Last month, I spoke in Toronto at the annual conference of the American Psychiatric Association (APA), a meeting I haven’t attended in many years. What drew me there was the invitation by former APA President Dr. Dilip Jeste to join several other psychiatrists and psychologists from around the country to talk at a symposium on Positive Psychiatry. Our group in Vermont, led by Dr. Jim Hudziak, has had a particular interest in bringing more aspects of wellness and health promotion into the purview of child psychiatry, and this seemed like a great opportunity to talk more about this important topic.
It is probably fair to say that the field of psychiatry is having a bit of an identity crisis lately. For many years, psychiatrists saw themselves primarily as skilled therapists. Then the explosion of neuroscience and the promise of medications added more dimensions to what we could do. Lately, however, it has felt like many of these roads have ended or at least been clogged with massive traffic jams. Doing therapy has become nearly impossible for psychiatrists who accept insurance, especially from public sources like Medicaid. This reality has pushed many psychiatrists to focus on medications. However, recent research has revealed that many of the risks of medications may have been under appreciated while the benefits somewhat overblown. As a result, enthusiasm for psychopharmacology has diminished. Furthermore, it has been a long long time since there really has been a truly new medication, as pharmaceutical companies continue to crank out “me too” drugs that just tweak the same old tired neurotransmitters in slightly different ways.
Meanwhile, in the world of neuroscience research, there continues to be this funny phenomenon of amazing studies with few practical consequences. Psychiatric journals document simply glorious pictures of the living brain and wondrous new genetic techniques that allow us to understand someone’s DNA and gene expression more quickly and cheaply than ever. Yet at the same time, many practicing psychiatrists are growing impatient because these studies rarely have any practical application in the near future. As cool and impressive these studies are, they lack immediate implications for what clinical psychiatrists actually do. The papers from these studies seemingly all end with a statement very similar to “these results may help improve the early identification and effective treatment of people struggling with (insert disorder here)” but in reality there remains a large number of dots to connect before that actually happens.
I’m a huge fan of neuroscience and do see it as a crucial endeavor for our field. But for now, if we can’t practice therapy and many medications aren’t as great as we thought and the practical applications of our neuroscience research are still years away, what are we supposed to do?
This is where positive psychiatry comes in, as what we can do is really become physician experts in mental health, rather than just mental illness. Learning about depression does not make one an expert on happiness. Helping a parent not abuse their child is critical, but positive parenting is much more than the absence of maltreatment.
As I’ve mentioned in many previous blog posts, science is telling us more and more that most if not all psychiatric disorders exist along a continuum rather than in a binary “disordered versus non-disordered” form. Further, wellness and health promotion measures have been shown to help not only the well become more well but also help individuals struggling with more significant levels of emotional-behavioral problems achieve improvement, remission, and even beyond. Mindfulness for anxiety, exercise for depression or ADHD, positive parenting for oppositional behavior, are but a few examples of evidence-based interventions.
When we look at other medical specialties, we see that many have already expanded into wellness. An example that Dr. Hudziak often sites is cardiology. Yes, a cardiologist is the person you want when having a heart attack, but they are also part of the group defining heart-healthy lifestyles.
For too long, psychiatry has had two primary interventions: psychotherapy and medications. Expanding our efforts into domains of wellness gives us so many more avenues to help children and families thrive, and we can begin to use them not in a decade, but tomorrow. Indeed, this evolution is quietly occurring already in clinical practice and in psychiatry education. In forming the new child psychiatry “milestones,” the knowledge and skill requirements on which all child psychiatrists in training will now be assessed, I was very pleased that the committee took my suggestion and included the provision that next generations be taught not only about psychopathology but also wellness.
This APA symposium was well attended and generated some excellent discussion. There is also a new book published this year on the topic, and I was privileged to have been asked to contribute a chapter. My hope is that these efforts will begin to cause a shift in how psychiatry defines itself, so that we can move towards claiming ground that probably should have been ours all along.
@copyright by David Rettew, MD
David Rettew is author of Child Temperament: New Thinking About the Boundary Between Traits and Illness and a child psychiatrist in the psychiatry and pediatrics departments at the University of Vermont College of Medicine.