P&S Journal: Fall 1994, Vol.14, No.3
Where is Psychiatry's Mind Today?
By Anna Sobkowski
If one word characterizes the practice of psychiatry in the 1990s and beyond, it is change. Change in the treatment of mental illnesses, change in the science of psychiatry, change in the demand for psychiatric services, change in the numbers and demographics of psychiatrists in practice, and change in the financing and management of psychiatric care. While some changes have caused slippery conditions underfoot, others signal a new phase of intellectual ferment and fervor.
Not too long ago, the bedrock of psychiatry was psychoanalysis, based on Freud's theory of understanding behavior by exploring the unconscious mind. In recent years, the study of the brain's biology and chemistry has transformed the understanding of behavior. This coincides with a growing "medicalization" of psychiatry, a tendency to look for disease processes, rather than only psychological problems, as causes of mental illnesses.
While the goal of psychiatry-to untangle the intricate web of human behavior-remains unchanged, diagnosis and treatment are influenced increasingly by scientific findings in such areas as molecular, neural, cellular, and behavioral biology.
With neuroimaging techniques, neuropsychiatric researchers can at last examine the brains of patients with mental disorders, looking for specific areas that are disrupted. Neuroimaging allows the brain to be studied in two ways. CAT and MRI scans are used to study the structure of the brain while SPECT and PET permit dynamic study of the brain as it performs specific acts, such as perceiving, thinking, or talking. These tools are used to observe the way structure and function are altered in individuals with mental illnesses.
MRI scans have shown that some patients with schizophrenia have an enlargement of the fluid-filled areas (termed ventricles) inside the brain, which may have resulted from abnormal brain development or injury before the onset of illness. SPECT and PET scans increasingly help in understanding schizophrenia, affective, panic, and obsessive-compulsive disorders.
Molecular genetics offers another major advance in scientific psychiatry by exploring the relationship between gene abnormalities and mental illnesses. Many mental illnesses, such as schizophrenia, anxiety, and depression, tend to run in families and appear to have a genetic component. Identifying genes that affect mental disorders will have a profound impact on the early diagnosis and treatment of mental illness and increase the psychiatrist's role in genetic counseling.
The medical approach to psychiatry has led to the pursuit of more reliable, precise diagnostic systems. An emerging trend within psychiatric research refines and breaks down illnesses into subtypes. Greater precision leads to the development of more disorder-specific treatments.
New antipsychotic and antidepressive drugs for panic disorder, agoraphobia, obsessive-compulsive disorder, and eating disorders have ushered in a second "drug revolution," similar to the pharmacological revolution of the 1960s. New short-term psychotherapies, such as cognitive therapy, family and behavior therapies, and interpersonal therapies, are used increasingly in combination with new drug therapies.
At a time of growing demand and need for psychiatry-the National Institute of Mental Health reports that about 15 percent of adults in the United States meet the diagnostic standards for psychiatric disorders in any given month-new problems have emerged.
In the 1940s and 1950s, more than 10 percent of U.S. medical school graduates entered psychiatry. By the end of the 1970s the number reached a low point of 3 percent. In 1988 the figure was more than 5 percent, but the number of medical school graduates entering psychiatry has declined by about 40 percent since then.
The Council on Graduate Medical Education has projected a need for nearly 55,000 psychiatrists in the United States by the year 2010, but current recruitment figures for U.S. graduates project that less than 33,000 psychiatrists will be available. The problem is complicated by health care reform, with its emphasis on primary care physicians and reimbursement for the least costly provider. Competition from other mental health professionals and continuing stigmatization of mental illness are other concerns that influence medical students as they consider careers.
Ironically, research in psychiatry and the neurosciences is growing at an unprecedented rate.
"There has never been a more exciting time to be in psychiatry," says Dr. John Oldham, director of the New York State Psychiatric Institute and associate chairman of psychiatry at P&S. "And as a leader in research, clinical care, and training, Columbia is at the forefront of the excitement."
Columbia and the New York State Psychiatric Institute are poised to continue their leadership roles into the next century, with one of the largest psychiatry departments in the country, a new state-of-the-art psychiatric institute building scheduled for completion by the state in 1997, a competitive residency program (200 applications were received for the 13 slots in 1993), and clinics that treat the entire range of mental disorders. Leading the move into the next century is the department's chairman, Dr. Herbert Pardes.
Also vice president for Health Sciences and dean of the faculty of medicine, Dr. Pardes is a voice of optimism for the future of psychiatry and a tireless advocate for the profession on Capitol Hill. "The good news in mental health is that major figures in the administration are advocating non-discriminatory mental health care for at least a segment of the psychiatrically ill," Dr. Pardes says. "One can argue that we are in a rather good position because mental health is being singled out for support and has many strong proponents to give us a benefit far better than anything we had ever anticipated."
Dr. Pardes argues that, for several reasons, psychiatry is more financially viable than generally believed. First, psychiatry has drastically improved in the past decade in its ability to help. The treatment success rate for bipolar disorder and panic disorder is estimated at 80 percent; major depression has a success rate of 65 percent and obsessive/compulsive disorder a success rate of 60 percent, far higher than for many medical procedures. With these kinds of figures, Dr. Pardes says, policy-makers have a solid basis for arguing for mental health coverage.
Health care reform may result in national policies that supersede insurance policies that cover mental illnesses inadequately. Coverage for the 37 million currently uninsured would mean a greater number of people who could benefit from psychiatric care would have access to it.
Columbia is taking steps to give P&S students the best possible introduction to the field, says Dr. Ronald Rieder, director of the residency training program and associate chairman for education for the Department of Psychiatry. "A new mentor program has been developed, even for first-year students; the Psychiatry Club has expanded; and we're working hard to make sure that first- and second-year lectures and third- and fourth-year clinical and research experiences are of top quality," says Dr. Rieder.
As the recipient of more than $42 million in federal and state research grants last year, Columbia psychiatry researchers are flourishing in both basic and clinical research. They are rewarded with prestigious awards (the McGovern Award from the American Association for the Advancement of Science, the Albert Lasker Award, the Gold Medal for Distinguished Research in Biological Psychiatry, and the Presidential Medal of Science Award, to name a few). Eight psychiatry faculty have received prestigious MERIT grants from the National Institute of Mental Health.and Columbia psychiatry faculty are frequently recipients of prestigious research awards from the National Association for Research in Schizophrenia and Affective Disorders.
"Nearly every single issue currently in the forefront of psychiatry is being grappled with and studied at Columbia," says Dr. Oldham.