more_vert
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
Thanks. It’s disappointing to see the explosion of services for the acopic… Noting our university student mental health service deliberately only provides services for those with the resources to help themselves! It has nothing for the seriously mentally ill students, they get referred to standard public resources… The seriously mentally ill are ignored at the expense of the worried well. Similarly new initiatives like Head to Health here in Adelaide are for those with life difficulties, there’s no psychiatrist onsite, the assumption is that the people presenting are the acopic and anyone with a serious mental illness will be sent to the ED for a real psychiatric assessment. Encouraging anyone and everyone to construct their difficulties in terms of mental illness has not served them or the community well, and given the neglect of the seriously ill, the focus on the lesser affected is inappropriate at best. Plus the elephant in the room… The inappropriate medicalisation of suicide, the absence of an evidence based for conventional responses like hospital admission, let alone involuntary treatment, for suicidal ideation, which chews up masses of resources which could otherwise be targeted to the seriously psychotic, our local ED has very little to offer suicidal patients and I think we need to tell people exactly how little we have to offer them. Either society chooses to provide more treatment resources for the suicidal or we are transparent with how little we have to offer someone. The farce of suicide risk assessments which are little better than chance…
I know Jon and he has always been an iconoclast. Most times I agree with his views. On this occasion I have to wonder what he means by ‘most damaged patients?’ Most of the patients referred to me are anxious to get off all the psychotropic drugs they have been put on. Those who have EBM diagnoses of psychoses I leave them on their medications or adjust as required. The others who are not necessarily ‘walking well’ by any means, work very hard within the framework of my psychological approaches to achieve a greater sense of well-being. I think I can say the majority leave me feeling better than when they came.
Whilst the Professor poses valid questions, they need to be asked in the context of valid data on the burden of psychiatric illness in the community. I doubt that we have that data and dismissing the disease burden in the estimated 20-25% of the population as the “worried well”, “many of whom don’t want help anyway”, minimises the suffering and havoc that this group can wreak in the community. To say that there has been no advances in psychopharmacology is to ignore the significant differences in therapeutic agents that can markedly affect an individual’s quality of life with respect to side-effects such as impotence, sedation, or obesity, for example, and differences about which many non-specialists (and some specialists, it seems) are ignorant.
As a physician, a large proportion of the patients I see (at least 25%) have some sort of chronic mental problem that has not been adequately dealt with, and has the potential affect compliance and aggravate their symptoms in some way.
I would say the issue the Professor is grappling with needs to restated as one of rationing: resources are inadequate so only the most severe cases can be cared for by psychiatrists on the public purse. We also need better data on the prevalence of psychiatric disease it seems. Also, it would seem that psychiatry is still well behind on the preventative aspects of its specialty; for example, it is only recently that I have heard of people like Gordon Parker from the Black Dog Institute talking about the “Science of Happiness”. If “regulators” have a role, it would be adequately fund the time needed to look after these patients properly.
BTW @ DTK: specialists in Australia, on the whole, are much better trained and more highly qualified but earn much less than any lawyer; and usually get better results.
A problem not mentioned by Dr Jureidini is that Joe Citizen does not see a general practitioner as a source of psychiatric help let alone psychotherapy other than a flawed form of crisis intervention. I believe this is because the public have been subjected to years of intense indoctrination by governments, psychiatry, psychology and other allied health professionals that, for mental health problems, the average GP does not have sufficient training or time to deal with their problems. This is the first issue with which an insightful GP has to deal before being able to pay some attention to the reason for presentation. The second issue is payment; many patients seeking “psychotherapy” have a Health Care Card and feel this entitles them to be bulk-billed and, if one is going to be able to help them achieve any progress, it is often better to go along with their demand. In any case, the schedule fee for items 36 and 44 on the MBS are so low that (a) the patient is more out of pocket seeing a GP than a psychiatrist or Allied Health Professional, and (b) given that two or three patients out of 10 don’t turn up anyway, one can provide a quality service and yet be a financial failure.
If the GP psychothapist is to provide for her/his retirement he has to choose between living life out on the pension or returning to the world of 10-minute consultations where the rewards are better and no questions are asked about his practice habits.
Jurendi has exposed the vulnerability of resource allocation for Australian model for mental health care.
The worried well, with mild to moderate mental health problems consume the majority of the mental health budget, attending psychiatrists, psychologists in private practice, and having the luxury of private hospital beds on demand. A cosy arrangement for both parties.
As Jurendi explains, they could be as well cared for by their grandmothers, with help form the community nurse and GP with similar outcomes.
The truly sick psychotic patients scramble for tight public beds, treated by registrars, interns and the few remaining public psychiatrists, all under stress with a restrained budget, inadequate beds,and a system in constant crisis. They also are forced to deal with the personality disordered patients, no mental illness, threatening mayhem, feigning suicide, and getting admitted as a risk management strategy.
We don’t need any more money for mental health, it just needs better distribution, going where it will get the best value, treating those where evidence shows benefit.
“What do we psychiatrists have to offer our patients therapeutically?”
I would suggest that the answer is: the same as any other medical consultant – sophisticated diagnostic and therapeutic skills, based on advanced training and experience. Like any other specialist, the psychiatrist has a “concentrated” experience within their own area – cases that present rarely in general practice are better recognised by someone with specialist experience. Likewise, one would have concentrated experience of the therapies and their associated evidence, be up to date with current research and accepted practice etc, etc. On this basis, a specialist would assess a complex patient, make or refine a diagnosis, advise on therapy and review as required. The primary care doctor would liaise with the specialist, prescribe medication, assess progress, manage intercurrent issues, conduct psychotherapy if they were skilled at it and refer as required. Why would that model be any different for psychiatry?
This article is spot on. Turning every minor stress into a “mental health problem” suits those who want to boost their funding and egos but does not help those who have actual mental health illness. This small but still significant group miss out due to the worried and stressed well who need help to cope with not getting that promotion. The so called “advances” in medications owe much more to marketing than science.
Well !!
“there has been no telling advance in psychopharmacology for decades.”
So are we wasting our time with all those new drugs, and just go back to the barbiturates
Peter Elliott
Prof Jureidini is to be congratulated for his thoughtful and indeed socially responsible article. My only disappointment is when listing what “We should:” do, he did not list liaison and referral to psychologists and counsellors. A GP in a usual 15-20 minute consultation can for “high prevalence disorders” prescibe and monitor medication but does not have sufficient time to offer therapy. There are too few GPs in most regions of Australia for them to be able to offer longer sessions. “Better access to mental health care” is a worthwhile scheme which allows lower cost access to psychologists. The medical profession needs to acknowledge more widely the contributions of other health professionals in the area of mental health and make appropriate referrals.
I think the big difference with the US is the pay differences aren’t as great. The MBS rebates for clinical psychologists are lower, but of the order of 20%. Both professionals rarely bulk-bill.
If a patient has both medications and psychotherapy, they are ahead financially seeing a psychiatrist-psychotherapist, if they are lucky enough to find one.
It seems Dr Jureidini is more philosophical than psychological; the article sounds nice but what does it mean? No mention of addressing suicide nor of improving emergency mental health facilities. Come down out of your academic ivory tower, Jon, and see the forest.
Thank you for your article on rethinking psychiatry. One possible way of making psychotherapeutic services from suitably qualified psychiatrists available to a larger segment of the community without increasing costs to Medicare is to cap the fee charged for a 50-minute session. Some members of this caring profession are now charging around $350 per session. The Medicare safety net protects patients from bearing the major burden of these costs, thus providing ‘carte blanche’ to those who will charge what the market (and Medicare) can bear. Lawyers’ hourly rates actually start at about the same amount, thus pricing legal services out of reach of many who require legal advice. The question arises as to why the medical profession should not be on par with the legal profession in fee setting, but do two wrongs make a right?