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A Modern Analysis

ONCE CONSIDERED MORE SUPERSTITION THAN SCIENCE, PSYCHIATRY IS STARTING TO SHAKE ITS STEREOTYPE.

The New Physician November 2004
How do you tell the difference between the psychiatrists and the patients at the mental hospital? The patients are the ones who eventually get better and go home.


OK, so psychiatry has had its image problems. And not just in the public eye; its image hasn’t fared much better within the medical profession. Throughout the last half of the 20th century, the number of medical school graduates entering the specialty suffered a steady decline.


The increasing emphasis during the past 50 years on clinical research and evidence-based medicine cast an aura of uncertainty on psychiatry, whose practices seemed to be based more on instinct and humanism than on hard science. Medical students were—and in some ways continue to be—stigmatized for their interests in this specialty, which hit rock bottom in 1998, when just 428 U.S. medical school graduates matched into general psychiatry residency programs. (See “Overcoming Psychiatry’s Stigma,” p. 9.)


But the field is making a comeback. By 2004, the number of U.S. graduates matching to psychiatry jumped to 641. And with foreign medical graduates picking up much of the slack, the total entering the field this year comes to 979.


There are plenty of reasons for the renewed interest. Despite its lingering image problem, psychiatry is more appealing thanks to changes in the way it’s practiced. Today’s psychiatrist has far more options for helping her patients than her predecessors had. The field also offers a wealth of career opportunities as well as job flexibility and the kind of family-friendly employment opportunities that can be hard to come by in other areas of medicine. But perhaps psychiatry’s most attractive feature is that it is one of the few specialties in which physicians can take time to establish relationships with their patients—not a small thing when surveys continue to show one of the primary reasons for dissatisfaction with the practice of medicine is that physicians spend more time with their paperwork than with their patients. And all of this is happening at a time when advances in neuroscience are chipping away at stereotypes, offering exciting new avenues for research and a wealth of increased treatment options.


REUPHOLSTERING THE COUCH


The public image of psychiatry is based largely on one psychiatrist and the school of therapy he founded. Dr. Sigmund Freud, the father of psychoanalysis, casts a long shadow over the field. Although the early years of the 20th century saw the development of a variety of psychological theories and therapies—some based on sound medicine, while such others as electroconvulsive therapy and the frontal lobotomy proved more alarming—it was Freud’s psychoanalysis that grabbed the spotlight. Freud theorized that conflicts between different aspects of a patient’s unconscious are the roots of all psychological problems, and he developed the discussion-type therapy to locate and deal with them. It is his method, his couch and even his beard that shaped much of psychiatry’s image.


Yet, no sooner had psychoanalysis taken hold than, like a Protestant religion, disagreements over doctrine, competing factions and opposition movements splintered the faithful and spawned a variety of new therapies ranging from Jungian analysis to variant psychodynamic techniques. Today, a savvy consumer of talk therapy has almost as much choice in the mental-health market as she does in the cereal aisle of the supermarket. And with such a wide array of treatment options, psychoanalysis is becoming one of the least popular.


But it’s by no means dead. The American Psychoanalytic Association claims 3,200 members, and “psychoanalysis is still a vibrant, intellectual field,” says Dr. Phillip Freeman, a training and supervising psychoanalyst at the Boston Psychoanalytic Society and Institute. It’s just that if Freud no longer defines the field of psychiatry, neither does he define psychoanalysis.


“Psychoanalysis has changed over time, with a wealth of attention to refinements that help the analyst do a better job,” Freeman says.


So, in recent years, strict Freudians have had to make room on the couch for other methods, styles and theories. One of the most commonly used methods of psychotherapy is cognitive behavioral therapy, which focuses on modifying the patient’s beliefs and changing her problematic behaviors rather than searching her unconscious.


Cognitive behavioral therapy is attractive to patients, insurers and practitioners, in part because of its efficiency. Whereas meeting the goals of psychoanalysis can take years, patients undergoing cognitive therapy can see results in months or sometimes weeks.


It “tends to be very pragmatic,” says Dr. Judith Beck, director of the Beck Institute for Cognitive Therapy and Research at the University of Pennsylvania and the daughter of cognitive behavioral therapy’s founder, Dr. Aaron Beck. One of the goals of this approach is to reduce the patient’s need for therapy. The cognitive therapist gives the patient skills she can use when she is not in the therapist’s office. “We want patients to feel better at the end of their sessions, but more important, we want them to feel better all week,” Beck says.


Cognitive behavioral therapy and similar techniques are popular, and clinical trials have shown them to be relatively successful. But, they face some stiff competition from the prescription pad.


POPPING PILLS


Today’s psychiatrist has at her fingertips pharmacological resources that would have seemed miraculous 50 years ago, and they are time- and cost-effective, leading more psychiatrists to replace talk therapies with chemical treatments.


The mid-20th century saw the development of the first psychotropic medications. In 1949, lithium became available for treating manic depression and was soon followed by such antipsychotics as Thorazine and such tricyclic antidepressants as Tofranil and Elavil. The availability of these drugs brought major changes to the treatment of mental illness, moving it from the asylum to the community clinic.


But the real psychopharmacology revolution has come only within the past 15 years, led by the introduction in the late 1980s of selective serotonin reuptake inhibitors (SSRIs), a hugely popular new class of drugs for treating depression. It is estimated that more than 10 million people in the United States take some form of antidepressant, mostly SSRIs. According to many clinicians, the drugs are remarkably good at alleviating depression with relatively few side effects.


Others, however, are not so sure, and SSRIs have recently become the subject of much criticism. Several studies have indicated that in clinical trials, SSRIs do not perform much—if at all—better than a placebo. The common minor side effects, including sexual dysfunction, nausea and insomnia, can be quite unpleasant—and the major ones are deadly.


When they first came on the market, SSRIs were accused of inducing violence and suicide in some patients. Although these initial claims were never substantiated—the drug manufacturers settled out of court on several cases—evidence now shows SSRIs can cause suicidal thoughts and behaviors in children. In September, the U.S. Food and Drug Administration (FDA) said as many as 3 percent of children taking SSRIs could blame their suicidal tendencies on the drugs and not their depression. An FDA advisory panel recommended the medications carry the strongest warning the agency can mandate, although at press time, FDA officials had not made a decision on the matter. And GlaxoSmithKline, the manufacturer of the widely prescribed antidepressant Paxil, recently settled a lawsuit with New York state by paying $2.5 million and agreeing to publicly disclose all of its findings in clinical trials about the drug’s safety in children, for whom it is often prescribed.


Despite the negative publicity, physicians continue to prescribe the drugs, perhaps too often. “SSRIs are probably being overprescribed,” says Dr. Michelle Pent, a chief resident in the Harvard Longwood Psychiatry Residency Training Program. “Many of the people on SSRIs are struggling to cope, suffering from ‘modern malaise.’ In these cases, medication is not always the best first step. But for the majority of my patients—most of whom have severe, debilitating, chronic illnesses, such as schizophrenia, bipolar disorder, major depression—various medications are the mainstay of my practice. In my experience, these drugs are keeping people out of the hospital and functional.”


FROM THE COUCH TO THE LAB


The marked increase in the use of psychoactive drugs may have been due in part to the pharmaceutical industry’s energetic marketing and to the relief the drugs offer patients, but it was almost certainly not due to a clear understanding of why these drugs work. The search for the biochemical underpinnings of mental illness has been on for some time, and the fact that adjusting certain chemical balances in the brain often seems to help has been accepted for years. But why this succeeds is still largely a mystery, although a recent surge of interest in neuroscience has led to a better understanding—or at least some new theories—of how the mind works, and therapies based on science may be on the horizon.


Noboru Hiroi, Ph.D., director of the Laboratory of Molecular Psychobiology at Albert Einstein College of Medicine, has done seminal work on the genetic basis of mental illness. “We are finding out a lot about the molecular basis of mental diseases,” he says, predicting researchers will be able to offer treatments based on scientific findings in about 10 years.


This bench-to-bedside approach, common in such fields as oncology, is a new one for psychiatry. “Psychiatry is really benefiting from this more organized, formalized approach,” says Dr. Michelle Riba, president of the American Psychiatric Association (APA).


Srijan Sen, an eighth-year M.D./ Ph.D. student at the University of Michigan (UM), agrees. “Psychiatry is a very exciting place to be.”


Sen recently completed his dissertation on locating the genes responsible for depression. While finding particular biochemical causes for mental illness is still a long way off, he believes progress is being made: for example, in finding the differences in gene patterns between depressed and healthy people and in using MRIs to discern changes in the brain after medication or psychotherapy. These discoveries, preliminary as they are, are already helping to reduce the stigma associated with mental illness. “The stigmas are definitely there, but that is changing. The more we know about the chemical changes in the brain associated with mental illness, the less the stigmas will hold up,” Sen says.


A FLEXIBLE AND CHALLENGING CAREER


With new and better tools at their disposal for helping their patients, clinical evidence to support their decisions and better science on the way, more future physicians are becoming interested in psychiatry, rapidly moving the field from the fringes of modern medicine to the mainstream. But there are also more personal reasons the specialty is gaining ground.


“There are so many opportunities for psychiatrists today; it’s kind of like being a kid in a candy store,” Riba says. Psychiatrists can specialize in child and adolescent, geriatric, addiction or forensic psychiatry, or they can do research. And these are just a few of the options. Practice settings vary from private offices to state hospitals to community health clinics, and a psychiatrist can combine various opportunities in creative ways to meet her intellectual and practical needs.


“It’s very exciting,” says Dr. Deborah Hales, the APA’s director of medical education. “A psychiatrist can have several types of careers at once.”


It can be satisfying on a clinical level as well. “People really do get better. We can do some prevention and help patients and their families go on and have happier, healthier lives,” Riba says.


And the career satisfaction continues after the white coat comes off at the end of the workday. Thanks to the multitude of practice choices, psychiatry can offer a controllable lifestyle, especially to women trying to balance a family and career. “Psychiatry is a very family-friendly specialty,” Riba says. “I know of two residents, both pregnant, who job-shared, shared [emergency room] call and that kind of thing. It worked well for them.”


Hales adds that unlike some specialties, in psychiatry it is easy to have a part-time practice, possibly one reason more women than men choose it.


That is not to say the specialty does not offer challenges. There is a definite shortage of psychiatrists, and funding for mental-health care can be scarce. Despite the availability of new therapies and a lessening of the stigmas associated with mental illness, more than one-third of those sick enough to need professional care aren’t getting it. The reasons are varied, but cost is a major factor.


According to a recent article in Psychiatric Times, states are cutting funding for social programs, community mental-health initiatives and Medicaid, on which 65 percent of schizophrenics and 25 percent of those with severe depression rely. Mainly due to staggering state budget deficits, the cuts to these programs can have devastating effects on patients and their communities.


And public health is not the only area in which mental-health funding suffers. Managed-care companies and other insurance providers are increasingly likely to refuse payment for what professionals deem necessary care. Legislation pending in Congress—the Wellstone Mental Health Equitable Treatment Act—would require group health plans to cover mental-health care to the same degree they cover medical and surgical services, and while the APA is working to get the act passed, it is a big battle. “We are very hopeful it will pass, but there are a lot of distractions right now,” Riba says.


However, the federal government isn’t turning a completely blind eye to the issue. The president’s New Freedom Commission on Mental Health found the nation’s mental-health-care network in dire need of some therapy and issued some recommendations, including the development of evidence-based practices, a national strategy for preventing suicides and the integration of mental-health care into primary care settings.


For the most part, mental-health experts and advocates support these suggestions. However, they do not welcome the report’s insistence that all the necessary changes can be accomplished without additional funding, a finding few see as realistic.


While these challenges don’t seem to be keeping future physicians from the field, they are impacting psychiatrists once they get there. Pent says her practice is rewarding, “but the realities of the mental-health system are worse than I expected.


“The financial resources are very limited. Insurance companies are not paying for what patients need, and all too often my hands are tied when it comes to providing my patients with what they need, rather than what insurance will pay for.”


GETTING THERE


For those future physicians willing and eager to take on psychiatry’s challenges and flexible career options, it is possible to tailor an education to match those plans, something even premeds can consider. Most medical schools’ curricula provide a basic preparation for psychiatry training, but different programs have different emphases: Johns Hopkins University School of Medicine is known for its biological approach and research initiatives; the University of Pennsylvania School of Medicine is home to the Beck Institute with its focus on cognitive therapy; and UM has given Sen and his fellow students the opportunity to conduct innovative research.


Future physicians should find a program that suits their approach and interests, but looking for a place that offers a wide variety of experiences is a good idea, too, advises Hales, pointing to the University of San Francisco as an example. The school’s three psychoanalytic institutes and quit-smoking clinic offer medical students clinical opportunities, while its San Francisco General Hospital provides a glimpse into psychiatry in a public-health setting. Opportunities for research in neuroscience and schizophrenia are also available.


The research element is important, Hiroi says. He urges students to take the core courses in the hard sciences and to consider entering an M.D./Ph.D. program. “In the near future, a psychiatrist will really need a background in a scientific area,” he says.


Hales agrees: “There is a crying need for researchers in psychiatry. But there is also a need for people with strong clinical skills. We need scientists, and we need humanists.” She predicts psychiatry will maintain its basic humanism, even as it becomes more scientific and evidence-based.


“Humanists who read Hamlet to better understand indecision can work alongside lab scientists who want to understand the molecular basis for behavior. The fact is psychiatry needs to embrace its dual nature,” she says. This could appeal to greater numbers of medical students, many of whom are devoted to preserving humanism in medicine.


And while it may be a long time before the stigma completely fades and the jokes improve—two psychiatrists pass each other in the hall. The first one says, “Hello.” The other thinks, “What did he mean by that?”—the field has at least convinced increasing numbers of new physicians that the specialty itself is no joke.
ew Physician contributing editor Avery Hurt is a freelance journalist based in Birmingham, Alabama. Direct comments about this article to tnp@www.amsa.org.