The Future of Psychiatry and Mental Health Services
A video copy of this talk is presented below:
My talk can only be a series of remarks about the current state of some aspects of mental health services and the field of psychiatry and where I think the path of these important institutions will meander in the future.
Lets start with the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association. Earlier this year we have seen the publication of the 5th edition (DSM-5).
Much debate has surrounded this new version. Some focuses on details – different criteria for the diagnosis of some conditions. Some is more systemic – arguments for spectrum of disorder rather than categories (especially advanced by psychologist colleagues) and the problem of numerous co-morbid conditions. Some is based on methodology – lack of reliability of diagnoses.
But perhaps the most serious criticism goes to the heart of the project – that it lacks validity. The director of the US National Institute of Mental Health (Dr Thomas Insel) in April this year said (as reported on Wikipedia):
“While DSM has been described as a ‘Bible’ for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. Patients with mental disorders deserve better.”
This was interpreted as the NIMH saying ‘goodbye’ to the DSM-5.
The NIMH has gradually moved to a new classification system – the Research Domain Criteria (RDoC) – that attempts to classify psychiatric disorder into five domains or constructs. The major RDoC research domains/constructs are:
• Negative Valence Systems (Fear, Anxiety, Loss)
• Positive Valence Systems (Reward learning, Reward valuation)
• Cognitive Systems (Attention, Perception, Working Memory, Cognitive control)
• Systems for Social Processes (Attachment formation, Social Communication, Perception of self, Perception of others)
• Arousal/Modulatory Systems (Arousal, Circadian rhythmn, Sleep and wakefulness)
The domains are tentative– “It is important to emphasize that these particular domains and constructs are simply starting points that are not definitive or set in concrete”.
This apparent abandonment of DSM V created a furor and had to be ‘hosed down’ or put in context. So in May this year Dr Insel, on behalf of NIMH, issued a joint statement with Dr Jeffery Liebermann, president of the American Psychiatric Association, that emphasized that DSM-5:
“…represents the best information currently available for clinical diagnosis of mental disorders. Patients, families, and insurers can be confidant that effective treatments are available and that the DSM is the key resource for delivering the best available care. The National Institute of Mental Health (NIMH) has not changed its position on DSM-5.” Dr Insel and Dr Lieberman say that DSM-5 and RDoC “represent complementary, not competing, frameworks” for characterizing diseases and disorders.
Problem solved? Not really. The core criticism of DSM-5 points to the fundamental problem facing psychiatry – we still have no system of classification or comprehensive understanding of mental disorders based on etiology. The NIMH approach is a long-term march toward understanding the causes of mental illness. But this approach is pinning hope on ultimate neurobiological explanations. Other competing models (psychodynamic, social) will need to be considered too.
I started training in psychiatry just as the original symptom-based DSM-3 was introduced in 1980. Then us ‘upstarts’ used the criteria-based DSM-3 to criticize senior colleagues about their diagnostic practices – especially lack of specificity.
Their defense was to say to us youngsters that patient conditions are more complex than they seem and DSM-3 was too simplistic – co-morbidity was the rule not the exception. Did not stop us from putting the ‘boot in’, at least in private.
But now 30 years later we have a DSM system that is struggling with concerns about validity and has problems dealing with the complexity of co-morbidity and conditions morphing into different forms over time in the one patient. Looking back our ‘seniors’ may have had a point!
Growth of knowledge in psychiatry
Over the last 30 years in addition to the iterations of the DSM I have seen other developments in biological psychiatry. All offered great hope in understanding mental illness.
In order we were introduced to neuroendocrine approaches, family and association genetic studies, structural brain imaging, functional brain imaging (fMRI, PET, MRI spectroscopy), human genome chromosomal gene analysis techniques, pharmacogenetics (leading to informed drug selection and individualized dosing), translational research, and nanotechnology.
All have led to interesting findings but so far have fell well short of uncovering the basic nature of mental disorders.
The pattern of growth in knowledge in psychiatry is like a continuous loop – at times one thinks we have returned to start, but the trend of each of the loops centre is on an incline upward and onward. Based on this reasonable view of the development of understanding in psychiatry I believe the future is bright.
I particularly look forward to further exploration of prevention of mental illness and reducing secondary disability by early intervention and treatment in conditions beyond early episode psychosis.
Over the past 30 years there has been a push by public mental health services to ‘mainstream’ the care of individuals suffering from mental illness. This means providing services for them within the general health system rather than a separate service for those with psychiatric illness.
While this has emphasized the role of general health services in providing treatment, and had some (limited) benefit of reducing stigma and curtailing the excesses of some treatment practices in the older, or more isolated stand-alone psychiatric hospitals, the policy has had (unintended) consequences for training of doctors and psychiatrists.
Most public psychiatric units have become gazetted units admitting many involuntary patients. As a result, public mental health services have gradually but progressively narrowed their clinical focus to patients suffering from drug induced and functional psychoses (often complicated by substance abuse), patients on forensic orders, and the more severe (often Cluster B – antisocial, ‘borderline’) personality disorders. This narrowing of focus is present in both inpatient and outpatient settings. While this is an important part of psychiatry, it is not representative of the range of conditions that psychiatrists should be familiar with.
As most of the training of medical students and psychiatrists takes place in public mental health services, the training opportunities for a balanced training experience in psychiatry are limited. Many of these services do not provide the breadth of clinical conditions and treatment programs required to provide an attractive and comprehensive training experience for psychiatric registrars and other mental health professionals.
Unfortunately, we are graduating clinicians with limited capacity to treat patients with non-psychotic (or high prevalence) conditions and act as expert resources for other doctors and health professionals who treat patients outside the public sector.
How can we correct this problem?
A substantial increase in training opportunities beyond public mental health services is required for medical students, psychiatric registrars, allied health professionals and nurses in order to provide comprehensive knowledge and skills in psychiatry.
More training positions in the private sector and in other settings (such as non government organization services) are needed and should be affiliated with learning organizations such as universities and institutes. Methods of funding these positions will be a major challenge, but without this broadening of psychiatric training the profession will wither.
Some small steps have been made to introduce psychiatric training positions into private hospital settings, but more needs to be done. A major advance will be to place psychiatric trainees in office-based private practices.
The push to mainstream mental health services has led to other unintended consequences. The unique needs of individuals suffering from mental illness have not been fully appreciated and provided for and this has led to a secondary marginalization of mentally ill patients in general health services.
One needs to look no further than the way patients with mental illness are treated in busy public hospital emergency departments to see evidence of this marginalization. Indeed, belatedly, there is now recognition that separate psychiatric emergency departments need to operate in public hospitals.
But beyond the emergency department the mentally ill need inpatient units with plenty of space, sub acute, step-down and extended care treatment facilities, and properly supervised community residential accommodation – all features that are not usually offered by or supported by general health services.
To address this problem an alternate model is required. I call it ‘parallel and integrated’. It would recognize the special needs of individuals with mental illness and build a system of care from there while utilizing the strength that comes from close association with general health services.
This change in direction would facilitate the development of community, emergency department, inpatient, sub acute, extended care, and residential supervised accommodation services that better meet the needs of the mentally ill.
Parallel and integrated services should replace the ‘mainstream’ model.
A major build of clinically supervised clustered accommodation around embedded rehabilitation and recovery services is urgently needed for longer stay patients. This would reduce the problem of patients with chronic severe disorders flooding acute inpatient units because of frequent relapses due to poor accommodation and inadequate supervision in the community.
Although suicide is a multi-determined behavior, surely the quality of mental health services for those who make contact with them prior to suicide has some role to play in preventing tragic outcomes – if not, then we should reconsider whether we should be in the business of providing care. I do not think we can just wash our hands and say that these suicides are ‘not preventable’.
A recent Queensland Health report highlighted the problems for psychiatric patients trying to access a health system under pressure. The report identified 140 unexpected deaths of patients treated by Queensland Health in the previous year.
More than half of these deaths (86) were of mentally ill patients who accessed Queensland Health services. Most of the deaths were by suicide; either within a week of a patient being assessed in Queensland Health emergency departments and not being admitted, or within a week of discharge from a psychiatric admission.
The finding of the high proportion of suicide deaths following discharge is consistent with many other studies.
These data raise the question of whether admission threshold practices in emergency departments, unavailability of inpatient beds, early discharge from inpatient care, and inadequate intensive community follow up of discharged patients has a role to play in increasing suicide.
How can we respond to this challenge?
I propose and ongoing audit be established to examine the pathways to death in all cases of suicide in Australia, whether occurring in hospital or in the community, in the public or the private sector.
The audit should be required to focus on the pathway to suicide of the individual and the nature of contact over the preceding three months between the individual and public and private mental health services.
The audit should make regular comment about the quality of services and make recommendations about improving these services.
An account of suicide statistics for each mental health service should be a public index of an important aspect of the quality of mental health services. An annual state and nation wide ‘suicide toll’ would be an extension of this idea.
Prof Philip Morris