Psychiatry: In the Crosshairs, at a Crossroads

Key points

• The field of psychiatry is currently under threat, and we are not responding effectively.
• Psychiatrists need to move towards, not away from, the things that make us unique.
• Specific steps we can take include returning to more in-person care, and moving away from "med checks."

This is not an anti-psychiatry post. I love my profession. I have seen it literally save lives and pull people out of very deep holes. But the very existence of psychiatry is under threat, and we are not responding in an effective way.

My beloved colleagues, it is time for some tough love.

We currently have psychologists doing this work with no medical training. We have nurses doing this work with no psychotherapy training. And, of course, we have emerging AI technology and all of its corporate backers, looking for an opportunity to take this work away from human beings altogether.

Our essential problem is that we are playing right into their hands. At the precise time that we should be leaning into what distinguishes us from other mental health professionals (and chatbots), our practices are becoming more homogenized, restrictive, and impersonal. At the exact time that we need data to support the defense of our field, we are spending our research time and money elsewhere. Meanwhile, our well-meaning but somewhat distracted professional organizations are so focused on fending off ridiculous attacks from external forces, including some from our own government, that we are failing to challenge and affect change with the group where we have the most leverage: ourselves.

Here is what we need to do if we want to save our field.

1. Come back to in-person care. Yes, telemedicine has an important role in mental health care, but we’ve vastly overplayed this hand. We like to tell people that telemedicine is all about patients, but the reality is that too often it is about us and our convenience and lifestyle. In balance, there is just too much clinically that is lost for too many people when care is given exclusively online. Continue this path, and we are practically begging to be replaced by AI.
2. End the 15-minute med check. Psychiatry was founded on some core principles. Among those is that human beings are complex, and that our relationship with patients and caregivers is an essential component of people getting better. We’ve lost that, too often moving to a quick “symptom and side effect” model of care that may pay the bills but makes psychiatry less effective, less human, and, frankly, less fun.
3. Take insurance. While mental health problems can affect anyone, they are disproportionately found among those with lower financial resources. At the same time, psychiatrists are the most likely medical specialists to refuse to take medical insurance, particularly Medicaid. These two things mean that psychiatrists are not meeting the clinical needs of many communities, with that gap being filled by other types of clinicians. If we wish to remain relevant, if we wish to be supported and valued by the communities we serve, we have to be there for everyone, not just rich people.
4. Put us to the test. It is well past time for some rigorous and comprehensive studies on psychiatric care quality that examine practical, real-world outcomes. Are patients really getting better? Are we following best practice guidelines? What factors support better patient outcomes? I continue to hold the belief that, on average, a well-trained, well-performing psychiatrist can deliver the best care for patients. It’s high time we prove that. The longer we wait, the more folks will be able to make vague equivalency claims to justify cutting us out of the picture.

I’m approaching retirement and not particularly concerned about my own personal job security. The worry is for my younger colleagues and for the future of my profession. Already we are being challenged to justify our increased salary, our more intensive training, our loftier status, and there just isn’t much data we can point to right now in our defense. How do we rationalize the need for medical training when we don’t even get vital signs at our online appointments? How do we defend the need for psychotherapy training when we don’t even use it in our 15-minute med checks? How can we tell an insurance company that the more expensive care we deliver is best when we don’t study it?

It is not too late. There is still a lot of excellent work being done, often in close collaboration with other types of medical and mental health professionals. There are “movements” afoot to improve our approach and the quality of care we provide in order to revitalize our field. This is where we need to focus, right now, if we are to remain healthy as a field in a world full of economic and technological change.