Managing Depression in Primary Care: Conclusions

Authors and Disclosures

Abstract and Introduction

Abstract

Background Current management in primary care of depression, with or without comorbid physical illness, has been found to be suboptimal. We therefore conducted a systematic review to identify clinician perceived barriers to and facilitators for good depression care.
Methods We conducted a systematic literature search to identify qualitative and quantitative studies published in the UK since 2000 of GPs' and practice nurses' attitudes to the management of depression. We used principles from meta-ethnography to identify common and refuted themes across studies.
Results We identified 7 qualitative and 10 quantitative studies; none concerned depression and co-morbid physical illness of any kind. The studies of managing patients with a primary diagnosis of depression indicated that GPs and PNs are unsure of the exact nature of the relationship between mood and social problems and of their role in managing it. Among some clinicians, ambivalent attitudes to working with depressed people, a lack of confidence, the use of a limited number of management options and a belief that a diagnosis of depression is stigmatising complicate the management of depression.
Conclusions Detection and management of depression is considered complex. In particular, primary care clinicians need guidance to address the social needs of depressed patients. It is not known whether the same issues are important when managing depressed people with co-morbid physical illness.

Background

Depression affects about 121 million people worldwide, and an estimated 5.8% of men and 9.5% of women will experience a depressive episode every year.^[1] Depression is a major cause of disability and distress^[2] and is expected to become the second most common cause of loss of disability-adjusted life years in the world by 2020.^[3] Rates of depression co-morbid with chronic physical illnesses such as coronary heart disease (CHD),^[4–6]asthma^[7–9] and rheumatoid arthritis^[10] are increased compared to those in the general population.^[11] When physical illness and depression co-exist, the conditions interact resulting in worse outcomes; for instance patients with CHD and depression have an approximate two-fold increase in morbidity and mortality.^[4–6]

In the UK 90–95% of patients with depression are treated solely in primary care,^[12] however, management is often suboptimal.^[13] Clinical practice is likely to be influenced by clinicians' attitudes,^[14,15] we therefore conducted a systematic review of qualitative and quantitative studies of GPs' and PNs' attitudes to managing depression. Our aim was to identify potential barriers to and facilitators for good depression care. To do this, we used principles drawn from meta-ethnography^[16] and recent guidelines for producing narrative syntheses^[17] to identify common and refuted themes across studies.

Methods

Eligibility Criteria

Inclusion Criteria 1) Qualitative or quantitative studies containing GP or PN generated data concerning their attitudes towards and experiences of managing depression.

2) Studies published in 2000 or later. This was a pragmatic method of including a manageable number of studies and ensured we obtained data on current and relevant attitudes (2000 is after the publication of the National Service Framework for Mental Health^[18]).

Exclusion Criteria 1) Studies not conducted in UK primary care settings. This was in order to obtain attitudes relevant to primary care practice in the UK, which is where a planned new intervention will be trialled.

2) Studies focusing on a single aspect of management, e.g. antidepressant prescribing. This was because our aim was to identify broad themes which could be addressed in planned later studies specific to CHD and co-morbid depression.

3) Studies of 'psychological distress', post-natal depression, intervention studies of depression education and validation studies of attitude questionnaires. These studies were considered unlikely to provide data which could inform primary care depression management.

Information Sources and Search

With the help of a specialist librarian, we devised a search strategy based on terms relating to depression, primary care and attitudes (Appendix 1). This was adapted for 4 databases (Medline, Embase, Psychinfo, British Nursing Index and Archives; search date 30^th June 2008). We also searched the reference lists of obtained papers.

Study Selection

Titles and abstracts were screened for relevance by 1 reviewer (EB); where this was unclear, the full text was obtained. The full texts of potentially relevant articles were assessed independently by two reviewers (EB and JM). Agreement was measured using Cohen's Kappa and disagreements resolved by discussion.

Quality Assessment of Included Studies

Two reviewers (EB, JM) independently assessed each paper for methodological quality. For qualitative papers, the CASP checklist ^[19] was used. As there is no established instrument for quantitative observational studies,^[20] we devised a simple checklist based on the STROBE statement^[21] and a recent review of tools to assess bias in observational studies^[22] (Appendix 2). Agreement was measured using Cohen's Kappa weighted for closeness of scores. Disagreements were resolved by discussion. In qualitative synthesis there is a tension between study quality and relevance,^[23] so in common with other such syntheses^[24,25] an inclusive approach was taken. Quality judgements were not used to exclude papers, but, the strength of findings was tested by examining whether they were supported by studies in the upper tertile of scores.^[25]

Data Collection Process and Data Items

Data concerning participant characteristics, aims, setting and methods were extracted independently by two authors (JM and EB) (Additional File 1. Table 1). Two further types of data were extracted:

1. First order constructs:^[26] reported attitudes and experiences of GPs and PNs (qualitative papers) and summaries of participant responses to questionnaire items (quantitative papers).

2. Second order constructs:^[26] author-derived themes, conclusions, interpretations and recommendations (qualitative papers) and results headings, conclusions and recommendations (quantitative papers).

Extracted data were tabulated. The original wording or a paraphrase was used to preserve meaning.^[27] The tables were examined and discussed by two authors (EB and JM) in order to ensure agreement and that second order constructs were grounded in clinician-generated data (first order constructs).

Synthesis of Results

A grid was produced using SPSS. The rows were the included papers and the columns were second order constructs. The second order constructs were translated across studies by combining columns with broadly related headings. Two authors (EB and JM) performed reciprocal and refutational syntheses^[28] to identify and summarise shared constructs across studies and constructs that were contested between or within papers. These syntheses were performed simultaneously as this is considered most informative.^[29] The resulting syntheses or 'translations' were agreed by all authors through discussion. The research team included an academic GP (AT), a psychiatrist (PW) and qualitative health researcher (JM) and a health psychologist and nurse (EB).

Results

We identified 826 papers; following the initial screen, 53 were reviewed in detail. 25 were not from the UK. The remaining 28 were screened independently by 2 authors (EB and JM). 17 papers (7 qualitative and 10 quantitative) were included in the review (Cohen's Kappa = 0.68). This process and the reasons for exclusion are shown in Figure 1.

(Enlarge Image)

Figure 1. Search results: numbers of included and excluded studies and reasons for exclusions.

All the studies concerned adults. Four studies focused on older adults (late-life depression); we report findings separately for this population only where differences were apparent. We found no studies of managing depression co-morbid with physical illness. Characteristics of the included studies are shown in Additional File 1.Table 1. They provide data from 2,738 GPs (2,595 in quantitative studies) and 476 PNs (466 in quantitative studies) who vary in gender, age, years in practice, practice type, geographical location, level of mental health training and ethnicity. In most studies, discrete data for GPs and PNs were not reported, accordingly, in our synthesis their data are combined and identified differences highlighted.

Quality Assessment

Agreement for qualitative papers was good (weighted kappa = 0.62). All but 2^[30,31] (CASP score of 5 out of 10), were rated as of at least reasonable quality (CASP score ≥ 7). Agreement was also good for quantitative papers (weighted kappa = 0.73). We considered most of these to be low quality (achieving ≤ 4 out of 7 quality markers). They suffered from poor response rates and lack of a validated instrument to measure attitudes (Additional File 1. Table 1), few reported their selection criteria.

Second Order Constructs

Most of the qualitative studies reported a simple thematic analysis and the data from the quantitative studies tended to represent similar themes. We identified 7 second order constructs; all were supported by at least one good quality study and by both qualitative and quantitative data. The identified second order constructs and supporting data from each paper are summarised in Additional File 2. Table 2. Other issues, which were identified and used to inform the synthesis, were the effects of patient gender, ethnicity and age.

1.) Professionals' Understanding of Depression Two contrasting understandings were identified: depression as a normal response to life events and a biomedical model of depression.

Depression as a Normal response to Life Events Problems of everyday living such as isolation, loneliness, family breakdown and lack of social support,^[32–34] work stress (especially in suburban areas),^[32] housing problems,^[32,33] crime, unemployment and financial problems,^[30,32,33] illness,^[33] loss^[33] and reduction in function^[34] were seen as justifiably contributing to depression. This view was pronounced in studies of late-life depression where depression was attributed to the distressing effects of events associated with getting older but not to ageing per se.^[33,35]

Studies concerning late-life depression^[33,34] suggest that clinicians working with ethnic minority patients may try to normalise depression by using words such as 'loneliness' and 'homesickness' instead of depression.^[34] This may stem from clinicians' beliefs that depression is less recognised in some cultures.^[33] There are insufficient data to determine if the same occurs with younger patients.

Clinicians holding a 'normalising' understanding of depression found it difficult to distinguish between distress and depression and worried about medicalising social problems.^{[30,31,33,34,36]} Such an understanding may therefore conflict with the way in which diagnoses are made and treatments offered.^[31,33,34]

"If depression is conceptualized as a normal response to disadvantage, in which existential despair is the principal component, then the question of an appropriate diagnostic and management strategy could become as intractable as the illness itself."^[32(p634)]

Biomedical Understandings Depression is seen by some as 'a medical condition distinct from everyday life'^[36](pe5) which is caused by neurotransmitters^[36] or biochemical abnormality.^[35,37] This is associated with a view that depression is not inevitable^[38] and is treatable.^[36] Some clinicians' encouraged patients to understand depression as biochemical even when they themselves did not hold this view.^[31,36] Their aims in doing so were to:

'clarify the experience of depression, remove blame and stigma and to provide a way forward to use antidepressants'^[36] (pe5).

2.) Recognising Depression This construct concerned making a diagnosis, presentations of depression and the effects of a diagnosis of depression.

Making a Diagnosis Clinicians struggle to distinguish between 'normal' distress and depression requiring treatment.^[30,34,39] Some reported using subjective processes:^[30,34]

"I have my own kind of mental ways in finding out if people are depressed."^[34(p372)]

Case-finding tools were criticised as excluding important external cues.^[30,34] Where ratings of depression were compared with patient ratings, little agreement was found.^[38,40,41] Clinician characteristics may influence recognition of depression: GPs' diagnoses were more accurate if they felt confident treating depression^[38] and more recently trained nurses believed a higher proportion of their patients to be depressed.^[42]

Case-finding tools were not used in older people,^[34] despite diagnosis in this group considered especially difficult.^[33,34] Older people were perceived reluctant to accept a diagnosis of depression^[34] or to talk about their mood as it would 'waste' the doctor's time.^[33,34] However, such perceptions may be justification for clinicians' reluctance to make a diagnosis when they feel they have nothing to offer the patient.^[34]

Presentation of Depression Cues to depression were found to arise slowly, with patients often raising the issue when preparing to leave.^[39] Younger compared with older people were perceived more willing to broach the subject, but this was only explored in studies of late-life depression.^[33,34] Older people were considered more likely to attribute depression symptoms to a physical cause,^[33] but, when probed, clinicians agreed that this is common in all age groups.^[33] High levels of comorbidity within older people may, however, complicate depression diagnosis and lead to delay in treatment.^[33]

Ethnic minority (i.e. Caribbean and South Asian) elders were also thought to somatise their depression.^[33,34] This was not addressed in studies concerning younger populations. Data around gender differences were conflicting. Clinicians were aware of a greater risk of suicide in men, but, where some found men less likely than women to raise psychosocial problems, others reported no differences.^[33]

Effects of a Depression Diagnosis Professionals may be reluctant to diagnose depression if they feel they have nothing to offer the patient.^[34] However, patients and professionals may experience secondary gain from such diagnoses.^[32] For patients it may be a 'way out' of social problems or a way of avoiding work; hence GPs felt many patients seek medicalisation of their problems.^[32] For the GP, giving a diagnosis of depression allows them to follow a pre-determined treatment plan and to avoid feelings of powerlessness.^[32]

3.) Management Strategies An individualised approach based on a wide range of management options was favoured.^{[30,34–36,43,44]} However, clinicians reported using antidepressants, psychological therapies, listening and specialist services. For nurses, the most common strategy was to make a referral to the GP.^[34,42]

Antidepressants These were used most often.^[43,45] GPs commonly considered this their only option due to a lack of availability of psychological therapy or other specialist services.^[31,32] However, despite beliefs that antidepressants are effective,^[35,39] it was found that prescribing guidelines were not always followed and prescriptions were for too low a dose and for too short a time.^[40,44,45] Prescribing may be influenced by perceptions of patients' attitudes to antidepressants,^[34,40] although GPs reported strategies to overcome negative beliefs.^[34] GPs' attitudes,^[38] length of experience^[46] or perception of depression as moderate rather than mild^[40]may also influence overall prescribing or antidepressant choice (older and more experienced GPs were more likely to prescribe tricyclics than SSRIs).^[46]

In older people, uncertainty among GPs was found as to the effectiveness of antidepressants, drug interactions and side-effects.^[34] There was also concern that structural factors within a practice meant that older patients on antidepressants would not be properly monitored.^[34] There was a lack of data from nurses concerning antidepressant use. This may be because the nurses studied were not prescribers; it is not possible to determine this from the data.

Psychological Therapies Attitudes to psychological therapies tended to be positive,^[32,35,39] but reports of a lack of access or availability were common.^{[32,34,39,40,43]} One study^[32] found that suburban GPs compared with inner city GPs reported greater access, but the patients may have been accessing services privately.

GPs may be less likely to refer older patients for psychological therapy, either because they 'forget' about it or assume it will not work in this population.^[34] There were no data concerning ethnicity or gender in relation to psychological therapy. Data are lacking concerning nurses' views. However, in one study^[42] half of the nurses reported 'counselling' patients; it is not clear what was meant by this.

Listening This was considered important^[30,32,36] in helping patients unburden themselves, helping clinicians uncover diverse perspectives, improving the doctor-patient relationship (by creating trust and encouraging empathy) and as a useful adjunct to antidepressants.^[36,39] However, some clinicians considered their patients unable to open up^[32,39] or reported an inability to empathise with a patient's chosen lifestyle.^[36] Others avoided listening as they feared uncovering feelings with which they were powerless to help.^[34,36]

Listening requires time;^[34,39,45] a lack of time was reported in several studies^{[31,32,34,43]} but was refuted by one.^[39] GPs in this study had confidence in the effectiveness of antidepressants, their skills in providing counselling support and their capacity to utilize time flexibly. This study^[39] focused on time management and was able to identify more complex attitudes than the other studies. GPs may therefore be more willing or able to spend time with depressed patients than is generally thought.

Specialist Services Secondary care psychiatry or psychology, voluntary services and social care services were considered good quality,^[43] but provision and/or access to them was commonly considered inadequate.^{[31,34,39,43]} Lack of access to external services was seen as more of an obstacle to providing effective treatment of depression than personal knowledge or skill.^[43]

4.) Shame and Stigma Older patients were considered more sensitive to stigma than younger patients. Older people were perceived to display embarrassment when disclosing their feelings of depression. Such feelings were hypothesised to be founded in wartime experiences where stoicism was highly prized and in 'old-fashioned' views that depression is a sign of weakness or failure to cope.^[33] Fear that others may find out about their condition may be a barrier to treatment.^[33] GPs were wary of using the word 'depression' with older patients in case of causing distress, but some had observed less negative reactions to questions about mood and energy.^[33]However, concern about stigmatisation may be constructed to hide a reluctance to explore depression with patients arising from a desire to avoid feelings powerlessness when management options seem limited.^[34]

Stigma was considered more important for some ethnic groups (Caribbean and South Asian).^[33] Stigma in these communities was seen as a barrier to addressing psychosocial aspects of the illness and to beginning treatment. No study examined perceived stigma in younger people from these ethnic groups.

5.) Relationships Between Professionals Studies of late-life depression^[33,34] indicated that GPs and PNs may have conflicting views of their roles. GPs perceived PNs as having a limited role in the identification and management of late-life depression.^[34] None of the participants in one study^[34] could recall a nurse referring a case to them; the GPs did not refer to nurses as they felt PNs have enough to do. In contrast, PNs saw some GPs as demotivated and unwilling to engage with depressed patients. In another study,^[33] PNs felt they were in a better position to deal with depression than GPs as they had more time to explore psychosocial difficulties and operated in a less 'medical' context.

Three studies considered relationships with specialist services. One study^[31] suggested that GPs' had unclear expectations of such services, another,^[43] however found that GPs were satisfied by the services of specialist professionals, but complained of lack of access. PNs reported little interaction with specialist mental health services which they felt made it difficult for them to develop their knowledge and skills.^[42]

6.) Attitudes to Managing Depression Attitudes were diverse. Negative attitudes included unfavourable views of depressed people themselves e.g. 'burdens', 'not particularly attractive', 'people who bore you',^[32,36] pessimism concerning outcomes,^[31,32,36] feelings of the work being unrewarding^[19] and lack of confidence in their management skills especially, but not exclusively, in PNs.^{[34,37,42,44]} Some participants were positive about the outcome of depression management.^[30,32,39] However, positive attitudes may be accompanied by ambivalence, for instance some GPs were confident in managing depression, but found it 'heavy-going'^[35] and required more training.^[46]

7.) Clinicians' Training Needs That GPs and PNs felt that they lacked knowledge and wanted more training was a consistent finding^{[32,38,42,46]} This may be more common among older GPs and those without psychiatric training.^[46] However, despite wanting more training, PNs did not prioritise training in mental compared with physical health.^[42] A reported lack of uptake by GPs and PNs of training in the management of old age depression supports this.^[37]

A consistent recommendation was that training should involve consideration of professionals' views and attitudes towards depression^[32,38,42] as these impact on clinical decision making.^[31,38] It is also because of findings that a negative past experience of mental health training was associated with PNs' current negative attitudes towards engaging with patients' mental health needs.^[42]

Discussion

This systematic review of British GPs' and PNs' attitudes did not identify any studies concerning the management of depression co-morbid with physical illness despite the common co-occurrence of mental and physical disorders.^[11] The identified themes indicate barriers to and facilitators for good care in patients with a primary diagnosis of depression. Below we consider how these may relate to the care of people with depression and co-morbid physical illness.

This review indicates that depression and its diagnosis are considered complex. This is unsurprising since there is ongoing debate as to the nature of depression,^[47] the 'medicalisation of misery'^[48] and the appropriateness of different case-finding tools^[49,50] which complicates judgements about whether depression is 'under-diagnosed' or 'optimally treated'.^[48] The use of case-finding tools was discussed in some of the included studies, but most of these were conducted prior to the introduction of financial incentives under the Quality and Outcomes Framework of the UK GP contract^[51] in 2006 when their use became routine. A recent study^[49] found, as did this review, that there is ambivalence among GPs as to their use. The detection of depression in people with physical illness, such as CHD is likely to be viewed as even more complicated given the overlap between somatic symptoms of depression and of CHD and the potential for increased anxiety in people with CHD which may also be associated with depression.^[52]

Management of depression is perceived as particularly complex when patients present with social problems. That GPs and PNs are aware of the relationship between social and mood problems is clear from this review, but they are unsure of its exact nature and of their role in managing it. This uncertainty may be exacerbated by a lack of attention in guidelines concerning the influence of social problems on response to treatment.^[53] It may be especially important to address social problems in depressed patients where co-morbid physical illness has resulted in impaired functioning. Enhanced depression care interventions such as stepped care or collaborative care, which provide depression severity related treatment guidance to clinicians, have been shown to improve depression in chronic diseases such as diabetes and heart disease, although mortality or other disease outcomes have not improved.^[54–57] However, such research has often been conducted using case detection questionnaires to identifying participants. As such, this may not reflect clinical practice where a dimensional approach to diagnosis of depression is often taken.^[58] This may be particularly the case for milder forms of depression.

The other issues identified by this review, such as ambivalent attitudes to working with depressed people, a lack of confidence among some clinicians in their ability to manage this condition, the use of a limited number of management options and a belief that some patients will feel stigmatised by a diagnosis of depression also complicate the management of depression. Nevertheless, in a recent qualitative study,^[59] GPs reported being able to balance a range of complex factors such as the patients' clinical presentation and motivation and their own ability to help in terms of time, skills and expertise in their decisions to refer patients for psychotherapy. It is not known whether this is the case when managing patients with depression and co-morbid physical illness.

This review has also shown that GPs and PNs vary widely in their attitudes to, confidence in and knowledge about managing depression. Most of the data is from GPs, but from the available data, PNs appear to have similar views on many issues. PNs may be less likely to manage depression than GPs, but where depression is comorbid with physical illness PNs' views may be more important since they are taking an increasing lead in chronic disease management.

Strengths and Limitations of This Review

There is no consensus concerning selection of studies for inclusion in syntheses of qualitative studies^[29] or syntheses of both qualitative and quantitative studies.^[60] Syntheses of qualitative studies have been conducted using a small sample of key studies^[27] or the first 10 relevant papers located.^[61] In common with previous work,^[29] we aimed to include sufficient studies to provide a manageable quantity of rich data and as such devised a search strategy that was specific rather than overly sensitive. Since we aimed to identify broad themes, only studies which considered the whole depression management process were included. Studies which considered specific aspects, e.g. antidepressant use,^[14] were excluded but may further explain the themes that we have identified.

We were interested in current experiences in the UK so we only included recent British studies, this review is therefore limited in its consideration of cross-cultural issues in managing depression. Some data concerning attitudes towards managing depression in different ethic groups was identified, but this is limited to studies of late-life depression. It is not possible to determine from this review whether this is due to a lack of emphasis on this issue in the included studies or whether the GPs and PNs studied did not consider ethnicity to be an important factor when managing depression in younger people.

A strength of this review is that the synthesis incorporates diverse perspectives from reviewers with clinical and academic knowledge of depression. This is important as syntheses of descriptive studies necessarily involve interpretation of data.^[23] This contrasts with systematic reviews of treatment studies which aim to aggregate data in a way that minimises the impact of reviewer opinion (bias).^[23]

'Bias' is reduced, or made explicit, in reviews of descriptive data through transparency of methodology. Here, this was achieved through the use of techniques from established qualitative synthesis methodologies such as meta-ethnography,^[28] critical interpretive synthesis^[29] and recent guidelines.^[17] For instance whether primary study authors' interpretations (second order constructs)^[26] were grounded in participant data (first order constructs)^[26]was tested, primary study authors' own words were extracted^[27,62] and agreements and disagreements between studies (reciprocal and refutational synthesis) were sought throughout the process.^[15]

In order to obtain the richest possible dataset, qualitative and quantitative studies were included. However, there is no established methodology for combining data from both types of study.^[60] The comparability of studies using different methodologies was therefore tested by tabulating study type within each identified construct (Additional File 2. Table 2); this showed that each construct was supported by both study types. Use of methods from systematic reviews of treatment studies also increased the robustness of the synthesis. For instance, study selection, data extraction and quality ratings were made independently by two reviewers. Each identified construct was supported by a least one study of reasonable quality (Additional File 2. Table 2). Nevertheless, it is possible that reviewers using different methodologies may arrive at different conclusions. The explicit description of the methods employed here will help others determine where different interpretations could have been made.

Conclusions

There is a lack of research exploring primary clinicians' attitudes to the management of depression that is co-morbid with physical illness. This review has found that British GPs and practice nurses consider the diagnosis and management of depression to be complex. In particular more guidance and support to address patients' social problems is needed, especially since mental health policy in the UK^[63] promotes stronger links between health and social care. It is not known whether the same issues are important to clinicians when managing depressed people with co-morbid physical illness.

The present study was conducted as part of 'UPBEAT-UK',^[64] a research programme funded for 5 years by NIHR to understand and better manage the impact of co-morbid depression on CHD in primary care. Findings of this review such as that clinicians may view and manage depression in older people differently and that certain groups are considered more likely to somatise symptoms of depression are especially relevant to the management of depression in people with CHD who are likely to be older and to have multiple physical co-morbidities. The issues raised by this review will be explored by UPBEAT-UK through qualitative studies of depressed CHD patients' and their clinicians' experience.

Where Has Psychotherapy Gone?: Is There a Solution?

Authors and Disclosures

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Editor's Note: Medscape recently invited Dr. Stephen Strakowski to moderate a virtual discussion between psychiatrist John Gunderson, MD, psychologist David Reinhardt, PhD, and mental health nurse practitioner Ruth R. Staten, PhD, APRN-CS, on the decreasing use of psychotherapy by psychiatrists and how this development is impacting patient care. What follows is a transcript of their discussion.

Where Has Psychotherapy Gone? Introduction

Stephen M. Strakowski, MD: As you all are aware, studies suggest that psychotherapy is becoming an increasingly rare part of many if not most psychiatric practices.^[1] What factors do you think are responsible for this decline, and is this change in practice important? How does it affect psychiatry's role and reputation in the United States?

Ruth R. Staten, PhD, ARNP-CS: It seems to me there are at least 3 factors that contribute to the changes in psychiatry: (1) demand/need for services, (2) complexity, and (3) economic/financial.

With an increased number of persons with psychiatric/behavioral disorders and a decline in the number of providers, the time that patients have to wait to see a psychiatrist can be unreasonably long -- sometimes up to 3 months. There are some areas of rural America that have few if no providers, but we all feel like clients should have timely access to care. This critical shortage is particularly true for medication management. Psychiatrists have had the struggle of having clients or other healthcare providers begging for persons in need to be seen more quickly. Additionally, once the client is in the care of the provider/psychiatrist, appointments may be needed on a fairly frequent basis, until the client is at least out of a crisis and moving toward stability.

Though caring for persons with psychiatric illness has been complex, with the multitude of medication treatment options and the degree of chronic illnesses and medications that often accompany those illnesses, providing medical management can be quite demanding. Evaluating their medical conditions, assessing medication interactions, and monitoring psychiatric, physical, and laboratory findings are quite time consuming. The majority of an hour session can be taken up with evaluation of these issues. This leaves little time for traditional psychotherapy. Additionally, we have some very specific psychotherapies that require a fair degree of time and are often "manualized" to be true to the therapy. One has to wonder if the more one has time to deliver these therapies, the better they would become, so those who focus solely on these therapies might be the best able to deliver them.

The economic/financial considerations are a constant battle -- changing regulations and reimbursements, the cost of just doing business and seeking reimbursements, the emphasis of reimbursement on procedures rather than specific outcomes -- and have fueled the need to maximize one's income just to cover expenses. There was an interesting article in the New York Times recently recounting a long-time psychiatrist's journey into 15-minute medication checks and all the thoughts and considerations that took him to that point.^[2]

Having said all of this, I cannot imagine, and I do not hear from my colleagues, that given a perfect world, they would choose this situation of managing medicines and doing very little psychotherapy. It just doesn't seem very rewarding in the sense that we were drawn to this work because it connected us to people in ways that other areas of healthcare may not.

John G. Gunderson, MD: Ruth nicely identified 3 reasons for the change in psychiatric practice. I would add a fourth: resident training.

Training of residents occurs within institutions governed by managed care thereby relegating most interventions to changing or initiating medications. This then is what gets taught, this becomes the role modeling, and this is how institutional jobs are defined. Confounding this has been the fact that biological/psychopharmacological research has been the major avenue for gaining academic credentials and advancement, so that academic departments rarely have places for those who are primarily psychotherapists -- certainly not in positions of power. Once again, modeling and incentivizing residents towards psychopharmacological practices.

Having said this, I do not believe that most modern residents are different than those I did my training with 40 years ago. Most still choose psychiatry because it promises more personal and closer relationships with patients and a better understanding of the human condition than any other field of medicine. While psychiatry today does far more good and far less harm than when I started, it has done itself a disservice by not making the necessary effort to retain psychotherapeutic competence as a requirement of training. The ex-Massachusetts General Hospital/McLean resident in the New York Times captured this. He hadn't learned during his training that listening to his depressed patient's sad story would enrich his practice and be very helpful to his patient.

David J. Reinhardt, PhD: I did an informal telephone survey for the National Alliance of Professional Psychological Providers researching the length of time involved to secure a new patient first appointment. I was gladdened that insurance coverage was not an important determinant; in those instances when we stated there was no insurance, we were not brushed off but given cost information and an opportunity to book. Time to first appointment ran a minimum of 6 weeks to as much as 3 months.

The knowledge of physical contributors to psychiatric disorders and the specialized knowledge needed to treat have mushroomed in the last 40 years, and so has our understanding of psychological insights and treatments. We are well past the age of the pastor/counselor as effective psychotherapist and have refined the application of a much larger "grab bag" of tools and techniques. As with physical medicine, the volume of knowledge demands increasing specialization if we are to be truly competent.

Insurance companies have limited reimbursement for psychotherapy to brief therapy, 4-8 sessions, which has not been, in my opinion, a bad thing. Still, this intense level of interaction, in addition to medication management and other physical medicine issues, seems more than can be accomplished in a therapy hour, and it is unlikely clients or insurance companies would agree to reimburse for longer sessions.

Could Some Patients Benefit From Multiple Caregivers?

Dr. Staten: This is a great conversation. It seems we are seeing things in pretty much the same way. I do wonder what current psychiatric residents think about their experiences. We who were trained years ago, with psychotherapy being central to our education and practice, mourn the loss of this approach to treatment. However, it seems that newer generations experience and accept the new reality. I cannot imagine that being a "prescriber" only would be rewarding in anyway, but I am not sure that the same would be true for new practitioners. This brings me to my other strand of thinking.

It seems we have not necessarily documented through research which patients might most benefit from having a provider who can provide medication management and psychotherapy and those who might do well with 2 different providers. I wonder if clients with numerous medical problems and psychiatric problems might best benefit from a provider who can do both -- assuming that there are so many interactions among all conditions and treatments that it would take one person to make all the necessary observations and interventions work together.

Often times these are the subjects who are excluded from the studies of particular interventions -- medication related or psychotherapy -- but may be just the patients who need a practitioner who can do both. We could ask the same of persons who may need very intensive psychotherapy and a little bit of medication. Perhaps they would best benefit from 2 different providers, each practicing from their greatest strength, one as a therapist and one as a medication manager. I'm saying all of this just to make the point that we really don't understand very well which patients need what level/type of care, and at what point they can return to their primary care provider for continued treatment.

The changes that are abreast give us some opportunity to think about things differently. However, I cannot imagine psychiatrists without some degree of psychotherapy preparation and skill. That might be the question -- not should they or shouldn't they, but what training should they receive? In psychiatric nursing, we have just gone through several years of review of advanced practice psychiatric nursing education and concluded that psychotherapy must continue to be an essential component of education and practice. How do we maintain these opportunities in a practice world that wants, needs, and rewards prescribing?

Psychotherapy: Where Are the Data?

Dr. Strakowski: I agree with John about residency training; it requires an institutional commitment to provide this type of instruction. In our own department, we are fortunate to maintain a strong relationship with our local psychoanalytic institute, in which many of the members are volunteer faculty who love to mentor and teach. We also have a good cadre of cognitive behavioral therapy (CBT) practitioners in the department. To capitalize on these opportunities, we created a resident psychotherapy clinic with a sliding scale out-of-pocket payment schedule, which permits us to teach therapy without entangling with insurance companies. I believe this approach provides a reasonable model within the economic factors that drive training; more relevant is that our example suggests that there are solutions that facilitate psychotherapy training. This approach is just one.

To comment on another point, I agree with Ruth that initial psychopharmacology visits can take an hour just to make diagnostic assessments and establish medication regimens. As patients stabilize, medication follow-up alone can be relatively brief (our family practice colleagues often spend less than 10 minutes with their patients). Consequently, in my own practice with a 30-minute medication/psychotherapy visit (code 90805), it is easily possible to provide 20 minutes or of therapy (I typically do CBT). As Ruth suggests, for patients who need more frequent therapy visits or more complicated therapy than I can provide, I then refer the patient to work with one of the therapists in the department, and we use a team approach. Our financial calculations suggest to us that this approach optimizes the quality of treatment with the revenue generated so that we can afford to actually provide care. However, we don't take a number of insurances because reimbursement is so poor.

One of the problems with psychotherapy is that the research base is insufficient, other than perhaps CBT. We don't really know how to define who will most likely benefit and from which therapy approach and what the right 'dose' is (Why weekly? Why 50-minutes session instead of 25-minute sessions?). I frequently challenge my analytic colleagues to start producing some outcomes data. I don't buy the argument that psychotherapy research is "too hard to do," that I hear so often. It is incumbent on the field to start producing some data.

Dr. Staten: Yes, this raises some critical questions about training and how we best prepare practitioners for the current and future realities of the need for mental health services. I have been involved with, reading about, and implementing primary/behavior health integration. It makes me think that for some people, a model for medication management will be to stabilize the patients and return them to their primary care provider, continue to see them for brief psychotherapy and medication management, or send them to a therapist (and primary care or behavioral health manage medications). One concern I have is that we may be holding on to persons who are stable on medications who could be managed by primary care and then not having enough accessible appointments for patients who need to be seen more frequently while they are being stabilized or are so complex, needing additional or more frequent time. I know this conversation may be getting away from the topic a little, but it does seem to have been a major influence in how/why things have changed.

I completely agree that we must generate some data. There are too few mental health provider resources and the dollars are too precious; we must be efficient and effective in how we deliver services to maximize the outcomes.

Are Today's Psychiatrists Qualified?

Dr. Reinhardt: Please bear with me as I vent a bit.

I'm a bit in the dark on a couple of things. A general practitioner (GP) sends a patient to another physician (a surgeon or a psychiatrist) when they lack sufficient training to do the work themselves. The GP did have "basic training" consisting in, I assume, at least a few classes in surgery, and perhaps one formal class in psychiatry. The GP could, with the same reasoning that I'm seeing here, have opened a free clinic to practice a bit and develop expertise in surgery or psychiatry. This would in no way qualify them, in my mind at least, to practice those specialties. Are we all agreed that GPs should not be handing out antipsychotics without adequate training? Yet I'm reading here that the role of psychotherapist is a part time gig. Please allow me to fill you in a bit on psychology.

As a psychologist, I have taken 4 years of classes, 8 semesters of formal education in just the brain and mind, including 8 full semester classes in statistics and study design. That is not including on-the-job training, internship or clerkship, although we do have an additional 3 years of that. These are required classes. The field of psychology is not as "unscientific" as one might suppose. Review, for example, the bylines of most of the articles appearing in neurology and psychiatry journals. Competent psychotherapy is not something you pick up from a 9-session class on the brain, nor from practicing at a clinic until you get it right. If a psychiatrist desires to be a competent psychotherapist they should consider investing in more than a couple of weekend classes in the specialty. Yes, many psychiatrists do seek out additional training, although I suspect this is a very small percentage of the whole.

This does take us back to the question of if psychiatrists should do psychotherapy without extensive formal training in this specialty. Hopefully, you have the same strong feelings about GPs being competent psychiatrists without more training.

Dr. Staten: One of the aspects I have enjoyed most about being in psychiatry/mental health/behavioral health for 30+ years is the interdisciplinary approach to care, both inpatient and outpatient. I love working with students to help them understand this unique care/team approach -- that is not always a part of other disciplines. The common threads of our (psychiatrists, psychiatric nurses, psychologists, social worker, and others) preparation make for a wonderful foundation for caring for persons with behavioral health problems. For the most part, we hold the same core values and approaches to care, yet our differences bring such strength to what we offer to patients and each other. After being in a situation for many years where I was one of the few mental health professionals -- always trying to explain what we do, why we do it and why it is important to overall health -- I am in heaven to now be in a behavioral health department where we all value the same things and have a core set of skills that are common (basic psychotherapy skills) and unique talents that provide the best care one could hope for.

Having said all that, most of us do recognize individuals and professional groups for what they do bring to patient/client care. At this point, I do believe that all psychiatric/mental health/behavioral health disciplines should educate and prepare their students to engage in a certain level of psychotherapy. I think about all the underserved areas of our country that would be lucky to have one provider; if the provider could do little but offer medications, I think that would be a huge disservice to those for whom we care for.

I see the change moving toward levels of intervention and psychotherapy. We see brief interventions being applied by nonmental health providers in a variety of settings; a next level is being provided by mental health professionals who have backgrounds that are suitable to delivering both medication management and psychotherapy, and others who are experts in providing psychotherapy to the very difficult to treat patients (as well as others). I have a perfect example of a client who had as severe obsessive compulsive disorder (among other things) as I have seen in years. His first appointments were made with myself (a seasoned therapist and medication provider) and a therapist (a very seasoned, skilled one), but the client recognized that he needed someone more skilled in psychotherapy, so an appointment was made with a very experienced psychologist. I am hopeful that between some serious psychopharmacology and some very high level intense psychotherapy he will find some relief.

This is a critical conversation for psychiatry and psychiatrists, in terms of the way we all work together. I really just can't imagine a psychiatrist without psychotherapy skills, but that does seem to be a trend. We will lose something in the foundation of our work without that. I don't want to get off track, but I have some concern that this change has also affected -- to the detriment -- the inpatient care that patients receive. There are lots of reasons that inpatient care has changed, but I would like to see it be a more therapeutic environment all together.

A Reimbursement Quandary

Dr. Gunderson: I often get impatient with therapies where there is not visible progress. Mostly, though, ineffective therapies don't endure. There is, in any event, something inherent in the therapeutic exercise that is valuable in the absence of outcome data. Patients deserve to be listened to, and they remain our primary resource for their understanding. If those processes get short-changed because we don't have outcome data, then who gains what? If they get prolonged because a doctor or patient likes it too much, who loses? Third party payors? Certainly. Psychiatry's integrity? I'm not so sure. Healthcare costs? Probably not, if I remember correctly from aConsumer Report a few years back.

With respect to psychoanalysis, I think it can enrich one's life but it is not a treatment for the mentally ill. It does not belong in the reimbursement debate.

While the current growth of evidence-based therapies (EBTs) provides a rationale for reimbursement and can assure more uniform benefits, these studies rarely if ever measure a comparator therapy provided by clinicians with any extended experience working with the designated patient type. It was therefore instructive that in a large multisite randomized controlled trial (RCT), the borderline patients treated by a self-selected psychiatrist with 5 or more years experience did as well as those treated with good quality dialectical behavior therapy.^[3] My point is that dedicated therapists get better with time and learning the specifics of an EBT expedites the learning, but their effectiveness doesn't mean that such training is necessary.

Do others think that reimbursement for psychotherapy should be limited to instances where the therapist has been certified as competent in an RCT-validated therapy? Very few therapists could meet this standard.

Dr. Staten: Two thoughts to this discussion are one having to do with basic preparation in psychotherapy and the other with utilization of psychiatric services, specifically, the medication/psychotherapy brief visit.

Our discussion leads us to the conclusion that all mental health providers need some level of psychotherapy training in their basic programs, including psychiatrists. There are 2 reasons for this. The first, I mentioned before: to continue the strong foundation of common values, experiences, and understanding across mental health providers. Training and education in psychotherapy not only provides a skill but also instills certain beliefs in the human experience and in the importance and dynamics of the therapeutic relationship beyond basic interpersonal communication. I hope we will hang on to this. When the psychiatrist does not have that background, it changes the dialogue among the disciplines but it doesn't add much to the mix beyond the family practice physician, except additional expertise in the myriad of medication combinations. I would hope that someone seeing a psychiatrist for medication management (even for the billing code 90805) would have a somewhat different experience than a visit to the family practice provider. Hopefully, that does not sound too harsh -- I really don't mean for it to. I work with 7 or 8 psychiatrists from fairly new to very seasoned and they all have roots in psychotherapy, so I am not completely sure how it plays out when that is absent or minimal.

This brings me to the question that John posed regarding the need for certification in specific therapeutic modalities for there to be reimbursement. I am not sure there is a simple answer to this question, and there are variables to be considered. Many of the psychotherapies build on some basic concepts and skills and can be enhanced or broadened to other EBTs through a variety of formats: reading, DVDs, supervision, CME, etc. While others (for example, eye movement desensitization and reprocessing) require some very specific knowledge, background, and practice to be safe and effective. There would be very few therapists or practitioners who could meet the standard for being certified -- think of the twist and turns some of the therapies have; would one have to be certified in each of these nuanced modalities?

I appreciate John's comments on the research behind our work, the problems with the way we have conducted RCTs , and the limits of these trials to real patients, providers, and situations. The exclusion criteria alone can make application to real, complex patients with complex lives difficult. Of course, I support creating a scientific base for what we do, but taking it to the next step with adequate comparisons and translating into practice settings is critical. Sadly, I have known therapists to avail themselves to many certificate programs while lacking some of the basics, which allow for connection with the patients. There has to be some balance in the approach to this part of the question.

I can't even really weigh in on the psychoanalysis question. One of the things I am becoming acutely aware of -- especially, when we keep persons too long in therapy or under psychiatric care -- is are we creating a self-image that takes on an "illness image" that might not be healthy for the patient? When could some of these clients be stabilized and returned to their primary care providers for continued treatment? These are great questions. I think finding some answers would help us get patients to the right providers and the right treatments and more effectively and efficiently utilize our limited mental health resources.

So Who's Responsible for What?

Dr. Strakowski: In response to Ruth's and Dave's last emails, I'm not sure where the impression arose that psychiatrists don't get psychotherapy training. Psychotherapy supervision and delivery remain a major part of our training program, particularly in the 3rd and 4th years, and I would assume it's similar elsewhere. As noted previously, we have a specific clinic to attract good therapy patients for our residents. In response to Dave's comments, I have chaired a number of clinical psychologist graduate student dissertation committees, and the level of psychotherapy expertise that they exhibit at graduation is not particularly different than our senior residents. As John said, in the end, though, much of the training really occurs after residency/doctoral dissertation and is dependent on how much individuals, regardless of their professional stripe, want to learn about therapy and apply it in their practice.

Dr. Reinhardt: Thank you for your response, Stephen. Yes, certainly I agree that predoctoral psychology students, having not experienced intense on-the-job" training, are unlikely to have substantially more clinical expertise than a post degree, final year resident medical trainee. They will, however, have received 4 solid years of didactic training in mental health, disorders, and therapy approaches.

I have the utmost respect for a quality psychiatrist. Before taking on the role of another specialty, the role of psychiatrist in the treatment milieu may need better definition.

As I and my physician friends see it, the role of the psychiatrist is to be aware and look for medical causes of mood and behavioral issues, using the ever-expanding database of contributors, then refer back for treatment of suspected medical issues, or select and guide use of appropriate psychotropics, and refer to that other specialist, the psychotherapist.

In the recent article published on Medscape Psychiatry, a study was reported strengthening evidence that selective serotonin reuptake inhibitors carry a risk for birth defects. Another article detailed the usefulness of anti-inflammatories in treating depression, and the usefulness of soy in treating menopausal cognitive and mood symptoms. Sleep disturbance, linked to many psychiatric conditions, is shown to be influenced by blood sugar issues. Allergies are linked to depression and suicide completion. Finally, the Neurontin marketing issues, along with the recent reports of antidepressants as a class being essentially worse than useless in most cases spotlight the need for a statistically sophisticated approach to guiding medication selection and management. The reality that a finding of "significance" in a study only gives you an idea of any effect vs chance effect and tells nothing about effect size or usefulness of a particular chemical is often lost on those with only basic (or no) education in statistics. Competent psychiatry requires a great deal of education, continuing education, and experience.

When a depressed patient comes to me for that "other" kind of treatment, I want to feel reassured that medical issues such as hypothyroidism have been ruled out. My GP friends know they themselves lack expertise in these areas. They do not send patients to psychiatrists just to get a psychotropic ordered. This all ties into the concern voiced by Ruth, that patients may be followed too long for medication management.

Thank you for opening up the question regarding the amount of training received. It may be that I am making assumptions about this issue. Several years ago, when I was working with a large psychiatric practice, I was given the task of providing the training to third-year medical students as a clerkship site. For 30 days, these wide-eyed preclinicians would follow me around, observing, asking questions, and trying to become familiar with what mental health treatment was all about. Maybe things have changed, and I am misjudging. 

Steve, what is the extent of formal psychiatric training? Harvard Medical School (HMS) lists as required courses 4 weeks of psychiatry "rotation," in addition to a total of 136 hours of classroom training in "Nervous System and Behavior," and 39 classroom hours in "Psychopathology & Introduction to Clinical Psychiatry." Is HMS unusual in this regard?

As I pointed out in my earlier post, each specialty has its unique training and place in the milieu. Little is gained by downplaying the importance of this training just because they are seen as competition.

Dr. Strakowski: Dave, I think there is some misunderstanding about how psychiatrists are trained. Medical school and psychology graduate school really don't align similarly. Psychology graduate school (plus internship) is more like psychiatry residency. Medical school trains students to be physicians, but residency trains them to be specialists, eg, psychiatry. During residency, trainees receive 4 intensive years of didactics and "apprenticeship" in psychopharmacology and psychotherapy. Having trained both psychologists and psychiatrists (I have appointments in both departments here), at the time both groups come out of residency (psychiatrists) and internship (psychologists) they are similarly trained. As Ruth and I observed earlier, it is really the subsequent years post-training (in post-docs, practice, etc) that really refine their skills.

Dr. Staten: It is interesting to notice the twist that our conversation took from the original question that Steve posed to the current dialogue about training. if we can track back through our conversation -- and how quickly we turned to current curricular-training issues -- it seems that the perceptions about psychiatry and psychotherapy are quickly changing. If in practice, "psychotherapy is becoming increasingly rare," then the give and take between reality and what is taught (and valued) begins to take shape. Over time, will the fact that "psychotherapy is becoming an increasingly rare part of psychiatrist practice," influence or diminish what is taught in residencies, etc? Could it be a matter of degree (emphasis--not education)? Yes, psychotherapy should remain a part of psychiatric education and practice, but would it be at the same level as 1960 or 1970 or 1980 (with the changes and discoveries in neurosciences)? Likely not. Then how that plays out in one's practice or career will vary widely regardless of the discipline.

It seems at this point in time, to some degree all disciplines are exposed to practice and training in some type of psychotherapy(ies), but I concur with Steve's response, "much of the training really occurs after residency/doctoral dissertation and is dependent on how much individuals, regardless of their professional stripe, want to learn about therapy and apply it in their practice."

I sense that we are all seasoned practitioners who have seen the ebb and flow of our own careers be influenced by opportunities and interests that have varied over time. Thus our expertise has shifted and developed and has likely given us wonderful variety in what we have been able to do professionally. Whether psychologist, psychiatrist, advanced practice psychiatric nurse, or other mental health practitioner, we hope that the basic preparation and values and beliefs instilled in that process do give us flexibility for the changing demands and needs of those we serve and the opportunities that come our way.

There is more than enough need for all of the mental health providers; figuring out which patients will benefit from what treatments delivered by whom, in an efficient and effective manner is important. Perhaps that is another question for another discussion.

Is There a Solution?

Dr. Strakowski: Ruth, thank you for your comments; they are particularly germane. The critical need is to provide high-quality healthcare throughout the United States, and this need is particularly acute in many places out of the large cities off the coasts. In the end, most patients require programmatic care that involves astute pharmacology, skilled psychotherapy, general healthcare measures, and life skills training. For more severe conditions, these skills inevitably need to be provided by a quality team, but in many parts of the country such a team is unavailable.

I think getting back to the original question, several factors we've discussed have impacted the amount of psychotherapy provided by psychiatrists including change in treatment emphasis, demand for pharmacology, reimbursement and finances of healthcare, and availability. Dave seems to think that psychiatrists should "leave the therapy to the psychologists," but that ignores the fact that there are good therapists among many disciplines -- in the department I head, we have several very good CBT providers that include psychologists, master's in social work therapists, and psychiatrists, all of whom have taken steps to achieve excellence, long after their training was complete (as Ruth noted).

Dr. Reinhardt: I agree that there are many good psychotherapists to be found among many disciplines. Those therapists that have not studied the psychodynamics of less simple disorders, such as Axis II disorders like borderline personality disorder, schizophrenia, and nonsituational depressions, are practicing an intuitive form of therapy. This is often effective but far from scientific, and it can sometimes lead to disastrous consequences.

Didactic training plays an important part of physical medicine. It plays an even larger role in training to become a competent psychotherapist. Unlike physical medicine, where an intern can learn to identify a particular type of wart during grand rounds, psychotherapy is an intensely personal experience for the patient, which does not lend itself to the medical school model of on-the-job instruction. There can be no "wise old physician" looking on and keeping the patient safe in a very private therapy office.

As a psychologist, I am concerned that psychiatrists are "biting off too much." I have worked for many years in acute, subacute, and skilled nursing environments as part of a treatment team. Each of us need the support (and reminders) of other team members to fully understand the patient and do the best job. It is common for a specialist, working independently, to fail to spot often simple drivers of mood and behavioral disorders. Psychiatrists have their unique skills and unique role.

GPs have neither the office face time or the specialized training to consider all of the factors that may contribute to a mental health condition such as simple depression. They rely on a psychiatrist to look for and test such things as thyroid issues, hypothalamic imbalance, cellular magnesium levels, and the contribution of drugs such as beta blockers. Conditions such as dementias and psychosis require a competent psychiatrist to do even more detective work. Psychologists trust that the physical aspects have been carefully considered by other team members, although we are often disappointed in this.

As a psychologist, I too have my unique skills. Most physicians have no trouble acknowledging this, including, for example, neurologists, who include a workup by a neuropsychologist as necessary for diagnosing dementia in the ANA treatment guidelines. Competent psychotherapy depends on competent psychology. "Intuitive talk therapy" by someone inadequately trained is not competent healthcare.

Dr. Staten: It is clear to me that there is support for the training and development of psychiatrists as psychotherapists, and that we all agree that we must do a better job with research and documentation of outcomes related to the most effective and efficient care.

It does appear that without specific effort that the perception of psychiatrists as not doing therapy or being trained in therapy could become reality. I hope that this conversation and others will support a clear and continued commitment to psychiatrists having psychotherapy skills.

I have enjoyed the conversation.

Dr. Strakowski: Thank you, Ruth, Dave, and John for a lively discussion. With psychiatric conditions being 5 of the top 10 most disabling illnesses in the world, there is clearly a need for more clinicians of all stripes.

Editor’s Note:
Care to contribute your thoughts on the decreasing use of psychotherapy in psychiatry? Join the discussion in Medscape Connect.

Psychiatry Is Seeing Life From the Inside Out

Tracey I. Marks, MD

Authors and Disclosures

I have been practicing psychiatry for a little over a decade now, but I was a relative latecomer in choosing this profession. When I started medical school, in fact, psychiatry wasn't even on my specialty radar. I didn't know anyone who had seen a psychiatrist, and I simply never thought of psychiatry as a meaningful branch of medical science.

During my third-year rotations, I managed to side-step the psychiatry clerkship. When it came time to choose a specialty, I landed in the field of internal medicine (IM). It seemed the most logical choice for me at the time: I had majored in engineering in college, and I viewed IM as the ultimate problem-solving specialty.

During my fourth year of medical school, I finally rotated through psychiatry, simply because it was required for graduation. By then, I was in the midst of completing applications to IM residency programs.

I soon discovered, however, that psychiatry was nothing like I expected. I found the patients and their disorders extremely interesting, and I saw first-hand how a person can be completely debilitated by emotional pain. I came to appreciate how the physical body is simply a vessel that eventually deteriorates, whereas the human mind plays a critical role in how the body functions and how a person responds to life experiences. For example, research shows a strong link between depression and mortality in some cancers.^[1] During my psych rotation, I saw time and again how the "mind over matter" principal actually works. The mind, in a very real sense, defines the quality of human experiences.

My engineering background led me to view the mind as the body's central processor. As an analogy, in the computing world you need peripherals to have an optimally functioning system. But if your "CPU" fails, your high-end color printer is rendered useless. Likewise, a dysfunctional mind can affect a person's physical health as well as quality of life.

Despite my growing interest in psychiatry, the reality was that my applications for internal medicine residencies had already been submitted. So I shook off any doubts and moved forward with that decision. When I received news that I was accepted into an IM residency program, I was excited; at the same time, I was concerned that I might have made the wrong choice. Fortunately, I was given the option to switch to a psychiatry program at the same institution, and I happily decided to make that switch.

Psychiatry training includes general medicine training. Typically the internship year involves spending 6 months or more on an IM unit, focusing exclusively on medical problems. This prepares you to evaluate patients in a psychiatric setting while taking into account any medical problems that may be contributing to their symptoms. Psychiatry residents also spend time on a neurology unit, learning about and attending to patients' neurologic disorders. Because of this multifaceted training, I see myself as a physician who is able to understand and appreciate the nexus between the mind and body.

The range of work within this discipline is enormous. As a psychiatrist you can choose to specialize in treating acute problems, such as mania resulting from Hashimoto thyroiditis, or intermittent psychosis due to temporal lobe epilepsy. Or you can help the overworked professional manage stress and anxiety and stave off the destruction of his marriage. Psychiatrists work in various settings such as outpatient multidisciplinary clinics, solo or group private practice, inpatient hospitals, academic institutions, emergency departments, jails, or military bases. Some psychiatrists work as consultants in occupational health settings.

As a psychotherapist (which I believe to be an integral feature of practicing in this field), I feel privileged to be invited into someone's inner world, to talk with him about his most vulnerable thoughts and feelings. Psychotherapy is a required part of your residency training and typically begins in the second or third year.

The best parts of psychiatry are forming relationships with people and helping someone rise from the depths of darkness and into light of hope. Even patients who don't have a severe disorder still have pain on some level. A person may lack desire for his spouse, feel fed up with his place in life, or feel trapped in a "dead-end" job. As a psychiatrist, you are able to recognize the problem and help the patient see the blind spots holding him back. You are in a crucial position to potentially change the course of someone's life for the better. I don't take that lightly and am thankful for the opportunity to help people accomplish their objectives.

As much as I love what I do, psychiatry isn't for everyone. For instance, those wanting to perform procedures would not be satisfied with this specialty; the closest we get to procedures is performing electroconvulsive therapy or transcranial magnetic stimulation.

One negative aspect of practicing psychiatry is income. Most insurance plans reimburse for mental health care at lower rates than that for medical care. As a result, compared with doctors who perform procedures, psychiatrists' salaries are lower, especially if you evaluate this based on time spent with a patient. For example, an insurer may reimburse a doctor $1000 or more for a surgical procedure that takes 1 hour of the doctor's time; that same company may pay only $100 for 1 hour of psychotherapy.

But if you love critical analysis and forming relationships with people, it just doesn't get any better than practicing psychiatry. If you are considering psychiatry as a specialty, talk to some of the psychiatrists on the faculty of your school. They can give you their personal insights and maybe even connect you with psychiatrists in the community who can expose you to different working environments.