As psychiatry is swept along by the evolutionary winds of change, will you be poised and trained for success? This question was posed to psychiatrists by Joel Yager, M.D., at the recent annual meeting of the American Psychiatric Association, at which he received the Seymour D. Vestermark Award.
Yager predicted that psychiatry will remain a highly gratifying profession with room for expression and creativity; he underscored, however, the need to greet the future with flexibility in the face of emerging new trends in patient care, technology, research and socioeconomic forces.
"This is not your father's psychiatry anymore," warned Yager, who is professor and vice chair, department of psychiatry, University of New Mexico School of Medicine. He expressed hope that psychiatry will continue to be "mindful and brainful, spiritual and thoughtful" while responsive to the changing realities of clinical practice.
Psychiatry must respond to rapidly shifting paradigms in approaches to care, he said, many of which are driven by market demand for alternative types of treatment.
Traditional axioms that longer treatment is better, that "deeper" treatment is better and that effective treatment involves working through the transference in psychoanalytic psychotherapy have evolved into axioms that embrace multidimensional approaches to practice, particularly treatments that are supported by outcome data, Yager said.
Managed care continues to drive a number of these developments, as practitioners of psychiatry and medicine in general compete to establish more effective and efficient treatments. One particular paradigmatic change confronting psychiatrists is that managed care institutions that authorize treatment are shifting away from an emphasis on diagnosis to an emphasis on functional impairments generated by a patient's diagnosis. Mental health is increasingly being asked to address just what is necessary to get a patient "back on track."
For their part, patients are demanding that psychiatrists continue to make varied and acceptable treatments available. In an ever more competitive marketplace, the patient will want to receive benefit from every appointment. Psychiatrists also are likely to find themselves called on to provide time-limited therapies. Clinical practice will require that psychiatrists stay abreast of developments in treatments that go beyond psychopharmacology. Practitioners will no longer find themselves with singular role definitions.
Yager reviewed a study of help-seeking behavior among Americans that illustrated the willingness of many individuals to use unconventional treatments (Eisenberg and colleagues). Individuals who sought alternative therapies had attended an average of 19 visits in the previous year and paid an average of $28 per visit out-of-pocket for complaints that included depression, anxiety and headaches. The Eisenberg study, Yager said, suggests that a substantial market segment wants treatments unavailable through conventional medicine. Relaxation training and imagery techniques were among the top 10 treatments sought by patients. New mental health plan models need to consider this information about consumers, in terms of their interests and willingness to pay for treatment.
The impact of these forces suggests that psychiatry consider a new set of four As to serve as guidelines for providing treatment, Yager said. These would add to Eugen Bleuler's four As of yesteryear: associations, affect, autism and ambivalence. Yager's four As are affordability, affability, accessibility and accountability.
An emphasis on cost-efficiency in health care is likely to force psychiatrists to pay greater attention to maximizing the use of face-to-face interaction with patients. It is also likely to drive the increased use of middle-level providers (health care professionals without a doctoral degree, such as registered nurses or social workers with a masters' degree) as the mental health care market experiments with different types of provider coverage. Yager speculated on the application of a "dental model" of psychiatric practice, in which there would be increasing reliance on "mental hygienists" to help psychiatrists maximize their time and expertise. Screening and diagnostic instruments that can similarly add value to a practitioner's efficacy are likely to be implemented with greater frequency.
Psychiatry also is faced with the need to incorporate and respond to rapid changes introduced by advances in research and technology, particularly computer-based information systems. New technologies are increasingly allowing for cross-fertilization of new ideas, particularly with the advent of global instantaneous communication and advancements in supercomputers. A few areas of research to benefit from these advances include developments in artificial intelligence and artificial life/genetic algorithms that model complex adaptive systems. New approaches to neuroscience are evolving from applying complexity theory, which addresses how simple systems develop into more complex systems, and then into brain systems.
1. Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States: prevalence, costs and patterns of use. N Engl J Med. 1993;328(4):282-283.