Friday, November 7, 2008

Who will take over Psychiatry?

I was thinking of writing about the future of Psychiatry. Surprisingly, Ajeesh has raised this issue in his reply to the post on "Many face of love". (It should have been Many faces). He writes that Psyhcology and psychiatry may be taken over by neurology in future. I have heard the same arguments from many other doctors, mostly neurologists and internal medicine specialists. Theoretically it sounds natural as neurology is THE medical speciality dealing with brain. But there are a few issues in practice.
The incidence of major psychiatric disorders are much higher compared to the pure 'neurological' disorders.The most common neurological condition is epilepsy. This is being treated by psychiatrists, internists, pediatricians and the GP without much problem. The skill sets needed to practice hard core neurology is different from those needed to practise psychiatry. In neurology things are more concrete and precise. In the field of mental health, most of the disorder are still vague and abstract. Enormous verbal skills are needed to listen to the patient, and offer psychological treatments. A neurologist may consider all this including the time spent for establishment of rapport as a waste. Of course, a neurologist or any other doctor with the right inclination can practice psychiatry well. Psychiatrists will outnumber neurologists in most countries.
I view things in a different light. The psychotic disorders need mostly drugs, some education about how to handle the illness (for the patient) and education about how to handle the patient (for the relative). To some extent this can be done by any willing doctor with reasonable expertise in psycho pharmacology, if there is a good social worker to help him with the education part. Usually most doctors are uncomfortable with these patients as they are prone to violence and cause disruption in their respectable consultation rooms. This is why they avoid seeing such patients.
The most common mental disorders belong to the category of neurotic disorders (anxiety, somatization and minor depressions). Here more intensive psychotherapy is needed. Hence a mental health professional is needed. My view is that these disorders are best handled by a good G P with adequate training.
If psychiatry is going to be taken over by another speciality, I wish this will be by the speciality of General Practice. This is more beneficial for the persons with the most common forms of mental illnesses. They can approach the GP without fear of stigma. If the GP has some training and is willing to spend some time, he can manage such cases properly. Thus a G P who is willing, can be trained to manage most mental illnesses and reduce the stigma. Only the most difficult cases and those with multiple diagnoses, need to be send to Psychiatrists. In fact this is true of most specialities. A good G P with adequate training can at least rule out serious conditions and refer only those cases needing real specialist care. It is sad that the speciality of G P is not developed in our country. I do not know why this is so. But I am sure this is one important step towards reducing health care costs. The general practitioners should outnumber the total of all the specialists together in a country.
I hope at least some of my friends and colleagues will respond to my arguments.

6 comments:

Anonymous said...

Dear Harish and others,

We are delving into guess works and speculations. I am starting this subject as half fun and half serious.

First about General Practice:

What will be the future of GP?

This question is also interesting to me. Patient education, number of OTC drugs and the safety level of self medication have dramatically increased. The not yet born Indian GP may be a still birth at last. I will not be surprised if GP merges into the patient itself.

More on later. Time to go home.

Thank you.

Anonymous said...

Continued…

As it is evident from Dr.Harish’s own earlier posts that up to 80% of clinically presented problems are psychobiological in nature, it is more reasonable to think of Psychiatrist working as a GP! His own observations are contradictory. GP should merge into Psychiatry according to his own observations. Most of the time, it is fun to know that truth is the opposite of popular beliefs. 80% is big enough to say ‘All’ for practical purposes. A psychiatrist is more likely to outperform a GP for general problems of the public. He can start the treatment with placebos, anxyolytics, antidepressants or simple psychotherapy for problems that do not require serious medical attention.


What is the future of Psychiatry or Psychology?

Mental disorders are unexplainable, partially explainable or higher order neurological disorders. It is also possible to argue that all neurological disorders are genetic problems but that is not important to our current discussion. There are many ways to look at these things, all views may be right.

In one of his past posts, Dr. Harish argued that only 20-30% of health problems are organic in cause. Strictly speaking he is wrong, but that is a semantic problem only. The remaining 70-80% of health issues is also organic but they are unexplainable neurological problems! As Crick noted once, we are a pack of neurons. Dr.Harish can correct his statement that most of the clinically presented problems are unexplainable neurological problems.

People are uncomfortable something left unexplained. In the history of past, people had difficulty explaining natural phenomena like solar/lunar eclipses, rain, lightening, diseases, epilepsy, day and night, mental disorders etc… but smartest guys of those times started to explain natural phenomena in terms of supernatural powers, religion or god. But after the explosive development of science and technology, religion and god died its natural death. Guys like Copernicus, Einstein or Darwin were the biggest murderers of god and religion. Freud killed the trend of explaining mental disorders in terms of supernatural powers. Our psychiatrists are one step ahead. They are explaining it as partially biological and partially sociological problems. It is a matter of time before we get a complete biological picture of mental disorders or about our conscious life. We have already learnt that severe psychotic disorders will get a different brain image in MR scans.

The problems of denial, neglect, epilepsy, capgras delusion, cotards syndrome etc… all were pure psychological issues once. People with compulsive shoplifting, fetishism or voyeurism always got beaten up from the society. Common people’s imagination does not lead to anywhere near biological dysfunctioning in these problems. Nobody thought of biological basis in Epilepsy, Huntington’s disease or Alzheimer’s many years ago.

Now let’s come to a more important point. People used to treat them selves with steam inhalation or massaging long years ago. Later people started to self medicate with Calpol or Avil. Sneezing or hike in temperature makes people swallow these drugs. Some of the guys in our society also started to self medicate with Antibiotics, Sleeping Pills or Analgesics and it is increasingly becoming common. Given sufficient time, people may swallow antidepressants or antipsychotics when they start to feel out of mind. I am talking in terms of bigger time frames, do not expect this to happen next year. Psychotherapy or managing the psychological symptoms of mind-brain disorders will become common knowledge in future so that a Neurologist won’t spend his precious time those things. Psychiatry may also become a super specialty for Neurology.

There is a possibility of Genetic engineering or molecular biology overtaking every thing. I am simply speculating but as usually in science a never thought of possibility may rule everything. All of these things are my wild imaginations and doesn’t have any scientific evidence.

In my mind, psychiatry is a dinosaur, a big thing that already gone extinct. The question of “What is the future of psychiatry?” was interesting 2 or 3 years ago.

I am in search of a new word for mental disorders. Mind-brain disorders are not completely satisfying because the word mind attached to it and carry a lot of stigma. The word Brain disorders is confusing in practical purposes. Can we coin a word like nervous system disorders? Does that refer to any other problems? I do not have any medical knowledge, so I am asking.
Mental disorders is an obsolete word for me, it should be replaced. I have distaste for it.


Thank you.

Dr. Harish. M. Tharayil said...

Dear Ajeesh and other readers,
People vary in their ability to be objective about any thing especially about their own health or psychological and physical symptoms. The dute of doctor is To cure sometimes..., to relieve often.... and to comfort always. This was stated by Wiliam Osler. So I think even if a pateint is eductaed about basic anatomey, physiology etc he will still need a human being rather than a computer for discussing his health concerns and seek reassurance. May be if all of become monitor gazers and would love this and prefer this to seeing real human faces, then things may change.
I was also indulging in fantasy when I wrote that post. We need specialists not only to treat patients, but to do research, find out new disorders, notice the changes occuring to existing disorders (the mutation of chikungunya virs occuring recently in India, making it a more sever illness and developing ability to spread by another mosquito species, is a case in point), etc. But still I feel we should have more gps tha specialists, because that seems to be closer to the real need. Docors of future may have the task of advising people not to take pills if things go the way Ajeesh projects - with higher rates of self medicating persons.
I agree that the developments in genetics may come with totally unexpected surprises.
Thank you

Faisal Poilkav said...

hi harish..
your blog is of rare kind.. give us tips to lead a healthy mental life..

blogger
www.pscoldquestions.blogspot.com
www.mangroveskerala.blogspot.com

Anonymous said...

Dear friends,

Some procedures considered complex and done in specialized settings are now done at home.

1. People monitor blood sugar levels at home. Some people adjust drug or injection doses according to their readings. Many people are injecting insulin themselves and doctors recommend this. There is new equipment available for automatic monitoring of sugar levels and supplying of required insulin as injection.
2. Pregnancy tests are done at home. What was the scene two generations ago?
3. Blood pressure and pulse are monitored at home easily.
4. ORS solution is used for simple diarrhea.
5. Steam inhalation and heat pressing were done under expert settings many years ago.
6. People often take paracetamol when they feel temperature and wait for 2 days. They consult a doctor if the fever persists.
7. Band aid for small wounds.
8. There are people who dress and apply medicine to small wounds.
9. People walk, listen to music or go to beach to relax and it is a primitive form of psychotherapy etc…

Most of the time, technology takes us by surprise. People may take ECG or MRI at home and interpret it themselves. Chemotherapy, radiation, small surgical procedures, X-rays etc.. may also become possible at home with the development of technology. You do not expect it to happen tomorrow or next year. It may take hundreds of years or may happen sooner than we expect. It is better to leave it there.

The current form of medical practice may not sustain. DTP operator was a great job when the computer and printers invented. Most of the people do type setting on their own home computer with ever increasingly user friendly software packages. The role of a DTP operator may go extinct at any time. Nobody ever dreamt of computers beating human brain in chess till the deep blue defeated the world champion Garry Kasparov. I will not be surprised if artificial intelligence beat chartered accountants or technical analysts. It may beat a general practitioner also with sophisticated monitoring devices and medical data combined with artificial intelligence. It may be improbable but it is not impossible.

Thank you.

Dr. Harish. M. Tharayil said...

Dear Ajeesh, Faizal and others,
I agree to Ajeesh's observation that the present system of medical pracitce may not last long. In fact it should not. People should have some basic idea of the anatomy and physiology of their body. Such topics should be included in High school level science text books. People should be empowered to take majority of health related decisions.
Dear Faizal,
My aim was to write more on mental health and ways to improve it. Shall try to add more. If you can put in specific queries, my task will be easier. I shall reply to any questions posted anonymously of with names. Thank you