|Partners for Mental Health - The Contribution of Professionals and Non-professionals to Mental Health (WHO, 1994, 110 p.)|
Alfred M. Freedman, M.D.
Professor and Chairman Emeritus
Department of Psychiatry/New York Medical
Visiting Professor, Harvard Medical School
World Psychiatric Association
The World Psychiatric Association was founded in 1961, replacing the International Society for the Organization of World Psychiatric Congresses set up in 1950. It was admitted into official relations with WHO in 1965. Its mandate is to advance international cooperation in the field of psychiatry by coordinating on a worldwide basis the activities of its Member Societies and in other ways promote activities designed to lead to increased knowledge in the field of mental health and better care for the mentally ill.
It has 80,000 members grouped into some 80 National Member Societies distributed in 75 countries. WPA organizes World Psychiatric Congresses every five years and also holds regional and interregional scientific meetings during which there is exchange of information concerning the problems of mental diseases and the strengthening of relations between psychiatrists working in various fields and between societies existing in different countries.
Studies of the role and status of psychiatrists presently and in the future tend to focus on the individual psychiatrist in regard to his or her practice, ideology, income, content of educational programs (with particular attention to skills and knowledge) and demography. These are extraordinarily important and valuable. However, it must be noted at the outset that psychiatrists in all their activities are actually in the midst of a matrix of very important forces that make necessary many aspects of their life and practice. A few of the forces can be mentioned now and others will be delineated below. First, the world-wide recession is having serious impact at the present time and will influence training and practice for many years to come. Private and national health programs are being restricted in growth or cut and too often mental health budgets are the first victim. Secondly, there has been a vast change in the manpower distribution in the "health-industry" complex. In the earlier part of the century doctors and M.D.s, made up the bulk of those providing services while as the years have progressed more and more non-M.D.s have entered the field and assumed important roles. In the United States, for example, 7.6% of the health-industry were M.D.s in 1988 (1). This is further compounded by the rise of corporate medicine and various forms of group practice (2). Third, newer technologies give promise of major alterations in the individual who will be administering diagnostic procedures as well as treatment. However, it must be emphasized at the outset that the overall knowledge and skills of the psychiatrist are indispensable for a successful Mental Health Program, although there may be alterations in the psychiatrists' role in the future.
In regard to the second and third points above, Professor Gavin Andrews (3) has made several very important observations and investigations. He points out that "the traditional role of psychiatrists as a central figure in the delivery of mental health services is changing." In his report, Professor Andrews addresses three issues, who diagnosis, who treats, and which treatments are used. All of these issues could alter the traditional role of the psychiatrist as the brightest star in the constellation of those who deliver mental health services. In regard to diagnosis, the specific diagnostic criteria described in DSM-III-R (4) and ICD-10 (5) not only made a great improvement in uniformity of diagnosis throughout the world but have given guidelines as well as criteria for diagnosis to psychologists, social workers and even lawyers. DSM-IV and ICD-11 will, it appears, advance the establishment of further criteria with widespread agreement (6). This agreement, as Professor Andrews points out, makes possible the application of structured diagnostic interviews to private practice and even has led to the establishment of computer programs to administer these interviews (3). He cites a number of uses of the computer program; clinicians may use it as a second opinion, community clinics may utilize such programs where psychiatrists are not available, students can be trained in diagnosis with such programs. Professor Andrews and his colleagues have already tested such computer programs and found that patients accept both the interview administered by an individual as well as that administered through a computer and found that both are equally acceptable. As such programs are further refined, one can see the possibility of most diagnoses being made utilizing the computer particularly where psychiatrists are in very short supply as in many developing countries or where the case loads are overwhelming. Psychiatrists may eventually be limited to those cases that are questionable or ambiguous or merely to certify computer results. In any event, psychiatrists will not have the exclusive responsibility as diagnosticians in mental health.
The issue of who treats should probably be more accurately stated as who is not treated. The Epidemiologic Catchment Area (ECA) study that was carried out by the National Institute of Mental Health in the United States showed that approximately 20% of the population had suffered a disorder that fulfilled criteria of DSM-III within the previous six months (7). Of that 20% only 20% sought or received any attention from professional health workers or others such as a pastoral counsellor (8). Thus, at most 4% were receiving any sort of treatment, however brief. This is not too different from Australian reports that state that between 2.5 and 3.0% of the population are currently in treatment for a mental disorder, however, excluding drug and alcohol disorders (2). If the latter were added then the total would approach the United States figure. It is noteworthy that in the ECA study more than 50% of the patients were seen by non-psychiatrists (7). Along the same lines, Gavin Andrews reports that "psychiatrists are directly responsible for only 1 in 5 patients in treatment, and the majority of persons with mental disorders will not be treated, directly or indirectly by a psychiatrist (2). What role does this leave for the psychiatrist? Since, as has been indicated the majority of patients are diagnosed and treated by general practitioners and other non-psychiatric physicians and a variety of mental health professionals and workers, the question arises in regard to the competence of their activities. Clearly in many of the situations supervision by a psychiatrist would be beneficial. This involves a training of all those who are involved in the diagnosis and treatment of individuals with mental disorders particularly the recognition of cases that require consultation or referral to a psychiatrist. Likewise, psychiatrists in such situations need training in supervision of community workers and general practitioners (8). Such training is sorely needed, as well as sensitivity training so that the supervision will be meaningful and accepted. Too often the arrogance and contempt of the psychiatrist negates the supervision.
Above all, the welfare and benefit of the patient is paramount. There should be no place for interdisciplinary rivalry, sometimes to the point of sabotaging the activity of those who are perceived or mis-perceived as competitors or enemies. Professor Morton Kramer has predicted a "pandemic" of mental illness in the 21st century (9). Yet, figures worldwide show such an enormous number of individuals at risk who have mental disorders and are not receiving treatment. This is occurring in a country with one of the highest number of individuals per capita in mental health in the world. If only part of that 80% could be brought to professional attention the resources would undoubtedly be overwhelmed. In 1970 it was estimated if every individual in the U.S. above the age of 15 were seen for 3 hours a year it would require at least 40,000 psychiatrists or other mental health professionals. Extrapolating to the present it would require 80,000 psychiatrists. If one adds children and adolescents the need would increase by at least 50% and exhaust available resources (10). It is essential that all in the mental health field address themselves to the promotion of mental health through public education in order to bring many of those who are suffering to facilities in order to receive adequate treatment. Psychiatrists can play a very important role in this endeavour but not exclusively. This will require collaborative efforts among professionals, ancillary staff and the public.
Raising the question, which treatment, unleashes a torrent of controversies? Psychotherapy is widely practised throughout the world but up to the present time there are no critical evaluations of the effectiveness of various forms of psychotherapy that are universally accepted. Studies range from those demonstrating benefit to those equating psychotherapy with placebo to those that report no benefit at all (11, 12, 13). Thus, one cannot fault others apart from psychiatrists and also clinical psychologists from practicing psychotherapy. However, this remains a troublesome issue. Biological therapies, particularly psychopharmacology have had critical evaluation with various double-blind studies. There have also been limited studies, for example, in mild to moderate depression comparing the effectiveness of a psychopharmacologic agent with interpersonal therapy and cognitive therapy (14). Over the long run, particularly interpersonal therapy and drug therapy seem to have similar outcomes with the cognitive therapies slightly behind. Over the short run there is some advantage to the psychopharmacologic agent. It would appear that in the administration of psychopharmacologic agents this should be the exclusive responsibility of psychiatrists and other physicians. However, there are numerous efforts, some with success, of clinical psychologists and others to obtain permission for prescribing drugs. The possibility remains that over time there will be enough success to these endeavours to further limit the practice of psychiatrists or at least to increase the competitiveness of other practitioners. It is well known that the majority of psychotropic drugs are prescribed by general practitioners, internists and surgeons.
Throughout this paper it must be emphasized that every nation must develop appropriate roles in mental health configured to the economy, manpower, traditions, history, culture and national health delivery system. Policies and programs from developed countries cannot be transferred intact to developing countries. Each has much to learn from each other.
There is an interesting illustration of the influence of external factors on practice when comparing psychotherapy in the United States and Australia. Psychotherapy reimbursement in Australia is open ended and psychotherapy is of much longer duration than in the United States where reimbursement for psychotherapy is sharply limited, if available at all (2). Thus, out of necessity, in the United States brief psychotherapy is receiving increasing attention and acceptance. This confirms the frequent statement that reimbursement often determines how medicine is practised and what modality is used, not what is best for the patient.
2. Trends in the delivery of services for the mentally ill
Another trend that will be influencing which treatment to administer in the future is the proliferation throughout the world of various treatment manuals for psychiatry. Australia during the past decade has produced 10 treatment outlines built on the basis of a review of the literature, of a survey of current practice and of advice from three or four elected experts (2). The American Psychiatric Association and the World Health Organization have also prepared or are preparing treatment manuals. While in every case there is avoidance of resenting the one and only best treatment for every category of mental illness, still it provides a guideline for treatment and justification of a procedure that can very well be utilized by professionals other than psychiatrists. One cannot deny the value of such manuals in codifying appropriate treatments but it does set very definite limits on experimentation and innovation. Further, in the United States we have seen in the famous Osheroff case (15) where a hospital was sued by a patient who had a depression for allegedly treating him only with psychoanalytic psychotherapy instead of with anti-depressant drugs. The lower court held that this constituted malpractice and awarded the patient $250,000 in damages. The case aroused a furor with sharp arguments between psychopharmacologists and psychotherapists, including psychoanalysts (16). While appeal was pending, the case was settled out of court but this is an indication of the hazards of specifying what is best treatment. The further implication is the great necessity for evaluation studies in various therapeutic modalities so that one has a data base to be able to say what is best for a particular patient at a particular time. This is a major task for future psychiatrists. Further, it may not be just one treatment but the combination of treatments, for example, psychotherapy and psychopharmacology that is best for certain patients with certain diagnosis (17, 18). This very important task is critical or else in the words of Professor Andrews, in the case of Australia, "The psychiatrists' continued endorsement of psychodynamic psychotherapy meaning that they 're becoming identified with an unproven and very expensive treatment" (2). Research must address not only neurosciences but research projects in regard to delivering services efficiently, with a high level of success proven by evaluation and inexpensively.
As a result of the above-mentioned trends and particularly the influence of economic limitations one can anticipate greater attention to crisis intervention and brief psychotherapy. Long term therapy will be inhibited by fiscal constraints as well as questions in regard to the efficacy of psychotherapy in general and long term therapy in particular. More and more in developed countries psychiatrists will be devoting the bulk of their time to serious psychotic illnesses. The treatment of problems of living, effort to improve the quality of life and possibly long term therapy will be managed by professionals in the mental health field other than psychiatrists. This is a developing trend that can already be discerned in developed countries and has always been true in developing countries.
During this century we have witnessed a steady evolution of the site of most treatment of the mentally ill. In the early part of the century most treatment by psychiatrists occurred in large government hospitals or private asylums. After World War II psychiatric units were opened in general hospitals accompanied by restriction of admittance as well as the discharge of patients from government hospitals, this latter tendency has become known as "De-Institutionalization" (19). This phenomenon taking place in many countries has been attributed to a variety of causes ranging from psychopharmacologic utilization to civil liberty enthusiasts and egregious conceptual errors on the part of leading psychiatrists. Upon careful study, at least in the United States, it has been demonstrated that a major factor in the development of "de-institutionalization" has been the initiation of a reimbursement procedure by the government, which made it profitable for state governments to discharge patients from government hospitals to the community and to prevent the admission of mentally ill patients to state hospitals and thus keeping them in the community. The regulations authorized reimbursement only for mentally ill patients in the community while denying reimbursement to patients in governmental mental hospitals.
A concomitant of the proliferation of new psychiatric units in general hospitals has been the emergence of consultation and liaison services. This has resulted not only in the development of a new sub-specialty of psychiatry but has facilitated closer working relationships between psychiatry and other medical specialties (20).
Also in the post WWII period one witnessed a very important trend namely that of community mental health centres and a variety of community mental health services (18). Although many psychiatrists have looked askance at such developments the importance of community services in the future cannot be denied. Part of the reluctance of psychiatrists to be involved in such community endeavours has been from lack of training to serve in such installations, reluctance to be involved in team work with other disciplines and rather meager financial rewards compared to other opportunities. Part of the problem has been the unfair criticism of community programs that unfortunately, not infrequently, made errors or were mis-managed. Again to look at the United States, one of the major difficulties of community mental health centres was the cessation of anticipated funding for community mental health centres so that only 1/5 of those originally planned were ever built. Soon after their establishment in the United States, for example, there was a general withdrawal of psychiatrists from community mental health centres, leaving these facilities under the direction of psychologists and social workers. Naturally, this resulted in predominance of psychotherapy and social intervention with concentration on individuals with neuroses, personality disorders and problems of living, which, as predicted by some, led to neglect of the seriously mentally ill. Fortunately, in more recent years there has been a trend toward the return of psychiatrists to community mental health centres and one can anticipate steady growth of psychiatrist participation (21). This is essential so that community programs will take care of a broad range of the mentally ill, including those with serious mental illness who reside in the community. Again, such involvement will mean modification of training programs to facilitate the involvement of psychiatrists in community programs. It is noteworthy although the movement from the large government hospital to community programs has been noted, too often training programs are modelled after the situation that existed in the first half of the twentieth century. That is to say the bulk of training programs is with psychotic patients in hospitals, with too little time devoted to patients in ambulatory clinics let alone facilities out in the community. One can expect major changes in this area (8).
3. Sub-specialization and training
Sub-specialization in psychiatry has taken an accelerated growth, particularly in developed countries. This is a natural outcome of increased knowledge that makes it difficult for any one psychiatrist to acquire the knowledge and skills necessary for many areas. Also the opportunities in a sub-specialty at the present time seem more promising than being a generalist. The burgeoning population of the aged in all parts of the world has stimulated the sub-specialty of psychogeriatrics. Likewise the very special problems of children and adolescence have eventuated in the emergence of sub-specialists not only for children but for adolescents. The escalation of substance abuse has fostered the development or sub-specialist in drug abuse and alcoholism. Although there are certain disadvantages in this trend toward sub-specialization, it appears to be an inevitable fact and training programs have to be established to conform to this development.
Training for new roles is of critical importance. As has been pointed out, failure to include training in community activities has had deleterious effects on services and participation by psychiatrists.
Psychiatrists are too often led to believe that they and they only can be leaders of teams in the community and that this role can be assumed irrespective of background and training. The team approach requires mutual trust and recognition that leadership should be assigned to individuals who have the training, background, capacity and time to provide wise and active leadership. Leadership skills and qualities are essential for this role, and psychiatrists may well assume leadership roles where qualified or at other times be valuable and valued members of the team. Psychiatrists must be ready to assume new tasks without abandoning traditional areas of work which may or may not be shared with other disciplines. Above all, the interests of the patient and whatever must be done to provide excellence of service, must be given the highest priority. The psychiatrist must at all times be a patient advocate. In the report on the informal consultation on the contributions of different professional roles to mental health (22) the barriers to the team approach are listed after emphasizing the need for strengthening team work that includes the need for common goals, philosophy and models of action necessary for team effort This report emphasized that the ancient dichotomy between psychological and physical approaches to mental health and illness is an obstacle to team approaches and the solution of this, as will be pointed out below, lies with the commitment to the biopsychosocial approach. A purely social approach can be as deleterious as a purely biological one. In the report the most frequently found barriers to the team approach are listed as follows:
A. Failure to understand other professions' language.
B. Lack of communication.
C. Personal and professional insecurity.
D. The amount of people and of professions involved in and dealing with a single person or family.
E. Administrative and legal obstacles.
The psychiatrist of the future must be trained to conform to community needs so that the community and professional knowledge can be integrated. It must be recognized that there has to be respect for local beliefs and that community programs that meet with success are ones that work with and through people living in a particular area or district. One must have as members of the team individuals that belong to and understand the culture in question.
There are two areas that might be termed missing ingredients both in training and the work of psychiatrists at the present time which will develop increasing importance as time goes on, namely prevention and psychosocial rehabilitation. Primary prevention is possible in certain organic and stress-related syndromes. First class para-natal services as well as attention to mother-child relationships and care of infants from the time of birth through school that integrates health, psychological development and education will be an important area for participation by psychiatrists and others. One can see the beginnings of another sub-specialty in infant psychiatry.
The area of after-care and psychosocial rehabilitation that has been termed tertiary prevention is the second missing ingredient in training and mental health programs. The importance of psychosocial rehabilitation cannot be underestimated and will be an area that will concern psychiatrists and other mental health workers more and more in the future.
Training in research methodology as well as opportunities for research are of utmost importance. While certainly only a small percentage of psychiatrists will wish to devote their careers to research, everyone should be trained in research methodology so that they can evaluate research publications and develop a healthy skepticism to unfounded assertions.
4. Trends in psychiatric manpower
Studies of trends in manpower in psychiatry indicate major changes that are now well under way. Noteworthy is the increasing number of women who are entering medical school as well as psychiatry (23). In the United States this has been of sufficient attention so that the term "feminization of psychiatry" has been utilized. It is not only that increasing numbers of women are entering psychiatric residency in the United States but this is particularly true of the younger medical school graduates indicating that this is a steadily increasing trend. Women still occupy fewer of the positions of power and prestige compared to their numbers in the field of psychiatry; however, this undoubtedly will be changing in the future. What is anticipated is that with the larger number of women entering psychiatry there will be a vast escalation of interest and commitment to social and community programs as well as social concerns. Also the whole field of child development, child care will be greatly stimulated by the presence of women. These two trends certainly will be welcome by all in mental health.
In summary, it is evident that there is a bright future for psychiatrists in a field where there are enormous unmet needs. This can only increase in the future, particularly because of the greater percentage of the elderly in all populations worldwide with most rapidly increasing cohort, those over 85. Mental health problems proliferate with age. The psychiatrist has a very special and unique role in the pantheon of mental health professionals. The psychiatrist's background in the basic natural and biological sciences with knowledge and experience in clinical medicine makes his or her contribution to mental health of inestimable value.
Very impressive developments in the neurosciences and basic biological studies of the brain as well as new technologies give great promise for future innovations in diagnosis and treatment. It is here that the very special training of the psychiatrist makes the physician anindispensable member of the mental health team. However, there have been advances in social and community care that should not be derogated. While the term reductionism in psychiatry has been generally thought to refer to biological reductionism we have seen periods of social as well as psychosocial reductionism. It is of the utmost importance that future training and commitment be to the biopsychosocial model that integrates biological, psychological and social factors with due respect for each category. Only in that way can progress be made in the future. New paradigms are needed for psychiatry and behaviour in general and the biopsychosocial model appears to be the best way of beginning in such new ventures (24). Thus, the psychiatrist of the future will need very broad training and the development not only of traditional knowledge and skills but new ones in the biologic, social and psychologic fields.
Psychiatrists will also be concerned with public education and mental health promotion especially to minimize and one hopes in the future to eliminate the stigma attached to mental illness. The challenges will be great but the opportunities are superb.
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