Psychiatry in the New Millennium

As psychiatry is swept along by the evolutionary winds of change, will you be poised and trained for success? This question was posed to psychiatrists by Joel Yager, M.D., at the recent annual meeting of the American Psychiatric Association, at which he received the Seymour D. Vestermark Award.

Yager predicted that psychiatry will remain a highly gratifying profession with room for expression and creativity; he underscored, however, the need to greet the future with flexibility in the face of emerging new trends in patient care, technology, research and socioeconomic forces.

"This is not your father's psychiatry anymore," warned Yager, who is professor and vice chair, department of psychiatry, University of New Mexico School of Medicine. He expressed hope that psychiatry will continue to be "mindful and brainful, spiritual and thoughtful" while responsive to the changing realities of clinical practice.

Psychiatry must respond to rapidly shifting paradigms in approaches to care, he said, many of which are driven by market demand for alternative types of treatment.

Traditional axioms that longer treatment is better, that "deeper" treatment is better and that effective treatment involves working through the transference in psychoanalytic psychotherapy have evolved into axioms that embrace multidimensional approaches to practice, particularly treatments that are supported by outcome data, Yager said.

Managed care continues to drive a number of these developments, as practitioners of psychiatry and medicine in general compete to establish more effective and efficient treatments. One particular paradigmatic change confronting psychiatrists is that managed care institutions that authorize treatment are shifting away from an emphasis on diagnosis to an emphasis on functional impairments generated by a patient's diagnosis. Mental health is increasingly being asked to address just what is necessary to get a patient "back on track."

For their part, patients are demanding that psychiatrists continue to make varied and acceptable treatments available. In an ever more competitive marketplace, the patient will want to receive benefit from every appointment. Psychiatrists also are likely to find themselves called on to provide time-limited therapies. Clinical practice will require that psychiatrists stay abreast of developments in treatments that go beyond psychopharmacology. Practitioners will no longer find themselves with singular role definitions.

Yager reviewed a study of help-seeking behavior among Americans that illustrated the willingness of many individuals to use unconventional treatments (Eisenberg and colleagues). Individuals who sought alternative therapies had attended an average of 19 visits in the previous year and paid an average of $28 per visit out-of-pocket for complaints that included depression, anxiety and headaches. The Eisenberg study, Yager said, suggests that a substantial market segment wants treatments unavailable through conventional medicine. Relaxation training and imagery techniques were among the top 10 treatments sought by patients. New mental health plan models need to consider this information about consumers, in terms of their interests and willingness to pay for treatment.

The impact of these forces suggests that psychiatry consider a new set of four As to serve as guidelines for providing treatment, Yager said. These would add to Eugen Bleuler's four As of yesteryear: associations, affect, autism and ambivalence. Yager's four As are affordability, affability, accessibility and accountability.

An emphasis on cost-efficiency in health care is likely to force psychiatrists to pay greater attention to maximizing the use of face-to-face interaction with patients. It is also likely to drive the increased use of middle-level providers (health care professionals without a doctoral degree, such as registered nurses or social workers with a masters' degree) as the mental health care market experiments with different types of provider coverage. Yager speculated on the application of a "dental model" of psychiatric practice, in which there would be increasing reliance on "mental hygienists" to help psychiatrists maximize their time and expertise. Screening and diagnostic instruments that can similarly add value to a practitioner's efficacy are likely to be implemented with greater frequency.

Psychiatry also is faced with the need to incorporate and respond to rapid changes introduced by advances in research and technology, particularly computer-based information systems. New technologies are increasingly allowing for cross-fertilization of new ideas, particularly with the advent of global instantaneous communication and advancements in supercomputers. A few areas of research to benefit from these advances include developments in artificial intelligence and artificial life/genetic algorithms that model complex adaptive systems. New approaches to neuroscience are evolving from applying complexity theory, which addresses how simple systems develop into more complex systems, and then into brain systems.

How researchers view the mind is being enhanced through technology that enables the modeling of virtual nervous systems. Functional brain imaging is promoting consideration of new paradigms of brain organization.

Emerging information and expert systems technologies are quickly becoming valuable to the delivery of psychiatric services as well. Practitioners are beginning to see the benefit of computer-based therapy and diagnostic adjuncts or "virtual therapists." For example, systems have been developed to help primary care physicians begin the assessment, diagnosis and treatment planning processes. Patients respond to questions posed by a computer, before being interviewed by their doctors, to help sharpen the focus of their presenting complaint. In preliminary ventures, patients have expressed satisfaction with computer-based interviewing, Yager said. Computer adjuncts may free practitioners from having to spend as much time on checklist-type interviewing, enabling them to use personal interviews with clients to address how symptoms are creating problems in living and to help improve patient functioning.

Yager described other experiments in computer-assisted therapy, such as those reported by Roger Gould, M.D., which include the use of computer-based interviews before patients interact in group therapy. Following a 45-minute interview with a computer, which guides patients through progressive iterations to help them identify how they feel, patients meet with one another and with a group therapist. Computer-driven treatments are also being developed to provide "virtual reality desensitization."

On-line systems that provide access to the Internet, including e-mail and home pages, offer fast information as well as new opportunities for patients and their families to communicate with one another about their experiences. In addition, on-line communication (as well as the use of video phones) opens up new opportunities for psychiatrists to provide remote-site treatment and consultation. Psychiatrists need to become well-versed in these rapidly developing resources.

On-line continuing education programs are anticipated. As funding for graduate education falls under increasing pressure, teaching efficiency will assume paramount importance, opening the door for cost-effective alternative training opportunities. Residents may be able to accomplish at least part of their knowledge-based learning on-line, even through access to transdepartmental curricula. Systems designed to present interactive interdisciplinary scenarios can promote problem-based learning. Will it be possible, Yager wonders, to complete a "virtual residency"? Faculty members may find their roles shifting accordingly.

Other training implications of changes in health care revolve around supply-and-demand forces for psychiatrists. Training institutions need to address the potential consequences of preparing too many or too few psychiatrists. Yager questioned the approach of preparing psychiatrists when they cannot be absorbed into the workforce.

As psychiatry anticipates the next century, Yager said, he believes outstanding clinical work, with honesty, integrity, caring and respect in the professional-patient relationship will still be possible. Practitioners will need to be flexible, but the potential for a rewarding career as a psychiatrist will remain.

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Reference

1.

Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States: prevalence, costs and patterns of use. N Engl J Med. 1993;328(4):282-283.