Book Review

Psychiatry in the New Millennium

N Engl J Med 1999; 341:1859December 9, 1999

Article

Psychiatry in the New Millennium
Edited by Sidney Weissman, Melvin Sabshin, and Harold Eist. 366 pp. Washington, D.C., American Psychiatric Press, 1999. $50. ISBN: 0-88048-938-3

At the end of this millennium, psychiatry is facing revolutionary changes that have already affected the training of psychiatrists and the ways in which they deliver care. The implications of these changes for the future of psychiatry are the subject of this book.

In their contributions to the book, Coyle, Hyman, Callicott, and Weinberger outline the scientific opportunities to unravel complex psychiatric diseases. Coyle gives a particularly useful overview of advances in neurosciences that are relevant to psychiatry, which highlights the brain's remarkable plasticity and vitiates a reductionist approach. The new neuroscientific foundation of psychiatry, encompassing molecular psychopharmacology and the genetics of relatively simple disorders, is being broadened to address polygenic disorders. For example, promising leads in the identification of linkage sites have been reported for bipolar disorder, and studies of transgenic mice and inbred strains of dogs have identified genetic loci associated with particular behavioral traits. Techniques such as the specific “knockout” of a particular gene permit the use of animal models of psychiatric disorders and thus provide unprecedented opportunities for the development of new treatments.

Brain imaging now provides anatomical, neurochemical, and functional views of the intact human brain to an extent that was unanticipated even by the research community. Nuclear magnetic resonance imaging, which does not require radioactive agents, can be performed repeatedly in children. Functional imaging has already identified specific, aberrant brain circuitry in a number of disorders, ranging from obsessive–compulsive disorder to schizophrenia.

Imaging studies in these areas of research interact in a dynamic way. For example, imaging studies of twins who are discordant for a disorder provide information about genetic and nongenetic aspects of the illness. Similarly, the use of imaging studies in trials of new pharmacologic agents informs our understanding of the physiology of mental illness in ways that earlier clinical studies of peripheral body fluids could not.

In spite of their unquestioned potential, however, the new neurosciences and genetics leave daily psychiatric practice untouched. These are extraordinary times in which new findings relevant to the genetics and imaging of the function and development of the brain make headlines, yet the problems of clinical practice in a managed-care environment are grim. In this book, Gabbard, Schatzberg, Klein, and other clinical experts address the reality of psychiatric practice today.

Some of the recent scientific discoveries, together with economic forces, have led to the creation of psychiatric jobs in health care organizations that few graduates of U.S. medical schools are choosing. Health care costs now account for 14 percent of the gross national product, and the costs of mental health services amount to about 10 percent of overall expenditures. Managed-care plans have had to address this issue. Because the services provided by nonmedical providers are most cost effective, physicians are being hired principally to prescribe medication.

The separation of psychopharmacologic treatment from psychotherapy is probably deleterious for many patients and has certainly led some physicians to overprescribe. As Klein points out in an excellent chapter, the data needed to evaluate the respective contributions of drug treatment and psychotherapy (which are being determined by hiring practices at the moment) are lacking. Klein provides a blueprint for a scientific approach to this question. Until neuroscience provides more practical answers, such research has the greatest practical potential for addressing the complexities of clinical practice. Sadly, research physicians, who are essential to such studies, may be vanishing from psychiatry, as they are from other specialties.

Carolyn Rabinowitz, formerly the founding director of the Office of Education of the American Psychiatric Association and now dean of the Georgetown University Medical School, provides an unflinching assessment of psychiatric education for the new millennium. Medical and psychiatric training is required to provide the skilled interpersonal care and drug treatment that severely ill patients need. Family practitioners, internists, pediatricians, and neurologists do not generally have the time or even the desire to acquire the knowledge needed to care for such patients. Moreover, the number of practicing psychiatrists is likely to decline, given economic forces, the availability of other health care providers, and the ability of other physicians to handle drug treatment well.

The challenge is enormous. The reduction or even elimination of subsidies for teaching and research may make teaching a nonaffordable luxury. The number of nondrug therapies and the growing data base in basic science that is relevant to psychiatry make a single core curriculum hard to design. Training will probably vary from center to center, and informatics will be key in satisfying these variable and changing educational needs.

Mirin stresses that there may be an oversupply of psychiatrists, with a predicted need of 4 per 100,000 persons (as in the United Kingdom), as compared with the current national level of 13 per 100,000 in the United States. The future of psychiatric hospitals is cloudy, despite the continued need for inpatient services to care for patients with severe psychiatric disorders. Sabshin completes this provocative and disquieting book with a chapter called “New Beginnings.” He stresses the need for improvements in diagnosis, prognosis, and the choice of treatment. Practice guidelines and probably the use of televised teaching networks will promote more cost-effective training and practice. Reducing the stigma of mental illness and preventing or curing major psychiatric disorders remain psychiatry's goals for the next millennium.

Judith L. Rapoport, M.D.
National Institute of Mental Health, Bethesda, MD 20892