Tuesday, September 23, 2014

Reducing numbers of psychiatrists in community mental health teams

Following up previous posts (What place for diagnosis in mental health care? and Responsible clinicians under the Mental Health Act) on Peter Kinderman's new book A prescription for psychiatry, I want to comment on a central theme of the book about replacing psychiatrists with GPs. I'm not necessarily against this suggestion. Too many psychiatrists are too biomedically orientated and may as well be replaced by GPs with a more psychosocial orientation. What GPs want from a mental health service is good assessment and management of their patients with mental health problems. Peter is clear that mental health care should reject the notion that it is (or should be) 'treating illnesses'. He would go along with the view of some mainstream psychiatrists, responding to what they see as the threat to their professional role (eg. see previous post), that psychiatry should focus its efforts on what it sees as the medical aspects of healthcare, specifically biological aspects of mental healthcare. Less psychiatrists may well be needed to do this.

I know what Peter means when he suggests mental health problems are not illnesses. This blog has often enough emphasised the lack of biomarkers for mental illness. Nineteenth century medicine developed because of its anatomoclinical understanding of disease. Just how misguided to expect the same advances in psychiatry is demonstrated by the awarding of the Nobel Prize in Physiology or Medicine to Wagner-Jauregg for malarial treatment of dementia paralytica and Moniz for leucotomy, and the nomination for the same prize of Sakel for insulin coma therapy, von Meduna for shock therapy with metrazol and Cerletti for ECT treatment of schizophrenia and manic-depressive illness. Have these really been the main advances in psychiatry?

I am happy to use the terms 'mental health problems' and 'mental disorder'. And, I am less worried about using the term 'mental illness' than Peter. In fact, I go along with Bill Fulford in Moral theory and medical practice that medicine is primarily an ethical activity. In that sense, psychiatry is the pre-eminent medical speciality. Many people go to their doctor with physical complaints whose origins are psychosocial. Peter doesn't mention this issue in his book. In Germany, for example, psychosomatic medicine has developed as a separate speciality. There may not be that much advantage in me having a medical training for much of my work as a psychiatrist, but at least I do understand psychiatric problems in their medical context. I'm certainly not advocating neuropsychiatry as the solution to the commonly identified crisis in the role of a psychiatrist (eg. see book review). What's needed is a more patient-centred approach to medicine in general. Peter's prescription for psychiatry may provoke this response. But encouraging psychiatrists to be neuropsychiatrists is not the right way to do it. This is a central theme of what Peter calls the 'Bracken manifesto' (see previous post). And clinical psychologists and other mental health professionals do need psychosomatic understanding to be complete practitioners.

1 comment:

MT said...

Does anyone actually think that receiving your mental health care from a GP will lead to a more "psychosocial" approach? Most psychiatric medications, particularly antidepressants and antipsychotics, are prescribed by GPs -- often off-label, i.e. inappropriately, such as using quetiapine for insomnia or aripiprazole for monotherapy of depression. Why would anyone believe that a GP, whose training and daily work consist almost entirely of diagnosing illness and prescribing the correct medication, would be less biomedically oriented than a psychiatrist who has received mandatory training in psychotherapy?