Recently, I have had the unusual experience of finding myself more in agreement with psychiatry’s establishment leadership (in the guise of Jeffrey Lieberman’s articles in Psychiatric News) than with some of my favorite psychiatry bloggers. This occurred in the context of discussions of a new buzzword within medical reform circles – Collaborative Care. It encompasses a number of topics and goals. One is to insure that people who are diagnosed with psychiatric disorders receive good medical care. The reported average life expectancy for people who are diagnosed with serious mental illness is 15-25 years shorter than that of the general population. Collaborative care is one means to address this. In this model, community mental health centers would provide primary medical care along side the other services typically offered.
I have been in favor of this for some time and our clinic has already moved in this direction. We collaborate with a Federally Qualified Health Center. They have opened a mini-office within our clinic so that people who come to us can meet with a family practice physician one afternoon a week. Many of my patients do not readily seek out general medical care. This clinic makes it much easier for them to do so.
But most of the attention among my psychiatric colleagues is based on the reverse situation – the co-location of psychiatry and so-called behavioral health services in primary care settings. My colleagues are concerned that this will end up constituting a further erosion of psychiatric care with psychiatrists functioning as consultants with limited direct care responsibilities. They worry it will continue the distillation of psychiatry into applied psychopharmacology. I think there is some truth to this but it does not concern me.
As people who have read my blogs know, I have a conservative view of psychopharmacology. In a general sense, the drugs’ effects have been overblown, they are often prescribed at doses higher than is needed and in combinations that are risky and untested. They are often continued for too long. But that is a problem that can occur in a private practice with a psychiatrist who is also offering psychotherapy as easily as it can in a clinic with a psychiatrist who only consults to other physicians. In our setting where we frequently consult with other physicians, we often recommend ways to reduce the use of psychoactive drugs. There is nothing inherent to collaborative care that promotes excessive prescribing practices. At the same time, this model does not ignore other forms of help. Where I work, psychologists and social workers are an important part of the collaborative team.
Some of my colleagues are concerned because in these new models psychiatrists are not the ones offering psychotherapy. I guess that bothers them more than it does me. And it is not that I am opposed to psychotherapy. I just do not think you need a medical degree to be a good therapist. These models are, among other things, seeking cost effectiveness and almost everyone else in this business costs less than a physician. I also understand that psychotherapy – being labor intensive no matter the practitioner – will always have to fight for time. But this is a problem now and it will be a problem in any system we have.
But my thoughts on this relate to another idea I have had recently – psychiatry in its current iteration could be subsumed by neurology. I do not think care would suffer and, in many ways, it would be much clearer to patients.
I have recently been reading Richard Noll’s excellent book, “American Madness“. It traces the emergence of modern psychiatry in the U.S. from the late nineteenth to the early twentieth century. This was a time of remarkable growth and development for medicine. Psychiatrists, first in Europe and then in the US, tried to emulate the practices employed successfully in the rest of medicine. It was predicated on an assumption that the problems we treat are fundamentally medical. Psychiatrists applied the methods of understanding disease processes to understanding the problems of people who inhabited the asylums of the time. This distinguishes psychiatry from other disciplines. We developed in a place – the asylums; other disciplines developed out of a study of organ systems in the body. Since those early days, psychiatry has taken a few detours – most notably the psychoanalytic one that was developing simultaneously and took hold in the US after World War II. This muddied our professional identity. But to be modern in a medical sense, psychiatry – as embodied by Dr. Lieberman’s APA and Dr. Thomas Insel’s National Institute of Mental Health – wants to take its place as the discipline that studies the nervous system. But we already have that discipline – neurology. I guess where I part ways with some colleagues is that I do not see this as fundamentally bad. But there is a critical caveat – I see all of this as peripheral to the needs of most people in emotional distress.
I continue to think that physicians have a roll to play in evaluating people who experience depression or hear voices or suffer from debilitating anxiety. Although many of these problems will turn out to be well handled in non-medical ways, not all of them will. There are endocrine disturbances, inflammations, vitamin deficiencies, even tumors that could be causing the problem. I once read a paper that was 100 pages long and listed all of the medical causes of psychosis. Someone needs the training to be able to assess for them. To be honest, most of them are rare, but still.
I also think that psychoactive drugs are here to stay. People have sought them out for a long time – well before the advent of modern psychiatry – and that seems unlikely to change. It is imperative that some branch of medicine specializes in understanding these drugs. I wish that branch would be cautious. It’s not that I more faith in neurology than I do in psychiatry to be judicious but that is a problem of modern medicine that is no better or worse in one discipline or another.
In the unlikely event, my little thought experiment were ever adopted, I imagine there would be a specialization within neurology that would approximate what psychiatry is today. But there would be no pretense about what this specialty was and the training could be focused on the medical causes of emotional distress. There is much that psychiatry residents can not learn these days because they are pulled in so many directions. Training in psychotherapy is arduous and time consuming. As it is, most residents just get a basic introduction. Perhaps without needing to put time into that area, these neurology residents specializing in this new sub-specialty would be able to acquire a depth of understanding of psychoactive drugs that is not always in evidence these days. Perhaps they could learn about those hundred other causes of psychosis. Perhaps they would gain an in depth understanding of the movement disorders the drugs we prescribe so often cause.
When I have discussed this with colleagues, there are several responses, none of them good. The primary objection is that I am dismissing humanism and promoting a largely neuroscience based understanding of human suffering. To be clear – I am not suggesting that all problems currently falling under the label of extreme distress or mental illness be solely treated by these neurologists. Far from it. I would have a whole battalion of people offering services. I like the model in Tornio, Finland. I think of the network meetings as the hub. People can get referred out for other help as the need arises. This could include peer services, cognitive behavioral therapy, psychodynamic therapy, employment support. These problems are varied and heterogeneous and the forms of support should be equally varied. In Norway, where they do similar kinds of work, the primary care physician plays an important role in the team. A neurologist could be pulled in when needed.
Another criticism is that psychiatrists are more prepared that other physicians to see the person in his or her context and grasp the complexity of human behavior. In this scenario, psychiatrists are the physicians who talk to people and understand their concerns. I will leave aside the many criticisms of psychiatrists I read on this site and just point out that these attributes should be intrinsic to all of medical practice. It does medicine as a profession a disservice to have a single discipline that is considered the holder of a humanistic approach to human suffering.
People are very confused about what psychiatry is. Psychiatry is a bit confused. I think my system would be clearer. If you want an evaluation to understand possible medical causes of your problem go to the nerve doctor. If you want to know if there is a pill for you, go to the nerve doctor. If you want to understand your experience as a human and the nature of your suffering, leave medicine out of it. Furthermore, I am suggesting that with regard to the kinds of human distress that has historically fallen under the purview of psychiatry, let medicine – under the umbrella of neurology – stand in the background, quietly in the corner, available for limited evaluations and consultations. I would have the rest of you take center stage.
