Psychiatry Is in the Midst of Major Transformation

The field of psychiatry is in the midst of major changes involving the delivery of clinical care, the development of new treatments, the elucidation of the scientific underpinnings of human behavior and the education of medical students and psychiatric residents. There are a variety of reasons for these simultaneous transformations.

Approaches to the delivery of psychiatric care are changing for practical reasons: there are not enough psychiatrists to provide direct treatment for the large number of very ill patients. Most family members of persons with severe psychiatric illnesses know that it is extremely difficult to schedule an appointment with a psychiatrist on short notice. Even finding a psychiatrist accepting new patients is challenging, especially for individuals without private health insurance. Even if there were a sudden dramatic increase in the number of medical students electing to specialize in psychiatry, it would take decades before this shortage would be eliminated. So how can psychiatrists help care for a large number of very ill patients?

Recently, psychiatrists have been developing collaborative care models in which they team up with other mental health providers to work with primary care doctors. In these models, patients receive much of their treatment in a primary care home. The primary care team may directly work with one or more mental health professionals including psychiatric nurse practitioners, physician assistants, psychologists, social workers and counselors. Common psychiatric disorders can be recognized by the primary care team and evidenced-based treatments can be initiated. The on-site team interacts with psychiatrists via meetings, phone conversations or telemedicine. If the patient doesn’t respond to first-line treatments, then he or she is referred to a mental health home where the psychiatrist takes a more direct role in providing care. Obviously, there will be patients who are too ill for the primary care team to manage. Such patients will require aggressive psychiatric care directly from the psychiatrist and the mental health team. But when such patients’ symptoms are stabilized, the primary care team can be engaged to manage the patient and continue treatment.

This collaborative care approach utilizing both mental health teams and primary care teams can provide care to a greater number of patients than more traditional psychiatric settings. Also, this model of care may encourage psychiatrists to keep up with clinically relevant scientific advances so that they can direct the implementation of new treatments – whether these involve psychotherapies, medications, cognitive training with computers, neuromodulation methods, or others.

As these changes in psychiatric care delivery are happening, psychiatric research is evolving rapidly. Much research in psychiatry is federally funded. The director of the National Institute of Mental Health (NIMH), Dr. Thomas Insel, has implemented a variety of initiatives to promote more rapid treatment development. These initiatives involve basic and clinical research and stress the importance of integrating research from multiple disciplines. Teamwork is emphasized. NIMH controls much of the psychiatric research budget and therefore researchers are well attuned to these changes. Also, new methods of brain imaging and new methods for studying genetic and environmental influences are developing rapidly. Thus, the tools necessary for major leaps in our knowledge are increasingly available. There is excitement about such advances, and this is leading to more research-oriented medical students selecting psychiatry as their specialty field. At Washington University in St. Louis School of Medicine, there has been a substantial increase in the number of students with combined M.D. and Ph.D. degrees choosing psychiatry for their specialty training. This bodes well for the future of psychiatric research and ultimately for the development of new treatments.

As research findings lead to advances in understanding the biologic basis of human behavior and as changing models of mental health care delivery are implemented, medical education will have to adapt. Psychiatric residency programs are experimenting with novel approaches for teaching neuroscience, neuroimaging, molecular genetics and other translational science skills to trainees. Medical school courses are addressing neuroscientific advances as they pertain to psychiatric disorders. Today’s medical school curriculum in behavioral science and psychiatry is quite different and more advanced than it was a decade ago.

One other interesting educational change could also strongly impact medical education. Undergraduates applying to medical school must take a standardized examination known as the Medical College Admission Test (MCAT). This test just underwent a major reorganization – the first significant restructuring since 1991. As of 2015, a substantial section of the test will be devoted to behavioral and social sciences. In order to prepare for the exam, undergraduates interested in medical school will likely be taking more psychology and social science courses in parallel to biology and chemistry courses. Hopefully, this will lead to students entering medical school with a better understanding of and appreciation for the science underlying normal and abnormal human behavior.

This column was written by Eugene Rubin MD, PhD and Charles Zorumski MD.