Redefining the role of psychiatry in medicine.
by Lieberman JA and Rush AJ
American Journal of Psychiatry. 1996 153:1388-1397.
… The delivery of psychiatric services would be reorganized to emphasize what psychiatrists can do best. For example, the initial diagnostic evaluation would involve a reordering of services, with psychiatrists being the first to consult [after primary care physicians] regarding patients with complaints or disturbances in behavior, affect, perception, and cognition. If a diagnostic evaluation revealed a common problem in living [e.g., marital problem, minor sexual dysfunction] for which only psychotherapy was called for, the patient would be referred to a nonmedical mental health practitioner for treatment, but after treatment the patient would be reevaluated by the psychiatrist to determine whether the treatment outcome was as expected. If the outcome was not satisfactory, revisions in the treatment plan would be made through consultation between the psychiatrist and therapist. This arrangement would help to ensure the appropriate use of time-intensive treatments by psychiatrists, who would have no economic investment in their extended use.In addition to having a pivotal diagnostic role, psychiatrists would treat with medication, psychotherapy [often by way of a therapist responsible to the psychiatrist], or the combination of these for patients with complex, "treatment-resistant," or chronic/recurrent disorders. Psychiatrists would have a greater role in the diagnosis and treatment of the psychiatric sequelae of general medical conditions [e.g., diabetes, cancer] and neurologic disorders [e.g., stroke], since they would be better prepared than primary care physicians to separate normal psychological responses [which require the passage of time with support and reassurance] from true psychiatric disorders that require formal treatment. What are now diverse bodies of knowledge found in neurology and psychiatry would be brought together to serve patients more efficiently. The extensive interpersonal and communication skills acquired by psychiatrists in their training would enable them to enliven even the most routine clinical functions, such as medication management.
The general notion is of a "one-stop" specialist for disorders that affect behavior, cognition, perception, and affect, whether from known or unknown etiologies. Emphasis on psychotherapy would not be eliminated but, rather, would be reduced in priority. The focus would be on the indications for and expected outcomes of different psychotherapeutic treatments to be delivered largely by nonphysicians. A limited number of psychiatrists might wish to specialize in psychosocial rehabilitation, which would be analogous to neuropsychiatric rehabilitation medicine…
I suppose their assumption that the psychiatrist would direct the show – a diagnostician first and foremost, making a diagnosis, delivering the medical-psychiatric care, farming out the psychotherapy, and certifying the result – made sense in light of how things had always been. Then there’s moving onto the medical floors for a greater role in the care of the physically sick [the enlivened med checks were perhaps a bit of fluff]. It’s not an unfamiliar model. It’s the model of Internal Medicine or other specialties. Once the evaluation is done, the diagnosis and plan put together, the delivery is often farmed out. It’s a mutually beneficial arrangement. The people delivering the care appreciate the up front expertise and the back-up. The specialist has time to "specialize." It’s something of a consulting relationship. Nowdays, the hospitalist or primary care physician is central, and multiple consultants come and go as needed.
With the pharmaceutical industry weary of investing in psychiatric drug development, collaboration across public and private sectors seems to be the only way to remedy a dearth of new treatments. Leaders from academia, government, the pharmaceutical industry, venture-capital firms, and clinicians met at APA headquarters March 8 to discuss the shrinking investment in new drug development for psychiatric disorders. The “Pipeline Summit” was organized and supported entirely by the American Psychiatric Foundation (APF) after APF was asked to convene the event by the leadership of the National Institute of Mental Health (NIMH) and National Institute on Drug Abuse (NIDA). They are concerned that psychiatry is facing a prolonged drought of no new drugs for years to come. One by one, major pharmaceutical companies have slashed or abandoned neuropsychiatric research programs.There are huge unmet clinical needs in mental disorders and addiction,” said Jeffrey Lieberman, M.D., incoming president-elect of APA and chair of psychiatry at Columbia University, who moderated the morning session. “There should be tremendous interest in this area, but there is not.” Psychiatric research and development programs have gained a high-cost, high-risk, and no-return reputation in industry after dozens of failed programs, agreed senior managers from several major companies at the summit….
One of APF and APA’s roles, Schatzberg said, is to continue to fight the stigma against psychiatry and psychiatric drugs. In addition to facilitating more collaboration between the government and the private sector, he proposed that APF and APA work with other stakeholders to create incentives for industry to reinvest in psychiatry. Philip Skolnick, D.Sc., Ph.D., of NIDA raised the issue of whether extending market exclusivity for compounds that are first in class and/or first in indication as is done abroad could promote investment. Thomas Laughren, M.D., director of the Division of Psychiatric Products at the FDA, suggested that APA could help the agency by organizing public discussions and publishing consensus on clinical endpoints, biomarkers, and standardized clinical definitions such as response and partial response. In addition, APA will continue to advocate for more favorable reimbursement conditions for psychiatric services and new medical devices for treating mental illness, said Schatzberg. “APA has a role in shaping what future psychiatric practice looks like,” Schatzberg stated. “More needs to be done now if we are to have new treatments in the next decade for patients with psychiatric disorders”…
As a profession, the people at the top have acted like Mafioso [literally, honorary family members by virtue of loyalty] with PHARMA – bought men. And they treated our professional colleagues like Strangeri [others, not in the family]. Neither expertise nor mutual respect flowed from the Psychiatric Mafia that has dominated enough of the Key Opinion Leader set to turn the opinion of almost everyone sour – mine included. For Alan Schatzberg to say that we need "to continue to fight the stigma against psychiatry and psychiatric drugs" or "[m]ore needs to be done now if we are to have new treatments in the next decade for patients with psychiatric disorders" in a meeting at the APA headquarters simply confirms their dependence on this unholy alliance. So long as psychiatry continues to function as an interest group a la Alan Schatzberg ["APA will continue to advocate for more favorable reimbursement conditions for psychiatric services and new medical devices for treating mental illness"], the decline will continue as our ranks thin from the bottom up.
What comes across is the regression from the stance of autonomous professional to professional victim in need of self advocacy. Physician, heal thyself, but first, cease to do more harm. Patients sure aren’t front, center, or really, anywhere to be seen.
As I wrote recently, the current “crisis” in psychiatry provides a perfect opportunity for the APA– if they truly advocate for effective psychiatric care, that is– to step up to the plate and argue in favor of more accurate diagnosis and better treatment in all modalities, not just pharmaceuticals.
Instead, they are (IMHO) taking the profession a step backwards, with the DSM-5 and its imperfections, and now this persistent defense of biological psychiatry (or, as aek points out, what comes across as “victimhood”).
Dr Schatzberg evokes some hope for the future when he says “the APA will continue to advocate for more favorable reimbursement conditions for psychiatric services,” but unfortunately, we all know that’s just a code for an attempt to maintain the only “turf” we haven’t ceded to other professionals– namely, the prescription of drugs.
First, I like the Mafioso/Strangeri analogy, but in the end, it really is more simply the fraternity attitude, except they as the APA have narrowed it to their own inner circle, which is also age related in favoritism too. Paternalistic attitude is not acceptable in professions that treat people as of the past 15 or so years at least, but, unfortunately my experiences with older colleagues since I finished training has been much more negative than positive. And listening to the usual reps coming out of the APA does nothing to change my attitude for the better.
Second, per SteveBMD above, we have ceded to other professionals, and these idiots who live in ivory towers or in shielded Association buildings tell us how and what to think are clueless to what they have fostered. I firmly believe if PPACA survives the Supreme Court decision that psychiatry will essentially be finished as a profession, as PCPs/Family Docs/Internists/OBGYNs/and Nurse practitioners will be over 90% of almost all psychotropic prescription providers, and letting DSM5 be their guide.
I just hope that once malpractice issues finally catch up with NPs in how they are practicing from what I have witnessed in the past couple of years, they will begin to think twice in pursuing prescription abilities when malpractice premiums slap them in the proverbial faces with the accountability it costs!!!
Comes back to the 1995 election between Harold Eist and Steven Sharfstein. Even though Eist won, psychiatry lost. The acceptance of managed care without much of a fight, god knows how many gonads just rolled across the floor that year!
And in your piece, you made a great point, “But why are psychiatrists defending antidepressants in the first place? If anyone should be defending antidepressants, it should be the drug companies, not psychiatrists.” I think that they are so into their mind-set that they have no idea what they’re saying or how it comes across.
But we do have a “turf” – expertise [or at least we used to]. And I doubt that any other mental health discipline or medical specialty will step up to the plate with expertise across the mental illness spectrum. So as things stand now, we’re abandoning our post and our patients.
From the article at http://psychnews.psychiatryonline.org/newsArticle.aspx?articleid=1096598 — well worth reading in its entirety:
….
In psychiatry, “[a] lot of drug targets [that were] validated in the lab have not panned out in clinical trials,†said Armin Szegedi, M.D., Ph.D., who heads the Clinical Neurosciences and Ophthalmology Department at Merck. The reason? Psychiatric disorders are not single-pathway diseases. For example, what is known as major depressive disorder may be a heterogeneous group of diseases with different etiologies and genetic factors, he said. Targeting one pathway may not help patients with other pathologies, and no one yet knows how to differentiate patients by their biology.
….
A pervasive antipsychiatry stigma in society is also a factor in the declining investment in psychiatric drug research, APA past President Alan Schatzberg, M.D., commented. Many within and outside the industry have the impression that plenty of drugs are available to treat all major mental disorders and discovering new antidepressants or antipsychotics is not as important as are new anticancer drugs.
Doesn’t it seem that there’s a great deal of delusion in Dr. Schatzberg’s assumptions? And what’s wrong with the current crop of drugs, hmmmm?
….
Mudhukar Trivedi, M.D., director of the mood disorders research program at the University of Texas Southwestern, observed that “we are creating a virtual world in which [psychiatric] trials are conducted in the [least-severely ill] patients by the least-qualified people, and then [we] are surprised by the placebo effect.†Consequently, the general public and part of the medical community believe that antidepressants are no better than placebo.
As for the American Psychiatric Foundation, here’s where it gets its funding:
http://www.psychfoundation.org/Functional/AboutAPF/CorporateAdvisoryCouncil.aspx
Foundation Patron
AstraZeneca Pharmaceuticals LD
Eli Lilly and Company
Patron
Genentech Inc.
Sustaining Member
Lundbeck, Inc.
Shire Pharmaceuticals, Inc.
Sponsor
Forest Laboratories Inc.
Novartis Pharmaceutical Corporation
Sunovion Pharmaceuticals, Inc.
Donor
Bristol-Myers Squibb Company
Cyberonics, Inc.
Merck Sharp Dohme Corp.
Neuronetics, Inc.
Purdue Pharma L.P.
APF is the arm of the APA that promotes cooperation with industry. NIMH and NIDA asked a pharma-funded organization to convene a meeting to juice up academic cooperation with pharma to develop new drugs — “translational medicine” is the term.
Alto: “Targeting one pathway may not help patients with other pathologies, and no one yet knows how to differentiate patients by their biology.”
For crying out loud, isn’t this precisely what the APA should be pounding the table for???? Maybe our current drugs do work, it’s just that we’re using them as one-size-fits-all garments, not recognizing that people come in all sorts of shapes and sizes.
I would go one step further, though, and instead of differentiating patients only by their “biology” (which, in today’s vernacular, means through brain scans and genomics), let’s try to differentiate them on psychological and social measures, as well, in order to provide truly “individualized” care.
Unfortunately, the frat boys aren’t interested in that. It’s not cool.
Re: Schatzburg’s comment, “Fight the stigma against psychiatry..”
How does psychiatry go about fighting a stigma it created upon itself?
Maybe its time the profession met with the mob to find out.
Good luck.
Oh, and the comment that was made about the need for “new medical devices”…
Medical devices?
Maybe the mob has some ties to the durable medical equipment industry.
Who knows.
It may be worth a shot.
At this point, psychiatry has nothing to lose.
It lost its soul long ago.
Duane Sherry
discoverandrecover.wordpress.com/warning
Duane Sherry
Here’s an opinion to ponder: if the standard of care for a diagnosed mental health disorder includes both medication and therapy, and the patient chooses to refuse the recommendation for therapy and wants to continue a meds only intervention, are you culpable for negligence or malfeasance to provide meds alone thereafter?
Especially with the rising comorbidity of Axis 2 that is seen these days.
The best medical analogy I can offer to illustrate my point is this: if you are treating a new onset diabetic who refuses to follow dietary changes and will not see a dietician, do you want to keep the patient and head towards insulin use that could possibly be avoided, if not greatly delayed?
Think about this. Medicating psychiatric issues alone and agreeing to it indefinitely is not defendable if brought into court. Just my opinion.
Thomas Laughren, M.D., director of the Division of Psychiatric Products at the FDA, suggested that APA could help the agency by organizing public discussions and publishing consensus on clinical endpoints, biomarkers, and standardized clinical definitions such as response and partial response. In addition, APA will continue to advocate for more favorable reimbursement conditions for psychiatric services and new medical devices for treating mental illness, said Schatzberg.
The FDA suggests a role for the APA that might enhance patient safety and clinician effectiveness, Schatzberg talks about going after the money.
New medical devices? How about portable brain scanners?