Is Future of Psych: IP vs OP?

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TerraceHouse

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Is future of psych inpatient or outpatient? Is it not that clear cut?

Will interventional psych, metabolic psych be more where it goes?

Curious to hear predictions, reasons, etc.

Interested to hear from docs who have 15-30 yrs left in their career and where they’re hedging their bets on this.

Factors to consider: mid levels, tech, politics, trends, public opinion, insurance, finances, health systems, VC/PEs, etc
 
IP and OP will both exist in strong numbers.
Some IP closures will continue.
CAP beds will have small uptick for nation as whole.
Units will mirror hospitalist service in that hospital for MD/ARNP makeup. But long term trajecotry is 1 MD medical director, with army of ARNPs.
Outpatient will continue to expand. Some metros will have ARNP over saturation - which I have experienced personally.
Bigger box entities will be less savory jobs, and even cut back, trying to replace with more ARNPs.
Jobs will exist in OP, but might not be the ideal you want.
PP will continue to be robust - but with more ARNPs - energy applied to make viable will slowly increase over time - i.e. having a pulse might not just be enough.

It's good to be CAP in all ways.

VC/PE will continue to pop up but they will continue to fall, not be too much in the psych world. A minimal presence, meant to teach people hard lessons in their career trajectory.

American is moving further away from its foundations of personal responsibility and independence. The delay in maturity age, increase in cannabis legalization, trans push, and foreign national pushes to poison america with drugs, social decay, destruction of societal institutions, means mental health will continue to have notable demand overall.

Tech won't change much.
 
TerraceHouse said:
Is future of psych inpatient or outpatient? Is it not that clear cut?

Will interventional psych, metabolic psych be more where it goes?

Curious to hear predictions, reasons, etc.

Interested to hear from docs who have 15-30 yrs left in their career and where they’re hedging their bets on this.

Factors to consider: mid levels, tech, politics, trends, public opinion, insurance, finances, health systems, VC/PEs, etc
Click to expand...
IP vs OP? Don't think it matters, I don't see major changes here other than what have been discussed ad nauseum here already.

Interventional psych is meh. Barring some miracle drug that is a mental health panacea I don't see this taking off or being world-shaking either.

Metabolic psych...there may be something there. Given the rise of GLP-1s as actual wonder drugs as well as the mental health effects (both therapeutic and side effects) is something that I see continuing to expand and possibly explode on all fronts. I've seriously been considering pursuing obesity medicine and starting research in this area seeing as these drugs have literally changed the landscape of entire fields (per my endocrine colleagues) basically overnight.
 
There will be both inpatient and outpatient. Both will continue to grow substantially. I actually see a trend towards reinstitutionalization. It's subtle and natal in most aspects, but you can see it just starting in things like outpatient commitment and CARE courts. I think the general population is starting to see that there are actually a fair number of people who cannot and/or will not care for themselves in the community. This includes many people who haven't committed formal crimes. I think the tolerance for letting people visibly suffer with psychosis in parks other community areas in general is waning. MJ induced chronic psychosis will be a huge long term growth area. In terms of MH NPs, yep, there will be more of them and more psychiatrists. There should be, we are one of the few developed countries with a growing population and mental health concerns are certainly not decreasing. I do think NP oversight will become an increasing component of a psychiatrist's job and hopefully resident training will start to include more of it. I don't see metabolic psych being a thing, sorry. Maybe some people on clozapine also get prescribed Wegovy...
 
To add, interventional psych may actually be doomed before it can take off. If scientologists have their way, we may no longer be performing ECT in 5-10 years d/t legal restrictions.
 
comp1 said:
There will be both inpatient and outpatient. Both will continue to grow substantially. I actually see a trend towards reinstitutionalization. It's subtle and natal in most aspects, but you can see it just starting in things like outpatient commitment and CARE courts. I think the general population is starting to see that there are actually a fair number of people who cannot and/or will not care for themselves in the community. This includes many people who haven't committed formal crimes. I think the tolerance for letting people visibly suffer with psychosis in parks other community areas in general is waning. MJ induced chronic psychosis will be a huge long term growth area. In terms of MH NPs, yep, there will be more of them and more psychiatrists. There should be, we are one of the few developed countries with a growing population and mental health concerns are certainly not decreasing. I do think NP oversight will become an increasing component of a psychiatrist's job and hopefully resident training will start to include more of it. I don't see metabolic psych being a thing, sorry. Maybe some people on clozapine also get prescribed Wegovy...
Click to expand...

I would wager money that 5-10 years from now we're going to see GLP-1-agonists as standard of care for neuroleptic-associated weight gain.
 
Eh, probably. I mean it's the standard today if the person is clinically obese. I'd much rather see some neuroleptics that don't cause weight gain, however.
 
comp1 said:
Eh, probably. I mean it's the standard today if the person is clinically obese. I'd much rather see some neuroleptics that don't cause weight gain, however.
Click to expand...
Personally, I'll take the metabolic side effects if we can eliminate EPS from the equation. We might get both if the TAAR-1 agonists take off.
 
Sushirolls said:
IP and OP will both exist in strong numbers.
Some IP closures will continue.
CAP beds will have small uptick for nation as whole.
Units will mirror hospitalist service in that hospital for MD/ARNP makeup. But long term trajecotry is 1 MD medical director, with army of ARNPs.
Outpatient will continue to expand. Some metros will have ARNP over saturation - which I have experienced personally.
Bigger box entities will be less savory jobs, and even cut back, trying to replace with more ARNPs.
Jobs will exist in OP, but might not be the ideal you want.
PP will continue to be robust - but with more ARNPs - energy applied to make viable will slowly increase over time - i.e. having a pulse might not just be enough.

It's good to be CAP in all ways.

VC/PE will continue to pop up but they will continue to fall, not be too much in the psych world. A minimal presence, meant to teach people hard lessons in their career trajectory.
Click to expand...

This is honestly really well put but add in making marketability a priority for psychiatrists in PP outpatient in a way that makes folks feel like there's added value in seeing a physician.

Sushirolls said:
American is moving further away from its foundations of personal responsibility and independence. The delay in maturity age, increase in cannabis legalization, trans push, and foreign national pushes to poison america with drugs, social decay, destruction of societal institutions, means mental health will continue to have notable demand overall.

Tech won't change much.
Click to expand...
Uhhhhh...
 
I really don't see a world where IP has major changes. Like any other organ system, people go inpatient when things get severe. We've already seen IP psych gutted to the point where only the absolutely sickest are approved for inpatient treatment. Can't fathom more cuts there. There's a strong multi-state push for more psych beds (and CAP beds) already.

For OP, I think organizations with connected IP are going to push for buying up more market share in OP psych. It is far more profitable than IP psych. And we know from a business perspective that if they can vertically integrate, they will make more money. The evil corporate incentives are all there to own the customer both IP and OP, and deliver the worst/cheapest care (NP, PA) at the highest level (OP -> IOP -> PHP -> IP). Luckily, psych still has the easiest specialty to put up a shingle, so we do have some tools to fight back.

I'm pretty bullish on interventional psych. Scientologists are so fringe now that their psychotic ramblings bear almost no semblance with general opinions on psychiatry. ECT has been and will remain a pretty rare treatment given the legal hurdles everywhere, with exception of some well-oiled ECT machine/teams that have unique set ups (legal, procedural, facility wise) where people are flown or driven in for treatment. I doubt ECT will be used even less than it is now, given it is already so sparse nationwide. ECT is so effective for so many illnesses that I can't see a way it could be completely blocked forever, regardless of bad/ill-informed actors.

TMS, ketamine, this is only the beginning. General public is way more receptive to interventional approaches than even taking a pill daily. Biggest hurdle currently is insurance blocking people from access. Interest is there, and I would expect it to grow exponentially in utilization. These tools are just too effective to ignore.
 
mistafab said:
For OP, I think organizations with connected IP are going to push for buying up more market share in OP psych. It is far more profitable than IP psych. And we know from a business perspective that if they can vertically integrate, they will make more money. The evil corporate incentives are all there to own the customer both IP and OP, and deliver the worst/cheapest care (NP, PA) at the highest level (OP -> IOP -> PHP -> IP). Luckily, psych still has the easiest specialty to put up a shingle, so we do have some tools to fight back.
Click to expand...
Don't forget residential (for teenagers and sometimes preteens)
 
michaelrack said:
Don't forget residential (for teenagers and sometimes preteens)
Click to expand...
Agreed.

I also think that addictions is somewhat of a stepchild of psychiatry. There remains a lot of opportunity for physician-owned vs corporate-owned programming at multiple levels of care, but many psychiatrists see addiction as a problem they are forced to deal with, rather than an opportunity to provide psychiatric services.
 
I think inpatient stays similar, maybe more NPs. They can keep cutting it further, but patients are still presenting to the ED. Someone has to sign the note that allows them to leave the hospital--whether that's psych, ED, or midlevel. I've never seen a hospital where the ED team wants ownership of it.

I think outpatient continues to get more competitive. Need to advertise and actually provide a service patient's want to pay for rather than just have a pulse as said above. Anyone can Rx the controlled substances including eskatamine. I think I read 30-50% of new outpatient evals are ADHD...you'll be slow to grow if you have something against amphetamines, especially when the competition down the street offers an all you can eat buffet.

I think the outpatient competition from midlevels is starting to and will become more stiff. Say what you want about clinical decisions, we all know rapport and the overall relationship is very important in psychiatry. They can also build good rapport with patients, which decreases the "good" patient pool. So what if they start bupropion for GAD? If the patient trusts their decision they're going to stay. Even if you start an SSRI there's a good chance it doesn't work anyway. If psychs are trying to do 10 min med-checks they better be rxing a controlled of they're going to lose patients. Overall outpatient is going to continue to need strong people skills or they'll need to work in a hospital system with captured patients who don't have the means to look elsewhere.
 
I'm bullish regarding interventional psych and bearish regarding psych in general. Markets are already getting more saturated, specially with NPs. I don't think most of the population cares, and big corporations certainly don't.

I believe private practice is the one and only way, as everything else will suck in the future. Around here in big corps people are seeing 20-25 patients a day with a bad pay.

When I mean Interventional I am thinking tms, ketamine, mdma, and psychedelics.
 
The past two decades have been shortening IP stays and a huge rise in RTC/PHP/IOP services. I would be very surprised to see these trends reverse. There is absolutely demand for comprehensive mental health services for people with significant functional impairment and the societal winds only show an increase in overall mental health demand.

Of course, OP will be the bedrock of the field but new medication/technology has always fallen short of expectation, the bandwagon in mental health has historically been not where you want to park your car.
 
mistafab said:
For OP, I think organizations with connected IP are going to push for buying up more market share in OP psych. It is far more profitable than IP psych. And we know from a business perspective that if they can vertically integrate, they will make more money. The evil corporate incentives are all there to own the customer both IP and OP, and deliver the worst/cheapest care (NP, PA) at the highest level (OP -> IOP -> PHP -> IP). Luckily, psych still has the easiest specialty to put up a shingle, so we do have some tools to fight back.
Click to expand...
Only thing I might disagree with. HCA inked deal with Talkiatry and has been closing their outpatient psych practices. Easier to refer out, don’t have to pay for staff for OP psych that doesn’t bring in much compared to their other medical specialties.
 
lobstar said:
I think inpatient stays similar, maybe more NPs. They can keep cutting it further, but patients are still presenting to the ED. Someone has to sign the note that allows them to leave the hospital--whether that's psych, ED, or midlevel. I've never seen a hospital where the ED team wants ownership of it.

I think outpatient continues to get more competitive. Need to advertise and actually provide a service patient's want to pay for rather than just have a pulse as said above. Anyone can Rx the controlled substances including eskatamine. I think I read 30-50% of new outpatient evals are ADHD...you'll be slow to grow if you have something against amphetamines, especially when the competition down the street offers an all you can eat buffet.

I think the outpatient competition from midlevels is starting to and will become more stiff. Say what you want about clinical decisions, we all know rapport and the overall relationship is very important in psychiatry. They can also build good rapport with patients, which decreases the "good" patient pool. So what if they start bupropion for GAD? If the patient trusts their decision they're going to stay. Even if you start an SSRI there's a good chance it doesn't work anyway. If psychs are trying to do 10 min med-checks they better be rxing a controlled of they're going to lose patients. Overall outpatient is going to continue to need strong people skills or they'll need to work in a hospital system with captured patients who don't have the means to look elsewhere.
Click to expand...
sorta besides the point, but I've heard many times not to use bupropion with GAD or very anxiously depressed patients because it supposedly increased anxiety as it is activating... but the data suggests otherwise. In fact, on average, pt's experience a decrease in anxiety and not a worsening. I'm sure there are exceptions, but it shouldn't preclude the use of it at all.
 
Gubernac said:
sorta besides the point, but I've heard many times not to use bupropion with GAD or very anxiously depressed patients because it supposedly increased anxiety as it is activating... but the data suggests otherwise. In fact, on average, pt's experience a decrease in anxiety and not a worsening. I'm sure there are exceptions, but it shouldn't preclude the use of it at all.
Click to expand...
Perhaps a bad example on my end. A better argument would be that you can use nearly any medication class for mood and anxiety disorders so the "acceptable" practice range is a mile wide making it hard to measure any sort of quality metric that would differentiate a good or bad treatment program especially in a larger hospital system measurement system. In a smaller private system the main metric is retention and I don't think that relates to picking the "correct" med either when compared to something like rapport.
 
lobstar said:
Perhaps a bad example on my end. A better argument would be that you can use nearly any medication class for mood and anxiety disorders so the "acceptable" practice range is a mile wide making it hard to measure any sort of quality metric that would differentiate a good or bad treatment program especially in a larger hospital system measurement system. In a smaller private system the main metric is retention and I don't think that relates to picking the "correct" med either when compared to something like rapport.
Click to expand...
I'm actually glad you guys brought this up. So true. Such a wide acceptable practice range, the rapport / the perception / the likability will actually win out in the end in the outpatient setting in MOST cases.
 
Going to put this in this thread since it is somewhat relevant.

I think in the future, psychiatrists need to be better versed in rarer treatment options. TCAs are powerful drugs. As are MAOIs. We like to trick ourselves in to thinking SRIs are equivalent in outcomes for all patients. However, we end up seeing more treatment resistant cases anyway given our field, so this assumption is just plain wrong.

It behooves psychiatrists to understand all these treatment options, and use them when it becomes appropriate. The days of rolling a patient around on 5 different SRI based drugs with ill effects and ongoing suffering for a year needs to stop. Pull the plug, and go big guns, or try interventional much quicker. If we are afraid to use these drugs where appropriate, then we are no better at psychiatry than a midlevel who will try the patient on the Nth trial of a middling SRI or antipsychotic dose and see them in another 2 months.
 
*Patients don't want TCAs once you mention weight gain.
**Patients don't want TCAs once you mention EKGs
***Patients don't want MAOIs once aware of dietary restrictions.
****People are referred to TMS/ECT/Ketamine earlier, but logistics (or price) often dissuade.
So, yes, let's try another SSRI
 
comp1 said:
There will be both inpatient and outpatient. Both will continue to grow substantially. I actually see a trend towards reinstitutionalization. It's subtle and natal in most aspects, but you can see it just starting in things like outpatient commitment and CARE courts.
Click to expand...

Outpatient commitment really isn't institutionalization of patients, it's institutionalization of care, i.e., bureaucracies and more tax dollars for them to support social workers, drum beating, lobbying, more nonsensical initiatives based of good vibes rather than data like Zero Suicide or more documentation/legal requirements, etc. The actual value and input of psychiatrists will continue to decline within large institutions, below the level of "prescriber", as the number of interested parties (payors, judges, politicians, social workers, therapists, lobbyists) vastly outnumber psychiatrists.

comp1 said:
I do think NP oversight will become an increasing component of a psychiatrist's job and hopefully resident training will start to include more of it.
Click to expand...

The only resident training needed to learn how to supervise NPs is basically 3 things: sign the hospital contract obligating you to "supervise" NPs, let The Man pimp your license, and shut your mouth lest you trigger NPs.
 
Sushirolls said:
*Patients don't want TCAs once you mention weight gain.
**Patients don't want TCAs once you mention EKGs
***Patients don't want MAOIs once aware of dietary restrictions.
****People are referred to TMS/ECT/Ketamine earlier, but logistics (or price) often dissuade.
So, yes, let's try another SSRI
Click to expand...
That has not been my experience, but we may be seeing different populations. Once folks are TRD in my office, they are usually hoping for relief at all costs.

Also, experience with MAOIs will show that the diet is really not hard. The risk is overblown. The actual requirements in the diet are very easy once implemented.

People are shocked they can eat pizza and have a can of beer without a "crisis." The data supports that.
 
mistafab said:
Also, experience with MAOIs will show that the diet is really not hard. The risk is overblown. The actual requirements in the diet are very easy once implemented.

People are shocked they can eat pizza and have a can of beer without a "crisis." The data supports that.
Click to expand...

This is so very, very true. they can eat pounds of mozzarella or kill a six pack of most beers without any kind of adverse medication effect. I have prescribed MAOIs to many and with the exception of one person who was truly passionate about kimchi, the diet's never been much of an issue.
Sushirolls said:
*Patients don't want TCAs once you mention weight gain.
**Patients don't want TCAs once you mention EKGs
Click to expand...

sure, some people refuse to touch any medications that involve weight gain, but the weight gain is nothing like what dopamine antagonists can do to people. Like @mistafab most of my patients have already done an SSRI or two by the time they get to me and are usually quite eager to try something different.
 
Sushirolls said:
Good to hear there are patient populations willing to try things a bit out of the norm.
Click to expand...
That's the opposite of my experience. Everyone wants the new thing be it Spravato, TMS, shrooms, brand name drugs, brainspotting, cold plunges, etc etc. I sell folks on the oldey but off the beaten path meds all the time (e.g. Lithium, Remeron). Almost no one who comes in wants another go at the SSRI wheel.
 
Been doing outpatient hospital as primary job for last couple of years. Did inpatient prior. Spoke to some inpatient jobs recently thinking about switching. Appears from small N, that hospitals are using more NP's to do the work and just want a MD inpatient to cover certain things but not sign and get the wrvu credit for the NP note. Yet still have to supervise them basically for free. Used to be there to assist me but now feels and sounds more like we are both "providers". Equals except when I have to do something they cannot like a capacity evaluation.

Outpatient I am still finding a role where most folks still want to see a MD to manage their medications especially ones with a Bachelor degree and commercial insurance. I enjoy inpatient work itself better but I keep being told on inpatient I have to round with the team (like 6 different folks) and then do some form of a treatment team later in the day. Feel like the SW and NP etc have about the same say in what is going on. Was not like that prior in my experience. The attending would see patients and make decisions and others would listen. At least in my outpatient clinic I generally have some say in who I will see and manage folks the way I want and do not have to have a "team" sign off. Got a much more marginalized feeling talking to inpatient folks recently.
 
J ROD said:
Been doing outpatient hospital as primary job for last couple of years. Did inpatient prior. Spoke to some inpatient jobs recently thinking about switching. Appears from small N, that hospitals are using more NP's to do the work and just want a MD inpatient to cover certain things but not sign and get the wrvu credit for the NP note. Yet still have to supervise them basically for free. Used to be there to assist me but now feels and sounds more like we are both "providers". Equals except when I have to do something they cannot like a capacity evaluation.

Outpatient I am still finding a role where most folks still want to see a MD to manage their medications especially ones with a Bachelor degree and commercial insurance. I enjoy inpatient work itself better but I keep being told on inpatient I have to round with the team (like 6 different folks) and then do some form of a treatment team later in the day. Feel like the SW and NP etc have about the same say in what is going on. Was not like that prior in my experience. The attending would see patients and make decisions and others would listen. At least in my outpatient clinic I generally have some say in who I will see and manage folks the way I want and do not have to have a "team" sign off. Got a much more marginalized feeling talking to inpatient folks recently.
Click to expand...
Why would we want the highest trained and experienced people making decisions when we can get people with online degrees that are no more capable than the average college grad to make complex decisions? I have spent way too much of my life listening to these people say stupid things during treatment team meetings and trying not to hurt their fragile feelings and insecurities when I have to intervene or override the decision in order to help the patient. Last job I had was me and a highly knowledgeable psychiatrist so as long as we agreed which was like 99% of the time, we didn’t have to worry too much about the others.
 
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