What is psychiatry becoming?

This is a difficult post to write, and is probably a reflection of many things – my own illness and return to work, the challenges of trying to change things in a clunky system, and maybe even just the simple need for a holiday. But I am weary of psychiatry. I just don’t know where it’s going, or why. I’m a person who has been heavily invested in psychiatry for well over half my adult life – I wanted to be a psychiatrist, then became a psychiatric patient, and finally actually became a psychiatrist. I loved psychiatry, it interested me. I wanted to know more, to speak with people, and, if possible help them.

Now, for the first time in my life, I say with great regret – if I was a medical student or a young doctor now, I don’t know if I would do psychiatry. It still interests me, I still think it is overwhelmingly important, but it has become something entirely different, and I’m not sure I can do it the way I want anymore. Some of the changes may be good, but we can’t do more without more, and perhaps that’s a big part of it.

Psychiatry is massive, and that’s one of its problems. But where you would see an endocrinologist for your diabetes, or a cardiologist for your ischaemic heart disease, the entire burden of psychiatry falls on the general adult psychiatrist. There are specialties – addictions, eating disorders, perinatal are examples, but they’ve had to fight for it, and patients can blend, often unseamlessly, back into general adult psychiatry if they don’t fit the often stringent criteria for these more specific disorders. 

So much is about inequality, poverty and trauma. These have always been the demons of humankind and make us more susceptible to all illness, but psychiatry is haunted by them, and by the inability to change them. Perhaps we can treat the depression, or the psychosis, a little, with medication, therapy or simple support, but we can’t change the grim root cause.

I think mental illness is an illness, the same as many others. Why wouldn’t the brain become ill, causing the symptoms we see? And, like heart disease, this might logically be worse for those living harder and more deprived lives. But, like heart disease, it might also hit anyone. You can become depressed without major trauma, and you may benefit from treatment. I don’t think our treatments are great, but they can help, and to my mind that’s worth it. But it does get rather complicated when you consider the illness model as it stands and try to apply it to psychiatry. We see people who are, for example, acutely depressed, and give them antidepressants, a bit like giving antibiotics for an infection, but less reliably effective. Sometimes it works, and, if it does, then we may consider we have cured them, we have treated a discrete episode of illness. My view is that we try to do this too much in psychiatry, a lot of things aren’t easily curable, but we need them to be, because our resources are limited. We also, as doctors, need to feel that we can make people better. 

There has been far more recognition of long-term conditions recently, like autistic spectrum disorder and neurodiversity. I don’t think any of us think we are going to cure these, but we do acknowledge that recognition and diagnosis can be of great importance, and the offer of any support or treatment can also make a big difference. And of course people can have several conditions – perhaps a longer term neurodevelopmental disorder and a more episodic illness, like a mood disorder, which may or may not respond to treatment. Anxiety disorders can be brief or lifelong. And there are other disorders, like schizophrenia, which may be episodic or may more resemble a persistent, sometimes worsening illness.

There are many more disorders, all of which can cause extreme distress and suffering, and I wouldn’t want to imply that any one is worse or better than another. That terrible bugbear, the personality disorder, has to be mentioned, as it is not usually a diagnosis that makes the patient feel better when they get it, nor is useful treatment often available; rather it may place the them in a category that makes things easier for the psychiatrist.

I suppose, if I’m trying to make any kind of sense of this, I see mental illness as something that may be a lifelong condition; that may be long-term but acquired (progressive or not); that may be episodic with complete remission; episodic with incomplete remission; or episodic and worsening. Clearly, these may all overlap. But there needs to be more planning around how services may help people. Brief interventions are often not the answer. Sadly there is never going to be sufficient resource to provide everything that people want or need, but seeing someone once a month for half an hour to properly listen to them, even if there’s nothing else that can be offered, could make a big difference to some.

Sometimes I actually feel guilty if I see someone just to listen to them – I feel the pressure that I should discharge them, that this is what a good doctor would do. I see this too in training – doctors have to do specific things, complete portfolios, write in electronic notes, carry out audits. Now, these are all important things to do, and I work with great trainees who certainly talk to patients, but I think it’s getting harder and harder for them. What I really don’t want to do is practise a kind of psychiatry that ticks boxes and is defensive. I don’t want to be part of a profession that is reviled, both due to general unrealistic expectations, and our unhelpful reactions to these.

I don’t know what’s going to happen to psychiatry, but I think there will always be a need as well as people who want to work in it. But we have to make the services workable; we have to make mental illness understandable, and to do this we have to acknowledge that our treatments for many disorders are still rudimentary. But, above all, psychiatry has to be kind, both to patients and staff, because, when it isn’t, it can never work.