Sunday, December 30, 2012

2012 Reflections: Psychiatry

The year 2012 is coming to an end. It has been a long year, full of joy and discovery, as well as grief and tragedy. Personally notable for this year is that I received my M.D. and began training in a combined family medicine and psychiatry residency program. It has been such an amazing mass of experiences thus far, and it's only just beginning. In this post, I aim to discuss why I feel it is such a fascinating time to be a young psychiatrist.

The field of psychiatry is developing at a breakneck pace. Great strides have been made since the mainly psychoanalytic era of the 1950s, with a much better understanding of the causes of mental illnesses, and the discovery of medications that can help treat them. Schizophrenia is an excellent example of the progress being made. Though there remains much still to be learned about the disorder, many of the dysfunctional neural pathways have been identified, multiple genes associated with its development have been discovered, and a host of very effective medications exist. Similar strides have been made with a variety of other mental illnesses, including major depression, bipolar disorder and PTSD.

As our understanding of mental illness has improved, a need for better conceptualization and classification has arisen. This is reflected in the much anticipated release of the new DSM-V in May of 2013. The DSM, or "Diagnostic and Statistical Manual of Mental Disorders" is the primary book used by psychiatrists to diagnose and classify mental illness. There has not been a full revision of the DSM since the release of the DSM-IV in 1994, though there was an update (DSM-IV-TR or "text revision") made in the year 2000. Work on the DSM-V began in 2010 and many steps have been taken to incorporate the last information on mental illness into its pages. I am thrilled to be in my residency during this exciting transitional period.

Despite these advances, there is a lot that still needs to be done. Why is there still so much untreated or undertreated mental illness? Much of it has to do with stigma. Even though we know so much about the genetic and biologic causes of mental illness, there are many who still think of it as being under the control of the sufferer. I daresay that many people think that those suffering from mental illness just need to "man up" or "cut it out" or "just get over it", though we would recoil in horror if someone used similar language to a person with cancer.

An abhorrent extension of this stigmatization is the so-called "mental health carveout" with health insurance. In many cases, psychiatric treatment is specifically written out of insurance policies. What about the countless mentally ill without health insurance? They fall back upon government funded institutions, whose severely limited funding has even further plummeted in recent years. The single county-funded mental hospital in my city recently had to shut down function of half of more than half its beds because of lack of funding. Gravely disabled patients and those suicidal or homicidal from mental illness sit in the city's emergency rooms for days waiting for placement. It's been a rare day for there to be an empty bed when I've worked on the psychiatric unit of the county jail.

All in all, I'm extremely excited about becoming a psychiatrist. We've learned so much and are continuing to expand our knowledge of mental illness and its treatment. There is so much still to be done in terms of decreasing the stigma and marginalization of mental illness as a weak will or deficiency of character, and so much work to be done in terms of increasing access to care to those who need it so desperately. I'm thrilled to be in the thick of it.