Psychiatry in the New Millennium
As the year 2000 has approached, many enterprises have found it appropriate to take stock of where they are and where they are going. This is certainly true of psychiatry, and Drs. Weissman, Sabshin, and Eist have assembled an eminent group of colleagues to summarize the present state of the profession and what the future may hold for it.
The book consists of four sections. Joseph Coyle begins the first, The Discipline of Psychiatry, with an account of the profound effects—some hopeful, some questionable—that the neuroscience revolution has had on psychiatry through discoveries in genetics, molecular biology, and brain imaging. Sidney Weissman follows with a statement of what he conceives to be the core values of psychoanalysis, derived primarily from Freud and Kohut, and how they may carry over into the next century. Joseph Flaherty and Boris Astrachan then delineate the reasons for the current downgrading of social psychiatry and offer hope for its resurgence.
Weissman cogently discusses the strengths and weaknesses of DSM-IV and proposes three new axes to add meaning and help in treatment planning. This suggestion, though stimulating, seems somewhat quixotic. Daniel Offer, rather surprisingly, invests the prosaic subject of normality with considerable interest by showing how different definitions of normality rely on contrasting biological and psychopathological views of psychiatric conditions and how they can be used by health maintenance organizations to their own advantage. Lois Flaherty shows how the decline in the dominant generalist view of psychoanalysis and the movement toward diversity has led to a rise in psychiatric subspecialties, with both positive and negative consequences.
The impact of research findings on the shape of psychiatry is dealt with in two chapters, one by Steven Hyman on the role of genetics and molecular biology in research on mental illness, the other by Joseph Callicott and Daniel Weinberger on functional brain imaging. These detailed and informative chapters offer hopeful prospects for psychiatry, but the authors are also honest enough to acknowledge that we still lack any reliable biological marker for major disorders and that brain imaging is not yet a significant aid for specific psychiatric diagnosis and treatment.
The second section, The Practice of Psychiatry, opens with a chapter on practice guidelines in psychiatry by John McIntyre, Deborah Zarin, and Harold Pincus. It presents an account of the pros and cons of guidelines in general and describes how the American Psychiatric Association has gone about organizing those guidelines. No mention is made of the protests of psychotherapeutic organizations against what they regard as an excessively biological approach in the guideline on panic disorders.
In "The Psychiatrist as Psychotherapist," Glen Gabbard mounts an almost impassioned defense of psychotherapy as the defining core of psychiatry, now threatened by the emphasis on biological psychiatry but apparently fighting back. He makes a case for the positive effects of adding psychotherapy to drug treatment for many psychiatric disorders. As a minor point, however, I must say that I was shocked—shocked!—by Gabbard's attribution of the origin of interpersonal therapy to Adolf Meyer rather than to Harry Stack Sullivan. In a chapter on psychopharmacology, Alan Schatzberg, using depression as a model, summarizes current pharmacological approaches while tossing something of a ritualistic bone to psychotherapy.
On the question of how to decide whether to select psychotherapy or pharmacotherapy in a particular case, Mark Levey points out that the decision can be made either by seeing each modality as indicated for different aspects of the patient's problems or by making both modalities part of an integrated treatment plan in which each has its place. He favors the latter course. This thoughtful chapter emphasizes the importance clinically, practically, politically, and ideologically of the vexed relationship between psychotherapy and pharmacotherapy, and it is relevant to the next chapter by Donald Klein, who surveys data on outcome studies of psychotherapy versus pharmacotherapy. Klein is skeptical about the value of many studies that support psychotherapy, a position contrasting with Gabbard's. Klein feels that outcome studies need to be collaboratively carried out by a psychotherapist and a pharmacologist, always with the use of a pill placebo control.
In the next chapter, Steven Sharfstein traces the path of the financing of mental health care from state to federal and now to managed care organizations, as each tries to avoid the expense of caring for the mentally ill, with clearly deleterious effects. Sharfstein believes the long-range solution is universal health care, with psychiatry fully integrated and not discriminated against.
In his chapter on ethical issues, Jeremy Lazarus emphasizes how the changing scene in psychiatry is responsible for new problems posed by such issues as accountability requirements, genetic engineering, and questions of divided loyalty. Psychiatrists, especially, must decide, under economic constraints, whether to continue to rely totally on the welfare of their individual patients in their ethical reasoning rather than include consideration of what's good for the population as a whole.
The third section, on the psychiatric workforce and education, begins with a chapter by James Scully describing the implications for psychiatry of the shift from an undersupply to an oversupply of physicians, with an emphasis on generalists rather than specialists. The declining domestic availability of psychiatrists along with the increasing threat to the supply of international medical graduates endangers the filling of psychiatric residencies and psychiatric care generally. Scully's rather dark tone is intensified by the concern expressed in the following chapter on international medical graduates by Richard Balon, Roderigo Munoz, and Nyapati Roa as they describe the contributions of these physicians to American psychiatry—they constitute 25 percent of APA—and to the American public.
In her chapter on psychiatric education for the new millennium, Carolyn Robinowitz describes the daunting task for psychiatric residency training of accommodating itself to a veritable sea change in the long-established paradigms of training, given a diminished psychiatric workforce and uncertain future but a still-urgent need to maintain the common integrated core identity for the profession.
The fourth and final section, on the future, contains chapters by the present and immediate past medical directors of APA. The current director, Steven Mirin, describes the "dramatic and unwelcome" effects on hospitals and patients resulting from the ascendancy of managed care organizations. He describes some of these consequences and offers ameliorative suggestions in a rather bleak forecast. Finally, from his broad perspective, Melvin Sabshin revisits many of the themes considered in the other chapters in the book and urges a continuing fight against the stigma still attached to patients with mental disorders.
What, then, can the reader of this book conclude about the state of American psychiatry at the millennium? A broadly hopeful view can be projected in light of the many current and forthcoming scientific advances materially aiding diagnosis and treatment of patients. But this perspective is counterbalanced by other factors: by the chilling effect that the increasing "biologization" and medicalization of psychiatry is having on psychotherapy, seen by some as the defining signature of psychiatry; by the economic constraints of managed care on all modalities of treatment; and by the decreasing popularity of the specialty among American medical students.
Psychiatry in the New Millennium is not encyclopedic. It gives short shrift to some topics, like the grave problems of deinstitutionalization, and neglects others, like forensic psychiatry. However, it is comprehensive, the chapters are generally of a high quality, and the editors have done a good job. It can be highly recommended to all American psychiatrists.
Dr. Chodoff is clinical professor of psychiatry at George Washington University in Washington, D.C., and is in private practice.
