Perspective: Upcoming Paradigm Shifts for Psychiatry in Clinical Care, Research, and Education

Department of Psychiatry, Washington University in St. Louis School of Medicine, Missouri, USA.
Academic medicine: journal of the Association of American Medical Colleges (Impact Factor: 2.93). 03/2012; 87(3):261-5. DOI: 10.1097/ACM.0b013e3182441697
Source: PubMed


Psychiatry is facing a crisis fueled by a fragmented and inefficient system of care delivery and a disconnection between the state of research and the state of psychiatry education and practice. Many factors contribute to the current state of psychiatric care. Psychiatry is a shortage specialty, and this will become worse in the near future. In addition, financial pressures have led to decreases in psychiatric inpatient and outpatient services and to shorter lengths of hospitalization for even the sickest patients. This has resulted in fragmented care and an overreliance on polypharmacy. To reach the large number of patients needing psychiatric services, health care systems must change and take advantage of collaborative and integrative care models and new technologies. Psychiatrists must learn to partner more effectively with primary care providers to extend their expertise to the greatest number of patients. Currently, psychiatric diagnosis is based on a criteria-based system that was developed in the 1970s. Advances in systems and molecular neuroscience are beginning to elucidate specific brain systems that are dysfunctional in psychiatric illness. This has the potential to revolutionize psychiatric diagnosis and treatment in the future. However, psychiatry has not yet been successful in incorporating the language of this research into clinically meaningful terminology. If neuroscientific progress is to be translated into clinical advances, this must change. Residency programs must better prepare their graduates to keep up with a psychiatry literature that will increasingly use the language of neural circuits to describe psychiatric symptomatology and treatments.

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    • "It is not possible to call it " system " . Nowadays even the integrated health and social care are fragmented in Finland and Europe (Rubin and Zorumski, 2012). As in America this " small-scale, cottage-industry approach can deliver finely crafted services, but the quality of those services is variable, and costs are typically high. "

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    ABSTRACT: Psychiatry is confronting challenges to create sweeping new paradigms for itself. The author contends that the psychosocial knowledge and psychotherapeutic skills of the psychiatrist must be integral to those paradigms. Abandoning crude, descriptive diagnostic categories in favor of discrete, dimensional measures that personalize selective neurobiological treatment for each individual is part of one proposed paradigm-but psychotherapy, especially psychodynamic therapies, have provided personalized therapy for over a century, using nature's own resources (human relationships and communication) to modulate the patient's unique, fixed patterns of thought, emotion, and behavior regardless of DSM diagnosis. Similarly, beyond the genetic core, the role of development and experience in shaping mental health and illness includes both neurobiological and interpersonal processes that dynamically modulate neural networks and their mental epiphenomena. Psychosocial interventions, using natural pathways, are vital for both prevention and treatment. Another proposed paradigm embraces closer coordination of psychiatric services with primary care in organized systems, which would probably include non-medical psychotherapists as well. Psychiatrists cannot effectively oversee, supervise, partner, or consult with other physicians or therapists if they have no psychotherapeutic awareness. Even when the primary mode of treatment is biological, skilled handling of the doctor-patient relationship is vital to adherence, to helping the patient manage his or her personal life, and even to effectiveness of medication at recommended doses. There is no substitute for instruction and extensive first-hand experience in learning to conduct psychotherapy or psychologically informed patient care. In a psychiatric residency curriculum that is likely to contain greatly increased attention to clinical neuroscience, time for the psyche must be preserved. The new paradigm might require a lengthened residency or additional fellowship years, which must include appropriate attention to psychosocial learning and psychotherapeutic expertise.
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  • No preview · Article · Nov 2012 · Academic medicine: journal of the Association of American Medical Colleges
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