Change, Challenge and Opportunity: Psychiatry in Age of Reform and Enlightenment

The line it is drawn, The curse it is castThe slow one now, Will later be fastAs the present now, Will later be past

—Bob Dylan from “The Times They Are a-Changin’

To paraphrase the old Chinese saying, we are either blessed or cursed to live in interesting times. I believe that it is the former. Of course, that may be a matter of opinion, and it may require a bit of cognitive reframing to convince ourselves that this is the case, but while there may be some question about whether the current times are good or bad, there can be no question that we are entering a time of change.

To address this profoundly important matter—important to psychiatrists as well as to our patients—this article will be the first of a three-part series on the topic of our changing profession. (It is not by coincidence that the theme of APA’s 2014 annual meeting is “Changing Practice and Perception of Psychiatry.”) The articles will focus on the forces that are impacting psychiatric medicine and mental health care, particularly health care financing and scientific discovery. This first article will place these events in historical context.

The discipline of psychiatry has evolved to its current form over the past 200 years. Its history is punctuated by certain inflection points, which mark transformative changes in our profession. I believe that we are approaching another such moment in our profession’s development. For this reason, it is useful to revisit and reflect on the past to understand better not just where we are now, but also where we are going.

Following Pinel’s enlightened conception of mental disorders as illnesses and moral (humane) treatment, the next milestone was the rise of the asylum movement beginning in Europe and then extending to the United States. Dorothea Dix, a Boston schoolteacher, is often credited with spurring the establishment of state mental hospitals in this country after she visited prisons and almshouses in her native Massachusetts and found mentally ill people confined under inhumane conditions. These new mental institutions were intended for patients affected by acute or chronic mental problems. Prior to these facilities, many people with mental illness lived untreated and on the fringes of society with little or no care.

At their peak, public mental hospitals totaled 560,000 beds in over 300 facilities. But as this system grew, the burgeoning patient population in many hospitals led to appalling living conditions and poor care.

The next pivotal point came with Sigmund Freud. His psychoanalytic theory and therapeutic methods provided an intellectually compelling conceptual framework for psychiatrists at a time when the field was lacking a scientific theory. They also moved psychiatry from asylums to office-based practice and psychotherapeutic approaches.

The wars of the 20th century served to position psychiatry alongside medical and surgical disciplines, a status that has only increased in prominence as the consequences of emotional trauma have become more prevalent and widely acknowledged in the context of the wars in Iraq and Afghanistan.

At the same time, psychopharmacology revolutionized psychiatric treatment. In the 1950s, the widespread use of psychotropic drugs led to new conceptions of the causes of mental illness and increased discharges from U.S. mental hospitals, setting the stage for deinstitutionalization policies. The Community Mental Health Act of 1963, passed as part of President John Kennedy’s New Frontier, was intended to fund community-based care as an alternative to institutionalization. However, problems developed as health care services in the community fell short, and many former patients were left homeless or were incarcerated.

In 1952, the Diagnostic and Statistical Manual of Mental Disorders was created to complement the World Health Organization’s International Classification of Diseases. DSM-I and DSM-II (1968) had no systematic organization and were both relatively short books. Studies in the 1960s and 1970s showed that diagnostic reliability among clinicians using the DSM was poor; the likelihood of any two clinicians agreeing on a particular patient’s diagnosis appeared no better than flipping a coin.

To remedy the problem, APA radically revised its diagnostic approach and published DSM-III in 1980. This edition dramatically expanded the number of disorders and provided detailed descriptions of their defining criteria, with precise lists of symptoms and behaviors. DSM-III revolutionized diagnostic precision in mental health care and provided clinicians with a common language to facilitate communication among themselves and with their patients. In the revisions that will follow DSM-5, which was released in May, we anticipate that psychiatric diagnoses will move beyond descriptive phenomenologic criteria to measures of pathophysiology and etiology and that they will involve laboratory tests to identify lesions and disturbances in specific anatomic structures, neural circuits, or chemical systems, as well as susceptibility genes—the kinds of tests that routinely inform the diagnosis of infection, cardiovascular disease, cancer, and most neurological disorders. The research that occasions these developments may not just enhance our ability to make diagnoses, but may fundamentally redefine the nosology of mental disorders.

Which brings us to the present situation. During the past 50 years, two forces were unleashed that promise to pervasively alter psychiatry and mental health care over the next decade. We cannot underestimate their power and the magnitude of the change they will bring. These forces are the rising cost of health care and the increasing pace and momentum of scientific discovery. The former has resulted in health care reform initiatives (for example, the Patient Protection and Affordable Care Act), a process that will change the way in which health care (including mental health care) is provided and financed. The latter will lead to changes in our understanding of the brain, behavior, and mental disorders and our ability to treat them.

For many, the combined effect of these forces has been frustration and fear. In the past few decades, the focus has shifted more toward the brain and away from the mind. And changes in reimbursement systems today have rewarded hurriedly written prescriptions and encouraged psychotherapy to be provided by nonpsychiatrist therapists. Paperwork, insurance procedures, and government regulation have stretched physicians’ tolerance and limited the opportunities for meaningful interaction with patients. Research has only slowly yielded findings that have been translated to psychiatric practice and improved mental health care.

However, rather than fear most of these forces, I suggest that we embrace them; they will ultimately improve the quality and status of our profession. We should prepare ourselves now for our future and how it will be formed.

Toward that end, subsequent articles will preview the health care reform process; how it will affect models of care, professional roles, and methods of reimbursement for psychiatrists; and how we anticipate scientific advances will transform psychiatry’s understanding and treatment of mental disorders. ■