What Does Psychiatry Need to Survive?

Shore, the Bullard Professor of Psychiatry and director of the Division of Mental Health Systems at Harvard Medical School, cautioned his colleagues against an angry and inflexible response to managed care during his lecture, "Psychiatry in a New Key: Assuring the Future of Our Profession." Regardless of whether psychiatrists like it, managed care reflects the realities of the marketplace and is here to stay, said Shore.

The excesses of managed care are already being restrained by a market in which quality is starting to replace cost as "the means of sharpening the competitive edge," he said. But Shore warned against unrealistic expectations of managed care's demise.

"That the market forces driving managed care are being altered and in some ways restrained by public attitudes and state legislation does not necessarily forecast a return to the old days of relatively secure professional autonomy, fee-for-service medicine, and cost reimbursement." Change, he noted, "is the way of the world."

If psychiatry is to establish a secure future, four things are required, according to Shore.

First, "we need to develop sophisticated understanding of health economics and health policy to understand in depth what is happening to health care and to psychiatry. We cannot act effectively without knowledge."

Second, "we need to live up to our professional ideals as the one medical specialty and one mental health profession that integrates all of the domains of knowledge that are essential to understand and treat mental disorders."

Third, "we need to follow the lead of successful organizations and demonstrate the capacity for innovation and new thinking in order to preserve our most important value, which is the opportunity to be of service to our patients."

And finally, said Shore, "we need to prepare ourselves for leadership among the mental health professions by accepting organizational responsibilities. To do so will require a different definition of our role and specific training in management and in leadership."

Although psychiatrists may feel beleaguered, the profession's current vicissitudes are not unique, observed Shore. Rather, they are part of sweeping changes reflecting "major restructuring of the global economy," he said.

A key aspect of this restructuring is the drive to improve productivity by lowering costs, including labor costs, said Shore. Health benefits are a major component of labor costs, and managed care is a response to the need to improve productivity.

There are inherent conflicts between the psychiatrist as consumer and the psychiatrist as clinician, said Shore. "As clinicians we want less interference and more reimbursement; as investors and consumers we want maximum return and lowest price. The market answers, 'You can't have both.' " Like it or not, "we are being pushed to become more efficient, like other industries."

Health Care as Public Good

Health care, however, is not a mere commodity, but a public good, similar to the services provided by police, firefighters, and utility companies. In this context, health care demands some protection from "the unregulated play of market forces," said Shore. Put differently, "we can tolerate some market inefficiencies such as overstaffed emergency rooms in order to protect human life," he added.

In the current economic environment, however, even public goods are being scrutinized for efficiency, and it is unrealistic to expect health care to escape such scrutiny, said Shore. Caught between professional values and market values, psychiatrists are being forced to "grope toward the point at which medical interventions can be demonstrated to provide the maximum needed benefit to the patient at the least cost consistent with quality."

Historical Perspective

Understanding the current economic crunch in psychiatry requires a brief look at the history of the profession beginning in the 19th century, said Shore. Initially, psychiatry was identified with the severely mentally ill and the asylum. But as better statistical methods emerged, it became clear by the last years of the 19th century that psychiatry had failed to keep pace with the rest of medicine in providing effective treatment for its patients.

This, in turn, led to a greatly reduced emphasis on the asylum and custodial care and an effort by practitioners "to redefine psychiatry as a medical specialty that applied its professional expertise to the vicissitudes of normal life," said Shore. Eventually the profession embraced the psychodynamic treatment of "healthy patients," said Shore, and this "has contributed mightily to our current problems."

The opportunity to practice long-term psychoanalytic therapy with healthy patients triggered a boom in psychiatry and other mental health professions, according to Shore. But "the snake in this mental health Garden of Eden was third party payments, which began to affect the practice of psychotherapy in the 1960's."

The clinical canon of psychoanalysis, which stated that patients had to pay for their own therapy if it was to be effective, "slipped quietly away, leaving nary a trace as health insurance coverage for mental disorders gained ground," he noted.

The increased insurance coverage was a triumph of lobbying by mental health advocacy groups and professional societies, but the unforeseen consequence was a rapid rise in costs in the late 1970's leading to harsh scrutiny of outpatient psychotherapy and helping to precipitate managed care, according to Shore.

Competition Intensified

The growth of third party coverage and the "preference of all the mental health professions to do outpatient psychotherapy" have led to more than two decades of "increasingly corrosive competition among the mental health professions," said Shore. This has been worsened by the failure of any one profession to demonstrate clearly its superior skill or qualifications to do psychotherapy without medication.

The essence of the problem, he commented, was once caricatured as the propensity of psychiatry to swing from "brainless psychiatry to mindless psychiatry, and vice versa," said Shore. Unless the psychiatric profession is able to adhere to the ideal of being the one mental health profession that integrates all the fields of knowledge needed to understand and treat mental disorders, it will lose "its defining characteristic and risks replacement by other medical and nonmedical disciplines."

Keeping this ideal in sight, psychiatrists must be prepared to innovate and step into leadership roles within organized systems of care so they can emerge as the leaders among the various mental health professions.

"Psychiatry in a new key has a strong and hopeful future as the medical specialty and mental health discipline that integrates the biological, psychological, and social perspectives in understanding and treating mental disorders," Shore concluded. "It is my contention that we are at risk as a profession to the extent that we fail to live up to that definition."

(Psychiatric News, June 20, 1997)