Dr Robert London

Perspective: Can This Specialty Be Saved?

Perspective: Can This Specialty Be Saved? (March 31, 2011)

About 2 years ago, a friend took his adolescent daughter to a psychiatrist. During that first-ever visit, they both were stunned by the psychiatrist’s first question, which was: "Tell me, when was the last time I saw you?"

Our beloved specialty is in crisis.

It hasn’t always been this way. Psychiatry used to be a specialty known for its ability to combine medicine and humanism. During my residency, we monitored and assessed medication efficacy, sent patients for routine blood tests, measured lithium levels, assessed for tardive dyskinesia, and aimed to understand mind/body interfaces. We also formulated a talk therapy to suit particular patients, and actually spent time with them. The talking therapy ranged from analytic, interpersonal, goal-oriented, rational emotive, or a host of other models. We got to know our patients within the context of their lives.

Today, much of psychiatry has moved to 15-minute per patient medication-management routines dominated by managed care. I was dismayed to read the recent New York Times article in which the featured psychiatrist told patients that he was not there to hear about personal crises, including serious family stressors. His brief visits with patients allow him to treat 1,200 people a month for "prescription adjustments," according to the article ["Talk Doesn’t Pay, So Psychiatry Turns to Drug Therapy," March 6, 2011, p. 1].

Against this backdrop, we’re seeing more and more of our patients getting care from primary care physicians who might be seeing 30 to 40 people a day for a myriad of medical problems, including upper respiratory infections, joint pain, GI upsets, and various infectious diseases. As I’ve said before, primary care physicians are well intentioned, and I hold them in the highest regard. But how can they have the depth of knowledge that we bring to caring for patients with mental illness after possibly only taking a weekend course here and there in prescribing psychiatric medications?

Between psychiatrists giving patients 15 minutes and primary care physicians practicing in an area of medicine for which they are not trained, the biggest loser is the psychiatric patient. In many cases, a nonmedical therapist might be part of the patient’s treatment, all to the good, I suppose. However, all too often, prescribers and therapists are not in communication. Although the existence of dual or split therapy might ease the conscience of the prescriber, there are no rules or regulations out there dictating that the two providers be in contact.

Thankfully, 15-minute medication visits are not the rule for all psychiatrists with expertise in psychopharmacology. Recently, I spoke with Dr. Maureen Goldman, a New York City psychiatrist who specializes in psychopharmacology, and she is quite clear: Spending 15-20 minutes every 4-6 weeks with psychiatric patients is the wrong way to manage medications. She spends at least 45 minutes with each patient and that time allows her to evaluate and monitor the medications as well as see patients in the context of their lives – whether or not they are also seeing a therapist.

"I won’t compromise good care and solid medical standards at the dictates of insurance companies that are doing what’s best for them financially rather than what’s best for the patient," she said in an interview. "Symptoms without context are meaningless. We need to view the whole person in an adequate time frame to understand the changing patterns of their illnesses and their lives."

Of course, modern medications have been of great help to so many patients needing psychiatric care, and if we turned the clock back to before the 1950s – before any meaningful psychiatric medications were available – we would realize how little we offered patients in those days. Nevertheless, even with today’s great advances in psychiatric medications developed by "big pharma," they are far from 100% effective. Often, sedation passes for treatment. This is especially true when a medication is not working particularly well and additional medications, one on top of the other, are added whether by psychiatrists or primary care physicians.

It is time for organized psychiatry to take a stand. Public awareness needs to be raised so that people understand that there are many treatment approaches within the talk therapy armamentarium, which includes various cognitive-behavioral therapies, behavior modification techniques, and hypnosis/relaxation therapies. They must understand that many of these approaches have a beginning, middle, and end, can be codified, and are as effective as medication management.

Organized psychiatry also must come to grips with insurers, which simply want to pay for medical management. Such a shift must begin in training programs, where currently in a 4-year residency, the main approach in the talk therapies continues to be the open-ended psychodynamic approaches, according to recent graduates of residency programs I’ve interviewed.

Just as pharmaceutical companies dedicate resources to getting the message out about what their medications have to offer, organized psychiatry and their patient advocacy groups need to find their voice. Organizations such as the American Heart Association and the American Cancer Society have found ways to get the word out through public awareness campaigns. We need to make similar moves in this direction. Perhaps demystifying our specialty will be a step toward destigmatizing our patients – and saving our specialty from insurers and from itself.

Dr. London, a psychiatrist at NYU Langone Medical Center, New York, has no disclosures. He can be reached at cpnews@elsevier.com.