High Anxiety : Psychiatrists See Drop in Status as Roles Shift

The nation’s shrinks are depressed.

Pressures to contain mental health costs, along with increased competition from psychologists and other therapists, are eroding traditional roles in the psychiatric profession.

Psychiatrists, whose stock and trade long has been talking with patients about their depression, anxiety and other mental disturbances, are in danger of being reduced to the role of diagnosticians and prescribers of medications.

The declining status of the specialty is already evident in the steadily falling number of medical school graduates choosing psychiatric residencies.

Unlike psychologists and sociologists, who provide mental health counseling, psychiatrists are medical doctors whose training combines psychology, biology and pharmacology. It is the continuing fragmentation of their multifaceted role that has psychiatrists on edge.

“Psychiatrists are experiencing a shift in the very nature of what they do,” said Ruth Yoshpe, health economist for the American Psychiatric Assn. “At a time when we are actually arriving at the greatest understanding of the mind and body connection, there are market forces that are working to separate that connection. . . . This is like telling Freud he can’t probe into the subconscious, that he can only prescribe medicine.”

Yet the profession’s critics--lawmakers and insurers among them--say therapy can be performed effectively by non-physician practitioners at less cost. In recent years, mental health care costs have been the fastest-growing segment of a national health care bill that is spiraling out of control.

Once the premier providers of on-the-couch psychotherapy, psychiatrists now find themselves going head to head with psychologists, clinical sociologists and social workers, all of whom have achieved increased status in the therapy arena.

Some psychologists and psychiatric nurses hope to expand the scope of their practices further by winning legal authority to prescribe medication. The Defense Department already has a pilot project to train Army psychologists to manage psychiatric drug therapies. Indiana passed a law last month that will allow psychologists to prescribe medications in federally sponsored programs, and movements are underway in 11 other states--including California--to lobby for similar legislative changes.

The “managed care” movement, which gives insurers more control over how, where and by whom medical care is provided, has already reduced the role of psychiatrists in providing medications. Under such plans, primary physicians are assuming greater responsibility for treating mentally ill patients, said Frederick Goodwin, director of the National Institute of Mental Health. About two-thirds of all prescriptions for anti-depressants are written by non-psychiatrists, he said.

The greater emphasis on managed care, led by health maintenance organizations that provide health care services at a flat monthly rate per person, has resulted in psychiatrists cooperating more with other mental health professions. Many in the field believe that cooperation, rather than strict separation of roles, is the wave of the future.

“What has been the error of medicine is that people have thought in terms of either-or: either psychiatrists, or other therapists like clinical sociologists,” said Janet Billson, assistant executive officer of the American Sociological Assn. “The most complex or resistant cases really need a team approach with follow-through.”

Despite projections of a greater demand for mental health care providers, psychiatrists will not be the ones serving the need if current trends continue. Last November, the federally funded Council on Graduate Medical Education said that while 55,000 general psychiatrists will be needed nationwide in the year 2010, it is projected that only 33,000 will be working in the field.

The number of graduating U.S. medical students choosing to specialize in psychiatry has dropped 36% since 1988--more than any other medical specialty--and is at its lowest point in 13 years.

The average annual income for psychiatrists has also been falling--and that makes the field a tough sell given the soaring cost of medical education.

Psychiatrists’ median income dropped from $113,750 to $104,170 from 1990 to 1991. The specialty moved from the fifth-lowest-paid physician group to the third-lowest. Only general practitioners and family physicians make less.

“Students are going more toward the better-paying specialties that have a better lifestyle,” said Don R. Lipsitt, professor of psychiatry at Harvard Medical School. “But who is going to do the teaching in medical schools if we are constantly losing psychiatrists?”

The greatest deterrent to doctors choosing the specialty may be the trend toward narrowing the role of psychiatrists, said Dr. Sidney Weissman, a Chicago-based psychiatrist and past president of the American Assn. of Directors of Psychiatric Residency Training. “If you convert psychiatry to a very narrow field that only focuses on the very severely mentally ill, then you are not going to attract the best and the brightest medical students. You would be converting psychiatry to a spoken version of neurology. It would be the death of psychiatry as we know it.”

In the future, “we are going to have to attract a new set of psychiatrists into the field from the ones who were attracted . . . in the previous decades--ones who are attracted to the technological side,” said Dr. David N. Osser, a psychiatrist in Wellesley, Mass.

“In the old days, medical students going into psychiatry had a largely psychological view of psychiatry,” Goodwin said. “They all wanted to practice psychotherapy in a discipline that wasn’t really part of medicine.”

Doctors go into psychiatry because they like “talking with people,” said Dr. Laura H. Wolfe, a second-year resident in San Francisco. “Prescribing medicines is not why we go into the specialty.”

Added San Rafael psychiatrist Dr. Charles B. Peek: “If it came down to just pushing pills, the hell with that, I’ll retire. I got into this profession to treat people.”

Shrinking Ranks

Because of the uncertainty about the future role for psychiatrists, the number of graduates of U.S. medical schools interested in specializing in psychiatry has been steadily declining each year. 1993 - 476 (Lowest since 1980)

Sources: National Resident Matching Plan; Sidney Weissman, M.D.