Is Redefinition of Psychiatry Underway?

October 1, 1997

Over the past decade, cost containment efforts have pushed psychotherapy patients away from psychiatrists and toward the offices of psychologists, therapists and other less expensive mental health workers. The availability of new drug treatments for psychiatric disorders has shifted many psychiatrists' practices away from a long-term therapeutic focus to that of short-term drug treatment. If psychiatry merely reacts to these economic and political forces, rather than managing them with a plan, the future of the field is highly uncertain.

Although not experts in health care policy or in psychiatric education, nor involved in health care administration, these two academic psychiatrists, engaged in research for most of their careers, have met periodically at conferences and compared notes about the vast changes taking place in the field, and in health care in general.

What's different about Jeffrey A. Lieberman, M.D., of the University of North Carolina, Chapel Hill, and A. John Rush, M.D., of the University of Texas Southwestern Medical Center in Dallas, is that they decided to put their ideas about the current and future status of psychiatry into publication. In a piece that appeared in the November 1996 American Journal of Psychiatry, Lieberman and Rush made a number of observations and recommendations about the effect of managed care on psychiatry that have garnered interest and commentary, not all of it positive.

Over the past decade, the authors note, cost containment efforts have pushed psychotherapy patients away from psychiatrists and toward the offices of psychologists, therapists and other less expensive mental health workers. The availability of new drug treatments for psychiatric disorders has shifted many psychiatrists' practices away from a long-term therapeutic focus to that of short-term drug treatment. And, they claim, as our understanding of the organic basis for many behavioral illnesses has grown, such diseases have been removed from the psychiatrist's bailiwick.

If psychiatry merely reacts to these economic and political forces, rather than managing them with a plan, the future of the field is highly uncertain.

"These types of changes are taking place, not just in psychiatry, but throughout medicine," says Lieberman, who is professor of psychiatry, pharmacology and radiology. "But psychiatry is being affected in a way that's potentially much more serious, threatening not only to reduce the capacity for services, but to eliminate the specialty and apportion it to general medicine, pediatrics, OB/GYN and nonmedical disciplines like psychology and social work. It seemed to us that the field needed to recognize the forces at work and the changes they were producing and try to determine what the field needed to do to ensure its future."

"Redefining the Role of Psychiatry in Medicine" advocates wide-ranging changes in psychiatric practice and training. Rush and Lieberman advocate greater emphasis on the primary care aspects of psychiatry, with a shift away from treatment of so-called "worried well" patients suffering from mild neurosis or depression.

"It's not to say that these people aren't worthy of our treatment," Lieberman says, "but that psychiatry doesn't have a good case for saying that we do it any better than psychologists, social workers or others."The field should begin focusing its efforts on its hardest-to-manage patients, the authors say, those who have normally been relegated to state care, such as severe schizophrenia patients and those with disorders that have proven intractable to treatment.

"Psychiatrists are best at treating diseases that are biologically based but manifested in behavior," says Lieberman. "That's what they're trained to do. Other disciplines of medicine have little interest in treating major mental illnesses that are the central focus of the psychiatric patient population."

In the meantime, they say, psychiatrists should be required to have one year of training in primary care medicine, since many patients see them more frequently than any other doctor; the second year should focus on neurologic disorders and their diagnosis; the third should combine in- and outpatient diagnosis and therapy of major psychiatric disorders; the fourth should offer exposure to various specialties; and an optional fifth year would allow the opportunity for subspecialization.

"I pretty much would endorse both the orientation they establish as well as recommendations they make," says John Oldham, M.D., director and Elizabeth K. Dollard Professor of Clinical Psychiatry, Medicine and Law at Columbia and the New York State Psychiatric Institute. "The main importance of their argument is returning us to biology, the new neurobiology of the clinical and behavioral neurosciences, which are crucial to our understanding of psychiatric illness."

While some psychiatrists laud the authors' call for greater emphasis on the biological aspects of mental illness, Jack McIntyre, M.D., chair of the department of psychiatry and behavioral health at the Unity Health System in Rochester, N.Y., says that Rush and Lieberman have ignored an important component of our understanding of the biological basis for psychotherapy.

"I feel that they've narrowly defined the role of biology in psychiatry," McIntyre says. "In the last decade, we've found that there are a number of variables that can determine the impact of psychology on illness, mental and otherwise, and that important chemicals can be affected by individual psychology."

Herbert Pardes, M.D., dean of the school of medicine at the Columbia School of Physicians and Surgeons, wrote in an editorial appearing in the same issue, that despite our improved understanding of the biological basis of mental illness, it would be a mistake to relegate the bulk of psychotherapy to nonphysicians, while limiting psychiatric training to brief psychotherapeutic interventions. Psychiatrists should be trained or expert in interventions for all types of mental illness.

"Can you imagine a pediatrician or an internist saying 'From now on, I'm only dealing with cancer; I'm not going to see people with cough or itching?'" says Pardes. "We can't undercut the psychiatrist as the person who gives the overview to the problem."

Psychiatrists are responsible for a certain amount of standard setting in psychotherapy, and some psychiatrists believe that without their presence in the field, the overall quality of psychotherapy may suffer.

"They're minimizing the impact of psychotherapy in terms of both benefit and harm," says McIntyre.

"Psychotherapy poorly done can be as harmful as medication incorrectly administered. My basic criticism is that, in approaching the field in a biopsychosocial manner, they have overexpressed the biological and understated the psychosocial part of the model."

Many psychiatrists feel that drastic accommodations to managed care changes have already been made. Harold Pincus, M.D., says that surveys of practitioners show that psychiatrists already treat more severely mentally disordered patients, as well as patients with general medical conditions and health problems."Forty percent of psychiatric patients' payment sources are public funds or uncompensated care pools," says Pincus, who is deputy medical director and director of the office of research for the American Psychiatric Association. "Across all different levels, the New Yorker cartoon image of the psychiatrist as the guy who takes care of a Woody Allen character is outdated. The bulk of what [Lieberman and Rush] are describing is not the future but the present."

Psychiatry is not the same field it was 20, or even 10 years ago, according to Pardes. And part of the field's strength may be an improved image-a force that can make a positive difference in people's everyday lives.

"The therapeutic capacity of the field has improved and the stigma associated with psychiatric illness has been reduced, and there are more people who will speak publicly about their psychiatric problems," he says. "I think that, if anything, psychiatry is better positioned than it was 20 years ago."

"There's much more recognition today of what psychiatry brings to the field of medicine," Pardes says. "Psychiatrists are deans of about a dozen medical schools. That tells me that medicine has embraced psychiatry as a full partner, and that there's an increased regard for the field."