Psychiatry in the New Millenium

This collection of articles is put together by psychiatrists at the heart of the establishment of American Psychiatry.  Weissman is at Loyola University Stritch School of Medicine, Sabshin is Medical Director Emeritus of the APA, and Eist is a past president of the APA.  It features articles by notable psychiatrists such as Glen Gabbard, Steven Hyman (director of NIMH), Donald Klein, and Harold Pincus.  So this is as close to a definitive statement about the current and future state of psychiatry as we are likely to get from those at the head of the profession. 

According to the editors, the book is aimed at practicing psychiatrists; the introduction says it is designed to provide “the conceptual tools that will enable him or her to assess and use psychiatry’s vast professional literature base” and also provide “a basis on which to effectively assess the presentations at scientific meetings.” (xxiii).  However, this stated aim seems to sell the book short, since it does more than this.  It gives us an opportunity to assess at least some aspects of psychiatry as it is currently understood, and to contemplate the future role of psychiatry in our society. 

There are twenty chapters grouped into four sections: the first is in two parts, “The Impact of Changing Conceptual, Organizational, and Philosophical Issues and on the Shape of Psychiatry,” and “The Impact of Research Findings on the Shape of Psychiatry,” then The Practice of Psychiatry, The Psychiatric Workforce and Its Education, and finally, The Future.

Joseph Coyle writes on “The Neuroscience Revolution and Psychiatry.”  He sets out come of the advances in out understanding of how mental disorder affects the brain, and some of the discoveries in genetics and molecular psychology.  He expresses hope that our expanded knowledge will lead great advances in treatment through medication, but he also emphasizes the dangers of reductionist attitudes.  He emphasizes that environment and psychotherapy can have measurable effects of people’s emotional lives and their brains.  He also stresses that psychiatric training needs to broad enough to enable psychiatrists to be leaders, and that we need to reverse the current trend of managed care putting the least qualified mental health professionals in charge of mental health care.  The chapter contains a great deal of interesting scientific information, presented in a technical manner that will be intimidating to people who are not familiar with the notation and terminology. 

Weissman’s chapter on psychoanalysis is lightweight.  He defends ten major psychoanalytic concepts by responding to critiques of psychoanalysis.  He says that there are two main reasons why psychoanalysis has been held in disrepute recently.  First, people think that recent advances in neuroscience have undermined it because psychoanalytic thinking is dualist.  Second, philosophers and others have criticized psychoanalysis for failing to meet the criteria of good science.  Weissman’s response it to point out that psychoanalysis is compatible with monism about the mind, and that Freud himself was a monist.  Furthermore, he points out that neuroscience has not provided anything like an explanation of the nature of experience.  He also says that although it is true that psychoanalysis is not as scientific as Newton’s theory of motion, this is not a significant criticism.  He points out, citing Duhem and Quine, that confirmation or falsification is never a simple relation between a single observation and a theory.  He then goes on to discuss familiar concepts of consciousness, the dynamic unconscious, repression, defense mechanisms, models of the psychic apparatus, drives, identification, empathy, and Kohut’s concept of selfobject, giving a few examples to illustrate these concepts. 

This defense of psychoanalysis and in particular his criticism of Adolf Grűnbaum (whose name he consistently misspells throughout the paper) are weak.  Grűnbaum is well aware of the work of Duhem and Quine, and his criticism of Freud rests on a particular argument of Freud’s, which he calls the “Tally argument.”  Weissman says nothing to give the reader any reason to think that psychoanalysis has a good evidential base or is worth taking seriously.  His assertion that people object to psychoanalysis because it is dualistic may be true, but this objection is not one that is taken seriously by any of the informed parties to the debate over psychoanalysis, since it is well known that Freud’s project was ultimately based on the hope that the mind could be understood in terms of brain function and that psychoanalytic theory be vindicated by out understanding of the brain.  Insofar as modern neuroscience is a threat to psychoanalysis, it is because it shows little sign of actually vindicating Freudian models of the mind. 

In the paragraphs setting out psychoanalytic concepts, Weissman seems to take himself as showing their usefulness in relation to his examples.  Of course, his discussion here is so brief that it could not possibly do anything more than hint at a defense of psychoanalysis, and he does not even acknowledge that there may be competing explanations of the phenomena he mentions.  These limitations of space is of course inevitable given the place of the paper in the book – a defense of psychoanalysis would really require a book – but it’s striking that Weissman does not refer to one other work that defends psychoanalysis from its critics.  Not only does Weissman fail to defend psychoanalysis here from anything but the most superficial criticisms, but also his paper exemplifies the shoddy state of thinking about psychoanalysis in psychiatry today.

Joseph A. Flaherty and Boris M. Astrachan write chapter 3 on social psychiatry.  This outlines how social issues and sociological discussion impact on psychiatry.  It includes epidemiology, substance use and abuse, violence, aggression and trauma, and breakdown of family bonds.  The simple message is that sociological issues are relevant to psychiatry.  The chapter contains no controversial claims.

Sidney Weissman writes on psychiatric diagnosis.  He explains how DSM-IV came to be as it is, and how we could improve our classification scheme.  The discussion is a little idiosyncratic.  It does not engage with other major discussions of psychiatric diagnosis.  Daniel Offer’s chapter on “Normality and the Boundaries of Psychiatry” is also eccentric.  This builds on previous work of Offer and Sabshin, and makes the basic point that psychiatrists are better at identifying abnormality than normality.  Studying normal coping methods and ways of living can be helpful to psychiatric practice.

Lois Flaherty’s “The Evolution of Psychiatric Subspecialities” ends this section of papers.  She points out that psychiatry has fewer subspecialities than other areas of medicine, and she suggests this may be due to the psychoanalytic ideal that practitioners should be able to master all psychopathology.  But given the modern pressures of clinical practice, it is inevitable that there will be increasing specialization, and the psychoanalytic idea is now less commonly shared.  Child psychiatry and geriatric psychiatry are the major specialities, but she also discusses clinical neurophysiology, forensic psychiatry, and other subfields, and the effect of increasing specialization on the whole field.  She provides a competent survey of issues.

In Chapter 7, Steven Hyman explains “The Role of Genetics and Molecular Biology in Research on Mental Illness.”  This is basically the information one would also find in a psychiatric textbook.  It is rather technical and only readers with a strong background in biology will be able to follow the details.  There’s very little discussion of the future of any of the wider implications of current research for the future of psychiatry. The chapter deals with a large topic, and so it’s inevitable that it cannot deal with all aspects of the issue, but given the theme of the book, it is still disappointing that the chapter does not venture into more speculation. 

Another chapter of great potential interest is “Functional Brain Imaging: Future Prospects for Clinical Practice,” by Joseph Callicott and Daniel Weinberger.  Neuroimaging has been one of the greatest areas of growth in modern psychiatry and there are often tantalizing announcements of new advances in the field.  The authors start by noting how few clinical applications have resulted from research so far.  The most common application is n the identification of structural pathology.  But the authors note that the structural abnormalities associated with the major mental illnesses are likely to be subtle, and they stress the difficulties of acquiring useful data when scanning people with major mental illnesses.  Given these concerns, they ask whether clinical functional neuroimaging is feasible.  They give a brief but technical summary of recent scientific progress in the field.  The upshot of the summary is that brain imaging cannot yet provide a diagnosis of a patient, but the authors remain optimistic that it will soon produce clinically useful results. New technology is developing that is less invasive, nonradioactive, and which can provide more fine-grained images.

The next section deals with the practice of psychiatry.  First to come under scrutiny is the use of practice guidelines, by John McIntyre, Deborah Zarin and Harold Pincus.  They assert that the APA (American Psychiatric Association) has “developed a rigorous process for the development of practice guidelines.”  (143).  The aim is to assist clinicians and patients in clinical decision-making.  These standards and options provided are not meant to be inviolable rules, but the authors say that exceptions to the recommendations “should be rare and require considerable justification.”  (143). 

            According to the authors, there are at least four reasons for the explosion in the development of practice guidelines in a wide range of professions. 

1. There has been an exponential growth in our knowledge base, and so it is very difficult to stay abreast of the latest developments, and it is hard to integrate all the data available. 
2. Health care costs have risen dramatically, and it has become necessary to contain expenditure.  Guidelines help to do this.
3. National guidelines help to minimize regional variation on treatment approaches.
4. The availability of guidelines helps patients and potential patients to be more involved in the decision-making process.

Recently in the health care profession, there has been more need for standardized guidelines, and the AMA has provided a series of principles to be followed in the development of guidelines.  The Institute of Medicine identified eight desiderata for guidelines: validity, reproducibility, clinical applicability, clinical flexibility, clarity, multidisciplinary process, scheduled review, and documentation.  (146)

There is also resistance to the use of guidelines.  Some have complained that they lead to a ‘cookbook’ approach to dealing with patients, and that they will limit innovations, as well as increasing professional liability exposure.  The authors suggest that guidelines should acknowledge their limitations, especially with regard to evidence, and this will leave room open for innovation. They also note that APA guidelines emphasize that they are not intended to serve as a standard of medical care, and that they do not ensure a successful outcome of treatment. They also say it is unclear what impact guidelines have on professional practice. 

The authors move on to setting out the APA guidelines for developing guidelines.  The eight stages are:

• Topic selection,
• Work group appointment,
• Evidence definition,
• Draft development,
• Review process,
• Dissemination and implementation,
• Evaluation, and
• Revision.

These are very much what one would expect.  The guidelines have the following format:

I.                    Executive Summary (with different recommendation weighted with its level of clinical confidence; substantial, moderate, or on the basis of individual circumstances)

II.                 Disease Definition, Epidemiology, and Natural History (which uses DSM-IV)

III.               Treatment Principles and Alternatives (three broad categories: psychiatric management, psychosocial interventions, and somatic interventions)

IV.              Formulation and Implementation of a Treatment Plan

V.                 Clinical Features Influencing Treatment

VI.              Research Directions

VII.            Individuals and Organizations That Submitted Comments

VIII.         References

Again, these are very much as one would expect.  The authors note that the development of guidelines has helped to identify gaps in psychiatric knowledge.  The APA is taking steps to fill those gaps.  It has formed the APA practice research network (PRN) to increase the communication between researchers and clinicians.  By 2000, it will have over 1000 APA members. 

Glen Gabbard writes an impressive chapter on “The Psychiatrist as Psychotherapist.”  He cites a wide range of data that demonstrate that psychotherapy is effective even with disorders identified as “disorders of the brain” such as schizophrenia and manic depression.  He emphasizes that it is important that psychiatrists continue to perform psychotherapy.  He expresses concern about the trend towards psychiatrists becoming merely dispensers of pills while other people with fewer qualifications do therapy.  He argues that not only does it improve the quality of treatment when it is one and the same person providing psychological and biological treatments, but also this approach can in the long term be the most cost-effective.  One of the major reasons for relapse of people with serious mental illnesses is that they stop taking their medication, and when psychiatrists are psychotherapists, patients tend to keep on taking their medication more than in other treatment circumstances.  While it may save money in the short term to get non-psychiatrists to do psychotherapy, this often turns out to be a false economy.  Of course, it seems likely that Gabbard’s warnings will go unheeded; managed care continues to divide treatment between different specialists, and most of the signs point toward psychiatrists having only one function, to prescribe medication.

            Maybe it is worth lamenting the fact that Gabbard has nothing to report on recent research on new forms of psychotherapy.  He takes it as given that we know the range of forms of psychotherapy that might be available, and while he acknowledges that some may be more appropriate for some kinds of disorders, Gabbard does not focus much on the differences between different kinds of psychotherapy.  One gets the impression that psychiatric research now has no interest in the idea of making psychotherapy better and improving its techniques. 

            The trend away from psychiatric psychotherapists might not alarm the author of the next chapter, Alan Schatzberg, who writes on “Psychopharmacology in the New Millennium.”  He surveys some of the medications that have come into use recently.  These are mostly approved for use as antidepressants, although they are used in a wide range of mental disorders.  The discussion is somewhat technical, depending on many terms from neuroscience, so it may be beyond the understanding of non-specialists.  He does discuss some of the new directions of research on psychopharmacology, but one can’t help keeping in mind that much of the research currently performed is confidential, since it is funded by corporations planning to make a profit from their research. 

            It is good that more attention is being paid to the efficacy of psychiatric medication with special populations, such as women and racial minorities.  It is a little disappointing that he did not mention the use of medication on children, even though such use of medication has increased significantly in recent decades and looks set to continue this upward trend.  Schatzberg emphasizes that the psychopharmacologist of the future will have to have even broader knowledge than before, but this is compatible with retaining an understanding of the whole person and a humanistic approach to mental disorders.  It is not clear, however, what steps the profession is taking to ensure that future researchers on brain processes do not lose sight of the persons who experience mental illnesses.

            Especially interesting is the division of labor between psychotherapy and medication in the treatment of mental disorders, and this is taken up by Mark Levy in “A Clinical Model for Selecting Psychotherapy or Pharmacotherapy.”  There have been some theoretical arguments that they are incompatible with each other, but no empirical evidence backs up such a view.  Indeed, evidence suggests that for many mental disorders, a combination of talk therapy and medication is most effective.  This still leaves us to explain why this is, and what kind of contribution to health each treatment modality makes.  Levy surveys various answers to this question, and also suggests some problems with those answers.  Some have argued, in a “two-track model,” that medication and psychotherapy treat different aspects of a mental disorder, but there’s little evidence to support this as a general thesis.  There are methodological problems too: it can be hard to separate out the effects of the two, since there are psychodynamic issues even in the interaction between a patient and the psychopharmacologist, and the medication can alter the course of psychotherapy.  The alternative to the two-track model is a unified model using an integrated approach, and Levy finds this has many advantages.  He points out that there is an important parallel in the discussion of the comparative benefits of different kinds of psychotherapy, and this leads him to a fascinating discussion of technical eclecticism versus theoretical integration.  He sets our various proposals about how to unify different approaches, and goes into detail in presenting a conceptual model for anticipatory anxiety.  His positive proposal is somewhat provisional and certainly it has elements that some will find problematic, but it merits investigation.  Even if his specific proposals do not win universal agreement, his discussion makes a strong case that these issues are at the center of the future of psychiatric theorizing.  Levy’s brief descriptions of some patients help to bring this point home. 

            In chapter 13, Donald Klein goes into related issues, explaining some of the technical details of trying to measure the effectiveness of psychotherapy compared with pharmacotherapy.  He emphasizes the difficulty of getting reliable data, because of the problem of creating a true pill placebo group.  He says that using studies of people on a wait list as a control group leads to positively biased estimates of efficacy.  He insists that a pill placebo case management control group is necessary in comparing pharmacotherapy with psychotherapy, and suggests that studies that have been performed without such a control group were a waste of time and money.  He is also skeptical about the value of meta-analyses of previous studies.  A 1990 study by Robinson et al. “demonstrated that the investigator’s alligiance may play an overriding role in determining differential treatment outcomes because partialling for allegiance removes any difference in effectiveness between studies.” (p. 227).  He concludes that it is difficult to prove the effectiveness of psychotherapy over placebo or to show any significant differences in different forms of psychotherapy.  Klein’s conclusion is that more careful work needs to be done in measuring the effectiveness of treatment.

The next two chapters have a good deal of overlap, although they have differences in approach.  Steven Sharfstein’s “Less Is More: Financing Mental Health Care for the New Century” details some of the major changes in the in the structuring of psychiatric treatment over the last century, and especially the rise in managed care companies.  His approach is to give a rather sweeping survey of major trends, and he gives only two references, one being the 1952 DSM, and the other being a 1983 APA report on “Madness and Government.”  In striking contrast, Jeremy Lazarus, discussing “Ethical Conduct of the Psychiatrist,” gives three pages of references; he focuses on how the rise in managed care introduces new ethical issues for psychiatrists.  Sharfstein suggests that a major issue is the fact that health insurance does not treat major mental illness and major physical illnesses equally, and lifetime limits on compensation tend to be much less for psychiatric treatment.  He also points out that often outpatient care, day hospital, and residential alternatives for major mental illness is more cost-effective than inpatient care.  For some reason he does not explain, he voices extreme optimism about the future of psychiatric care, saying that the remedicalization of psychiatry will lead to greater integration of mental health care with the rest of medicine, and this will ensure that there will be no more discrimination against the mentally ill.  The challenge for the future is to ensure that mental health care is regulated in an ethical manner, with humane treatment for the seriously ill.  Given that allocation of funds for different forms of health care is inevitable, which is to say that we cannot avoid rationing treatment, Sharfstein points out that the standard methods of cost containment and profit making – “risk selection, denial of care, and the dumping of the most seriously ill,” (247) – need the oversight of government to avoid the problematic policies this mentality can lead to.  He suggests that the APA needs work as an advocate in order to ensure the future excellence of psychiatric treatment. 

Lazarus takes up this point, writing, “The principal ethical question is how health care professionals either balance or integrate their responsibilities as patient advocates and members of society.” (252).  He echoes many of the Sharfstein’s concerns concerning managed care and his predictions about the integration of psychiatry with the rest of medicine.  There are potential ethical problems in the cost containment of managed care and the use of financial incentive for physicians to curtail the care they provide.  He says in the future there may be more ethical issues in the use of technology such as brain scans for diagnostic and treatment purposes, and also as we become increasingly able to use genetic engineering to influence people’s susceptibility to mental illness and to enhance their desirable character traits.  Other examples where psychiatrists may become involved in social issues include the treatment of prisoners condemned to death and of sexually violent predators – the primary problem here is the conflict between the responsibility to the patient and the responsibility to society. 

Psychiatric research on new treatments will continue to pose important ethical questions.  Other perennial issues include the question of when it is unethical for psychiatrists to have romantic or sexual relationships with patients or past-patients.  The question of how to deal with boundaries of the profession need continued attention.  As psychiatry becomes more ruled by the principles of commerce, there is a danger that ethical issues may be left aside, but obviously this is not an ethically allowable outcome.    Lazarus ends with a list of eleven guidelines for psychiatric ethics, which although verging on the platitudinous, are nevertheless important to keep in mind.

The next two chapters, dealing with the psychiatric workforce, focus on the role of immigrant physicians.  James H. Scully explains predictions that there will be a surplus of physicians in the near future, and how ways to deal with this surplus may affect psychiatry.  Some have suggested that the best plan is to reduce the number of immigrant students allowed to enter medical school.  This gives cause for concern in psychiatry, however, because international medical graduates (IMGs) because the psychiatric profession relies heavily on IMGs.  Richard Balon, Rodrigo Muñoz and Nyapati Rao take a stronger stance, pointing out not only how immigrants to the USA have contributed to psychiatric thought and research, but also that, “Poor, severely mentally ill, and minority patients have been and will continue to be treated predominantly by IMGs,” (298) and state categorically that “the United States cannot afford to reduce the number of IMGs in psychiatry.” 

Carolyn Robinowitz surveys the future of psychiatric education.  Her message is that the changes in psychiatry directly affect the knowledge and skills that future psychiatrists will need.  She predicts that the changes in the educational experience will be major, although it is hard to know exactly what they will be.  Certainly neuroscience will be an increasingly important part of psychiatry, but it will still be necessary to use a variety of treatments apart from medication.  It is likely that there will be less training in hospital settings.  Computers and the Internet will have a large effect on how psychiatrists in training get their information and how their abilities are measured.  Maybe the most significant point that Robinowitz makes concerns the level of job-satisfaction of psychiatrists.  She says that many middle-aged and older teachers are dissatisfied, and they communicate this to medical students, making psychiatry a less attractive choice for many students.  This will mean that there will be increased reliance on international medical graduates.  It is important to continue to put energy into faculty development and retention as well as recruitment if psychiatry is to be a vital field.

The book ends with two chapters on the future of psychiatry.  They recap much of the information and many of the ideas of previous chapters.  Steven Mirin engages in “Predictions About the Financing and Delivery of Care.”  He says that mental health care costs have risen for individual services, and the use of these services has also increased.  Managed care organizations (MCOs) have become more prevalent, and they have introduced policies to deal with these rising costs.  This has had significant impact on clinicians, hospitals, and patients, and it will continue to do so.  It is likely that hospitals will have a reduced role in the provision of mental health care, and many hospitals will have to fight for their survival.  Furthermore, psychotherapists and providers of other psychosocial treatments will have to fight against financial pressures to reduce their availability to patients. 

One of the distinctive ideas mentioned by Melvin Sahshin is the role of theory in psychiatry.  He suggests that psychiatry will move away from its current atheoretical tendency to a more theoretical approach grounded in evidence, as the evidence becomes available and it becomes more feasible to formulate testable hypotheses.  He also suggests that there will be a gradual reduction in the stigma associated with mental illness. 

In sum, Psychiatry in the New Millennium provides a broad overview from a mainstream perspective of the current state of psychiatry.  Naturally, some chapters are more thoughtful or careful than others, and there are some differences of opinion between authors, especially concerning the effectiveness of psychotherapy and the role of psychiatrists in providing psychotherapy.  There is a fair amount of overlap of information in different chapters, and the editors could have done more to divide up the topics between different authors, maybe reducing the size of the book a little.  Nevertheless, most of the chapters provide useful surveys of their topics, and I recommend this book to those looking for an inside look at the primary concerns of the leaders of American psychiatry.

© 2001 Christian Perring. First Serial Rights.