Two Psychiatries

A common—and ever-increasing—complaint of physicians is that so many variables interfere with our ability to diagnose and treat disease:  many patients have little or no access to preventive services; lots of people are uninsured; insurance plans routinely deny necessary care; drug formularies are needlessly restrictive; paperwork never ends; and the list goes on and on.  Beneath the frustration (and, perhaps, part of the source of it) is the fact that medical illness, for the most part, has absolutely nothing to do with these external burdens or socioeconomic inequalities.  Whether a patient is rich or poor, black or white, insured or uninsured—a disease is a disease, and everyone deserves the same care.

I’m not so sure whether the same can be said for psychiatry.  Over the last four years, I’ve spent at least part of my time working in community mental health (and have written about it here and here).  Before that, though—and for the majority of my training—I worked in a private, academic hospital setting.  I saw patients who had good health insurance, or who could pay for health care out of pocket.  I encountered very few restrictions in terms of access to medications or other services (including multiple types of psychotherapy, partial hospitalization programs, ECT, rTMS, clinical trials of new treatments, etc).  I was fortunate enough to see patients in specialty referral clinics, where I saw fascinating “textbook” cases of individuals who had failed to respond to years of intensive treatment.  It was exciting, stimulating, thought-provoking, and—for lack of a better word—academic.  (Perhaps it’s not surprising that this the environment in which textbooks, and the DSM, are written.)

When I started working in community psychiatry, I tried to approach patients with the same curiosity and to employ the same diagnostic strategies and treatment approach.  It didn’t take long for me to learn, however, that these patients had few of the resources I had taken for granted elsewhere.  For instance, psychotherapy was difficult to arrange, and I was not reimbursed for doing it myself.  Access to medications depended upon capricious, unpredictable (and illogical) formularies.  Patients found it difficult to get to regular appointments or to come up with the co-payment, not to mention pay the electric bill or deal with crime in their neighborhood.  It was often hard to obtain a coherent and reliable history, and records obtained from elsewhere were often spotty and unhelpful.

It all made for a very challenging place in which to practice what I (self-righteously) called “true” psychiatry.  But maybe community psychiatry needs to be redefined.  Maybe the social stressors encountered by community psych patients—not the least of which is substandard access to “quality” medical and psychiatric services—result in an entirely different type of mental distress, and demand an entirely different type of intervention.

(I should point out that I did see, at times, examples of the same sort of mental illness I saw in the private hospital, and which did respond to the same interventions that the textbooks predicted.  While this reaffirmed my hope in the validity of [at least some] mental illnesses, this was a small fraction of the patients I saw.)

Should we alter our perceptions and definitions of illness—and of “psychiatry” itself—in public mental health?  Given the obstacles found in community psychiatry settings (absurdly brief appointment times; limited psychotherapy; poor prescription drug coverage; high rates of nonadherence and substance abuse; reliance on ERs for non-emergency care, often resulting in complicated medication regimens, like dangerous combinations of narcotics and benzodiazepines), should we take an entirely different approach?  Does it even make sense to diagnose the same disorders—not to mention put someone on “disability” for these disorders—when there are so many confounding factors involved?

One of my colleagues suggested: just give everyone an “adjustment disorder” diagnosis until you figure everything out.  Good idea, but you won’t get paid for diagnosing “adjustment disorder.”  So a more “severe” diagnosis must be given, followed closely thereafter by a medication (because many systems won’t let a psychiatrist continue seeing a patient unless a drug is prescribed).  Thus, in a matter of one or two office visits (totaling less than an hour in most cases), a Medicaid or uninsured patient might end up with a major Axis I diagnosis and medication(s), while the dozens of stressors that may have contributed to the office visit in the first place go unattended.

Can this change?  I sure hope so.  I firmly believe that everyone deserves access to mental health care.  (I must also point out that questionable diagnoses and inappropriate medication regimens can be found in any demographic.)  But we psychiatrists who work in community settings must not delude ourselves into thinking that what’s written in the textbooks or tested on our Board exams always holds true for the patients we see.  It’s almost as if we’re practicing a “different psychiatry,” one that requires its own diagnostic system, different criteria for “disability” determinations, a different philosophy of “psychotherapy,” and where medications should be used much more conservatively.  (It might also help to perform clinical trials with subjects representative of those in community psychiatry, but due to their complexity, this is highly unlikely).

Fortunately, a new emphasis on the concept of “recovery” is taking hold in many community mental health settings.  This involves patient empowerment, self-direction, and peer support, rather than a narrow focus on diagnosis and treatment.  For better or for worse, such an approach relies less on the psychiatrist and more on peers and the patient him- or herself.  It also just seems much more rational, emphasizing what patients want and what helps them to succeed.

Whether psychiatrists—and community mental health as a whole—are able to follow this trend remains to be seen.  Unless we do, however, I fear that we may continue to mislead ourselves into believing that we’re doing good, when in fact we’re perpetuating a cycle of invalid diagnoses, potentially harmful treatment, and, worst of all, over-reliance on a system designed for a distinctly different type of “care” than what these individuals need and deserve.

26 Responses to Two Psychiatries

  1. Kevin says:

    Great article. I managed an outpatient psychiatric clinic for three years, and agree with pretty much everything you said. I do, however, disagree with your claim “that medical illness, for the most part, has absolutely nothing to do with these external burdens or socioeconomic inequalities.”

    Much research has been done on this, and it strongly and clearly shows that many, if not most, medical illness has *very* much to do with said burdens and inequalities, as well as other immaterial factors, mostly related to emotions. Even illnesses like cancer, diabetes, and heart disease are strongly affected by emotional factors such as these.

    See ‘When the Body Says No’ by Dr. Gabor Mate for more details.

    Again, great article. Thanks.

    • stevebMD says:


      Thanks for your comments and for the Gabor Mate reference. You are absolutely right, illness does depend upon social, economic, and intrapersonal factors. My statement was meant to pertain to the underlying pathology alone: My infected gall bladder or atherosclerotic coronary artery looks just like yours and should be treated the same way, regardless of the pathways we took– or choices we made– to get them.

      In psychiatry, the “immaterial” factors to which you refer are writ large. Not only is there no clear “pathology” most of the time, but one is often inferred simply on the basis of a provider’s expectations, practice setting, and patient demographic. In community psychiatry, these actors usually steal the show, and an attempt to do a thorough assessment (i.e., to practice “real” psychiatry, in my unfortunate use of that term) is usually thwarted by one of a panoply of obstacles, which themselves deserve much more of our attention than we give them.

  2. Discover and Recover says:

    Dr. Balt,

    You wrote:

    “This involves patient empowerment, self-direction, and peer support, rather than a narrow focus on diagnosis and treatment.”

    Which is precisely why these people recover!


  3. Nathan says:

    While firmly against the idea of creating “two psychiatries” and the idea that real psychiatry is practiced in one kind of setting and an adapted one in another, how about a conceptualization of well-being takes into account that everyone is embedded in a socio/economic/political/historical framework that shape our experiences and health in profound ways. This comes with a very critical examination of how psychiatric practice has come to be (background of psychiatrist, expectations for their lifestyles, how patient populations are conceptualized and treated differently and to whose benefit, etc.) Your hopes that the mental disorders you treated had validity is belied by the fact that they were diagnosed in particular kinds of patients with particular means and by your own admission that they are quite different than the patients you treat in community health settings. With such a limited and nonrepresentative sample, it does not surprise me that “traditional psychiatry” is often seen as more beneficial for that population (from/for which it was designed) than more generally. This has happened since the beginning of modern era psychiatry starting with the early analysts who made sweeping claims based on a very limited and very similar patient demographic (and even then had to fudge a lot of the source material of those claims.)

    • Nathan says:

      And just had to add, after rereading the first paragraph of this essay, how disheartening it is to know that physicians are pretty aware of the deeply unequal, loaded, difficult systems and conditions in which medicine is practiced and how it affects their patients. As a profession that purports both scientific and practice authority on human health, high social prestige, some of the highest incomes of the professions, large numbers, and already well funded and organized professional organizations, doctors are in the best position to organize and advocate on behalf and with their patients to challenge the conditions that interfere with the ability for all people to access quality care. If doctors are complicit in the face of such inequities in healthcare, then I certainly am ok with the continued push to de-center the roles of physicians from the top of health care systems and manage them as part of more just health care delivery systems where they do not set the agenda.

      • stevebMD says:


        Physicians’ roles have already been decentralized, thanks precisely to those professional organizations that should “advocate on behalf and with [our] patients.” And it ain’t getting much better.

      • Nathan says:

        My language was bit strong, but it is pretty deary then that professional organizations of doctors are not advocating for quality and accessible patient care. I just naively wish that physicians could be more aggressive in pursuing health justice given the resources and power they could muster in that pursuit. Them not doing it forces others to do it, with less capability and with less medical education/experience. It is an opportunity for doctors to be honest and impressive with their knowledge of health, but it just doesn’t happen. Perhaps the track to a medical career does not leave a lot of time for thought or interest in health (I often see health promotion and practiced medicine as often at odds), and in developing skills in medicine, doctors do not learn how think about other ways to promote well-being that enable or compliment their practice and values.

      • stevebMD says:

        A doc can get paid $200K+ for seeing >30 patients and simply writing scripts all day in a community clinic.

        If that same doc wants to “promote well-being,” it’s often on his own dime.

        Any questions?

      • Nathan says:

        I guess that’s why I have become less trusting of physicians, more skeptical the knowledge base from which they derive authority, and more at odds with values the they bring to their work.

        I suppose I advocate for pay to be associated with outcomes, not outputs (the robustness of benefits experienced by patients when engaged in health systems, not how many patients seen, prescriptions written, tests, performed, etc.) Teachers are moving in this direction, with teachers whose students achieve greater educational outcomes being paid more than usual and teachers whose students who do not do as well getting axed. Good teachers can make more money and education improves.

    • stevebMD says:

      Good points. Perhaps a better title for this post would have been “Will The ‘Real’ Psychiatry Please Stand Up?”

  4. Jay says:

    I thoroughly appreciate your willingness to address controversial issues in this blog. And your willingness to take flack.

    Health care disparities are receiving a lot of press these days, and Psychiatry access is one of the more glaring examples. I’ve worked for a CMH agency for 26 years and can attest to the dismay expressed by the local physicians about the inability to have someone seen by a psychiatrist. Our agency receives 40 hours of Psychiatry coverage per month. This county has a population of 120,000 residents. Our medication clinic is severely restricted to folks who carry severe/persistent mental illness diagnoses.

    We currently have a great doc and are blessed that she shows no signs of bailing. We have rarely had one who has stuck around for more than two years, making it an ongong shell game for our long-term clients. “Community Psychiatry” is hardly attractive or lucrative. Except for those in academic settings, Psychiatry remains one of the lowest paid medical professions, and the liability risks are daunting. My heart goes out to all of you in this field, flying by the seats of your pants.

    • Nathan says:

      I do also appreciate Dr. Balt’s willingness to tackle difficult issues and be open to criticism.

      I also appreciate that there are many people with intent to be helpful in the field of community psychiatry (or psychiatry in general) who could have pursued a more clearcut medical career with a higher income. I may share some empathy for people with good intent, but do not share admiration of a field that has advanced only as far as practitioners “flying by the seats of [their] pants.”

      If the science underpinning the practice of psychiatry is underdeveloped, weak, contradictory, and ideologically/fiscally driven (even in comparison to other medical specialties), then no matter the intent of the practitioners or what they potentially gave up to pursue their helpful intent, if their patients do not experience outcomes from treatment, their efforts are far from generally helpful and can be potentially harmful.

      I don’t like to doubt that doctors do want to help people, but wanting to help people is not enough for people to experience relief/benefit/recovery. There are plenty of ways to be robustly helpful that aren’t psychiatry. If people choose to channel their energies into psychiatry, then they have a responsibility to advance the science of the field, design effective and just healthcare systems for people to access quality care, and to continually model their effectiveness. If psychiatrists can support people in experiencing valuable outcomes, then they can show evidence of the value of their work they can use to ask for higher pay.

  5. mara says:

    It sounds like the biggest barrier to appropriate treatment is money. I heard some interesting theories about how to fix the healthcare system. One was to completely cut out insurance companies. That would drive down the cost of care. And that actually sounded like a good idea to me. What if healthcare was (gasp!) affordable. What if no one even thought twice about going to see a doctor or a therapist, unless they were ultra poor, because it was just a given that your average person could afford it. And we could just subsidize all the people who are low income. I would think it would be easier on doctors to just cut out the insurance companies because they wouldn’t need to hire people specifically to deal with the insurance companies. Also, it would give them more opportunity to be innovative and run their practices how they want. The quality of the care might go up too.

    I heard another theory, which is that everyone in America should be put on Medicare. And then people can buy something nicer if they want it. But I don’t know how interested Medicare is in innovation and better quality care for low income people.

    • stevebMD says:

      Mara, I know it’s a cliche to say that doctors just want to “cut out the insurance companies,” but I can say that from first-hand experience, it would make life a lot easier and improve the care I provide. When Medicaid cares more about the content of my notes than in whether my patient gets the metabolic syndrome or TD, then I know it’s time (regrettably) to leave public-sector psychiatry.

      I am considering starting a solo, cash-based private practice later this year. I always told myself I wouldn’t be one of those psychiatrists treating only the “worried well” who could afford to pay cash for their office visits with me. Unfortunately, not only is this the only viable business option (blogging pays zero!), but it’s the only way I would get to practice the type of psychiatry I espouse in this blog.

      PS: To get a sense of the finances of a typical medical practice, check out this story in today’s Wall Street Journal. Note, in particular, that there’s a 1:7 (!) ratio of doctors to staff. Mostly for billing purposes, I’m sure.

    • stevebMD says:

      “…everyone in America should be put on Medicare. And then people can buy something nicer if they want it. But I don’t know how interested Medicare is in innovation and better quality care for low income people.”

      Sounds like the way health care is administered in some European countries, like Germany (where I lived for a while). Paradoxically, “innovation and better quality care,” while it sounds good, is not always what we need. Consider atypical antipsychotics, transcranial magnetic stimulation, and PET scans; these are “innovative” additions to modern psychiatry over the last decade, but do they always lead to “better quality care”? And if so, at what cost?

      • mara says:

        I really don’t blame you for wanting to go cash only. If you accepted insurance, then you probably wouldn’t get to see your patients for much longer than 15 minutes (even when they need far more time to discuss options). They might as well just go see their GPs once a year and get their meds from them. They can get psychotherapy from a counselor. If you want a practice that is more dynamic than what an insurance company will reimburse for you might as well go cash based. I really think the only reason I retained a psychiatrist was because I didn’t trust my old GP to prescribe psych meds. I might trust the new one. You can always take a certain amount of low income patients and just treat them at reduced price or as a charity. You can eventually do what One Boring Old Man does. Now that he’s retired, he just works for free once a week.

        Innovation doesn’t necessarily need to mean technological innovation. I’m actually talking about something so much more simple that: getting out of the idea that spending more than 15-20 minutes with the patient is excessive, looking for physical causes (why go to med school if you can’t even do that?), and prescribing non medicinal solutions.

        I get why Daniel Carlat thought psychiatrists shouldn’t go to med school and should get more streamlined training instead. It’s not like you guys are taking vitals and running all kinds of tests to determine if the body is functioning correctly. When was the last time you actually checked your patient for a heart condition before prescribing a stimulant or ran tests to see if your patient’s fatigue was caused by more than just depression.

  6. vacquarterly says:

    I understand the argument for psychiatrists not going to med school, but I also know a psychiatrist who was able to recognize a patient’s ostensibly psychiatric symptoms as actually being a brain tumor. He recommended the patient get tested for a brain tumor and that was indeed the case. Apparently this psychiatrist has had that (and similar) experiences many times in his 30-year career. I think anyone treating people’s minds absolutely *needs* to have a thorough training in treating bodies (anatomy/physiology) as well, as the two are, at the end of the day, inseparable.

  7. Psychiatrists are medical doctors—the medical conditions which are negative effects of the neuroleptic and other psychiatric drugs prescribed by psychiatrists to my son both as a minor and an adult are and have always been ignored—e.g. medically neglected by the ‘doctors’ whose ‘treatment’ caused them. It is standard practice for iatrogenic illnesses and injuries to be called, ‘tolerable side effects’ and for drug-induced iatrogenesis to be attributed to the patient’s ‘worsening condition’ which is pretty convenient…but not at all ethical. Somewhere along the line some ‘professionals’ have deluded themselves into believing that what is and is not tolerable is a determination that they the doctor makes. It is obviously a the determination that can only be made by the patient. It cannot be the treating physician’s; it is not the physician who is tolerating the deleterious impact of the prescribed ‘treatment’! It is equally obvious that the medical examination to exclude other causes for the symptoms that are used to diagnose schizophrenia are rarely done; which is strange, since schizophrenia is a diagnosis of exclusion. How can a diagnosis of schizophrenia be valid or ethical without excluding the other potential causes for the symptoms? In my son’s case, Temporal Lobe Epilepsy was excluded by taking it off his medical record…which is not ethical or legal.

  8. dreamingnp says:

    I am a psych NP who just survived her first year of practice in a community behavioral health outpatient clinic. Fresh out of school, I found myself with a near 50% SMI caseload. I can definitely relate to the two psychiatries dilemma. My clients rarely present like the DSM. Cut and dry MDD, bipolar I, ADHD, GAD etc are not my norm. I felt completely confused and incompetent clutching my DSM and medication algorithms.

    My clients have PTSD and Axis II disorders from appalling chronic child abuse/neglect. My clients have either current or previous substance abuse. They live in poverty. They do not have stable residences or even phone numbers. They have chaotic home lives with domestic violence and/or too many children to take care of.

    I am very fortunate to get 30 minute appointments (perhaps a NP perk?) so I spend a lot of my time assessing environmental stressors and education that their meds will not work well without treating both!

    I get very frustrated as Mood Disorder NOS is not considered an acceptable diagnosis. The moment comes when I must fill out the axises and unable to Mood disorder NOS, do I:
    -MDD (risking a label which may end in catastrophic medication choices for one who has bipolar)
    -bipolar (risking a sticky label which may etch itself into the client’s self-concept)
    -BPD axis II (an even more stigmatizing label).

    I try and emphasize to my clients (not in psycho-babble) that diagnoses are a work in progress, often representing only cross-section presentations until years of regular treatment.

    I find myself digging into the atypical cabinet as fire extinguishers. What do I do when someone comes into my office, with a chaotic environment which either cannot be changed or client refuses to change and/or with refusals of psychotherapy or to work on any non-medication mode of treatment? The person is out of control with anger outbursts and/or emotional meltdowns with suicidal ideation… I dig into the atypical off-label cabinet with a certain amount of shame and attempt to match acceptable side effect profiles the best I can.

    Any wisdom would be much appreciated =)

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