Andres Barkil-Oteo is an assistant professor of psychiatry at Yale University School of Medicine, with research interests in systems thinking, global mental health, and experiential learning in medical education. Find him on Google+ here.
Last spring, the American Psychiatric Association (APA) sent out a press release [pdf] noting that the number of U.S. medical students choosing to go into psychiatry has been declining for the past six years, even as the nation faces a notable dearth of psychiatrists. The Lancet, a leading medical journal, wrote that the field had an “identity crisis” related to the fact that it doesn’t seem “scientific enough” to physicians who deal with more tangible problems that afflict the rest of the body. Psychiatry has recently attempted to cope with its identity problem mainly by assuming an evidence-based approach favored throughout medicine. Evidence-based, however, became largely synonymous with medication, with relative disregard for other evidence-based treatments, like some forms of psychotherapy. In the push to become more medically respected, psychiatrists may be forsaking some of the important parts of their unique role in maintaining people’s health.
Over the last 15 years, use of psychotropic medication has increased in all kinds of ways, including off-label use and prescription of multiple drugs in combination. While overall rates of psychotherapy use remained constant during the 1990s, the proportion of the U.S. population using a psychotropic drug increased from 3.4 percent in 1987 to 8.1 percent by 2001. Antidepressants are now the second-most prescribed class of medication in the U.S., preceded only by lipid regulators, a class of heart drugs that includes statins like Lipitor. Several factors have contributed to this increase: direct-to-consumer advertising; development of effective drugs with fewer side effects (e.g., SSRIs); expansion in health coverage for mental illness made possible through the Mental Health Parity Act; and an increase in prescriptions from non-psychiatric physicians.
Unfortunately, not all of these psychiatric drugs are going to good use. Antidepressive drugs are widely used to treat people with mild or even sub-clinical depression, even though drugs tend to be less cost-effective for those people. It may sound paradoxical, but to get more benefit of antidepressants, we need to use them less, and only when needed, for moderate to severe clinically depressed patients. Patients with milder forms should be encouraged to try time-limited, evidence-based psychotherapies; several APA-endorsed clinical guidelines center on psychotherapies (e.g., cognitive behavioral therapy or behavior activation) as a first-line treatment for moderate depression, anxiety, and eating disorders, and as a secondary treatment to go with medication for schizophrenia and bipolar disorder.
Moreover, while some people taking drugs they probably don’t need, in many cases we are actually under treating. For example, effective anti-craving medications (e.g., naltrexone, acamprosate) are prescribed in only 10% of the cases where they are indicated. Overall, only 30% of people with conditions listed in the DSM-IV (the widely used guide to psychiatric diagnoses) are receiving mental-health treatment of some kind. In contrast, 68% of people with high blood pressure are getting medication. Hypertension is of course easier to diagnose than mental disorders—an inherent challenge of psychiatry—so I propose thinking about practicing mental health care as a stool with three legs, which helps highlight many of the current problems with over- and undertreatment:
- Diagnosis: A lot of mental-health treatment has moved from psychiatrists’ offices to those of primary-care doctors. Over the last 20 years, the rate of treatment by non-specialist doctors increased more than 150%. The effect is that 50% of mental-health care is delivered outside specialty clinics, and 79% of antidepressants are prescribed by non-psychiatrists. Despite the promise that mental disorders would be treated more efficiently by virtue of this shift, this doesn’t seem to be the case. For instance, some people with severe depression present with somatic complaints instead of psychiatric ones; in primary care, many are not asked about tell-tale symptoms of depression, which leads to significant underdiagnosis.
- Treatment: Even when people with psychiatric issues are diagnosed in primary-care settings, they tend to be undertreated, with minimum medication dosages, for short periods of time, with poor adherence to treatment, no good follow-ups, and no psychosocial treatment.
- Access: The problem of undertreatment is particularly acute in low socioeconomic status segments of the society, where severe depression is more common and access to physicians more difficult. Sadly, the increase in treatment of mental illness has not reduced sociodemographic differences in access to care; indeed, in absolute terms, these inequalities increased: Black people were only 50 percent as likely as whites to receive treatment when both received a diagnosis of a disorder of the same severity.
So how can we improve the current system? Given that so much mental health care is delivered outside specialty services, psychiatry ought to be an integral part of the primary care sector. Collaborative care—providing mental health services in primary care clinics—should become one of the main activities for psychiatrists. Two-thirds of primary care physicians reported in 2004–05 that they could not get outpatient mental health services for patients—a rate that was at least twice as high as that for other services.
While there are many obstacles, including rigid financial compensation schemes and outmoded billing practices, there are models for success, such as the University of Washington’s IMPACT program. These programs offer rational use of antidepressants, more access to behavioral treatment, and greater coordination of care. They include the use of patient registries, so treatments are followed up. They employ coordinators to integrate patients’ medical and psychiatric needs, because patients’ symptoms are rarely isolated according to our various specializations.
For psychiatry to save itself, it needs to embrace evidence as the standard for all practices, remember that prescribing is only one tool among many, take a leadership role in reaching out to primary-care physicians, and try to not only treat mental illness, but increase their community’s general mental health [pdf].