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.