Wake-up call for British psychiatry

The recent drive within the UK National Health Service to improve psychosocial care for people with mental illness is both understandableand welcome: evidence-based psychological and social interventionsare extremely important in managing psychiatric illness. Nevertheless,the accompanying downgrading of medical aspects of care hasresulted in services that often are better suited to offeringnon-specific psychosocial support, rather than thorough, broad-baseddiagnostic assessment leading to specific treatments to optimisewell-being and functioning. In part, these changes have been politically driven, but they could not have occurred withoutthe collusion, or at least the acquiescence, of psychiatrists.This creeping devaluation of medicine disadvantages patientsand is very damaging to both the standing and the understandingof psychiatry in the minds of the public, fellow professionalsand the medical students who will be responsible for the specialty’sfuture. On the 200th birthday of psychiatry, it is fitting toreconsider the specialty’s core values and renew effortsto use psychiatric skills for the maximum benefit of patients.

INTRODUCTION

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INTRODUCTION

British psychiatry faces an identity crisis. A major contributoryfactor has been the recent trend to downgrade the importanceof the core aspects of medical care. In many instances, thishas resulted in services that are better suited to deliveringnon-specific, psychosocial support rather than a process ofthorough, broad-based diagnostic assessment with formulationof aetiology, diagnosis and prognosis followed by specifictreatments aimed at recovery with maintenance of functioning.These changes have been driven in part by government, but therehas been both active collusion and passive acquiescence bypsychiatrists themselves. Our contention is that this creepingdevaluation of medicine is damaging our ability to deliverexcellent psychiatric care. It is imperative that we specifyclearly the key role of psychiatrists in the management ofpeople with mental illnesses.

Psychiatric illness and ‘mental health’

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Psychiatric illness and 'mental...

How many of us have, in clinical discussions, been aware ofuneasiness in colleagues in defending ‘the medical modelof care’¹ or been the only one using the word ‘patient’when discussing service delivery or planning? However, despitethe recent misguided tendency by many to caricature a medicalpsychiatric approach as being narrow, biological and reductionist,we are struck by how keen other members of staff are for themselvesor their relatives to be seen by an experienced psychiatristwhen mental illness affects them. Moreover, when patients wereasked how they would prefer to be described by a psychiatrist,67% preferred ‘patient’ and only 9% preferred ‘service user’.² This disjunction cannot be a healthy state ofaffairs and aggravates public and health professionals’difficulties understanding psychiatric illness and the psychiatrist’srole.

One key issue is that the concept of mental illness has broadened considerably since Reil first coined the term psychiatry 200years ago.^3,4 As a result, many people with mild psychiatricsymptoms have developed exaggerated and unrealistic expectationsof psychiatry. Indeed, psychiatric services may not be bestplaced to manage the majority of individuals with such mildsymptoms, who would be better served by other more general services. It is probably in the best interest of such individuals toavoid medicalising both the terminology and the type of helpthat they may require or want.

Certain circumstances do, however, require professionals withmedical training to diagnose and treat underlying psychiatricor non-psychiatric physical disorders. Further, those withsevere mental disorders can and do benefit from the processof a medical psychiatric assessment, diagnosis and treatment.^5–7 For those with severe mental illness, to avoid medicalisationis at best confusing and at worst damaging or even life-threatening.These individuals, the very people for whom Reil argued thatpsychiatry was needed,^3,4 are being let down by the currentstate of affairs. These considerations about the nature andbreadth of psychiatry bear upon the fundamental issue as to where its appropriate boundaries lie, and whether practitionerscan and should continue to try to span such a broad spectrumof skills, knowledge and interests.⁸

We have spoken naturally about psychiatrists treating mentalillness: use of the term ‘mental health’ to describeservices for those with mental illness risks undermining thereal importance and impact of these conditions on patients.The recent renaming of one Welsh trust’s psychiatricout-patient clinic to ‘Mental Health Well-Being Clinic’takes this confusion one step further. Using such terminologiesmay in turn undermine the priority of psychiatric illness for health commissioners and politicians. Psychiatry is more orless alone among medical specialties in the extent to whichit has adopted this approach that so distorts its originalpurpose.

The influences that encourage demedicalising the care of thosewith severe mental illness are legion and apply in part toother fields of medicine. They probably include political drivesto cut costs, interprofessional rivalries, the scepticism ofsome psychiatrists towards biomedical explanations of illness⁹and service development predicated on the false assumptionthat severe psychiatric illness equates only to chronicityand poor treatment response.¹⁰ The net effect of these influences,however, is the same: to obstruct our primary medical dutytowards patients with severe psychiatric disorders. Hence, itis imperative that we take action to ensure that patients withmental illness are not disadvantaged compared with others withinthe National Health Service (NHS).

Patients have a right to expect more than non-specific psychosocial support

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Patients have a right...

The drive within the NHS to improve psychosocial care for thosewith mental illness has been both understandable and welcome:evidence-based psychological and social interventions are extremelyimportant in managing psychiatric illness. However, an unintendedadverse effect is that there is an increasing tendency formany services to be based on non-specific psychosocial support with extremely limited therapeutic ambition.¹⁰ In order tofollow clinical guidance (such as that provided by the National Institute for Health and Clinical Excellence (NICE))⁷ to develop excellent ‘mental health’ care (for those withmental illness), it is important to recognise that a biomedicalcomponent, with access to appropriate facilities and appropriateservice pathways, is usually crucial. Many recent NHS changes,including, for example, those outlined within the NationalService Framework for Mental Health,¹¹ have provided an extensivediscussion of important generic issues, including social inclusiveness,stigma and access. What they have not done, however, is to placesufficient weight on medical fundamentals such as the need to distinguish the major forms of mental disorder, the implementationof appropriate evidence-based treatments, the subsequent monitoringof mental state for optimal outcome and the importance of addressingthe physical morbidity and mortality associated with almostall types of psychiatric illness.

For example, in some crisis intervention teams, the focus onthe general practicalities of a crisis can lead to patientsnot receiving the benefit of a thorough diagnostic assessmentat the time of acute illness. The effect of this may be tohave a negative impact on the outcome of the acute episode. Even if the episode resolves, lack of a thorough diagnosticassessment, including physical examination and investigations,may result in inappropriate, suboptimal or ineffective managementbetween episodes and a failure of relapse prevention. Sucha scenario could have major consequences for the life experiencesof the patient as well as implications for ‘service costs’.

One of the great strengths of medicine, when practised well,is its focus on making a demonstrable difference for the patientand its willingness to be pragmatic in using whatever approachesare shown to be effective. We should seek to minimise the unhelpfulinfluences of political idealism or rigid adherence to particularschools of practice or thought and must strive to ensure thatthe effectiveness of all therapeutic modalities is judged using similar standards of evidence.¹² We must face up to our professionalresponsibilities to ensure that all aspects of management areas good as possible. This includes advocating the maintenanceof the skills, facilities and resources to provide excellencein biomedical care for patients with psychiatric illness. Givenour training and our statutory position as prescribers of medication,psychiatrists have a particular responsibility to ensure thatpharmacological interventions as well as other interventionsare used appropriately and according to the best availableevidence. We must not contribute to stigmatising and disadvantaging psychiatric patients by denying them access to treatments thatwork.

Patients referred by their general practitioner should be assessed by a named psychiatrist rather than an anonymous team

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Patients referred by their...

Psychiatry is a medical specialty. We believe that psychiatryshould behave like other medical specialties. When a generalpractitioner is confident that a psychiatric assessment isnot needed, it should be possible for a referral to be madedirectly to a relevant non-psychiatric professional. However,where the general practitioner is unclear about diagnosis or treatment, the patient should be assessed by the most appropriatelyskilled and experienced professional on the team, the psychiatrist.This is analogous to managing back pain, where in many instancesa general practitioner is confident that a medical orthopaedicopinion is not needed and will refer directly to a physiotherapistor an alternative therapist such as an osteopath or chiropractor.However, in severe, persistent or otherwise complex cases an orthopaedic referral should be made, because an assessmentby an orthopaedic surgeon is required to ensure accurate diagnosisand exclude or treat causes that are remediable, thereby improvingthe patient’s quality of life and minimising the riskof complications such as paralysis.

In psychiatry, it is psychiatrists, who are trained in diagnosingphysical and mental illness, who are competent to formulatediagnoses that incorporate physical, mental and social factorsand, where appropriate, recommend initiation of one or moreof a range of possible medical treatments. As in other medicalspecialties, initial assessment may also involve important contributionsfrom other non-medical members of the team, and may include relevant medical investigations such as blood tests or imaginginvestigations. Assessment, in many cases, may lead the psychiatrist,as a leader in the clinical team, to conclude that the mostsuitable treatment is a psychological or social interventiondelivered by the member of the team with the most appropriateskills. This approach allows the patient the benefit of a thorough,broad-based assessment by a highly trained professional in order that the most appropriate management is implemented at theearliest opportunity.

This approach contrasts in important ways with an alternativemodel advocated in the move to New Ways of Working.¹³ Thisis an initiative developed jointly by the UK government’sNational Institute for Mental Health in England and the RoyalCollege of Psychiatrists. The report New Ways of Working forPsychiatrists: Enhancing Effective, Person-centred Servicesthrough New Ways of Working in Multidisciplinary and Multi-agencyContexts claims to be ‘about a big culture change; it is not just tinkering at the edges of service improvement’.Within the New Ways of Working model of distributed responsibilityand leadership, a secondary care patient may never see a psychiatristor may see one only when problems are identified by other teammembers. This means that many patients will not benefit froma thorough psychiatric diagnostic assessment before startingtreatment. Given the complex relationship between psychiatricand non-psychiatric disorders,¹⁴ and their common co-occurrence,¹⁵ providing suboptimal or inappropriate treatment may have detrimental consequences for patients. For example, a patient may receivepsychological therapy for symptoms best treated pharmacologically,or caused by an unrecognised treatable organic condition; or,potentially just as damaging, a patient may continue on inappropriatemedication when, with correct assessment, a psychological orsocial intervention would have been indicated.

It is easy to understand how we have arrived at the model ofdistributed responsibility and leadership as a pragmatic, short-termresponse to recent crises in staffing and morale in general psychiatry.^16–19 However, we should not assume thatthis pragmatic emergency ‘solution’ is an ideal,or even desirable, state of affairs.²⁰ Although distributedresponsibility may make life easier for psychiatrists and appears to be the cheaper option, it does not follow that this is inthe best interests of patients. Should we not be arguing forbetter evidence-based services and the resources and workforceto deliver these services?

We suggest a useful thought experiment: if a member of yourfamily were a patient, is a distributed responsibility modelthe one for which you would opt?

Recruitment into psychiatry

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Recruitment into psychiatry

One of the major problems confronting contemporary British psychiatryis difficulty with recruitment into, and retention within,the specialty.^21–24 Reil argued that only the best doctorsshould become psychiatrists. We would assume that the mostable, broad-minded and enthusiastic students, who may becomethe best doctors, would be attracted to specialties in whichit is clear that they are able to make best use of their skillsand knowledge within a service that values their extensivebroad-based training. Would such individuals be attracted toa specialty in which skills that have been acquired over along period of training are at a high risk of early disuse atrophy?In this context of a devaluation of specialist medical skills,it is commonplace in the UK to hear non-psychiatrists –and frequently psychiatrists themselves – referring topsychiatrists as not being ‘proper doctors’. Thislack of professional confidence and self-confidence contributesto the retention problems in psychiatry.^25,26

In contrast to this negative view, it is much more accurate,and fully consistent with Reil’s original suggestions,to think of psychiatry as being the only specialty in whichits practitioners are fully trained doctors, incorporatingpsychology and social-based knowledge and skills as major componentsof training. The absence of such skills in other medical specialtiesis a common cause of patient dissatisfaction. It is interestingto note that the distinguished neurologist Henry Miller said:‘the psychiatrist must be first and foremost and allthe time a physician... In fact, psychiatry is neurology withoutphysical signs, and calls for diagnostic virtuosity of thehighest order... The simple fact (is) that a psychiatrist is a physician who takes a proper history at the first consultation’.²⁷ Indeed, Henry Miller went one step further in emphasising thispolymath function: ‘the psychiatrist should not onlyfirst be a physician but ideally a superlative physician’.²⁸

To embrace this more positive and self-confident view of psychiatrywould, of course, require a commitment by psychiatrists toaim for excellence in the core medical aspects of their role.This would include excellence in the prescribing of psychotropicmedications as well as maintaining and developing expertisein the relevant aspects of assessment and management of the non-psychiatric illnesses that so commonly co-occur with psychiatricdisorder and which are associated with decreased life expectancyof psychiatric patients.^14,29 Although this may not appealto some practising psychiatrists, it is interesting to notethat consultants are much more likely to believe that recruitmentproblems arise because our specialty is ‘too psychosocial’rather than ‘too biological’.²⁶ Whatever the personalpreferences of some current psychiatrists, for the sake ofthe health of our patients²⁹ and our specialty we need toensure that these skills are expected of future psychiatrists.

All too often in British psychiatry, thinking is dominated bythe need to respond to the short-term practical constraintsof whatever initiative is current at the time. However, asa profession we should be thinking with a longer-term visionof the needs of patients with psychiatric illness and how thosecan best be delivered now and over the coming years. Such strategic thinking should inform the profession’s advice to thehealth service and government as well as shaping training andrecruitment initiatives for the specialty.

The future

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The future

Conclusion

ACKNOWLEDGMENTS

REFERENCES

It is hard to imagine that psychiatry will not assume increasingimportance over the coming decades. Mental illnesses are, andwill continue to be, major causes of human suffering and mortality.Mood disorders on their own are predicted to be second onlyto ischaemic heart disease as a cause of disability acrossthe globe by 2020.³⁰ Major advances in molecular biology andneuroscience over recent years have provided psychiatry withpowerful tools that help to delineate the biological systems involved in psychopathology and impairments suffered by patients.³¹We can be optimistic that over the coming years these advanceswill facilitate the development of diagnostic approaches withimproved biological validity and enhanced clinical utilityin terms of predicting treatment response. We can expect thatcompletely novel treatments will be developed based on detailed understanding of pathogenesis.³¹

With this, we need to have appropriately skilled and knowledgeable psychiatrists working within services that can accommodatethe processes of diagnosis and management involved. Patientsshould expect prompt and accurate diagnosis followed by implementationof appropriate evidence-based treatment – much as isexpected by the cardiology patients of today. We can anticipatethat this will involve biological and psychological tests and neuroimaging as well as detailed clinical assessment (analogousto the enzyme tests, exercise electrocardiograms and cardiacperfusion studies that currently constitute assessment of cardiacpatients). Psychological and social interventions will, ofcourse, continue to be crucially important in managing psychiatricillness (as they are also in non-psychiatric disorders). However, in addition, patients have the right to expect that biologicalfactors are fully considered and, where appropriate, evidence-basedinterventions delivered.

Conclusion

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The future

Conclusion

ACKNOWLEDGMENTS

REFERENCES

A great deal has changed in the 200 years since Reil introducedthe term ‘psychiatry’ into medicine. It is a welcomeadvance that current management of psychiatric illness seeksto take a broad approach to care, embrace the benefits of multidisciplinaryworking and make optimal use of the skills of our colleaguestrained in other disciplines. However, in recent years changesin psychiatric practice and thinking within the UK NHS are in danger of throwing the baby out with the bathwater. This isnow to the potential disadvantage of many of our patients.Unless steps are taken to redress this balance we believe itwill not be possible to translate the improving scientificunderstanding of psychiatric illness into clinical benefitsfor patients. There is a very real risk that as the understandingof complex human diseases steadily increases, recent movesaway from biomedical approaches to psychiatric illness willfurther marginalise patients in comparison with those sufferingfrom physical illness.

We believe it is fitting that, on the 200th birthday of ourspecialty, we should reconsider our core values and renew ourefforts to use our psychiatric skills to the maximum benefitof our patients. Psychiatric patients deserve nothing less.

ACKNOWLEDGMENTS

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The future

Conclusion

ACKNOWLEDGMENTS

REFERENCES

The authors are grateful to the following for helpful discussionsand comments that have informed the article: Drs Maria Atkins,Jonathan Bisson, Martin Gee, Claire Jones, Izabella Jurewicz,Malcolm Liddell, Rob Potter, Ajay Thapar, Martin Williams andProfessors Peter Jones and Anita Thapar.

REFERENCES

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