The Future of Psychiatry

[worriedwell]

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With prescribing rights possibly going to psychologists (lets not debate whether this should or shouldn't happen, lets just assume a strong likelihood) and the advances in the hard neurosciences and behavioral neurology as they relate to traditionally psychiatric illnesses, do people have a sense for which psychiatric niches will flourish and which will not?

I met some researcher in neurology in the elevator and told him that I was dong a psychiatry residency and the first thing he said was "you know, you should know that at some point soon psychiatry won't exist and it will all be the realm of neurology". Besides wanting to smack him for the complete lack of timing or tact that he had, I was also a bit worried that he might be right (or on the right track).

The psychologist prescribing right also scares me. The irony is, I like behavioral neuroscience research and I also like psychotherapy (with medical management), but it seems like there may be truth to the full or partial reallocation of those areas to other disciplines. It seems that consultation psychiatry is becoming a hot area, and I could see myself doing that as a career. But one of the appeals of psychiatry for me was the multitude of directions I could or could have gone with it. Are these options becoming more limited due to various advances/pressures? Where is the future of psychiatry?

 

[OldPsychDoc]

....

I met some researcher in neurology in the elevator and told him that I was dong a psychiatry residency and the first thing he said was "you know, you should know that at some point soon psychiatry won't exist and it will all be the realm of neurology". Besides wanting to smack him for the complete lack of timing or tact that he had, I was also a bit worried that he might be right (or on the right track).

Next time tell him, "oh yeah, well I heard that *neurology* won't exist and it will all be in the realm of interventional radiology!" (--except for the behavior problems, of course, which they are already all too fond of turfing to us).

Yes we're going to be more brain-based in psych, but the way "our" diseases manifest are still behavioral in nature, and most neurologists won't touch those with a 10 foot reflex hammer. They'll still be asking us to actually talk to the suicidal and psychotic patients on their services...

 

[Miklos]

(--except for the behavior problems, of course, which they are already all too fond of turfing to us).

Yes we're going to be more brain-based in psych, but the way "our" diseases manifest are still behavioral in nature, and most neurologists won't touch those with a 10 foot reflex hammer. They'll still be asking us to actually talk to the suicidal and psychotic patients on their services...

Great points.

Neurologists dealing with behavior?!! That'll be the day!

 

[mdblue]

With prescribing rights possibly going to psychologists (lets not debate whether this should or shouldn't happen, lets just assume a strong likelihood) and the advances in the hard neurosciences and behavioral neurology as they relate to traditionally psychiatric illnesses, do people have a sense for which psychiatric niches will flourish and which will not?

I met some researcher in neurology in the elevator and told him that I was dong a psychiatry residency and the first thing he said was "you know, you should know that at some point soon psychiatry won't exist and it will all be the realm of neurology". Besides wanting to smack him for the complete lack of timing or tact that he had, I was also a bit worried that he might be right (or on the right track).

The psychologist prescribing right also scares me. The irony is, I like behavioral neuroscience research and I also like psychotherapy (with medical management), but it seems like there may be truth to the full or partial reallocation of those areas to other disciplines. It seems that consultation psychiatry is becoming a hot area, and I could see myself doing that as a career. But one of the appeals of psychiatry for me was the multitude of directions I could or could have gone with it. Are these options becoming more limited due to various advances/pressures? Where is the future of psychiatry?

That's a very primitive defense
Don't worry about psych-in another 20 yrs it'll definitely change the way we practice it today. Think of the analytic oldtimers from 60s and 70s. They can't tell psychiatry from neuro these days-to them contemporary psychiatry is corrupt. There was a guy called Mosher, who was the first NIMH director of schiz research(or something), who resigned from APA in late 80s because he felt psychiatry was going in the wrong direction(being too drug-based). He preferred treating schiz w/ psychotx only. There are a lot of big names like that who believed psychiatry only deals w/ mind, which clearly is wrong. It may sound ridiculous now, but there was a big struggle during re-medicalizing psych in post DSM III era.
I think we are going towards more clearer delineation of mental d/o, increased validity of dx, more integration of psychiatry w/ mainstream clinical practice and more $$$ for the drug comps. For psychiatrists, the pts will be more psychotic/resistant schiz, severe mood d/o w/ multiple comorbidity, more axis II dx, because the bread-n-butter uncomplicated mood/anxiety d/os will be taken care of by the NPs/PAs/PCPs.
RxP will try to bring bills and the APA will continue to fight them-however teaching them all the intricacies of drug interactions may actually scare them off from prescribing
CL psych is coming back in a big way, but unfortunately there is little $$ in it for the psych, so I don't know how acceptable it will be in the long run.
Just my 0.02c

 

[Anasazi23]

I met some researcher in neurology in the elevator and told him that I was dong a psychiatry residency and the first thing he said was "you know, you should know that at some point soon psychiatry won't exist and it will all be the realm of neurology". Besides wanting to smack him for the complete lack of timing or tact that he had, I was also a bit worried that he might be right (or on the right track).

Statements like the one this neurologist made make no sense. There will always be psychotic patients, suicidal patients, complicated medical masquerading psychiatric patients, and very importantly, a huge OUTPATIENT population looking for psychiatric services. That, especially the outpatient portion, is not conducive to being taken over by neurology. If anything, psychiatry will become more super and sub-specialized, which is usually associated with increased income and demand.

I'm constantly being told by both internists PMDs and surgeons that they don't have enough psychiatrists in their referral list to send patients to, and that they can't wait for me to graduate. Some of this has to do with accepting medicare and other billing issues, but the main point stands. Just because a medical specialty (like all others) has and will evolve and change does not mean the death of that specialty. There is still demand and great job and earning opportunities for cardiologists, toxicologists, rheumatologists, hematologists and other medical specialists, like there is for psychiatry. Psychiatry, like all the aforementioned specialties, has evolved tremendously over the past 20 years.

 

[Milo]

Neurologists? Touch Psych? Not with a ten foot clown pole.

 

[meisteckhart]

You know, these issues are not new. There was talk of neurology taking over psychiatry 20 years ago, and it doesn't really seem any closer to happening now than it did then. (or so I've been told) I don't think that either specialty will take over the other, but if you think about it, it would actually make more sense for psych to take over neuro if it was going to happen. Psych comes from a tradition of dealing with behavior and mental health type issues, and we are moving in the direction of knowing more neurology and neuroscience. If we play our cards right and continue to encourage people to break down the stigma of mental illness, I think the explosion in research into the brain will open up more opportunities for us, not limit us.

In terms of the issue of psychologists prescribing rights, this is not an issue unique to psychiatry. Its been mentioned on this forum before, but the primary care fields have nurse practitioners, anesthesiology has nurse anesthetists, OB/GYN has midwives, ortho has podiatry, radiology is threatened by outsourcing, etc.etc.etc. Whether psychologists get prescribing rights or not, we will not just disappear into oblivion or start taking huge pay cuts.

 

[OldPsychDoc]

... I don't think that either specialty will take over the other, but if you think about it, it would actually make more sense for psych to take over neuro if it was going to happen. Psych comes from a tradition of dealing with behavior and mental health type issues, and we are moving in the direction of knowing more neurology and neuroscience. If we play our cards right and continue to encourage people to break down the stigma of mental illness, I think the explosion in research into the brain will open up more opportunities for us, not limit us.

One reason I picked psych over neuro is that we really deal a lot more with brain functions than they do. The majority of neuro is really "cardiology of the brain"--e.g. plumbing and packaging, not brain functioning. And as the interventional radiologists and neurosurgeons take care of most of that end, the neurologists are left with seizure disorders, movement disorders, and the peripheral nervous system. There are times when you really want a neurologist taking care of your patient, but psychiatrists know far more neuro than neuro knows psych...

 

[50960]

I also believe that movements like psychologists prescribing and the like will only increase the need for psychiatrists...especially specialists like child psychiatrists etc..
The concensus amongst the medical staff at my hospital is that moreso than any other MD, neurologists know everything, but do nothing.. (this is not my opinion or that of SDN blah blah..). The argument that nuero will overtake psych is like saying orthodontists will take over dentistry..

 

[PublicHealth]

I also believe that movements like psychologists prescribing and the like will only increase the need for psychiatrists...especially specialists like child psychiatrists etc..
The concensus amongst the medical staff at my hospital is that moreso than any other MD, neurologists know everything, but do nothing.. (this is not my opinion or that of SDN blah blah..). The argument that nuero will overtake psych is like saying orthodontists will take over dentistry..

psisci,

I'm curious. As I understand, you're a psychologist in a major hospital in California. Could you tell us more about what you do from day-to-day? I'm on the east coast, so I'm curious to know if the roles of psychologists are different in any way. What kinds of patients do you typically see? What types of treatments do you employ? Is your time spent primarily in assessment, treatment, or education/administration? How's the pay out there?

Thank you!