The golden years of psychiatry are in the future
Authors: RODRIGO MUÑOZ
Journal: World Psychiatry (2010)

My ideas about H. Katschnig's paper are deeply influenced by my training and practice in the United States. Though I have no problem with his statements about our current challenges, I have a different vision of the future. Robins and Guze 1 proposed almost forty years ago a group of validators for schizophrenia and other psychiatric diagnoses, which were a crucial basis for the establishment of diagnostic criteria for use in psychiatric research 2. These criteria have been modified for clinical use in DSM-III, DSM-IV, DSM-IV-R, and now in preparation for DSM-V. None of them has been rejected on the basis of new research, but they have been modified because of new findings. This is not different from the ongoing diagnostic processes in other branches of medicine. I personally believe that the painstaking process of transferring research to better diagnoses will continue to receive severe criticism, specially by those less interested in diagnosis research. Those interested can always go back to each diagnosis and propose new research projects that should produce new diagnostic approaches based on clinical facts. There is no perfect match between patients’ clinical characteristics and therapeutic responses, so that progress is still predicated on new ideas and new understanding. Much research has shown that psychotherapy enhances somatic treatments, and patients with the same diagnosis may respond in a different fashion to the same treatments. I and many others think that most and probably all patients need verbal interventions, and the separation between psychotherapy and medication therapy is mostly artificial. I personally agree that we need “mega-trials” with participation of expert psychopharmacotherapists and psychotherapists as well as rigorous experimental design and measurement. In the meantime, we need to judiciously use the best information available, noting that a nihilistic position is not tenable. As in all medicine, we have to experiment with the best therapies available looking for the best results possible. H. Katschnig's writing confirms that we all share a large tent that has a place for almost any kind of thinking about psychiatric disorders. A cross-sectional review of psychiatry reveals that unrelated and even opposite ideas seem to have some representation in our field. I am glad that medical inductivism has progressively penetrated psychiatry in the last fifty years, gradually replacing other approaches. Inductive thinking has provided approaches that bring psychiatry squarely in the field of medicine. What about those who refuse to follow the inductive way of thinking and put forth ideas minimally validated by rigorous research? In my opinion, they should be treated according to the verifiable value of their ideas. The route to a psychiatrist office is tortuous and full of side roads leading away from the office 3. Delay of treatment often ranges from 6 to 8 years for mood disorders and 9 to 23 years for anxiety disorders. Most patients with psychiatric disorders do not see a mental health professional, and a minimal number see a psychiatrist 4. The issue of psychologists being allowed to prescribe has never been predicated on their demonstrated training, ability or performance. It has been created by the desire of some to increase their practice. The problem will not die as long as there are enthusiastic lobbyists and willing legislators 5. Their main obstacle is their lack of training, experience or knowledge to practice medicine. As I visit many locations in the United States and talk with my colleagues about their own activities, the message I get is that we are seeing all the patients we can, and there is an excess of willing patients who have not had access to psychiatrists. We clearly need more psychiatrists and better opportunities for offering easy access to our offices. The National Comorbidity Survey Replication 3 studied patients with anxiety, mood, impulse control, and substance disorders. Of 12-month cases, 41.1% received some treatment in the last 12 months, including 12.3% treated by a psychiatrist, 16.0% treated by a non-psychatrist mental health specialist, 22.8% treated by a general medical provider, 8.1% treated by a human services provider, and 6.8% treated by a complementary and alternative medical provider. The chances are high that this situation will not be changed without strategies that increase the general public's education about mental illnesses and their treatment, accompanied by programs that increase access to quality psychiatric care, and programs that promote the integration of psychiatry with other specialties 4. Better information and formal integration seem the best alternatives to the current disarray in referrals. The history of psychiatry is one of progressive recognition by organized medicine, by planners of services, by legislators, by families, and more gradually, by the public. After many years of isolation in state hospitals, psychiatry is now in community hospitals and almost all the centers of medical care in the United States. At national, state and local levels, psychiatry is part of efforts to improve medicine and enhance access to quality services. In our country, new legislation is providing equal payment for psychiatric services. This legislation has often been possible through the cooperation of many key leaders who have personal insight about the effect of mental illness in their families. As of December of 2008, there were 4,751 resident physicians on duty in accredited psychiatric programs in the United States 6. We should and are actually developing more slots for psychiatric training, but psychiatry continues to attract a solid number of the best among young physicians. Having been intimately involved with psychiatry since I was in medical school, the identity of “psychiatrist” has accompanied me for decades. So far, I have not had an opportunity to regret such situation, or to receive disparaging comments because of a profession that I practice with a feeling of high honor and distinction. Psychiatry has been gaining greatly in scientific standing, solid knowledge in diagnosis, better strategies for evaluation of treatment, standing among medical organizations, respect by those who know us and use our services, and programs that better serve our patients our communities. Pessimism about psychiatry's future is not warranted by the facts. To the contrary, the golden years of psychiatry are in the future.