what is the future of psychiatry?

[ronaldo23]

my dads a psychiatrist, and although he loves his jobs and gets compensated very well, he has basically warned me not to go into psychiatry and says that all his coworkers say the same thing to their kids.

he says that psychologists are gaining more and more rights and in some states are being allowed to prescribe meds and that this undermine the whole practice in the future. what do you all think?

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[whopper]

There's some truth to what you mentioned, but as of now, there is a severe shortage of psychiatrists.

This while good for psychiatrists now--may not be true in years. I don't know where you are now in your education. At least as of now, I don't see any reversal of this trend because at least the last time I checked, medical students going into psychiatry residencies isn't going up. Its staying low. (Someone correct me if I'm wrong).

According to the former President of the APA (and I discussed this with him in person), he said to not worry that psychology will overtake psychiatry. He mentioned that psychologists taking over prescribing power is in large part due to the shortage; in the areas where psychologists have gotten prescription power, those are the areas with the worst shortages, and everyone would still rather have a psychiatrist.

My own concerns about the future is how TMS will affect the industry. If TMS is as successful as some portray it to be, it could lessen the need for psychiatrists.

Another thing I'm thinking may hurt the industry is every 10 years, people look back on what the industry has done wrong (E.g. One Flew Over the ****oo's Nest) and this can demonize psychiatry. I can see a few potential issues now that I'm not happy with such as the overmedication of children.

 

[Therapist4Chnge]

I agree with whopper. There are already too few psychiatrists, so you'll always have opportunities. I can't speak to the other issues, but I know many psychologists aren't interested in meds management, which is why I see prescribing psychologists as a niche group. I think in the end a bunch of states will have privileges, but I don't see a huge shift because many psychologists will stick to assessments, therapy, etc. I am doing the training so I can manage the meds of a small private practice caseload, not work in a hospital, etc.

I would be more concerned with healthcare in general (universal healthcare, etc), regardless of where you decide to go.

-t

 

[OldPsychDoc]

I just was on the unit, overhearing one of our SWs talking on the phone: "He did say he has lots of weapons at home, but they're all locked up...I'm not sure if that's such a great idea for a guy with his kind of brain injury...".

I just looked at my SW and said out loud: "We are NEVER going to be out of a job here."

 

[Therapist4Chnge]

I just was on the unit, overhearing one of our SWs talking on the phone: "He did say he has lots of weapons at home, but they're all locked up...I'm not sure if that's such a great idea for a guy with his kind of brain injury...".

I just looked at my SW and said out loud: "We are NEVER going to be out of a job here."

That is scary. Seriously scary.

-t

 

[mgdsh]

my dads a psychiatrist, and although he loves his jobs and gets compensated very well, he has basically warned me not to go into psychiatry and says that all his coworkers say the same thing to their kids.

he says that psychologists are gaining more and more rights and in some states are being allowed to prescribe meds and that this undermine the whole practice in the future. what do you all think?

Keep in mind that the "grass is greener on the otherside" mentality applies through out medicine. I know GI doctors who say that about GI, surgeons who say that about surgery, etc. No field is perfect and will always have its issues. Psychiatry is a great field, and if it indeed matches up with you personality and what you want to do, I really doubt your dad would be disappointed.

Let me also add, that my dad too is a psychiatrist and he too told me the same things about the concerns of psychologists having prescribing powers, etc. When I told him I was going into psychiatry, he was happy with it. At the end of the day it still provides for a comfortable living.

 

[psychfriend]

At my last rotation, the psychiatrist said the exact opposite of your dad. He said there is already a massage shortage of psychiatrists and the supply is going to get even smaller when the baby boomers retire since they comprise a large portion of the current psychiatrists.

Also, I think medical students will always avoid psychiatry to some degree because of the nature of the field regardless of it's compensation and lifestyle. Yes, I'm aware that in medicine, demand increases with increased income. No one wanted to do radiology 15 years ago but when the demand (and money) for radiology escalated, the field became competitive. I don't see the same analogy occuring with psych because many people have an aversion to working the mentally ill regardless of how much it pays.

Lastly, our culture has changed and is more accepting of psychiatry. In the past, it was taboo to see a psychiatrist or a therpaist. Now, it's commonplace and people are no longer afraid to admit they see someone or inform people they are taking antidepressants or ADHD medication. In the past, people were afraid to see a psychiatrist out of guilt that they might be crazy or unaccepted. Now, you see professionals see a psychiatrist regularly for their anxiety, depression or lack of focus. Parents have changed too. Now, parents seek psychiatrists for common problems like children misbehaving or acting out whereas in the past, parents would have probably just cracked the whip. Schools are also getting involved and will suggest seeing a psychiatrist for attention problems or learning disabilities if a child is underachieving. Again, in the past, schools would have probably just expelled them or moved them to another school.

Psychiatrists and psychologists are taking a team approach to mental health care. Many psychiatrists refer their patients to psychologists for CBT while they manage their drug regimens. This works well for both parties as many psychiatrists do not enjoy psychotherapy and would rather see their patients as clinicians managing their prescriptions and physical health (monitoring their vitals in regards to medication etc.). There are also many new advancements in neurology and psychiatry so that psychiatrists have options aside from just psychotherapy such as brain mapping. And like someone mentioned above, psychologists prefer psychotherapy since that's where the bulk of their training lies. There is not an adversarial relationship among psychiatrists and psychologists as I once presumed. And the states that allow psychologists prescription power are New Mexico and Louisiana which have severe physician shortages let alone shortages in psychiatrists, so you can imagine why those states had no choice but to empower psychologists. I don't see this trend occuring in states with large metropolitan areas that have enough physicians. Sure, this trend might spread to states like South Dakota, Montana, West Virginia, Kentucky Wyoming and North Dakota but I doubt it will occur in California, New York, Florida, Pennsylvania, Illinois, Ohio, Michigan and Texas. The large and powerful physician lobbies in those states would not allow it.

Lastly, the majority of patients today seek psychiatrists with the intent of being put on medication whether that's an antidepressant or a psychostimulant. For example, many parents will bring their children to see a psychiatrist with the purpose of acquiring Ritalin or other stimulants. Patients are aware that psychologists lack the ability to prescribe medication so they make appointments to see psychiatrists.This isn't like 20 years ago. People today are well informed and read up about medication on the internet. There are drug companies that advertise antidepressants and other psych-related drugs on television that entice consumers to make an appointment to acquire a prescription for that particular drug. Again, those patients are not going to make appointments with psychologists.

The one concern I do have is that psychiatry could potentially be the hardest hit by medicare's lower reimbursements due to the fact that there aren't any procedures in the field.

 

[rainbowman]

Beware Tom Cruise. "I think psychiatry should be outlawed...I think it's an utter waste of time. There's nothing scientific about it."

I think I'll find another specialty

 

[OldPsychDoc]

Beware Tom Cruise. "I think psychiatry should be outlawed...I think it's an utter waste of time. There's nothing scientific about it."

I think I'll find another specialty

OMG! 😱 He really said that??! 🙄

I'd better retrain. After all, MILLIONS of mentally ill people will now leave their psychiatrists in droves on the word of this wacked-out Hollywood star! He's clearly an authority--he can fly F-14s, fight aliens, hack into high-security computer labs, drive stock cars, and oh yeah--he had sex with that cute little prostitute on the bus once...
And after all, look how many addicts are entering rehab in emulation of Lindsay, Britney, and gang....
🙄🙄🙄🙄

(May I suggest a first post to the forum that more directly indroduces you to us as a student interested in psychiatry? Try something like, "Hi, I'm rainbowman, and I'm a pre-medical student." )

 

[jjbmsiv]

In other words: what a dip****.

With regard to whether I am referring to Cruise or the pre-dentist, I ask you- Does it matter?

 

[rainbowman]

It was a joke, and I'm actually premed I'm just too lazy to change it on my profile. I couldn't care less what Tom Cruise thinks. He is a tool. A SCIENCE FICTION writer invents a RELIGION to get rich, because you have to pay to progress. L. Ron Hubbard, founder of Scientology (that is, the science of making money) had personal issues with psychiatrists (because he was a nutjob or something or insulted that they suggested and he needed help). Cruise, I don't think he realizes he's pissing away his money (which is fine by me, he's overpaid anyway) on a b.s. religion and that he in actuality knows nothing of what he is talking about, he's spewing hatred against psychiatry because the fudgepacker who invented Scientology had a vendetta against psychiatrists. Some people think he's a hero for speaking out against human rights abuses in psychiatry-that was decades ago, everyone knows, we don't need some **** action movie star with an 11th grade education insulting our intelligence-because that's what he's doing. I've seen psychiatrists myself and am interested in being one, I was making a sarcastic remark about his idiocy

 

[Therapist4Chnge]

Psychiatrists and psychologists are taking a team approach to mental health care. Many psychiatrists refer their patients to psychologists for CBT while they manage their drug regimens. This works well for both parties as many psychiatrists do not enjoy psychotherapy and would rather see their patients as clinicians managing their prescriptions and physical health (monitoring their vitals in regards to medication etc.). There are also many new advancements in neurology and psychiatry so that psychiatrists have options aside from just psychotherapy such as brain mapping. And like someone mentioned above, psychologists prefer psychotherapy since that's where the bulk of their training lies. There is not an adversarial relationship among psychiatrists and psychologists as I once presumed.

I definitely agree with this sentiment. Because of the complexities within mental health, a team approach is absolutely necessary in many cases to fully address the issues. I've had the pleasure of working with some great psychiatrists, NPs, RNs, nutritionists, etc. and I've seen the positive contributions that each person makes. It seems that much of the animosity is amongst people coming up now, and not so much in the established field. With the way healthcare is trending (and not in a good way), healthcare professionals need to do less of the in-fighting, and direct their attention to the people and places that want to do things to negatively impact the area. (Reimbursement cuts, universal healthcare, lowering treatment opportunities, etc)

-t

 

[psychfriend]

It was a joke, and I'm actually premed I'm just too lazy to change it on my profile. I couldn't care less what Tom Cruise thinks. He is a tool. A SCIENCE FICTION writer invents a RELIGION to get rich, because you have to pay to progress. L. Ron Hubbard, founder of Scientology (that is, the science of making money) had personal issues with psychiatrists (because he was a nutjob or something or insulted that they suggested and he needed help). Cruise, I don't think he realizes he's pissing away his money (which is fine by me, he's overpaid anyway) on a b.s. religion and that he in actuality knows nothing of what he is talking about, he's spewing hatred against psychiatry because the fudgepacker who invented Scientology had a vendetta against psychiatrists. Some people think he's a hero for speaking out against human rights abuses in psychiatry-that was decades ago, everyone knows, we don't need some **** action movie star with an 11th grade education insulting our intelligence-because that's what he's doing. I've seen psychiatrists myself and am interested in being one, I was making a sarcastic remark about his idiocy

I try to look at Tom Cruise's comments in a positive way. I can either get upset at the guy for his brashness or I can acknowledge that there is some truth to what he said and we need to acknowledge it. Yes, my first reaction is similar to yours and I do think scientology is a cult and Cruise is unedcated. However, Tom Cruise is a huge celebrity on the scale of Oprah so he did bring this issue to the forefront regardless of how many psychiatrists discuss this in the brackground. And there is truth to what he said about how medication is being overprescribed. Half the work my psychiatrist does is undoing overmedication by previous psychiatrists. For example, one 6 year old male was prescribed Anaphranil, Adderal and Paxil for ADHD related symptoms. What the he!! was the previous psychiatrist thinking. This kid was not OCD. He was a typical ADHD child. My psychiatrist took him off those other meds and put him on straterra which he is doing extremely well on. Ask these psychiatry residents in this forum and they will all tell you there are a significant number of bad psychiatrists in the industry that resort to these types of practices. I'm not generalizing psychiatrists. The overwhelming majority of psychiatrists are competent physicians but that's not to say that there are a significant number of irresponsible psychiatrists who simply try to cure symptoms because they don't have the desire or patience to understand the underlying problem. They just want to make parents happy and will give them a multitude of drugs and send them away.

 

[Anasazi23]

The regimen doesn't sound unreasonable for a case that has acute symptomatology. Just because a patient isn't exhibiting a particular symptom at a given time doesn't mean they didn't have it before.

The only thing Cruise does is deter some patients that are on the fence about seeking help from receiving it.

There continues to be this false dichotomy that psychiatry is divorced from other branches of medicine. This likley stems from the fact that a person's personality or thought processes are less understood and reflect the workings of a person's core, and therefore should be less accessable to change by a physician.

His ramblings are grossly uninformed, and do not generalize to psychiatry by a long shot. I appreciate people trying to see the silver cloud within an ignorant rant, but let's call a spade a spade...

Why don't people become outraged and jump on couches over the pending super virus that's developing because every patient that goes to the PMD for an earrache or cough gets a z-pack or levaquin. Well, it's not brain or mind related....a z-pack doesn't produce a stigma or cause people to temporarily lose their rights and be admitted to hospitals - so it's okay. Until 12 year-olds start dying from bronchitis and pna again. Then maybe Oprah will do a special.

 

[psychfriend]

The regimen doesn't sound unreasonable for a case that has acute symptomatology. Just because a patient isn't exhibiting a particular symptom at a given time doesn't mean they didn't have it before.

OCD symptoms are difficult to control and are unlikely to disappear on their own especially just a few months later. If a patient genuinely displayed those symptoms initially, it's unlikely they would cease when he was placed only on straterra. It's more likely the physician initially misdiagnosed the patient.

The only thing Cruise does is deter some patients that are on the fence about seeking help from receiving it.

If those patients are going to stop taking stimulants based on something Tom Cruise said then it's unlikely they will be very compliant in the first place. And I don't agree that he deterred people from taking stimulants. The number of prescriptions for stimulants has increased since that time. If anything, he caused people to question taking them which I don't necessarily see as a bad thing. It's a safer approach than parents who walk into an office and demand that their child be placed on Ritalin or Adderral without considering that their child may not need them. His rant may have been illogical and unsubstantiated but it did raise awareness of pescribing stimulants and some good has arisen from that. For example, the makers of Adderrall have created a new stimulant with a release mechanism similar to Concerta in that it can't be crushed and snorted thereby reducing potential abuse among high school students.

There continues to be this false dichotomy that psychiatry is divorced from other branches of medicine. This likley stems from the fact that a person's personality or thought processes are less understood and reflect the workings of a person's core, and therefore should be less accessable to change by a physician.

I don't think the overall medical community or the general public discredit the field of psychiatry as being medically relevant. Tom Cruise is a scientology nut-job so his view will obviously be skewed. The issue focuses on judgment in prescribing certain medications. The issue isn't whether to prescribe stimulants but rather when to prescribe stimulants. No one is disputing the therapeutic value that stimulants possess but should it be the first line treatment in every case or should other medications be sought first such as Straterra or CBT? This type of questioning isn't limited to psychiatrists. Pain specialists are questioned continuously. OB/GYN are questioned about the excessive C-sections and whether they are truly performed to avoid litigation or in the best interest of the patient. Plastic surgeons are being questioned for performing breast augmentation on teenagers even with parental consent. There are many other examples of this

Why don't people become outraged and jump on couches over the pending super virus that's developing because every patient that goes to the PMD for an earrache or cough gets a z-pack or levaquin. Well, it's not brain or mind related....a z-pack doesn't produce a stigma or cause people to temporarily lose their rights and be admitted to hospitals - so it's okay. Until 12 year-olds start dying from bronchitis and pna again. Then maybe Oprah will do a special.

I don't think people are in an uproar over this issue any longer. The Tom Cruise incident has been over for a some time now. It's hype had as much to do with his live feud with Matt Lauer as it did with the field of psychiatry. No one had ever see a combative and passionate side of Tom Cruise in public, since he had always been p.c. with the media. Also, PCP's are as much to blame if not more so than psychiatrists for over -prescribing stimulants to children. Also, antibiotic resistance encompasses a far greater scope of people over a much more extended period of time. There are no short-term and direct effects that can be seen from creating antibiotic resistance through excessive use of antibiotics.

 

[Anasazi23]

1. The arguments made are relevant, but pipe-dream. i.e. "CBT" for every child that comes in displaying intolerable behavior is simply not realistic. While this doesn't mean that medication is therefor the default correct course of action, it is more often than not, in my experience, a result of a more innate biologically/socially driven severe behavioral problem less likely to respond to talk therapy than with medications. For every month you keep the child out of school in intensive therapy, they're missing school, becoming more isolated from peers and alienated from teachers.

2. OCD symptoms are absolutely controllable a few months after their presentation. No one is saying they disappear on their own. Medication does a great deal of good for these patients.

3. You're perpetuating the myth that psychiatrists prescribe whatever parents come in and demand. I've never found this to be the case. Are stimulants over-prescribed? Perhaps. Since we're using unscientific opinions, I'll say that many patients that I treated on my c/a rotation did not receive ANY medication. Oh, the shock.

4. Pain specialists and OB/GYNS dont' have celebrities people jumping on couches on one of the most-watched television shows in the U.S. Let's be honest. Psychiatry is under attack from multiple sources. Again, I won't apologize for psychiatry's practice; yet I will say that every medical specialty has room to improve. Also again, the concept of "the human condition" permeates this to a subconscious degree more than is realized. Ritalin won't generally kill a kid (rare exceptions exist). Antibiotic resistance will and has killed many kids. Nobody's jumping on couches.

5. The good 'ol USA. Nobody's "in an uproar over this issue any longer?"
I can't find the link....but today's MSN site had a full article questioning why people question the "religion" of scientology. In good old American fashion...if the media beats something into you long enough, you'll come to embrace a presidential candidate who has as part of his name Hussein, and soccer.
OB/GYNs and c-sections? Plastics and parental consent? Not even close to the backlash that psychiatry receives.

No short-term or direct effects of antiobiotic resistance? Have you worked as a medical intern in a hospital lately?

 

[Therapist4Chnge]

1. The arguments made are relevant, but pipe-dream. i.e. "CBT" for every child that comes in displaying intolerable behavior is simply not realistic. While this doesn't mean that medication is therefor the default correct course of action, it is more often than not, in my experience, a result of a more innate biologically/socially driven severe behavioral problem less likely to respond to talk therapy than with medications. For every month you keep the child out of school in intensive therapy, they're missing school, becoming more isolated from peers and alienated from teachers.

Many times the kid doesn't 'need' medication or intensive therapy, the kid needs a parent who is willing to put in the time....to you know, parent. I did research a couple years ago involving intensive behavior modification for severe ADHD / ADD children, and you'd be surprised the kind of improvement that can happen when the kids is worked with and the parents learn/apply a few things and stop being their 'friends' and start being their 'parents'. With that being said.....meds may still be necessary in some/many cases, but aren't always needed in all cases.

Okay...now the psychoanalyst in me feels dirty for advocating so much behavioral stuff!! Time to start talking about the kid really vying for his mom's affection and trying to come in between his father and mother....etc.

-t

ps.

 

[Milo]

I have to admit I have very mixed feelings about psyd/phd prescribing rights.

Tuition being what it is I think there is excellent money to be made teaching psychopharmacology.

I bet there would be a fair amount of people that would pay the tuition and then flunk out on the final exam question...

Spell the generic name of Abilify. 😕

 

[Anasazi23]

Many times the kid doesn't 'need' medication or intensive therapy, the kid needs a parent who is willing to put in the time....to you know, parent. I did research a couple years ago involving intensive behavior modification for severe ADHD / ADD children, and you'd be surprised the kind of improvement that can happen when the kids is worked with and the parents learn/apply a few things and stop being their 'friends' and start being their 'parents'. With that being said.....meds may still be necessary in some/many cases, but aren't always needed in all cases.

Okay...now the psychoanalyst in me feels dirty for advocating so much behavioral stuff!! Time to start talking about the kid really vying for his mom's affection and trying to come in between his father and mother....etc.

-t

ps.

You expect parents to parent? Another pipe dream.

In the child unit where I worked, there was a very large percentage of lower income non-families with much more severe problems than acting out in class. Many of these children were prodromal schizophrenic, and/or engaged in self-harm or brutal violence toward other children (and adults). People always seem to refer to child psychiatry as ADHD. While this may be the most common diagnosis made in the C/A world, it doesn't preclude the fact that sick kids need medication regimens. To deny them this could be argued as unethical.

The point of all this over the last number of posts was simply to remind people, especially those entering the field, that what you might see in front of you could very well be a misdiagnosis, or may be improperly treated. However, there are countless times in your career whereby you'll see a patient on what appears to be a complex med regimen. Simply taking off or reducing some or all of these medications may garner an initial response, but will often result in relapse shortly thereafter.

The common term for this is the "honeymoon" period of finding a new doctor - everything's changed, is wonderful and improved. Then, depending on the degree of pathology, things might go very sour.

 

[whopper]

You expect parents to parent? Another pipe dream.

Unfortunate but true.

Anyways, there's a shortage of psychiatrists and while it may be good for our wallets, its not necessarily good for our profession.

I have a few attendings in my program that IMHO leave something to be desired. That being said, I still think my program is a good one because I've seen this in almost every program I've seen, no matter the field. How this is a problem is that in a field where there is not a shortage of doctors--e.g. Internal Medicine, the department has an easy time replacing a doctor that's not doing their job.

At one of the local community hospitals I work at, its very difficult for them to replace a doctor, so they have to let the doctors get away with a few things they can't let the IM docs get away with.

And this causes a problem for residents because we're expected to clean up the messes some of these attendings make--with a smile. E.g. a patient is on the unit for a few days, only covered by an attending, and when I get the patient assigned to me, I notice some of the labs weren't checked, they've been diagnosed with Bipolar but aren't on a mood stabilizer, etc. I can't go to the attending and say "hey what's your problem!?!?!"

I've seen several outpatient show up to the inpatient unit with some errors in their management that were very easy to have corrected but their outpatient doctor did not do so (outside our residency system). E.g. a patient on valproic acid for years and their attending never checked labs such as an LFT or valproic acid level, and then they get some pretty bad side effects that are permanent.

Its very difficult in my area (and I know this is a nationwide problem) to get a psychiatrist at all.

So while it is better for our wallets, the shortage does create a lot of problems--several of which also hurt us & our patients.

 

[BabyPsychDoc]

I've seen several outpatient show up to the inpatient unit with some errors in their management that were very easy to have corrected but their outpatient doctor did not do so (outside our residency system). E.g. a patient on valproic acid for years and their attending never checked labs such as an LFT or valproic acid level, and then they get some pretty bad side effects that are permanent.

I don't want to sound naive, but what about primary care physicians? What is their involvement in cases like these?

 

[PsychMD2100]

You need not look further than CNN or any other news source to realize that our place is secure. As long as we have Virginia Tech, etc, there will always be a need for psychiatrists. The shortage of psychiatrists will only improve our situation, although it is worse for mental health care in America.

I'll respond to this thread in 2 ways. The first is that psychiatrists will do just fine. The second is that psychologists are simply psychiatrist-extenders. Rather than competing with us, they enhance the delivery of mental health care.

As long as there are mentally ill people, there will be a place for psychiatrists. I can tell you that there will always be mentally ill people.

 

[whopper]

I don't want to sound naive, but what about primary care physicians? What is their involvement in cases like these?

Several of our patients, and I'm sure this happens everywhere do not get a PCP even though we've told them to do so and have referred them to specific places that will treat them, even if they cannot afford it. Its gotten to the point where several of them had to sign documentation acknowledging that we urged them to get a PCP.

However in the case I mentioned the psychiatrist (and again this was not in my program) didn't even check the labs themselves. Any psychiatrist should order the appropriate labs for their patients--and when it comes to valproic acid--an LFT, CBC & valproic acid levels are musts. Some docs I know also order a serum ammonia level when dealing with valproic acid. This is not something a psychiatrist should just assume the PCP is handling. In most cases in outpatient, at least in my neck of the woods, the psychiatrist was more knowledgeable in dealing with the problems caused by the meds than the PCP.