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Up from the couch

The practice of psychiatry has changed a great deal in the last 30 years, but the stigma still lingers

By MOIRA FARR | AUG 04 2009
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Dr. Susan Abbey has just spent two days interviewing prospective medical residents for positions in psychiatry with the University Health Network of Toronto. As a clinical program director for the University Health Network of Toronto and president of the Canadian Psychiatric Association, she juggles a number of roles, from training young residents to educating the public about the realities of mental illness. While she was impressed by the calibre of the 2009 applicants (many were in the top 10 percent of their class), she also worries about the lingering stigma and stereotypes surrounding mental illness and the role of psychiatrists in treating it.

The stigma exists not only in society as a whole but also within the medical profession itself. “One applicant said that she loves psychiatry, but her family isn’t happy with her choice,” recalls Dr. Abbey. “Another said that a director of internal medicine had told him, ‘you’re too smart to waste yourself in psychiatry … you’ll make more money doing surgery.’”

Dr. Abbey, who became a psychiatrist in the 1980s and has no regrets about her choice, is dismayed by these kinds of attitudes. “I chose psychiatry because I loved the complexity of human behaviour, and thought of psychiatry as the last great frontier of medicine.”

Like any frontier region, psychiatry has seen dramatic changes in the way it’s practised, even in the course of her career. Patients used to be treated mainly with long-term psychotherapy; now the emphasis is on evidence-based treatments involving neuroscience and psychopharmacology. With few exceptions, patients no longer lie on couches talking to a mainly silent presence sitting in a chair behind them during weekly, or even daily, treatments that went on for years. According to today’s psychiatry teachers, Sigmund Freud is a historical figure but no longer a model for practice among young doctors in the field.

Nowadays, it’s family physicians who are the front-line prescribers of antidepressant medication for patients suffering from mild to moderate depression, and psychologists and other counsellors who offer psychotherapy. Psychiatrists today treat the more severely ill patients suffering from major depression, bipolar disorder or schizophrenia, most often in hospital settings. Some may do psychotherapy, but will not confine their practices to that.

In fact, critics like Joel Paris say that during the 1980s and ’90s, the pendulum swung too far in the direction of neuroscience, as psychiatrists sought to cast off the old view of the profession as overly subjective and unscientific in its approach.

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Ontario’s Provincial Lunatic Asylum in the 19th century.

“The leadership has shifted to neuroscience, and so far, it promises more than it delivers,” says Dr. Paris, professor of psychiatry at McGill University and editor-in-chief of the Canadian Journal of Psychiatry. Heavy use of prescription pads may serve the needs of an over-crowded system of mental-health care delivery, but it doesn’t serve the needs of every patient, he contends in his new book Prescriptions for the Mind: A Critical View of Contemporary Psychiatry.

“For all that it has accomplished, neuroscience has not yet delivered a convincing understanding of the causes of mental disorders,” he writes.

That is likely to change in the future, as brain research continues to make dramatic advances year by year. Dr. Paris and other professors emphasize the need for a more balanced “bio-psycho-social” approach to patient care. “Psychiatrists must be trained for a new era, and must resist an either-or attitude when it comes to the study and treatment of mental illness,” he asserts.

A changing discipline

Perhaps the most promising psychiatry research is in the field of “neuroplasticity,” which is shedding more light on the brain’s astonishing ability to change negative patterns of functioning without drugs or surgical intervention. Some studies have shown that short-term cognitive-behavioural therapy of one year or less can be as effective in reducing symptoms of depression and anxiety as antidepressants taken on their own. The human brain – “the last black box in medicine,” says Dr. Abbey – is revealing itself to be far more resilient and elastic than anyone previously understood.

“Mindfulness” is a relatively new field of study and treatment. It suggests that mental illness, stress and chronic pain can be managed through meditative techniques such as yoga, deep breathing and walking. More psychiatrists are looking at these techniques as a real alternative for those whom Dr. Paris calls “the worried well” and perhaps even for more seriously mood-impaired patients. These doctors are inspired by the work of Dr. Richard Davidson at the University of Wisconsin. His laboratory of affective neuroscience uses brain imaging to document interaction between the prefrontal cortex and the amygdala (the part of the brain that controls several emotions, especially fear), and has shown how this interaction affects the regulation of mood and emotion.

 

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Electroshock therapy in the 1950s.

For anyone entering the field today, the huge leaps in understanding mental illness offered through research are a tremendously exciting incentive. But old attitudes die hard; many still think of psychiatry as less than scientific and that suffering from mental illness is something shameful. Although low funding levels and outdated billing structures are being addressed in some provinces, nonetheless today’s psychiatrists tend to earn less than specialists in other fields.

As a result, Dr. Abbey and her colleagues see a potential crisis looming. Demand for mental-health services is growing across Canada, but the supply of well-educated psychiatrists is not keeping pace. Unfilled resident positions mean fewer people are receiving treatment, and those who do are getting it from doctors with very large case loads.

Canada has 17 medical schools offering postgraduate psychiatry education, and approximately 4,000 practising psychiatrists, their average age 55 to 58. That compares with internal medicine, for instance, with close to 7,500 practitioners, the majority well under age 50.

Research dollars do not come easily: just 6.67 percent of funding from the Canadian Institutes of Health Research went to mental health and addiction in 2005-06. It’s a pattern seen internationally – in 2008, the U.K’s Royal College of Psychiatrists noted that mental health research received 6.5 percent of total research funding compared with 25 percent for cancer research and 15 percent for neurological diseases.

 

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Insulin therapy was used in the 1940s and ’50s to treat schizophrenia.

That translates into a shortage of mental-health resources, certainly in Canada. According to the Canadian Mental Health Association:

• 20 percent of Canadians will experience mental illness in their lifetime;
• the cost of mental illnesses in Canada to the health care system is an estimated $7.9 billion;
• $6.3 billion more is spent on uninsured mental health services and time off work for untreated depression.

“When you look at the amount of mental illness there is,” says Katharine Gillis, acting chair of psychiatry at the University of Ottawa, “the mortality, the loss of work productivity, and then the ratio of research dollars, we are frighteningly underfunded.”

That’s why educators believe it is critical to attract more medical students to the field of psychiatry. “Every one we turn out is precious,” says Dr. Gillis, who’s also director of psychiatric resident training at the Royal Ottawa Hospital.

Well-rounded professionals

Today’s graduates must be well-rounded professionals who base their treatment on evidence-based medicine and combine good scholarship, management skills, communication skills and collaborative abilities. Medical schools today must demonstrate that the curriculum reflects these kinds of broad-based educational goals to maintain accreditation, says Dr. Gillis.

In addition, psychiatrists need to use a balanced approach in treating patients, says Clare Gray, U of Ottawa’s director of education in child and adolescent psychiatry. “We are facing life-and-death issues many times every day, dealing with [attempted suicide], and we see the effects of family situations, poverty, homelessness. We can’t just measure someone’s hemoglobin. We have to be interested in each person’s story, to help them deal with very difficult life situations.”

 

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The father of psychoanalysis, Sigmund Freud.

Daunting, perhaps, to the average person, but the challenges and demands of psychiatry haven’t stopped people like Andrea Bardell, a fourth-year resident, and Mathieu Dufour, in his second year, from choosing psychiatry as their specialty.

“It’s dynamic and exciting,” says Dr. Bardell during a lunch break at the Royal Ottawa Hospital. She likes the very fact that psychiatrists are in demand, that the stigma toward mental illness needs to be addressed, and that the field is going through significant changes. “As psychiatrists, we have a responsibility to conquer the stigma. If we feel it, imagine what it is like for our patients.”

Both she and Dr. Dufour have had some surprises in the early stages of their careers. For Dr. Bardell, it was a change in perspective. She says that when she began she wanted to focus on biochemistry, but now she sees how psychiatrists need to look at a more balanced picture to treat patients well. For Dr. Dufour, the surprise was discovering that he really enjoys dealing with elderly people. “I like to sit down and hear their stories.”

Both say they feel respected by colleagues in other fields, whom they often consult with about patients with cardiac and other physical problems. “They may joke that we’re more art than science – and there is still a lot that’s mysterious about psychiatry,” says Dr. Dufour, “but they see us as a valuable part of the medical team.”

Speaking as advocates for the mentally ill and talking about the lingering stigma is part of the psychiatrist’s job, says Dr. Bardell. “We have to be assertive as professionals,” she says, before dashing off to meet a patient. Psychiatrists can’t “shy away from politics” if they want to maintain high-quality services and get more funding.

Canada has lagged behind other countries in establishing a national mental health strategy. But the Mental Health Commission of Canada, set up in 2007 with a budget of $55-million, should help make that a reality.

U of Ottawa’s Dr. Gillis says she is optimistic that positive changes are coming in the profession and with them, better attitudes all around toward psychiatry. “If these are the people coming out of our schools,” she says, “our country is in good hands.”

 

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Crystal ball gazing

What is to come for psychiatry?

As research continues and psychiatry evolves in the coming decades, its value may be recognized more and more. McGill’s Dr. Paris ends his book Prescriptions for the Mind, with predictions for the future of psychiatry in Canada. He expects to see:

• increased knowledge of the causes of mental illness and how the process of illness affects the brain;
• an altered diagnostic system that focuses on “the process of disease and not just on symptoms;”
• psychotherapy still offered, but for shorter periods and with an evidence-based approach;
• more psychiatrists working in hospitals and clinics than alone in offices;
• psychiatrists’ incomes coming from salaries or pooled funds.

As far as training and practice, Dr. Paris says, “The commitment of psychiatry should be to science, and science tells us that both biological and psychological interventions are, each in their own way, prescriptions that can heal the mind.”

During the 1960s, along with the advent of tranquillizers, antidepressants and anti-psychotic meds, came “de-institutionalization.” Releasing mentally ill people into the community created its own problems, due to lack of social supports. Community programs have since been developed, but poverty and homelessness among the mentally ill are still rampant.

Although Freudian psycho-analysis is no longer a mainstream treatment for mental illness, about 400 psychoanalysts are listed as members of the Canadian Psychoanalytic Society. Affiliated with the International Psychoanalytical Association since 1957, it held its 35th annual general meeting in June 2009 in Quebec City.

It’s estimated that today, half of psychiatrists’ time is taken up with long-term patients who comprise one-eighth of the case load

This past April, Jeffrey Meyer, head of neurochemical imaging in the mood disorders program at the Centre for Addiction and Mental Health (U of T), became the first psychiatrist ever honoured with the Royal College Medal Award in Medicine.

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