- Email: [email protected]
Diagnosis and treatment prescription: Psychiatry's special value
EDITORIAL
DONALD F. KLEIN, M.D.
Diagnosis and treatment prescription: Psychiatry'S special value Over the past 25 years, a marked shift has occurred in our view of the causes and care of mental illness. Several developments underlie this shift: the advent of powerful psychopharmacologic agents with a very wide range of effectiveness; the development of new, persuasive genetic data from adoption studies indicating the important role of heredity in a broad range of mental illnesses (in addition to a validation of the spectrum concept); the development of many alternative, apparently equivalently effective, models of psychotherapy, thus calling into question the intellectual monopoly of psychoanalysis; the development of a systematic clinical trial methodology that makes it possible to assess whether any treatment, pharmacologic or nonpharmacologic, produces any specific benefit; and a growing disillusionment with the optimistic belief that social and community efforts can suffice to reverse severe mental illness. In light of these changes, Paul Wender and I have advocated new methods of organizing care for those afflicted with mental disorders.! The properly trained psychiatrist is the best person to evaluate whether the troubled patient is suffering realistic unhappiness, personality limitations, or a psychiatric illness with a major Dr. Klein is professor ofpsychiatry at the Columbia University College ofPhysicians and Surgeons and director ofpsychiatric research at the New York State Psychiatric Institute. Reprint requests to him at the Institute, 722 W. 168th St., New York, NY 10032.
organic component. Further, the psychiatrist is the only professional who can be sufficiently conversant with psychosocial as well as physical methods of treatment, since he can both prescribe for and supervise the entire range of useful interventions. Further still, all patients considered for psychotherapy or any form of care for emotional disorder should have a general medical evaluation, reviewed by a psychiatrist knowledgeable about how medical disease may mimic emotional disorder. The essential feature of our recent remarkable successes has been the improved ability to diagnose medication-treatable illnesses. It is crucial, therefore, that all patients be given modern, informed, psychiatric evaluation and prescription of care. In settings that allow for treatment teams, it is quite likely that psychotherapeutic procedures, when prescribed, can be carried out with equivalent benefit by personnel with only a moderate degree of training. We can predict that these recommendations will be greeted with disapproval by the professional groups currently active in the system of mental-health care. Those psychiatrists or psychoanalysts who are primarily identified with carrying out individual psychotherapy will protest that their leyel of skill and training allows them to produce profound beneficial results that are unobtainable by other methods. We urge them to show the evidence that will allow the scientific evaluation of this claim. Many psychologists, social workers, and nurses will (continued)
AUGUST 1982 • VOL 23 • NO 8
791
EDITORIAL resent our position that they do not have the back.ground that would enable them to conduct a sufficiently broad evaluation to allow a synthesis of both the psychosocial and the organic factors. Also, the fact that these groups are not legally allowed to prescribe medication will make many of them uneasy with our biopsychiatric approach, which emphasizes that for many patients medication is not only useful but is the best available treatment. If psychologists, social workers, and nurses cannot perform the optimum diagnosis, and cannot prescribe medication, it then becomes clear that both evaluation and prescription absolutely require the services of a properly trained psychiatrist. (Many currently practic-
ing psychiatrists, however, have not received adequate training.) Such conclusions may well be attacked as a form of psychiatric imperialism rather than a reasoned judgment derived from available facts. We assert that the current organization of clinical care for those with emotional and mental disorders is out of date. Its reorganization will occur only if an informed citizenry demands it. 0
REFERENCE 1. Wender PH, Klein OF: Mind, Mood & Medicine: A Guide to the New Biopsychiatry. New York. Farrar, Straus & Giroux, 1981.
Psychosoma ·c Illness eve Starting in next month's issue of Psychosomatics: A series of authoritative review articles on some of the major illnesses seen in clinical practice that can readily be identified as "psychosomatic" Topics will include: H88dache O~
Peptic ulcer
DennatoIogic disorders Thyroid disorders Essential hypertension Irrita bowel syndrome
Chronic pain
Rheuma1Did arthritis Psychosomatic gynecologk disolrden
These clinically oriented articles will review and update our understanding of how mind and body interact in producing or exacerbating illness and will discuss the approaches to management that have worked best Don't miss this exciting series, which starts next month with an article on Migraine, by Neil H. Raskin, M.D., of the University of california, San Francisco.
AUGUST 1982 • VOL 23 • NO 8
DONALD F. KLEIN, M.D.
Diagnosis and treatment prescription: Psychiatry'S special value Over the past 25 years, a marked shift has occurred in our view of the causes and care of mental illness. Several developments underlie this shift: the advent of powerful psychopharmacologic agents with a very wide range of effectiveness; the development of new, persuasive genetic data from adoption studies indicating the important role of heredity in a broad range of mental illnesses (in addition to a validation of the spectrum concept); the development of many alternative, apparently equivalently effective, models of psychotherapy, thus calling into question the intellectual monopoly of psychoanalysis; the development of a systematic clinical trial methodology that makes it possible to assess whether any treatment, pharmacologic or nonpharmacologic, produces any specific benefit; and a growing disillusionment with the optimistic belief that social and community efforts can suffice to reverse severe mental illness. In light of these changes, Paul Wender and I have advocated new methods of organizing care for those afflicted with mental disorders.! The properly trained psychiatrist is the best person to evaluate whether the troubled patient is suffering realistic unhappiness, personality limitations, or a psychiatric illness with a major Dr. Klein is professor ofpsychiatry at the Columbia University College ofPhysicians and Surgeons and director ofpsychiatric research at the New York State Psychiatric Institute. Reprint requests to him at the Institute, 722 W. 168th St., New York, NY 10032.
organic component. Further, the psychiatrist is the only professional who can be sufficiently conversant with psychosocial as well as physical methods of treatment, since he can both prescribe for and supervise the entire range of useful interventions. Further still, all patients considered for psychotherapy or any form of care for emotional disorder should have a general medical evaluation, reviewed by a psychiatrist knowledgeable about how medical disease may mimic emotional disorder. The essential feature of our recent remarkable successes has been the improved ability to diagnose medication-treatable illnesses. It is crucial, therefore, that all patients be given modern, informed, psychiatric evaluation and prescription of care. In settings that allow for treatment teams, it is quite likely that psychotherapeutic procedures, when prescribed, can be carried out with equivalent benefit by personnel with only a moderate degree of training. We can predict that these recommendations will be greeted with disapproval by the professional groups currently active in the system of mental-health care. Those psychiatrists or psychoanalysts who are primarily identified with carrying out individual psychotherapy will protest that their leyel of skill and training allows them to produce profound beneficial results that are unobtainable by other methods. We urge them to show the evidence that will allow the scientific evaluation of this claim. Many psychologists, social workers, and nurses will (continued)
AUGUST 1982 • VOL 23 • NO 8
791
EDITORIAL resent our position that they do not have the back.ground that would enable them to conduct a sufficiently broad evaluation to allow a synthesis of both the psychosocial and the organic factors. Also, the fact that these groups are not legally allowed to prescribe medication will make many of them uneasy with our biopsychiatric approach, which emphasizes that for many patients medication is not only useful but is the best available treatment. If psychologists, social workers, and nurses cannot perform the optimum diagnosis, and cannot prescribe medication, it then becomes clear that both evaluation and prescription absolutely require the services of a properly trained psychiatrist. (Many currently practic-
ing psychiatrists, however, have not received adequate training.) Such conclusions may well be attacked as a form of psychiatric imperialism rather than a reasoned judgment derived from available facts. We assert that the current organization of clinical care for those with emotional and mental disorders is out of date. Its reorganization will occur only if an informed citizenry demands it. 0
REFERENCE 1. Wender PH, Klein OF: Mind, Mood & Medicine: A Guide to the New Biopsychiatry. New York. Farrar, Straus & Giroux, 1981.
Psychosoma ·c Illness eve Starting in next month's issue of Psychosomatics: A series of authoritative review articles on some of the major illnesses seen in clinical practice that can readily be identified as "psychosomatic" Topics will include: H88dache O~
Peptic ulcer
DennatoIogic disorders Thyroid disorders Essential hypertension Irrita bowel syndrome
Chronic pain
Rheuma1Did arthritis Psychosomatic gynecologk disolrden
These clinically oriented articles will review and update our understanding of how mind and body interact in producing or exacerbating illness and will discuss the approaches to management that have worked best Don't miss this exciting series, which starts next month with an article on Migraine, by Neil H. Raskin, M.D., of the University of california, San Francisco.
AUGUST 1982 • VOL 23 • NO 8