Response to Dr. Lieberman on the Changing Times for Psychiatry

Jeffrey Lieberman, MD is the current President of the American Psychiatric Association (APA).  He came out today with the first in a series of three statements on the changing profession of psychiatry.  He starts out with an uneven historical recap of the first 200 years of the profession.  I am probably sensitized to his use of Freud as an inflection point with my recent study of the philosophy of science.  Freudian psychoanalysis and Adlerian psychology were Popper's original example of fields that did not meet logical criteria as a science.  They were not falsifiable and therefore were unscientific.  At the same time the neuropsychiatric movement based on phenomenology and neuroanatomy associated with German asylums is not mentioned.  I suppose that a historical context is appropriate when considering all of the inflection points for the profession but let's face it - the first 150 of those 200 years are irrelevant to any scientifically based psychiatry and can be disregarded.  He added a few paragraphs on the advent of psychopharmacology and the DSM as additional innovations and ends with his idea that the rising cost of health care and the pace of scientific discovery will be the two forces that shape the profession of psychiatry going forward.

My first problem with this statement is that there seems to be no role for psychiatrists or their professional organization in shaping the profession.  We are there to be buffeted by rising costs and scientific discovery.  Like most fields of medicine innovation has been driven by the clinicians and researchers in the field.   When Len Stein, MD and his collaborators noticed that patients at the Mendota State Mental Health Institute were residing there in appalling conditions, they invented community psychiatry and community support teams and moved them out.   There have been a long list of innovators in psychotherapy, psychopharmacology, neuroscience and in the general methods of psychiatry.

Taking Dr. Lieberman's points individually and starting with the rising cost of healthcare - what does that mean exactly and what does it mean in terms of psychiatric services?  Thirty years ago some health plans covered unlimited psychotherapy.  Many psychiatric trainees underwent psychoanalysis as part of their training and it was covered by health insurance.  Today they would likely get a brief evaluation or a checklist and the offer of antidepressant medication if they scored high enough on a rating scale.  If they were very fortunate they might see a crisis counselor for two or three sessions.   How could this change in care possibly be related to rising costs?  Psychiatric care has never been cheaper.  The rising costs in medicine have to do with services that have pricing power and that never involves mental health.  The real challenge here is a political one.  It is very apparent that political systems and their partners in the business community will do everything possible to restrict access to psychiatric services - no matter how cheap they are.  In the general scope of actual payments to providers there are no services that are more cost effective than psychiatry and until very recently that was essentially guaranteed by special billing codes that reimbursed psychiatry less.

The impact of rationing of psychiatric services by managed care companies, state and federal governments go beyond the purely economic.  When psychiatric services are easily rationed, evidence based services that are more expensive like Assertive Community Treatment can simply be made a non covered service.  There are few functional detoxification facilities for people with severe drug and alcohol problems.  Most people are sent home from an emergency department with medications to "self detox" or sent to a county run facility with no medical services.  They are readmitted when that fails or when they develop complications that require intensive care such as seizures or delirium tremens.  The majority have no chance to achieve sobriety from outpatient detox of significant addictions.  The hospital evaluation and treatment of severe disorders that often take weeks or months to assess and treat are restricted to a few days.  The actual admission and discharge decisions from hospitals and treatment centers are no longer medical decisions but they are based on arbitrary guidelines made up by business organizations.  Entire hospital and clinic environments are run by administrators with no psychiatric training.  There are actually situations where administrators seem to believe that they can design treatment programs that target behavioral problems when they are not clinicians.  The "rising cost of health care" rhetoric is frequently used to rationalize a nationwide approach to mental illness that is totally nonfunctional.  This has been the result of a series of "reforms" that basically turned the field over to the managed care industry.

Psychiatric research and the neuroscience research that applies to psychiatry is vast.  When physicians are trained we are all taught to value ongoing education.  At some point the education of physicians also became a political football.  There are initiatives to teach physicians how to treat pain.  A decade later there are initiatives to retrain physicians who are prescribing too many opioids - despite the fact that the original initiative had a goal of appropriate assessment and treatment.  Specialty boards and the oversight board unilaterally decided that the public wanted board certification to be time limited.  They came up with a Maintenance of Certification (MOC) procedure despite the lack of evidence that it was necessary.  That allowed several states to consider tying medical licensing to these costly and unnecessary exams.  The best way to educate physicians is an active collaboration at both the clinical and basic science levels like many specialty boards were doing at the time of the new idea about MOC.

These are the dimensions that shape my world as a psychiatrist every day.  They have been responsible for the deterioration of the practice environment and decreased quality of care across most treatment settings.  Contrary to Dr. Lieberman's points there has been no reform and there certainly is no enlightenment.  Despite all of the research and expanding knowledge clinical psychiatry is in the Dark Ages as external forces suppress psychiatrists and limit creativity and innovation.

George Dawson, MD, DFAPA



Jeffrey Lieberman, MD.  Change, Challenge, and Opportunity: Psychiatry in Age of Reform and Enlightenment.  Psychiatric News August 29, 2013