Psychiatry is alive and well.

More than 30 years ago, E. Fuller Torrey published “The death of psychiatry” 1. He predicted psychiatry’s demise on the basis that disorders of the brain would be subsumed under the neurological specialty and problems of the mind would be taken over by the psychology professions. As we enter the 21st century, the specialty of psychiatry is not only alive but is thriving. It is thriving because of the excitement generated by scientific discoveries of the brain, the practical and growing applications for psycho- pharmacology, the emerging new science on genetics and mental health, as well as a renewed interest in psychosocial interventions and psychotherapies. The most profound reason for the survival and success of the profession of psychiatry, however, relates to the continuing mysteries of mental illness and the fear of mental illness in individuals and the community at large. Stigma, the pervasive issue that affects patients and providers alike, paradoxically benefits psychiatry and helps the survival of this medical specialty. Essentially, no one wants our patients except us. The acutely psychotic, the demented, the morbidly and suicidally depressed, the paranoid and manic, the personality disordered are not welcomed by other medical specialties or even other mental health disciplines, which compete with us but prefer to treat less disturbed or ill individuals. The issues for a successful psychiatric practice and the survival of the profession have much less to do with referrals than with adequacy of reimbursement for the difficult work entailed in diagnosis and treatment for the seriously mentally ill. Paying for quality psychiatric treatment is a challenge everywhere, especially since the majority of our patients are poor (or eventually become poor). The epidemiology and need clearly are present but the financing is inadequate. In response to this economic challenge, subspecialization is growing. The new subspecializations in psychiatry that, I believe, are a strength and a source of optimism for the future of the field underscore the adaptive nature of psychiatric practice. A decade ago, I wrote a small article on the future of the profession, entitled “In the year 2099” 2. I made a number of predictions, including a projection that psychiatry itself would become an expanded specialty, certified in one of four major specialties of practice – neuroscience, medical psychiatry, psychotherapy, and social psychiatry – with subspecialties in geriatrics, adult, substance abuse, developmental disabilities, and forensics. And, since the brain would be a continuing frontier of learning and research in 2099, many more physicians would consider themselves psychiatric specialists than today. Another example of coping and adaptation by psychiatrists is the experience in Washington, DC, of the federal employees’ health benefits program in the early 1980s. For many years, psychiatrists enjoyed excellent insurance coverage through the insurance held by federal employees and dependents, but in 1980, because of budgetary constraints, these benefits were cut back. Inpatient care was limited to 60 days per year and outpatient visits to 30 per year. The unlimited benefit and large number of federal employees who availed themselves of it had made Washington, DC, a destination for psychiatric practice and the highest proportion of psychiatrists per population in the United States in private practice. As a result of this cutback, I made the prediction that 100-200 psychiatrists in the Washington, DC, area would have to move to find enough patients to continue their practice. At the end of the first year we studied, there was a net gain of ten psychiatrists despite these dire predictions. A survey of the membership of the Washington Psychiatric Society 3 illuminated the reasons for survival (even growth) of the profession despite a financial recession due to the cutback in insurance. What we found was the psychiatrists rapidly found other work in community, forensic, and health care settings; they lowered their fees and were able to receive payment out of pocket from patients where insurance had paid before; and managed to survive by taking on part-time salaried positions and adjusting their private clinical practice. The prediction of the death of psychiatry in Washington, DC, was greatly exaggerated. This is not to make light of the challenges on which H. Katschnig elaborates in his excellent essay, but we need not despair. Our technologies may be “halfway”, that is, we help individuals and communities be better but not well, and most of our illnesses are chronic and relapsing. Our successes, however, increase the demand for our specialty services and now we just have to find a way to get paid adequately for the quality that we bring to the task.