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The future of psychiatry

  • Femi Oyebode (a1) and Martin Humphreys (a1)

Summary

There is widespread concern among psychiatrists that the profession is in crisis and that it faces an array of external and internal challenges. Indeed, some observers have questioned whether the psychiatrist is an endangered species. This paper argues that medical specialties can become extinct as the case of the apothecaries exemplifies. The training template for psychiatry in the UK was put in place 40 years ago and there is a need to carefully examine whether it is still fit for purpose. Advances in theoretical knowledge and in basic understanding of psychiatric disorders have not significantly influenced the structure of clinical placements; rather it is service developments and administrative demands that have been the determinants of changes in training. Urgent action is required to address the need for reform of training that will ensure the future of psychiatry as a profession.

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Copyright

Corresponding author

Femi Oyebode, Department of Psychiatry, College of Medicine, University of Birmingham, The National Centre for Mental Health, 25 Vincent Drive, Edgbaston, Birmingham B15 2FG, UK. Email: Femi_Oyebode@msn.com

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Declaration of interest

None.

Footnotes

References

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1 Whittet, TD. The apothecary in provincial gilds. Med Hist 1964; 8: 245–73.
2 Anonymous. Introductory essay comprising an account of the origin of the association of apothecaries and surgeon-apothecaries and of their objects. In Transactions of the Associated Apothecaries and Surgeon-Apothecaries of England and Wales (Vol 1): 1138. Burgess and Hill Medical Booksellers, 1823.
3 Craddock, N, Antebi, D, Attenburrow, M-J, Bailey, A, Carson, A, Cowen, P, et al. Wake-up call for British psychiatry. Br J Psychiatry 2008; 193: 69.
4 Katschnig, H. Are psychiatrists an endangered species? Observations on internal and external challenges to the profession. World Psychiatry 2010; 9: 21–8.
5 Maj, M. Are psychiatrists an endangered species? World Psychiatry 2010; 9: 12.
6 Bullmore, E, Fletcher, P, Jones, PB. Why psychiatry can't afford to be neurophobic. Br J Psychiatry 2009; 194: 293–5.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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The future of psychiatry

  • Femi Oyebode (a1) and Martin Humphreys (a1)
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eLetters

The Future of Psychiatry: Experience from a Developing Country-Sri Lanka

K.A.L.A. Kuruppuarachchi, Professor of Psychiatry
07 March 2012

Oyebode and Humphreys highlighted an important aspect of future psychiatry in their recent editorial (BJP 2011) which is very relevant toour part of the world as well.

Psychiatry has evolved as a medical discipline and gained acceptance among the other non-psychiatric colleagues all over the world during the last century. Obviously there are many positive developments in the field despite drawbacks due to uncertainties in the aetiology and the management with regard to many psychiatric ailments and stigmatizing attitudes towards psychiatry.

As correctly highlighted in the article it is desirable to go along with the main stream of medical disciplines in order to minimize the alienation from them and to ensure acceptance of our discipline among the other medical colleagues which will also help to reduce the fear and stigmatization attitudes towards psychiatry and may enhance the recruitment. The need for improving the recruitment in to the field of psychiatry is obvious. The factors influencing the attraction of good caliber medical undergraduates to the field have been discussed. The importance and the advantages of improving the quality of undergraduate teaching and the other important issues related to this area have been highlighted(Sierls 2003). In Sri Lanka also this issue has been highlighted in the universities , for instance Faculty of Medicine of the University of Kelaniya , Sri Lanka has incorporated psychiatry as a separate subject in the final year of the undergraduate assessment and increased the duration and the quality of the training to a considerable extent. A preliminary survey carried out in Sri Lanka has demonstrated that the attitudes towards psychiatry amongst the undergraduates changed positively after increasing exposure and making psychiatry as a separate subject in the final year of the undergraduate carrier/assessment (more details are available from the author on request). A Spanish study has demonstrated that the career choice for psychiatry is about 6 % whereas it is about 4.5 % in the U.S.(Pailhez et al. 2005). This figure is as low as 2 % in Sri Lanka( Kuruppuarachchi 2008).

The importance and advantages of adhering to the broader meaning of "Medical Model" and the rational use of it when addressing the issues related to understanding the aetiology and management of mental disorders have been discussed (Shah et al. 2007).

The factors adversely influencing the field of psychiatry including the threats to the discipline as well as possible remedial measures have been addressed (Katschnig 2010).

As practitioners and academics in developing countries we also tend to follow the trends and developments in the west and inclined to incorporate them in our practices irrespective of the relevance and outcomes for instance tendency to keep away from the main stream of medicine and to associate more and more with allied professionals. On the other hand some units have replaced the word psychiatry by using other terms when naming their units for example "Nervous Disorders Unit" with the hope of minimizing the stigma attached to the discipline.

Many other professionals such as psychologists, counselors and non-western practitioners as well as religious figures are dealing with mentally ill. In addition to them other colleagues such as neurologists and general physicians attend to psychiatric problems. In developing countries many patients present with somatic symptoms in disorders such asdepression and anxiety and seek help from non psychiatric colleagues and other professionals.

The other point needs to be addressed is when the aetiology of a certain disorder is clear for example epilepsy , then it will be taken over by the other colleagues like neurologists. This can lead to problems such as narrowing the discipline further.

Psychiatric trainees should have a sound basic medical knowledge as well as a thorough neurological knowledge to be in far with the other medical professionals. As correctly mentioned in the editorial we need to be aware of this important aspect in psychiatric training globally. The academic bodies such as Psychiatric Royal Colleges need to be vigilant in this area/issue.

Obviously there is a real and perceived threat to the branch of psychiatry in our part of the world as well. Unless we address these issues in a healthy manner without much delay there is possibility of encountering more and more adverse consequences.

References

Oyebode F, Humphreys M. The future of psychiatry. British Journal of Psychiatry 2011; 199:439-440.

Sierles FS, Yager J, Weissman SH.Recruitment of US medical graduates into psychiatry: reasons for optimism, sources of concern. Academic Psychiatry 2003; 27 : 252-259.

Pailhez G, Bulbena A, Balon R. Attitudes to psychiatry : a comparisonof Spanish and US medical students. International Psychiatry 2005; 10: 6-8.

Kuruppuarachchi K.A.L.A. Recruitment and retention of psychiatrists in low-income countries. Psychiatric Bulletin 2008; 32: 154-155.

Shah P, Mountain D. The medical model is dead - long live the medicalmodel. British Journal of Psychiatry 2007; 191: 375-377.

Katschnig H. Are psychiatrists an endangered species? Observations oninternal and external challenges to the profession. World Psychiatry 2010; 9: 21-28.

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Conflict of interest: None declared

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There is hope for the future of Psychiatry

Stania Kamara, Foundation Year 2 Doctor
08 February 2012

Dear Sir,

We wish to congratulate Oyebode and Humphrey's on their well written and most stimulating editorial. As a foundation doctor currently applying for a psychiatry training post and her consultant supervisor we find the position put forward of psychiatry as a profession in crisis, and possiblyfacing extinction, emotionally stirring and thought provoking.

We are both convinced that, despite the challenges, psychiatrists remain best equipped to lead on the delivering of modern mental health care. We believe that solutions are available to the profession, starting from tackling the current state of under recruitment at postgraduate training level (BMA news, 2011). Traditionally many junior doctors disregard psychiatry as a career option under the premise that it is not 'real' medicine or a 'soft' specialty in which there is little evidence base for the treatments available. From our experience, Psychiatrists are seen as belonging on the periphery of the wider medical fraternity.

Whilst we believe that these attitudes are based on myths requiring debunking, they are most likely grounded in some historical realities and perpetuated in modern day practices to which junior doctors (F1, F2, and GPVTS) on attachment are exposed. Like the authors we too recognise a number of areas in which undergraduate and post-graduate psychiatry training can be put to better use with the aim of increasing the attraction of the speciality.

In the experience of the junior doctor, teaching at undergraduate level seems disproportionately weighted towards psychology rather than theneurobiology, psychopharmacology or genetic basis of mental health disorders. This is often reinforced in postgraduate academic programmes; leaving the trainee with a superficial understanding of areas such as psychopharmacology, despite this being a central, and defining, expertise of the psychiatrist. We suggest an overhaul of teaching programmes with a view to making them more clinically relevant.

Over the last few years psychiatry placements have been adapted to fit the training requirements of a wide range of trainees, from core trainees to GP trainees and foundation doctors. It is no secret that it isoften seen as a 'break' or 'time out' from the normal pace of the general hospital or the GP consulting room. Paradoxically, the reduced intensity of on-call shifts and unsocial hours combined with increased senior supervision often translates into less responsibility on the junior doctorwith a perceived lowering of the professional standards expected.

We welcome the suggestion that psychiatry trainees rotate through medical placements. In addition to gaining relevant medical expertise it would also help to foster a culture of mutual appreciation between psychiatrists and their medical colleagues. For medical students the experience of seeing psychiatrists working and training within a medical setting may dispel the notion that it is a fundamentally different specialty from the rest.

These are only a few measures to be considered in addressing a complex and multilayered problem facing the profession. Their advantage lies in their potential for an impact in the short term and the involvement of a new generation of doctors who are still keen on training in psychiatry against all odds.

BMA news. 2011. Battling for hearts and minds. [Accessed Jan 15 2011]. Available from: http://web.bma.org.uk/nrezine.nsf/wd/BSKN-8LBGEU?OpenDocument&C=10+September+2011

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Conflict of interest: None declared

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The future of psychiatry. Apothecaries - a cautionary tale.

Paul Harrison, Professor of Psychiatry
23 January 2012

The editorial by Oyebode and Humphreys (1) is the latest, and the most purposeful, of a series of such articles drawing attention to the increasingly urgent problem about the future of psychiatry (2-4). Their points are all well taken, and one could add to them the desperate lack ofrecruitment into the specialty. Although the problems and their origins are not limited to the United Kingdom, the situation here is acute.

We hope that our sense of complacency about the scale and imminence of the challenges we face is incorrect. Drastic steps are needed, not just to 'patch up' the immediate recruitment problem, but to acknowledge and address what we see as its root cause - the failure to define and defend psychiatry's unique place in the ecology of mental healthcare. In the respect that psychiatrists treat people with mental illness, we are like all other mental health professionals. However, in that we are medically trained, undergo six years of specialist training, and have correspondingly specific knowledge and skills, psychiatry is distinct. It is this distinction that needs to be highlighted and built upon: providing clear clinical leadership, re-differentiating ourselves from allied professions, and championing and demonstrating the added valuewe bring as doctors specialised in translating evidence-based advances in biomedical science for the benefit of patients.

Achieving a 're-medicalisation' of psychiatry will be challenging for many reasons. The place to start is probably with training. In this regard, we agree with all of Oyebode and Humphreys' recommendations, not least the exposure of all psychiatrists to some general medicine and/or neurology, and the need to review the whole issue of clinical placements, to ensure that they are tailored to (and promote) the 'medical psychiatrist' of the future. The proposed reorganisation of post-graduate medical training (5) provides a timely opportunity for radical rethinking about how, what, and where psychiatrists are taught.

Our belief is that a re-medicalised psychiatry would have a bright and dynamic future. We emphasise that re-medicalised does not mean biologically reductionist, nor does it diminish the crucial 'non-medical' elements of mental health care. It simply means that, as doctors, we should concentrate on doing what doctors do best, and are best placed to do; equally, we should challenge our involvement in activities or serviceswhich are not of this kind. In this way, psychiatry's medical identity, and thence its purpose, limits, and value, will be more apparent. From many conversations with medical students and Foundation doctors, we have no doubt that psychiatry's attractiveness as a career choice would be markedly enhanced, leading to competition for places and higher quality recruits. Without change, a combination of financial pressures and lack ofrecruitment will indeed leave us like the apothecaries 300 years ago: in decline, mental health care increasingly left to a poorly coordinated coalition of other health professionals. We feel strongly that this would be detrimental to patients. We support Oyebode and Humphreys' call for urgent action, and for the College to show leadership.

Paul Harrison. Professor of Psychiatry, University of OxfordEd Bullmore, Professor of Psychiatry, University of CambridgePeter Jones, Professor of Psychiatry, University of CambridgeShitij Kapur, Dean and Head of School, Institute of Psychiatry, LondonAnne Lingford-Hughes, Professor of Addiction Psychiatry, Imperial College,LondonMichael Owen, Professor of Psychiatry, Cardiff UniversityDigby Quested, Consultant Psychiatrist, OxfordPeter Sargent, Consultant Psychiatrist, Oxford?

1. Oyebode F, Humphreys M. The future of psychiatry. Br J Psychiatry 2011; 199:439-440.

2.Craddock N, Antebi D, Attenburrow MJ, Bailey A, Carson A,Cowen P, et al. Wake-up call for British psychiatry. Br J Psychiatry 2008;193: 6-9.

3.Bullmore E, Fletcher P, Jones PB. Why psychiatry can't afford to be neurophobic. Br J Psychiatry 2009; 194: 293-295.

4.Harrison PJ, Baldwin DS, Barnes TRE, Burns T, Ebmeier KP,Ferrier IN, Nutt DJ. No psychiatry without psychopharmacology. Br J Psychiatry 2011; 199: 263-265.

5.Ovseiko PV, Buchan AM. Postgraduate medical education in England: 100 years of solitude. Lancet 2011; 378: 1984-1985.

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Conflict of interest: None declared

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Teaching of evolutionary biology and ethology should be included in the new curriculum

Agnes K Ayton MD MMedSc FRCPsych, Consultant Child and Adolescent Psychiatrist
18 January 2012

I was delighted to read Oyebode and Humphreys' Editorial. I hope thatthey will get sufficient support from the College Membership for a major overhaul of psychiatric training. If psychiatry is to survive as a discipline, we need to strengthen medicine, modern biology and thorough academic training for the profession. We need to ensure that future generations of psychiatrists are well equipped to help their patients in atruly holistic way, and have the knowledge and confidence to recognise andmanage their patients' physical problems (in collaboration with other specialities). This, apart from helping the survival of the profession, would also reduce the shameful gap in life expectancy between the mentallyill and the general population.

Otherwise, how can psychiatry justify remaining a medical speciality if psychiatrists do not feel confident in using their medical skills, while psychological interventions are delivered by a range of other professionals? How can we remain leaders of academic progress and the translation of new scientific knowledge into clinical practice if rigorousacademic training is only available to a handful young psychiatrists in the UK, while hundreds of psychologists complete PhDs as part of their clinical training every year?

Furthermore, rather than following an intellectual framework frozen in time, we need to change the curriculum to reflect developments in relevant sciences. We should begin to build a new theoretical framework for psychiatry based on modern biology and ethology. Both of these fields are firmly built on evolutionary theory and have made rapid progress during recent decades. Psychiatry, on the other hand, has remained preoccupied with outdated ideas and has continued to ignore the significance of evolution on human mind, development, behaviour and socialinteractions. Incorporating evolutionary theory is essential if psychiatryis to survive as a scientific discipline combining biology and humanities.When we have the first basic textbook to begin the history of psychiatry with Darwin's The Expression of the Emotions in Man and Animals we would finally be on the right track.

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Conflict of interest: None declared

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Defintely there is a future for Psychiatry

Abdul K Al-Sheikhli, Consultant Psychiatrist
04 January 2012

Editor,It was interesting to read the Editorial of Oyebode, and Humphreys,The future of psychiatry,

Br J Psychiatry 2011 199:439-440; My comment,I fully support the authors regarding changes within the postgraduate training in psychiatry and the MRCPsych examination.It is not only becauseof the need to have more competent psychiatrists in the future,but also itwill make it more attractive for newly graduates of the medical schools,updates in Neurology and Medicine conferences wheather organised by The Royal College of Psychiatrists or other agencies attract most of the time good attendance,It will be interesting to have the opinion of themembers of The Royal College about that,another thing medical students canbe asked ,wheather they will chose psychiatry in the future if changes aremade in the training and membership examination to include neurology,..etcbeside psychiatry in the training,It will be also remove the stigma from psychiatry.

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Conflict of interest: None declared

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