Psychiatry is an expensive burden on our health system. Let's get rid of it.

I'm not coming at this from some kind of Scientology anti-psychiatry jihadist point of view that psychotropics will "kill your child," or you, and that the way to become clear is to be audited on an e-meter.

And I'll try not to come at it from the full-disclosure point of view of myself as a psychologist, who coincidentally was trained 40-years-ago at the same now-defunct hospital, Michael Reese, in Chicago, as Dr. Levine. I'll readily admit the self-interested turf war proclamations from the American Psychological Association that drug therapy is enhanced by psychotherapy, or that psychotherapy is better than drug therapy-(that is, when some of my other colleagues are not pushing for prescribing privileges for themselves).

I'll stipulate that psychotropic medications do some good-and in some cases a lot of good.

I'm simply saying we don't need expensive psychiatrists to do most of what it is that expensive psychiatrists do.

Those looking to wring savings out of our health care system could do worse than to eliminate them. Medical school costs aside, specialty residency programs are largely funded by Medicare. Each year, psychiatric residency programs pump out 1,000 new psychiatrists at a cost to taxpayers of at least $110 million. A drop in the bucket compared to our multi-trillion dollar national medical expenses, but to this we have to add in the costs of having trained the already existing 22,000 psychiatrists, and the premium patients and insurance companies pay to see a psychiatrist rather than a primary care physician. Overall, Medicare spends $7,000,000,000 annually on medical education, and the cost of a residency does not account for all kinds of other indirect costs in training psychiatrists.

We woefully need primary care physicians.

According to a report by the Association of Medical Colleges, we will be short 46,000 primary care physicians by 2025. At the high end, eliminating psychiatry and diverting those medical students to primary care, would reduce the 46,000 shortfall by almost a third.

But surely we need psychiatry. The National Institute for Mental Health says that 57.7 million Americans have a diagnosable mental disorder-nearly one in six. Who will treat them if not highly trained psychiatrists?

They're already missing in action. Psychiatrists provide a minority of the treatment for those who seek it. In 2006, only one in four of the 472 million psychiatric prescriptions were written by psychiatrists. Most are written by primary care physicians, nurse practitioners, and other medical specialists. Garden-variety neurotics are more comfortable telling Dr. Welby than Dr. Levine that they are down in the dumps or having panic attacks. There remains the stigma that you're crazy to see a shrink. When I had a practice in a small New England town, I'd get clients from the next small town over telling me they didn't want their neighbors to see them entering their local shrink's door. I compared notes with that colleague in the next town over, and he getting his share of clients who lived down the street from me.

And there's the money aspect. If I choose Dr. Levine, my insurance company will charge me more for a "specialty visit," and they will pay Dr. Levine more too.

But surely, you get value for that money. Those four years in a psychiatric residency, plus all that post-residency training and testing to become board certified.

We are long past accepting the idea that psychiatrists do better psychotherapy than others-even when they still do it as Dr. Levine used to. (Even our founder, Dr. Freud, said the only advantage a physician has over a lay-therapist is that a physician experiences the death of patients and thereby learns to accommodate failure.) A psychiatrist would be hard pressed to produce a study showing that his colleagues are better at it than me. And I won't be able to produce a study that my supposedly better-trained colleagues are any better at it than social workers, ministers, any trained listener-or even a gifted amateur.

I like to say that the only tool we therapists have is bedside manner, and medical school is quite irrelevant to that.

But even as the psychiatrists have left psychotherapy to the likes of me, there's not a lot of evidence that Dr. Levine's patients are getting better drugs than Dr. Welby's either.

A recent survey, 2007, in the American Journal of Psychiatry, screened 539 patients at 15 sites for anxiety disorders. "Nearly 21% were receiving medication only for psychiatric problems, 7.2% were receiving psychotherapy alone, and 24.5% were receiving both medication and psychotherapy," Risa Weisberg and her colleagues discovered. They found that psychiatry did not make a difference in care: "Patients receiving psychopharmacological treatment received similar medications, often at similar dosages, regardless of whether their prescriber was a primary care physician or a psychiatrist." Sadly, almost half, 47.3 percent received no treatment at all.

Studies like this point to the need for fewer psychiatrists, more primary care physicians and more lay psychotherapists.

In my current work as a psychologist in nursing homes, I deal with a population that, on average, takes nine different medications each day. Leaving aside the question of whether these medications are effective or needed-studies indicate that anti-dementia medications are as useful for Alzheimer's as garlic was for the bubonic plague-the nurse practitioners with whom I work do most of the prescribing, and the psychiatrists play primarily a consultative role. So, already, in my group's practice the need for a psychiatrist is quite circumscribed. (To be fair, when Medicare pays me to diagnose dementia, when I tell the family that mom is very confused, it's not something they don't already know, but I feel good about myself when I tell them that mom is not confused but dazed by depression because, after all, she is institutionalized in a nursing home.)

Psychiatry, as a defined specialty has been around for only a century, and as anything that pretends to be a science, it continues to evolve. Whatever the qualities of Dr. Levine as a psychiatrist, he has arguably been a good role model to his son, who is about to embark on his own psychiatry career. When Levine, the father, was a student, therapy was an essential part of the training. Now you can become board certified without once uttering, "And how do you feel about that," although "I'm sorry, but our time is up," is still with us. Time is money, and psychiatry, for both reasons of economics and science, has become biochemistry, not psychotherapy. I doubt that Dr. Levine, the younger, will find that his training is out of whack with his practice.

But I predict he will feel the pressure from supposedly lesser-trained practitioners who will be able to medicate cheaper, and just as well.

I could see keeping some of them around. After all, someone has to do the research. But where have you gone Dr. Welby? Our nation turns its anxious, depressed, lonely eyes to you.

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