Steve Koh, MD, MPH, MBA

What is the scope of psychiatry as a medical practice? Is it just therapy or psychopharmacological modality of practice? Is it confined to the hospital or traditional outpatient clinical setting? Should it continue to just conjure up the image of a couch in a private practice room? Is psychiatry limited to urban centers or community clinics?

I would argue that psychiatry is all of these and much more. As a medical field, it is unique in that it can claim to be both a primary care and a specialty care discipline at the same time. Our scope can extend beyond our traditional roles in a medical setting and is well suited to be practiced in wide ranging collaborative, innovative, and integrated models of care. We can be contributors in the basic sciences laboratory and to society at large. The richness of how psychiatry can be applied and contribute in our community is the focus of our special issue.

With the rise of information technology, psychiatrists can provide evidence-based care to remote, underserved areas with ease. One of telemedicine’s first application was in mental health and we continue to push the boundaries in how psychiatry is delivered.

As discussed by Dr Saeed, psychiatry has moved beyond using 

 as just a tool in reaching distant areas. It is now being integrated in mobile personal devices, leveraging application tools and has linked diverse providers. It has also evolved into a specialized delivery system to support diverse clinical-care models. Allowing for more flexibility in how psychiatry can be delivered, telepsychiatry has blossomed into a potent tool in our drive to increase access to high quality care.

The positive impact of psychiatry can be found in places many may not expect. Our work is not just about dealing with mental illness but also promoting mental well-being. As such, our input is valuable in settings outside of traditional medical buildings and clinics. As illustrated by 

, involvement of psychiatrists in supported housing can lead to great improvements in success of a homeless client-this is truly a patient centered delivery of psychiatric care.

In looking at societal impact on health, psychiatry can contribute to the ongoing dialogue about poverty and mental well-being. In “

,” Drs Simon, Beder, and Manseau, use a case vignette to illustrate the ways in which a psychiatrist can best impact those in poverty. They don’t just focus on clinical outcome of an illness but take on the total human experience.

Finally, Dr Davidson and colleagues make an argument for 

. As psychiatrists, we can partner with our patients in leveraging their strengths and experiences to help others. This collaborative approach with peer support should be encouraged and can serve to extend psychiatry’s reach to those who continue to be underserved and stigmatized.

In this Special Report, the topics may seem diverse and wide-ranging. However, this is precisely the point. Psychiatry can contribute in ways that some medical fields cannot. It comes down to the fact that our work boils down to alleviating the suffering of the human condition itself. As psychiatry evolves, we should be encouraged by the fact that our work is not limited by traditional confines of medicine.

Reflections on Psychiatry in Supported Housing

Using Telehealth to Enhance Access to Evidence-Based Care

Revisiting the Rationale and Evidence for Peer Support

Dr Koh is Associate Clinical Professor, Department of Psychiatry, University of California, San Diego. Dr Koh reports no conflicts of interest concerning the subject matter of this Special Report. 

Articles

Here's where psychiatry extends beyond a medical setting into collaborative, innovative, and integrated models of care..

Introduction: The Scope of Psychiatry

Slideshows

The need for more mental health providers has galvanized our interest in special populations, each of which requires a vision and framework for establishing assessment and treatment as a standard of care.

5 Special Populations in Psychiatry

When discussing psychiatry as a potential career with medical students, I used to feel defensive about my chosen specialty field. I remember making a case about how fascinating the human brain was, how interesting and dynamic human behavior and relationships were, and how medical knowledge has advanced. While all of these reasons are still true, recently I find myself asking medical students, “Why 

 you go into psychiatry?” In fact, some now come to me trying to figure out what parts of psychiatry I do not like. This is different from being asked to explain why I like my field. There are clearly many reasons why this switch in perspective may be happening.

[[{"type":"media","view_mode":"media_crop","fid":"49454","attributes":{"alt":"Â© Bruce Rolff/shutterstock.com","class":"media-image media-image-right","id":"media_crop_7265124476751","media_crop_h":"219","media_crop_image_style":"-1","media_crop_instance":"5981","media_crop_rotate":"0","media_crop_scale_h":"124","media_crop_scale_w":"125","media_crop_w":"220","media_crop_x":"130","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"Â© Bruce Rolff/shutterstock.com","typeof":"foaf:Image"}}]]The changes that the Affordable Care Act has brought to mental health services have been well documented in peer-reviewed journals and in mass media. The Act makes it a requirement for health plans to cover mental illness and substance disorders, and it reinforces mental health parity. Over time, while stigma still exists, mental health issues have become more accepted in general public discourse. However, as demand for mental health treatment increases, the number of psychiatrists is not keeping pace. Furthermore, the attention to mental health care has increased the focus on special populations with unique needs and innovative opportunities to deliver effective care. In this environment, psychiatrists find themselves in demand as never before, and there are ample opportunities to practice in diverse settings and with special populations.

In this Special Report, we offer 5 articles on special patient populations and different potential models of delivering mental health care.

Children in Foster Care: Special Issues and Concerns

” gives us an overview of and current data on child maltreatment. The author uses guidelines from the American Academy of Child and Adolescent Psychiatry to give recommendations on how to care for foster and/or welfare children.

The need for more mental health providers has galvanized our interest in special populations.

Combat Veterans: Adaptation to Transition

” gives us a convincing perspective on active duty military personnel who are transitioning to civilian life. It presents a personal account to illustrate the topic of transition and adaptation studied by Schlossberg. As we are called on to serve those who served, the importance of transition to psychiatric presentation and needs is emphasized.

Wearable Devices for Mental Health: Knowns and Unknowns

” reviews the ways in which new technology can be used to help our patients and allow us to extend our therapeutic reach. It acknowledges that advancements in technology do not mean that wearable devices are used with abandon but instead should be considered as one of many adjunctive tools we can use to help our patients.

Treating Physicians: Special Issues, Sensitivities, and Considerations

” deals with working with our colleagues with mental health needs. Unfortunately, physicians bear significant stigma in seeking out and getting help for mental health problems. The article gives valuable advice and recommendations in working with our colleagues in a respectful and meaningful way.

Collaborative Opportunities: Working With Nurse Practitioners to Meet the Needs of Underserved Patient Populations

” presents a way for psychiatrists to function as collaborative team leaders and to partner with psychiatric nurse practitioners to deliver mental health care to underserved populations. This is one of several ways to extend psychiatric care capacity to underserved areas.

In recent years, psychiatry has become more diverse and exciting to practice. While the need for more mental health providers is real and at a critical point, it also has galvanized our interest in special populations and innovative ways to serve our patients. The articles presented here are just a small sample of the diversity of practice modern psychiatry can serve to meet the needs of our patients.

Dr. Koh is Assistant Professor in the department of psychiatry at the University of California, San Diego. He reports no conflicts of interest concerning the subject matter of this Special Report.

Children in foster care; combat vets; physicians with mental health needs: Dr Koh introduces a series of articles on these and other special patient populations.

Introduction: Unique Needs and Innovative Opportunities

How do you use the DSM, doctor? Is it an integral part of your diagnostic decision making? Do you use it to help you select treatment or gauge a patient’s prognosis? Do you rely on it mainly for coding and billing? For something else entirely?

There is strikingly little information available in the literature regarding how clinicians actually use the DSM in their everyday practice.

Getting a better understanding of how the DSM is used by clinicians is important for several reasons:

• Many of the uses of the DSM (eg, communicating diagnostic information to other clinicians, accurately applying research studies that define study groups using DSM criteria) depend on a relatively faithful application of the DSM criteria.

• Given that one of the primary goals of making DSM revisions is to improve its clinical utility, establishing a baseline of current usage is critical to inform future proposals.

• Knowledge about how clinicians use the DSM is important in determining the likely impact of changes to the diagnostic system on practice patterns-a major source of criticism during the DSM-5 revision process.

 and his fellow members of the Group for the Advancement of Psychiatry (GAP) Psychopathology Committee recently called for additional research that focuses on determining clinicians’ actual use of the DSM. 

 subsequently posted a survey on its Web site that was developed by the GAP Psychopathology Committee.

Although the survey will be analyzed in detail at a later date, we wanted to take this opportunity to provide you with some preliminary results.

 The survey is open for a few more weeks and we welcome your participation: 

To date, 894 readers have completed the survey. The demographic breakdown:

• 62% of respondents reported that they currently use DSM-5; 38% still use DSM-IV

• 92% of respondents provide more than 4 hours per week of direct patient care

• 5% are under age 30; 30% are 30 to 49; 43% are 50 to 64; and 22% are over 65

• 60% of the respondents report being a psychiatrist; 14% are psychologists; 5%, social workers; 6%, counselors; 11%, nurse practitioners or physician’s assistants; and 4%, lawyers, administrators, or “other”

• 88% report being Adult clinicians; 31%, Child clinicians; 19%, Geriatric clinicians; 13%, Forensic clinicians; 20%, Addiction specialists; 17%, Community-based clinicians; and 14%, Consultation-liaison (the percentages do not add up to 100%, since respondents were allowed to indicate more than one specialty)

• 59% report being in outpatient private practice, 35% practice public sector psychiatry, 28% are academically based, and 16% are non-academic hospital-based

• Respondents report spending average times of up to 72% clinical, 16% administrative, 11% research, 13% teaching, 14% consultation, and 12% other.

Respondents were first asked about their everyday DSM usage when making initial diagnoses during the assessment phase of treatment across a variety of different uses (

). They were then asked the same question-but as it pertains to ongoing treatment (

). They were also asked about usefulness of DSM in everyday practice (

In both initial and ongoing everyday practice, the majority of the respondents use DSM codes for administrative/billing purposes. About half report that they “sometimes,” “often,” or “always” use DSM to review specific criteria with the pa-tient or family and more than 60% use it “sometimes,” “often,” or “always” to review relevant text for specific disorders. In the initial evaluation of a patient, close to 85% “sometimes,” “often” or “always” use DSM diagnostic criteria from memory-but not as much during ongoing treatment.

Overall, a significant minority do not find the DSM to be very helpful in selecting treatment, and about half do not find it helpful for determining prognosis. It is seen as most useful in meeting administrative requirements, in communicating with colleagues, and in teaching.

Whatever controversies surround the DSM, this manual is already in widespread use for multiple purposes. This survey gives us the first picture of how clinicians are using the DSM-and for what purposes. We hope that these preliminary findings will stimulate further study of DSM use in clinical practice as part of the American Psychiatric Association’s plans for further revisions.

 First MB, Bhat V, Adler D, et al. How do clinicians actually use the 

Diagnostic and Statistical Manual of Mental Disorders

 in clinical practice and why we need to know more. 

 Kweskin S. Why we need to know how clinicians use the DSM. 

Given that one of the primary goals of making DSM revisions is to improve its clinical utility, establishing a baseline of current usage is critical to inform future proposals. For this and other reasons, the authors provide preliminary results from research focused on determining clinicians’ actual use of DSM.

Author | Steve Koh, MD, MPH, MBA

Articles

Introduction: The Scope of Psychiatry

5 Special Populations in Psychiatry

Introduction: Unique Needs and Innovative Opportunities

How Clinicians Actually Use the DSM: Psychiatric Times Survey Results