Psychiatry’s Identity Crisis, and How to Start Fixing It

By Guest Blogger | August 6, 2012 9:30 am

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

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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].

  • Joe

    It is interesting that evidence best practices are mentioned. Afterall, we went through an entire era when providers and provider agencies asserted that all care was predicated on evidence based practices. This was before the successive eras of best practices, recovery and now recovery and wellness.

    Sadly in the mental health system glib representations (puffery) far exceed reality. This is reflected in the fact the outcomes are little better then they were 20 years ago. The burgeoning population of individuals on disability by virtue of mental illnesses is the testament.

    Would any physician wish to commit his future to a mental health system which can deliver so little?

  • Julian Penrod

    In fact, psychology, psychiatry have a number of very ugly secrets.

    One is that they do not resemble “sciecnes” at all. No “scientific” discipline would have as many inherently different “theories” as psychlogy do, from Freud’s manic obsessions to Jung’s pre programmed archetypes to Skinner’s machine like regimentation. No “theory” has ever dropped out! They just keep piling them on! And that relates to the greatest ugly secret of all of psychology. The “theories” that are supposed to describe normal, healthy people all, every last one of them, are derived from case studies of mental patients! They look at how an ax murderer thought and use that to “define” how normal people think! It’s like looking at jaundice patients and saying everybody must have bright yellow skin!

    All the “theories” derive from the delusions of some on or another lunatic! Then they are “fit” to every other case history!

    Psychology works by being, basically, a salve, a kind of placebo, for people whose mental weakness and incipient malleability is already proved by the fact they have to see a psychologist!

  • http://none Jack Rosenblatt

    Joe,

    The problems that complicate and obstruct psychiatry are similar to those that do the same apropos of other medical specialties. Outcomes are “little better” now because once treatments are considered effective by consensus, the character of samples in subsequent studies changes. One of the changes that keeps outcomes stable is inclusion of more “treatment-resistant” patients, patients with atypical features and more (and more severe comorbidities). This has itself been well-documented and is relatively recently introduced evidence (past 15 years or so).

    I cannot address everything you assert, but suffice it to say(with no offense intended) that you really don’t seem to know very much about the problems that you broach. In fact, I am tempted to say that you are so far out that you’re not even wrong. Learn more. Learn, for example, that the number of “individuals on disability” may increase because some disabilities have become easier to get (and for reasons that have little to do with psychiatry).

    Blaming psychiatry for its problems is facile and just plain dumb. And then assuming that “therapy” is a unitary entity (underused) is just (well, it’s one of those things that is so far out it’s not even wrong). Variability in samples and practitioners makes each study about psychotherapy a unique psychotherapy. Standardization is poor; artifacts many; cognitive biases rampant. The only “positive” is relative absence of greedy Pharmsters and academic competition as a perhaps more benign corruptor of content.

    Learn more; don’t expect solutions to be one liners; stop reckless blaming; we aren’t doing too badly; after all, the eminence-based propagation of what was represented as evidence that could generate generally effective solutions is almost gone. (Freud is almost gone.) But, you know (and I don’t think you do know) psychiatric pharmacotherapy is almost always dispensed with a referral for psychotherapy. (Evidence-based information indicates better outcome than either as monotherapy.)

    Pharma is an important obstruction to optimization. Its desiderata are different in almost every respect from those to which the values of doctors give rise. Unfortunately, those values are highly soluble in cash, and psychiatrists who have “solld out” know enough to keep solvable problems festering. They are the most serious obstruction to generation of valid and reliable information and clear exposition of that information. Pharma and doctor-collaborators are about persuasion and about creating representations of evidence. The companies control their crucial preapproval trials every step of the way. There is deep rot in the foundation of evidence generation that very little can be done about when Pharma lobbyists outnumber members of Congress. It’s hard (cognitively and emotionally) to be a psychiatrist these days. I counseled my own daughter to stay away from psychiatry when she was considering specialization. Other medical specialties face similar problems, but find more effective and more perspicuous solutions in their methods of validating diagnoses and effectiveness of treatment (laboratory markers and imaging studies, for example, which psychiatry lacks).

    The solutions for psychiatry’s most difficult problems are known (more or less); it’s the implementation that bedevils the efforts.

    A psychiatrist not sorry to have chosen psychiatry thirty-plus years ago (but one who would not choose it again were the years that remain to me enough to allow another choice)

  • Pingback: Weekly Psych Rounds 17-08-12 « Shrink Things()

  • http://lunatickfringe.wordpress.com/ Frank Blankenship

    There have been an abundance of psychiatrists coming to the defense of psychiatry AS IF the profession was threatened. The truth is psychiatry is not under siege, and if it were, it is not a profession we even need. The primary treatment role can easily be subsumed by psychologists, social workers, and even trained ex-patient paraprofessionals.

    The medicalization of all aspects of life fostered by psychiatry and psychiatrists constitutes the real problem. Iatrogenic–physician caused–disease is epidemic in the mental health field because the prevailing school of psychiatric theory–biological psychiatry–serves the rapacious interests of the drug industry to the detriment of the physical health of our citizens.

    Outcomes are not only “no better” than they were 20 years ago, they are actually much worse. We’ve had 50 + years of putting people on drugs that do damage to people in the name of benefiting them. The panacea of psychiatry, the psychiatric drug, is going beyond maiming, it is literally killing.

    The contemporary paradigm that relies so heavily upon these potentially deadly chemical compounds needs changing. All that a human being is should not be dismissed with the bestowing of an entirely dubious disease label. Toxic drugs and damning labels do people serious injury. A different approach to treatment, that doesn’t depend upon any chemical quick fix, but that deals with the social contexts in which troubles arise is required.

    When this basic approach to treatment changes, with or without psychiatry, then the numbers of people in treatment can contract rather than expand the way it has done so much of late. This is to say that when the approach to treatment changes to something more fundamentally sound than a chemical fix, more people will completely recover from their mental distress than do at present. Should this not occur, there will come a time when the problem, even more than it has today, will lead to disastrous consequences for more and more people.

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