Entering Psychiatry in This New Era: Existential Questions

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PSYCHIATRIC VIEWS ON THE DAILY NEWS

Introduction by H. Steven Moffic, MD

As my colleagues and I debate and process the evolving adverse mental health impacts of our government’s new policies and orders, it is easy to ignore its impact on psychiatric residents and others early in their career. That certainly is not the case with Solomiya Tsymbalyuk, MD, and her supervisor Steven Sharfstein, MD. Dr Sharfstein is one of the great psychiatrists of our time and personally has done much to address our challenges over the decades, including pointing out how much psychiatry had become too bio-bio-bio. This column is anything but that. Dr Tsymbalyuk reminds us of the concerns of our upcoming graduates, along with our collegial and educational responsibility to guide them during this transition. By recognizing and analyzing the wider problems and challenges in psychiatry and society, it would not be surprising if she—and this column—turned out to be part of the solutions. There is no learned helplessness here. Rather, it is an inspiring ethical endeavor to improve the mental health of our communities.

When deciding on a career in psychiatry, I was moved by how recently psychotropic medications revolutionized psychiatric care. It seemed that the growing societal recognition of the importance of mental health and renewed scientific interest in the field promised advancements to expand our understanding of psychiatric illness and offer more targeted treatments, further transforming our field.

I chose to do my residency training in Baltimore knowing that my program prioritizes providing high-quality, ethical care to those with serious mental illnesses in underserved communities. As I approach graduation, I feel secure in my knowledge base, but I have growing doubts about the future of psychiatry, particularly for this patient population. Signaling from our nation’s leaders indicates skepticism about the validity and value of psychiatry.

The American Psychiatric Association’s (APA) Principles of Medical Ethics (PME) describes the responsibility of all physicians to contribute “to the improvement of the community and the betterment of public health.”¹ The recently issued federal policy changes related to federal spending, medical sciences, diversity and inclusion, and immigration enforcement pose new challenges for psychiatrists attempting to navigate providing ethical care while in compliance with these orders. As an early career psychiatrist, I am left wondering whether my training has prepared me to practice in the uncertainty that is to come.

Proposed Spending Cuts

The overwhelming majority of patients I have treated in training, both outpatient and inpatient, are insured by Medicaid. The proposed federal spending cuts passed by the House in February of 2025 risk cutting Medicaid coverage to millions of individuals.² Substantial cuts to this program will disproportionately affect individuals who are low-income, have disabilities, and have mental illnesses, and they already face significant barriers in accessing health care. It is unclear how community clinics can continue to serve these patients without reimbursement for these services.

As someone interested in community psychiatry, I have been fortunate to be part of assertive community treatment (ACT) teams and organizations like Healthcare for the Homeless, both of which rely heavily on government funding. I worry whether there will be enough public support through Medicaid or other funding for me to have a sustainable job in a community health center or an ACT team. Is it ethical for psychiatrists to respond to these threats by further entrenching ourselves in the treatment of the middle and upper classes and turning away from those most in need?

Psychotropic Medications

As our public leaders question the “threat” posed by psychotropic medications and the “integrity” and “methodological rigor” of scientific study,³ it becomes increasingly unclear whether I will be basing my treatment decisions on our field’s best practices, as I have been taught. It remains to be seen whether our leaders’ doubts about psychotropics will translate into any medication bans, stricter medication monitoring, or other concrete measures to limit psychotropic use, or how such measures would even be enforced. However, the effects of this public scrutiny of science and psychiatry are more insidious than the practical considerations, worsening the stigmatization of mental health and further complicating the treatment relationship between patients and providers.

Diversity, Equity, and Inclusion

My training has emphasized the APA’s core guidelines that a psychiatrist “should not be a party to any type of policy that excludes, segregates, or demeans the dignity of any patient because of ethnic origin, race, sex, creed, age, socioeconomic status, or sexual orientation.”¹ Various social determinants of mental health, such as discrimination, social exclusion, low educational attainment, and underemployment are underpinned by the unequal and unjust distribution of opportunity, which are driven by public policies and social norms.⁴ How can I continue to address these determinants of mental health despite policies attempting to restrict the discussion of these topics?

Immigration Customs and Enforcement

With the recent expansion of US Immigration and Customs Enforcement’s (ICE) jurisdiction to include hospitals, physicians are now more likely to encounter ICE. Despite this, guidance from lawmakers, institutions, and professional societies on how to navigate these encounters is limited, with no mention of cases in which the patient is in ICE custody. However, at my hospital, psychiatry has already been asked evaluate patients in ICE custody and to comment on these patients’ safety to return to ICE detention centers.⁵ Without any knowledge of staffing conditions and safety provisions at ICE facilities, it becomes difficult to comment on patients’ safety at these centers. In the case of someone presenting at an increased risk of suicide while in ICE custody, I have been taught to favor inpatient admission as the next step, but is admission a viable option in this scenario?

Concluding Thoughts

Section 3 of the APA PME states that a physician “shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.”¹ These new federal guidelines call for a clear, unified response from mental health professionals advocating for our patients and in defense of the value of this field.

Dr Tsymbalyuk is a fourth-year psychiatry resident at the University of Maryland/Sheppard Pratt Psychiatry Residency Program in Baltimore, MD.

This column represents her personal views, not the views of the organizations with which she is affiliated.

Acknowledgement: Dr Tsymbalyuk would like to thank Steven Sharfstein, MD, whose expertise and mentorship throughout the Mental Health Policy Elective was instrumental in shaping this paper.

Dr Moffic is an award-winning psychiatrist who specialized in the cultural and ethical aspects of psychiatry and is now in retirement and retirement as a private pro bono community psychiatrist. A prolific writer and speaker, he has done a weekday column titled “Psychiatric Views on the Daily News” and a weekly video, “Psychiatry & Society,” since the COVID-19 pandemic emerged. He was chosen to receive the 2024 Abraham Halpern Humanitarian Award from the American Association for Social Psychiatry. Previously, he received the Administrative Award in 2016 from the American Psychiatric Association, the one-time designation of being a Hero of Public Psychiatry from the Speaker of the Assembly of the APA in 2002, and the Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill in 1991. He presented the third Rabbi Jeffrey B. Stiffman lecture at Congregation Shaare Emeth in St. Louis on Sunday, May 19, 2024. He is an advocate and activist for mental health issues related to climate instability, physician burnout, and xenophobia. He is now editing the final book in a 4-volume series on religions and psychiatry for Springer: Islamophobia, anti-Semitism, Christianity, and now The Eastern Religions, and Spirituality. He serves on the Editorial Board of Psychiatric Times.

References

1. American Psychiatric Association. Principles of Medical Ethics: With Annotations Especially Applicable to Psychiatry. 2013. Accessed March 20, 2025. https://www.psychiatry.org/getmedia/3fe5eae9-3df9-4561-a070-84a009c6c4a6/2013-APA-Principles-of-Medical-Ethics.pdf

2. Lovelace B Jr. Medicaid coverage at risk as Congress considers budget cuts. NBC News. February 28, 2025. Accessed March 20, 2025. https://www.nbcnews.com/health/health-news/medicaid-cover-congress-proposed-budget-cuts-felt-rcna193897

3. Trump DJ. Establishing the President's Make America Healthy Again Commission. February 13, 2025. Accessed March 20, 2025. https://www.whitehouse.gov/presidential-actions/2025/02/establishing-the-presidents-make-america-healthy-again-commission/

4. Shim RS, Compton MT. The social determinants of mental health: psychiatrists' roles in addressing discrimination and food insecurity. Focus (Am Psychiatr Publ). 2020;18(1):25-30.

5. Tsymbalyuk S. Psychiatrists and other physicians interfacing with ICE: legal and ethical challenges. Psychiatr Serv. In press.