiatric illness. In particular, the “loss of faith” in psychiatry that many in the general public evince stems from another set of concerns, both more pressing and more pragmatic than the academic debates swirling around DSM-5.
I very much doubt that many Americans lose sleep over whether psychiatry has a “unified model” of so-called mental illness; nor do I believe that the public’s animus toward psychiatry2 stems primarily from concerns over the DSM-5’s development or content (although well-publicized critiques of the process have certainly not enhanced the profession’s stature).
I believe the American public’s jaundiced perceptions of psychiatry stem from the confluence of 5 main factors, specifically:
1. Psychiatry’s inability, thus far, to develop robustly effective, well-tolerated treatments for several major disorders, such as schizophrenia, autism, and most of the severe personality disorders (despite our having moderately effective treatments for bipolar disorder, panic disorder, and several other conditions).
2. Psychiatry’s increasingly and inappropriately close ties with the pharmaceutical industry in recent decades.
3. The decline, over the past decade, in the use of psychotherapy among US psychiatrists3 and the attendant public perception that psychiatrists “no longer listen” to their patients.
4. A lack of understanding among the general public of the benefits of psychiatric treatments, and not simply the risks; for example, the erroneous belief that psychiatric medications are highly “addictive” or merely “cosmetic” in their effect.4
5. Vituperative attacks on psychiatry by critics both within and out-side the profession, often exacerbated by Internet-based anti-psychiatry groups and lurid depictions of psychiatry in the media.2,4
So, what is required to regain the confidence of the general public? On a concrete level, psychiatry needs to advance goals and initiatives that address each of the factors noted; for example, by: (1) lobbying for more robust and better-funded research to develop more effective and better-tolerated treatments; (2) restraining the influence of pharmaceutical companies on psychiatric education and practice while seeking a healthier and more transparent relationship with such companies; (3) ensuring that comprehensive psychotherapy training is a central part of every psychiatric residency program; (4) bolstering “outreach” and public education efforts2 as well as improving communication with non-psychiatric physicians; and (5) rebutting unwarranted attacks on psychiatry while remaining receptive to constructive criticism from within and outside the profession.5
To the Editor:
Dr Pies' March 2012 piece on the status of American psychiatry misses one key point. We are not reimbursed adequately by insurance plans for talk therapy. I believe this accounts for a good deal of the decline in numbers of psychiatrists practicing psychotherapy, as well as the near impossibility of finding a clinical position that allows psychiatrists to conduct psychotherapy. As long as psychiatrists expect earnings on par with other medical colleagues and reimbursements for psychotherapy are as low as they are, psychiatrists will not be able to afford to practice psychotherapy in private practice or in institutional settings. I believe the economics of modern psychiatry is playing a larger role in shaping our professional identity than Dr. Pies acknowledges in his otherwise excellent piece.
Sincerely,
David Geltman, M.D.
Jamaica Plain, MA
617-971-0074
dg@myblueatlas.net
Dear Dr. Emiliani--
Many thanks for your cordial note and comments! I fully agree with you that "Psychiatry is an integral part of medicine and therefore is a sub-specialty of medicine." Set adrift from general medicine, I see little future for psychiatry; conversely, we need to do more to integrate--or perhaps, re-integrate--with general medicine. In everyday practice, this means being more available to our non-psychiatrist MD colleagues, doing more educational programs for PCPs, and learning from their experience as well. I also agree with the broad-based, multi-disciplinary approach for psychiatry that you describe--which is one more reason to consider a 5-year psychiatric residency! --With best regards, Ron Pies
To the Editor:
Dear Dr. Pies,
I have read most of your articles in Psychiatric Times for many years and have enjoyed them as well as learned from them. I hold a great deal of gratitude and respect as well as admiration of your work as editor. For this reason, I am responding to this article since I share your same concerns of how we can save Psychiatry in North America.
In my training as a global Psychiatrist, I have some very basic premises about Psychiatry as follows:
1. I strongly believe that Psychiatry is an integral part of medicine and therefore is a sub-specialty of medicine.
2. Psychiatry, as well as medicine, has a large number of sub-specialties that are holistic and accepted independently and should be recognized as such as well as practiced in this manner in order to serve the field as well as patients and Science. Such as, Psyhopharmacology, Child and Adolescent Psychiatry, Sleep Disorders, Behavior Therapy including CBT, EMDR, etc. Therefore, we should expect that all training centers should cover all of the above skills/subspecialties in order to have a broad base and well-informed Psychiatrist. Unfortunately, this is not being enforced consistently.
3. We also need to drastically reform the APA and probably make it apart of the AMA since the Mental Health Parity law has already been past by Congress but not funded.
I would hope with the implementation of the above initiatives we would be able to motivate more young physicians to choose Psychiatry as a serious and holistic medical specialty.
As for my own personal status, I am a Psychopharmacologist, Addictionologist, Behavior Therapist, with interest in Child Psychiatry, Psychological Trauma, Stress Management which as helped me integrate, understand, and better serve patients.
Cordially,
Nicholas A. Emiliani
Medical Director, Behavior & Stress Management Center
Dear Dr. Pies
Thank you for your very interesting article. In my opinion unless we make psychiatry more medically valid with the diagnostic supportive aid of biomarkers there will always be room for uncertainty and doubt for the medical basis of psychiatry, its therapies and future research. I also advocate in the holistic approach of treating patients nevertheless I want to believe that I am providing medicines for the brain, not the psyche, the latter is an abstract concept that makes our specialty vulnerable and scientifically vague.
Marios Efstathiou MD
Thanks very much for your comments, Dr. Efstathiou. I certainly agree that psychiatry must remain fully integrated with general medicine and neurology, and reflect an accurate knowledge of brain function. We should also seek endophenotypes and biomarkers for our diagnostic categories, as you say. I think a holistic approach is also needed, and prefer to say that the "object"of our treatment is neither the brain, nor the psyche (whatever that is), but the suffering person. As Maimonides said more than 8 centuries ago, "The physician does not cure a disease, but rather, the diseased person."
Hi, Dr. Daviss (...or Steve, if I may)--
I very much appreciate your kind comments on my article, and even more, your efforts at the APA (alas, I missed your talk). It is indeed the case that we have been too passive, as a profession, in allowing others to "define"us--and often, to defame us. This is not to say that psychiatry as a profession is doing a wonderful job, or that we have nothing to learn from our more responsible critics--far from it. It is to say that the kind of visceral contempt and hatred evinced by some of the APA "protesters" has no place in a civilized exchange of views. I commend you, Dinah Miller MD and Annette Hanson MD for your efforts at "explaining, educating, and engaging" , both in your book and on your website!
By the way, your readers should take a careful look at the posting by Dr. E. Fuller Torrey, at:
http://www.treatmentadvocacycenter.org/index.php?option=com_content&task...
in which Dr. Torrey demolishes many of the claims of one of psychiatry's most prolific (and often misguided) critics.
Best regards,
Ron Pies
Dr Pies,
I just discovered your wonderful article about saving Psychiatry, after returning from the Annual Meeting in Philadelphia where four other psychiatrists and I gave a symposium on regaining control of the public image of psychiatry.
The "vituperative attacks"on psychiatry that you mention were certainly present at the meeting, both in the streets, with people marching around with professionally printed antipsychiatry placards, bullhorns, and expensive video screens, as well as in the Twitterverse, with half of the #apaam12 tweets coming from two psychiatry critics. Our message inside the conference room was that we are letting others define us and our profession, and that we cannot afford to hunker down, but instead must take every opportunity to explain, educate, and engage. If all 600 educational sessions were put up on Youtube, for example, then when people type "psychiatry" in the search bar, they would get more appropriate hits than the current crop, which includes "Psychiatry: Industry of Death" and "Psychiatric Drugging of [fill_in_name_of_vulnerable_group_here]."
We advocate open discourse, humility, humor, and acknowledgment of our limitations and past errors as a profession. If we don't address these public perceptions, then we will continue to sink in cultural and medical relevance.
Explain.
Educate.
Engage.
=Steve Daviss MD DFAPA
=Co-author, Shrink Rap: Three Psychiatrists Explain Their Work
=Chair, Dept of Psychiatry, Baltimore Washington Medical Center, Univ of Maryland
Dr. Pies,
I'd like to see a few things change:
1. No more assembly line psychiatry.
2. Properly trained clinicians i.e. Psychiatric Mental Health Nurse Practitioners are different from Family Medicine NP's and PAs who enter psychiatry without specific training or proper mentorship. Working with geriatrics and children takes specific training as well and should be required.
3. Primary Care Medical Providers who are willing to rule out non-psychiatric causes of mental illness i.e. do an MRI, EEG, etc.
Thank you
Thanks for those comments, Dr. Gardiner (please forgive me if I have your professional credentials wrong). I certainly agree that no medical specialty should ever be reduced to "assembly line"practice, and I know that many psychiatrists are not at all happy with the trend toward 15-minute "med checks". That said, the average time spent with a patient in psychiatry has not dropped very much in recent years; and, as Dr. Dinah Miller pointed out in a recent piece, 70.2% of psychiatrists still provide psychotherapy to all or some of their patients.
See:
http://www.clinicalpsychiatrynews.com/views/shrink-rap-news/blog/108-a-l...
But we can and must do better.
I was addressing psychiatry per se in my blog, and I don't feel qualified to comment on the other professionals you mention. I do have great respect for the nurses, nurse practitioners, and other allied professionals who do so much of the work for our patients. I also favor a much stronger working relationship between psychiatrists and PCPs, so that investigations like MRIs and EEGs occur based on medical necessity and cost-effective practice.
Of course, I completely agree with the need to consider and rule out "organic" pathology in many patients presenting with apparent "psychiatric" problems, and many such patients are now given short shrift
in terms of their work-up.
Thanks again for commenting!
Best regards,
Ron Pies
I thank Dr. Geltman for his kind comments, and I agree that the issue of reimbursement is a significant concern for many psychiatrists, especially as regards compensation for psychotherapy. As Mojtabai and Olfson noted,
"There has been a recent significant decline in the provision of psychotherapy by psychiatrists
in the United States. This trend is attributable to a decrease in the number of psychiatrists
specializing in psychotherapy and a corresponding increase in those specializing in
pharmacotherapy-changes that were likely motivated by financial incentives and growth in psychopharmacological treatments in recent years." [Arch Gen Psychiatry. 2008;65(8):962-970.].
On the other hand, with a median annual income of about $163,000 [according to Medscape], psychiatrists do out-earn most primary care docs, endocrinologists, and pediatricians. So perhaps the general public will not be
very sympathetic to our complaints about compensation. Still, I think Dr. Geltman's point is well-taken, and
must be addressed if we expect psychiatrists to continue doing psychotherapy as a major part of their work.
Let us hope we can find other non-monetary motivations, as well, however!