"Geriatric psychiatry is a long-term growth industry," said
Charles Reynolds III, M.D., as he stepped into the role of president of the
American Association for Geriatric Psychiatry (AAGP) at the association's 2009
annual meeting in March in Honolulu. He was only half joking.
Charles Reynolds III, M.D.: "Our training is based in clinical
neuroscience. We are at the convergence of psychiatry, neurology, and internal
Reynolds is the University of Pittsburgh Medical Center endowed professor
of geriatric psychiatry. He also is a professor of neurology and neuroscience
and senior associate dean of the School of Medicine, and a professor of
behavioral and community health sciences at the University of Pittsburgh
Graduate School of Public Health. His presidential address was titled"
Tipping Point: The Future of Psychiatry." In it, he argued that
the profession of psychiatry is on the brink of dramatic changes and growth
and that geriatric psychiatry is well positioned to take the lead in greater
collaboration with neurology, internal medicine, and other disciplines and to
translate research into public health
"The strategies that we [geriatric psychiatrists] have developed ...
have enormous relevance to the future of psychiatry at large," Reynolds
Psychiatry underwent a previous "tipping point" in the 20th
century, according to Reynolds, when randomized, controlled clinical trials
elevated the standard for clinical evidence and fundamentally changed
practice. Now, psychiatry is at another tipping point at which transformation
of the entire profession is imminent. He pointed to areas of change to which
psychiatry must adapt: strengthening psychiatry as a "discipline of
brain science" and translating evidence into practice, building a better
business model to pay for its mission, placing more emphasis on early and
continuous multidisciplinary training, and improving the "academic
infrastructure." The future of psychiatry, said Reynolds, will progress
in the directions of both clinical neuroscience and public health, especially
the prevention of mental illness on a population scale.
Some psychiatrists had suggested that once the etiology of a disorder was
ascertained, the disorder was no longer in the realm of psychiatry and fell
into another medical specialty. "That's not the case any more,"
Reynolds said, thanks to the advances in neurosciences that increasingly
reveal the causes and pathology of psychiatric illnesses. "The boundary
between psychiatry and neurology is increasingly artificial. Our foci are
However, Reynolds does not think that psychiatry and neurology will merge
as one discipline, but that they will become more closely intertwined. One of
the growth strategies for psychiatry, he suggested, is to "re-integrate
the education of psychiatry and neurology on multiple levels. Partnerships in
undergraduate and graduate education would be to the benefit of both
Despite the scientific advances, Reynolds pointed out that society's
psychiatric needs are far greater than psychiatry's current capacity to treat
all patients effectively. Among the key weaknesses in the profession, he
noted, are "inadequate investment in studies of etiology,
pathophysiology, and rational—theoretically based, pathophysiologically
informed—prevention and treatment" and "inequities in the
delivery of mental health services to disadvantaged populations."
"There is a good but not an excellent armamentarium for assessment
and treatment of mental illness," he said. Psychiatry needs more
integrated approaches in research and funding and increased"
institutional support for junior faculty and infrastructure of academic
The coexistence of neurologic and psychiatric illness burden is especially
common in geriatric psychiatry. This allows geriatric psychiatrists to provide
a model of synergy in multidisciplinary teams for the rest of psychiatry,
according to Reynolds.
"Our training is based in clinical neuroscience. We are at the
convergence of psychiatry, neurology, and internal medicine," he said,
pointing out that geriatric psychiatrists are well versed in the language of
neurologists while taking a holistic approach to treat the emotional and
psychiatric issues of patients, caregivers, and families.
In an interview with Psychiatric News, Reynolds discussed the
progress made in the research and application of psychosocial interventions
for depression and anxiety in not only geriatric patients but also in the
caregivers of these patients. Evidence has emerged to support interpersonal
therapy, problem-solving therapy, and cognitive-behavioral therapy in helping
patients and caregivers cope with the difficulties of mental illnesses such as
dementia. During his term as the association president, one of the agendas for
AAGP will be to give more prominence to psychosocial research in educational
A lack of new blood in the academic sphere of psychiatry concerns Reynolds."
Our training needs, but often lacks, a robust public health
dimension," he observed. "In some ways, we have a 'professional
inferiority complex.'... We're not always as proud as we should be or deserve
to be for the work we do."
Geriatric psychiatry is facing a serious shortage of new practitioners and
researchers, Reynolds told Psychiatric News. "This is a
relatively small field.... There are about 1,500 geriatric psychiatrists
nationally." In fact, there is a similar shortage of geriatricians
across the country, he noted.
Reynolds was a member of the Committee on the Future Health Care Workforce
for Older Americans organized by the Institute of Medicine. The committee
released a report in April 2008 forecasting dire shortages in the health care
workforce caring for the aging population and called for an urgent expansion
and fundamental reform in the recruitment, training, and retention of
geriatric health care providers, including those in geriatric psychiatry.
Geriatric psychiatrists face many challenges, one of which is the lack of
reimbursement for care coordination, Reynolds noted. Furthermore, as the
number of dementia patients balloons with the aging population, the workforce
shortage will hit caregivers hard, ranging from family members to direct care
workers in nursing homes and long-term-care facilities. Another challenge
facing the subspecialty is the barrier of stigma, especially among minority
elderly patients, since the proportion of elderly minorities will certainly
increase in the next decades. "The need for culturally sensitive care
cannot be overstated," he commented.
As a member of the DSM-V Task Force and Sleep/Wake Disorders Work
Group, Reynolds is convinced that prevention of mental illness in individuals
and in populations will take a much larger role in the coming years. This area
of research and practice is especially relevant for aging adults, with
exciting new evidence related to the prevention of geriatric depression and
dementia that links psychiatry closely to cardiovascular health and other
Reynolds emphasized that training for future geriatric psychiatrists
requires a broader view of public health. "This is a new and exciting
time. The clinical needs are great. We need to properly incentivize young
people to enter and stay in geriatric psychiatry."
When asked about his outlook for the future of AAGP, Reynolds concluded,"
I am optimistic. We can help the nation age successfully."▪