Jon Jureidini: Time to rethink psychiatry?

A RECENT article in the New York Times reported the plight of a Philadelphia psychiatrist “forced” by insurance regulators to see 40 patients a day, mostly in 15-minute appointments to adjust medications.

The sad psychiatrist felt obliged to say to his patients, “I am not your therapist”, reporting that he had to train himself “not to get too interested in their problems”. Insurance companies in the United States will not support psychiatrists to  practise psychotherapy, because there is no evidence that they do it better than a less expensive health professional.

Through Medicare and less expensive medical education, patients and psychiatrists in Australia are protected from the US predicament.

But we do need to ask whether, and when, it is justified for the taxpayer to fund the additional cost for patients to see a psychiatrist rather than a less expensive therapist, a general practitioner, or no one at all.

What do we psychiatrists have to offer our patients therapeutically? We have a huge choice of brands of medication but few different categories of drugs, and there has been no telling advance in psychopharmacology for decades.

If we exclude the benefits of the therapeutic relationship between prescriber and patient, most of these drugs do little more than take the edge off suffering. While this reduction in pain is a benefit, it hardly justifies our professional identity.

If you listen to opinion leaders in the field, our society experiences an overwhelming burden of psychiatric disability. There are two groups of potential patients for psychiatrists:

• A core of 1%–2% of Australians who are intermittently or permanently crippled by severe psychosis, mania, fear or melancholy.
• A further 20%–25% of Australians who at some point in a 12-month period meet criteria on population surveys for at least one of many available psychiatric diagnoses, including alcohol misuse.

The first group does require expert mental health intervention. Many in the second group don’t even acknowledge a problem and, if they do, it often resolves without medical intervention. Many want no medical attention anyway.

Unfortunately, in public pronouncements on psychiatry, the second group is often conflated with the first, as in claims that hundreds of thousands of young Australians are currently locked out of the mental health care that they desperately need. This exaggerates the needs of the second group while deflecting attention from the unmet needs of the first.

Psychiatrists working one to one with the second group must face up to the fact that we have no good evidence that we get better outcomes than our less expensive colleagues. Eventually, regulators will become intolerant of forking out for us to do this work.

We must rethink our therapeutic orientation. We should:

• re-invest in the total care of severely ill patients, facilitating and providing a secure and ongoing therapeutic relationship with patients and their families rather than just medicating
• energetically advocate for social needs including housing
• invest in working with GPs who, if adequately supported, provide better, more immediate and sustained treatment for high prevalence disorders
• strengthen consultation/liaison work where we can make dramatic contributions to the wellbeing of medically ill patients.

Do we psychiatrists bring something to these tasks that justifies our expense? I think so.

Our medical training equips us to maintain equanimity and good judgement in the context of trauma, cruelty, despair and death. Compared with other mental health professionals, we might be more able to help our patients to develop coherent and cohesive stories about their complex and confusing experiences.

We must do a better job of demonstrating and articulating these special skills. Neither reaching for a prescription pad nor proselytising for a mental health explanation for all human suffering will do as an alternative.

The future of our profession depends on demonstrating that we can bring something unique to the therapeutic relationship with the most damaged patients.

Professor Jon Jureidini is head of the department of psychological medicine, Women’s and Children’s Hospital, Adelaide, senior research fellow in the department of philosophy, Flinders University, and professor in the disciplines of psychiatry and paediatrics at the University of Adelaide.

Posted 11 April 2011

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