Are psychiatrists losing their political clout when it comes to influencing the direction of Michigan's mental health care? The last time a psychiatrist headed Michigan's Department of Mental Health was the late 1970s, before the deinstitutionalization movement. Currently no psychiatrist holds an administrative office in the Michigan Department of Community Health (MDCH). Psychiatric News asked several Michigan mental health officials whether they thought that if a psychiatrist were again steering the department, it would be further along in solving the serious problems plaguing the mental health system.

"I firmly believe that a psychiatrist should have the job," said Michael Engel, D.O., a past president of the Michigan Psychiatric Society. "As psychiatrists, we are losing the political battle to advocate for patients and for the services that are essential. The political reality is that nonphysicians have taken over the system. They have changed its focus and don't understand the responsibility they have to patients."

Engel believes the most serious problems can be traced back to the 1980s when social workers took over control of the Department of Mental Health. He noted that the director was a social worker when the state hospitals started to be closed during the 1980s. "Psychiatrists have been relegated to prescribing drugs, and we are disengaged from the delivery of [the rest of] health care. Legislators seem to think that if they bring a doctor into the decision-making process it's going to cost more money. So they changed the system, and it is now more like a social-services program," he said.

Medical director of Detroit-Wayne County Community Mental Health Agency Michelle Reid, M.D., sees things differently. "I feel that a nonphysician could be a competent leader of a state department of mental health, but the position cannot be fully developed without adequate psychiatric leadership," she said.

Reid said that both Michigan Psychiatric Society and MDCH recognize the importance of having a psychiatrist as chief medical officer at MDCH. "A [psychiatrist] chief medical officer at MDCH would coordinate efforts of the many physicians who work for MDCH and reduce fragmentation of its various medical services," she said. "In addition, a [psychiatrist] chief medical officer would assure that decisions related to medical practice received input from department physicians before being implemented."

"It is incorrect to say that social workers have hurt the MDCH system," said Mark Reinstein, Ph.D., CEO and president of the Mental Health Association in Michigan. "I don't attribute MDCH's woes to social worker leaders at all, but more to what the previous administration did, including burying what had been a separate state mental health department in a super-department dominated by Medicaid, which has proven very damaging."

Patrick Barrie, deputy director of the state Mental Health and Substance Abuse Administration, asserted that many of the MDCH's difficulties are not clinically based, although they might end up having a clinical impact. He said the major problems involve finances, organization, and structure issues, some of which can be addressed by psychiatric leadership, such as those involving treating people with co-occurring disorders. "But, on the whole, I don't think a psychiatrist would be any more effective at influencing legislative decisions about funding or solving our revenue problems," he said," though this is not to take anything away from their clinical expertise at all."

MDCH Director Janet Olszewski did not return several calls requesting an interview.▪