New Directions in Psychiatry

[[{"type":"media","view_mode":"media_crop","fid":"22570","attributes":{"alt":"","class":"media-image media-image-right","height":"186","id":"media_crop_1433478246362","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"1645","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"margin: 5px; float: right;","title":" ","typeof":"foaf:Image","width":"126"}}]]It is important to appreciate and understand the current problems and significant limitations of the present approach to psychiatric therapy before considering new directions. The largest problem is that while there is ample evidence of the limited long-term benefit of psychiatric medications, psychiatrists are pressured to be psychopharmacologists instead of psychotherapists. Psychiatrists are influenced by the pharmaceutical industry, which makes enormous profits from psychiatric drugs. In addition, psychiatrists are under pressure by insurance companies that pay more for 15-minute medication checks than for effective psychotherapy treatments.

Telemedicine has been used successfully for psychotherapy, yet many programs stress evaluation and medication management. At the same time, psychiatrists are not providing care using treatments for which significant progress is being made, such as cognitive processing therapy, eye movement desensitization and reprocessing, mindfulness-based therapy, and short-term psychodynamic psychotherapy, to name a few.^1-4

Research on pharmaceuticals over the past 20 years clearly demonstrates the limited benefits of medications, particularly in the long term; there is growing concern that the harm is likely to outweigh the benefits. Even for short-term depression therapy, STAR*D findings suggest that only about 30% of patients have complete depression symptom remission with active treatment.⁵ The CATIE trials showed that overall improvement in therapeutic benefit with new-generation neuroleptics is minimal compared with older drugs and that significant symptom remission appears to be a very difficult therapeutic target.⁶

Recent research on the pharmacotherapy for ADHD shows that the initial results fade over time and that the medications may do more harm than good.^7,8 Recent research on benzodiazepines and new hypnotics suggests that they may increase mortality as much as smoking cigarettes.⁹ It has been known for a long time that the mortality rate in patients with schizophrenia far exceeds that of the unaffected population. Dose reduction or discontinuation of antipsychotics during the early stages of remitted first-episode psychosis achieves long-term recovery rates superior to those achieved with maintenance therapy.¹⁰ This finding clearly goes against recommendations that schizophrenic patients have to continue taking medications long-term to prevent relapse. While there are some medications that have a role, such as carefully supervised lithium therapy for bipolar disorder, basing the future practice of psychiatry on medications is a folly.¹¹

New directions
Psychiatric practices tend to be referral-based. The initial diagnosis is made by a primary care physician (PCP), and patients have already undergone 2 or 3 medication trials before they are referred to a psychiatrist. As such, the chances that the patient will respond to medications decreases. Many patients are in the 50% subgroup who do not respond adequately to medications. When the psychiatrist sees these patients, he or she needs to determine-often in a single visit-whether there have been adequate medication trials, whether other diagnoses have been missed, and whether medical or nutritional issues are affecting treatment. The psychiatrist’s training and experience are often needed, as well as time and financial support, to address complex cases.

In developing new directions, it is important to first “do no harm.” If possible, we must focus on finding more effective, less harmful therapies than medications. For example, exercise may work as an antidepressant for some patients.¹² Exercise has risks, but it also has many health benefits. Using motivational therapies to assist patients in making changes we know to be effective can provide significant health benefits and might replace ineffective medications in treatment-recalcitrant patients.¹³

Redirecting research
The current practice of psychiatry is so focused on medications that other potential approaches have been neglected. Nutrition, for example, has not been a significant aspect of psychiatry and yet people who eat a Mediterranean diet or greater amounts of fruits and vegetables have been shown to have significantly less depression than a comparative population of those who eat a standard diet.^14,15 Further research is needed to explore potential approaches to psychiatric treatment, other than medications.

The best research can only give us a general direction. It does not tell us what to do when treating each patient. Even with a simple, straightforward case, the patient’s general medical condition, motivation, family support, basic belief systems, and culture must all be considered. Diagnostic possibilities, previous therapy and outcomes, efficacy of potential treatments, timing and implementation of treatment, immediate adverse effects, and long-term risk of therapy, as well as the therapeutic skill of the physician in managing the follow-up care, must all be considered.

We can guard against making mistakes by changing the culture of psychiatric practice. Instead of focusing on medication, in-depth comprehensive assessments might be more beneficial. The patient-physician discussion can be oriented so that the patient understands the need for a thorough evaluation, the results of which will guide therapeutic recommendations.

New models of care
Given the limitations of some of our current treatments and the opportunities for new directions, it is imperative that we expand our therapeutic skills to include new treatment models. The Affordable Care Act and new, innovative services in Canada provide a unique opportunity to change direction and influence care in a positive way.

On January 1, 2014, the Patient Protection and Affordable Care Act went into effect, dramatically expanding coverage for psychiatry and behavioral health.¹⁴ No longer are health plans allowed to limit psychiatric care, and preexisting conditions cannot be a barrier to coverage. In addition, depression screening for all children and adults is available with no copayments, regardless of the type of insurance. The Affordable Care Act provides for obesity screening in adults as well as substance abuse and nicotine dependence screening for adults and adolescents. Prevention and disease management with measured health improvements is the focus of new health care models.

Up to now, behavioral health care has been provided by psychologists, social workers, and counselors working in primary care settings, which excluded psychiatrists. By being an integral part of the collaborative care team, psychiatrists are now in the position to lead the development and management of behavioral health care initiatives to address problems quickly, smoothly, and effectively. The Affordable Care Act makes this a clear priority, with financial incentives for those able to demonstrate results. Having psychiatrist involvement creates a new dimension and expands the ability to provide care.

PCPs see the majority of psychiatric patients. With the support of a psychiatrist, the PCP can decrease the use of potentially harmful medications when alternative treatments would be more appropriate. Psychiatrists can also assist PCPs in identifying the complex patient for referral. PCPs, with the support of psychiatrists, would also be expected to have basic skills in mental health education, cognitive-behavioral therapies, and safe medication management.

When new models of care are developed, it will be important that methods for intake and referral are seamless, with easy handoff. Patients can have multiple entries into a system through primary care, midlevel providers, and behavioral health workers, with easy referral to clinicians who have more training and experience. Certain patients with a single or uncomplicated diagnosis will likely continue to be managed by the PCP, midlevel provider, or behavioral health provider. Psychiatrists and PhD psychologists can provide supervision and oversight of care. More complex cases can be referred directly to senior psychiatric staff.

More than 60% of patients with MDD have comorbid medical conditions, such as hypertension, congestive heart failure, chronic back pain, diabetes, and arthritis, and would benefit from combined psychiatric and medical care. It would follow that referral patterns then should have more to do with the complexity of the patient’s condition than any specific treatment modality. Frequently in behavioral health settings, psychologists provide therapy and psychiatrists prescribe medications. But each discipline has areas of special expertise: PCPs are especially skilled in case identification and acute management; social workers are skilled in case management and certain therapies, such as eye movement desensitization and reprocessing; psychologists have special expertise in psychotherapy and neuropsychological testing; psychiatrists are skilled in evaluating complex patients, developing treatment plans, and providing psychopharmacology and psychotherapy. Complex patients would, out of necessity, have more time allotted for evaluation and treatment. Senior staff would be more involved in supporting those with less training, and the best trained and most experienced clinicians would constantly review and establish standards of care.

In this system, provision of care would vary in order to meet the needs of the patient rather than follow a specific treatment modality. It would also be important to create systems of care that are flexible and can use the ability of existing staff in the best possible way.

In collaborative integrated care, all clinicians could be involved in health coaching and basic cognitive-behavioral strategies-the licensed social worker and the psychiatrist might both do eye movement desensitization and reprocessing. A licensed independent social worker might work with a less complex patient while the psychiatrist provides eye movement desensitization and reprocessing for patients with comorbid disorders, eg, bipolar disorder and PTSD. This does not exclude the social worker from providing care for victims of sexual abuse or collaborating with the psychiatrist on complicated patients.

In collaborative integrated care, psychiatric practice would be dynamic and challenging. Psychiatrists would take the lead and would have multiple responsibilities, such as providing oversight and clinical supervision, evaluating complex patients, developing comprehensive treatment plans, providing medication management and psychotherapies for complex patients, directing treatment teams, doing telepsychiatry, and planning patients’ discharges. Psychiatrists would also need to lead the team in providing cultural- and age-appropriate outreach, evaluation, and care: minorities have greater difficulties in accessing care,¹⁵ and the aging population requires the same attention and oversight.

The cost factors associated with psychiatric care are often a concern. Psychiatrists and other health care professionals would also need to ensure that optimum treatment is provided at the lowest cost possible.

Conclusion
It is time that psychiatry moves away from its present focus on medications and takes a new direction that uses other modalities of care-evidence-based psychotherapies. To fail to do so will lead to less effective treatment, and we will fall short in our ability to provide care for our patients. Expanding our therapeutic range for those with serious psychiatric disability within the bounds of honesty and transparency and within the context of research will lead to new treatments. As we discover more about those who achieve full remission, we can direct our research and treatment toward the goals of prevention and cure.¹⁶ We can set our sights on having a healthy, productive population with much reduced pain and suffering. The support from the Affordable Care Act for the new paradigm in the US and innovative programs in Canada can be a major impetus for moving in the right direction.

Disclosures:

Dr Neidhardt was the Clinical Director for Northern Navajo Counseling Center in New Mexico with the Indian Health Service. He is in private practice in Santa Fe, New Mexico. He is board certified in psychiatry and integrative holistic medicine.

Dr Ortiz is a former Professor at the University of New Mexico School of Medicine, has worked as a VA psychiatrist, and is currently a consulting psychiatrist in substance abuse programs, cultural psychiatry, and managed care in Albuquerque, New Mexico.  She is board certified in psychiatry, addiction psychiatry, and geriatric psychiatry.

Dr Wright is Professor in the Departments of Anesthesiology, Pharmacology, and Therapeutics and Medicine at the University of British Columbia in Vancouver, BC. He is also the Co-Managing Director of the Therapeutics Initiative and Coordinating Editor of the Cochrane Hypertension Review Group. He is board certified in internal medicine and a practicing clinical pharmacologist.

Dr Roessel has spent most of her career working as one of the few Navajo psychiatrists in the Indian Health Service and consults to the First Nations Community Health Source in Albuquerque, New Mexico. She is in private practice in Santa Fe, New Mexico and is board certified in Psychiatry.

The authors report no conflicts of interest concerning the subject matter of this article.

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