\nRedefining the role of psychiatry in medicine.<\/font><\/strong><\/u><\/a>
by Lieberman JA and Rush AJ<\/sup>
American Journal of Psychiatry<\/font><\/strong>. 1996<\/font><\/strong> 153:1388-1397.<\/div>\n<\/p>\n
… 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. <\/p>\nIn 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. <\/p>\n
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…<\/sup><\/div>\n<\/blockquote>\n
This wasn’t that long ago – sixteen years. It was in some ways a capitulation, or maybe some kind of acceptance of the state of affairs at the time – the rise of Managed Care and the turning over of psychological treatment [psychotherapy] to other disciplines – perhaps not so much by design but rather adapting to the lay of the land. But there are some things in the assumptions made by Dr. Lieberman and Dr. Rush that, in retrospect, look naive. In their model, they place the psychiatrist at the top of a mental health heirarchy:<\/div>\n<\/p>\n
• "with psychiatrists being the first to consult"<\/div>\n• "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"<\/div>\n• "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"<\/div>\n• "a greater role in the diagnosis and treatment of the psychiatric sequelae of general medical conditions"<\/div>\n• "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"<\/div>\n• "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"<\/div>\n<\/sup><\/ul>\n
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<\/em> 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.<\/p>\n
Well it didn’t exactly work out as they planned. None of it. They made the assumption that psychiatrists would be in the driver’s seat as they always had been in mental health. The DSM-IV was in its infancy and had become the industry standard. What they didn’t take into account was that the position they envisioned for psychiatrists was hardly a given – it was to be earned through demonstrated expertise and by mutual respect. Psychiatry, as a specialty failed dramatically in both dimensions. Prophetically, in 1996, Author John Rush was in Texas starting up TMAP, a pharmaceutical scam for all seasons and planning STAR*D, a $35 M research failure. He’s currently on the lam in Singapore. Dr. Lieberman fared better, moving that year to UNC, shepherding the CATIE Trial, and becoming Chairman at Columbia in 2005. He’s slated to become President of the APA in May 2013 at the time when the DSM-5 will be released to what looks like may be an international boycott, and this week he moderated a relatively bizarre APA\/APF Conference: <\/div>\n\n