Patients must be able to derive maximum benefit from a psychiatrist’s medical skills and broad training

H. Katschnig provides a summary of many of the issues that confront psychiatry and psychiatrists at the beginning of the third millennium. Although there is relatively little discussion of the question posed in the title (“Are psychiatrists an endangered species?”), the author concludes that he finds it difficult to imagine psychiatry disappearing and acknowledges that the specialty needs to develop a positive identity. He ends by stressing that he believes a core issue is that a psychiatrist’s therapeutic skills must include biological, psychological and social interventions.

We agree substantially with much of the article, including that it is important that psychiatry develops a clearer definition of its remit and the expertise and training required by its practitioners 1. However, we suspect that part of the current identity problems have arisen from an overly inclusive, often nebulous, and frequently indiscriminate implementation of the dictum that psychiatrists must embrace biological, psychological and social approaches 2. Of course, it is essential that all these domains are taken into account in management, and psychiatrists must have the knowledge and skills to understand which are the most important and appropriate interventions across all these domains – including knowing when specific interventions would be unhelpful or damaging. However, as Katschnig discusses, there is now a wide range of highly trained fellow professionals working in mental health, and for many psychological and social interventions these other professionals may (and often will) be better trained and more experienced than a psychiatrist and will almost always cost less per unit time for delivering the intervention. Thus, although psychiatrists may like to feel they can or should be able to deliver all domains of therapeutic interventions, is this realistic or sensible? We think it is not. Rather, we need to ask what are the special skills and expertise that psychiatrists can use for the benefit of patients. To put it into management speak: what are a psychiatrist’s unique selling points? Surely this must be the core of the psychiatrist’s positive identity.

Psychiatrists are medically trained. They are the members of a mental health team that have expertise in diagnosis and management of physical illness. They have training in the biological disciplines of physiology, biochemistry, anatomy, pathology and pharmacology. They have training in diagnostics. Given the importance of identifying the key issues as early as possible and setting the patient along the most appropriate therapeutic path, the psychiatrist can be used effectively to undertake/coordinate the initial diagnostic assessment process, as well as to make appropriate diagnostic reviews if new information arises. The psychiatrist is uniquely placed to take account of physical illness, both as a contributor to the psychiatric picture (for example when thyroid dysfunction contributes to affective disturbance) or as a comorbid condition (such as recognizing heart disease co-occurring with depression) or as an adverse effect of psychiatric treatment (such as type 2 diabetes associated with treatment by antipsychotic medication). Finally, in addition to the psychiatrist’s core medical skills, he/she has training in psychological and social issues. Thus, the psychiatrist is uniquely placed to take the “big picture” overview that includes the biological, psychological and social domains within the assessment. Further, the medical training emphasizes pragmatism (i.e., the willingness to use whatever works, rather than close adherence to specific schools of thought) and the need for an evidence base.

Thus, although individual psychiatrists will vary greatly in their background, expertise and interests, the core, unique contributions that they can bring to a mental health team are: a) broad-based diagnostic assessment, b) understanding the interface between physical illness and psychiatric illness, c) understanding the “biological” parts of the bio-psycho-social spectrum 1-3. With the advances in knowledge of the workings of the brain and processes involved in psychiatric illness, including from molecular biology 4 and imaging 5, it can be expected that expertise in biological understanding will become increasingly important for diagnosis and management of mental illness and it will be essential that there are appropriately trained and skilled clinical researchers and practitioners who can ensure that advances in understanding are translated into benefits for patients 1.

Psychiatry is a “broad church” and accommodates an enormous range of views. Indeed, the bio-psycho-social model itself can be thought of as a rather poorly-defined concept that allowed practitioners with almost any view of psychiatry to “sign up” and then practise whatever they want 2. Perhaps we now need to bite the bullet and move to a clearer definition of the remit of psychiatry in the 21st century, with a focus on the special contributions that can be made by psychiatrists to the care of patients with mental illness. This must be clearly justifiable on the basis of evidence and costeffectiveness.

We conclude by using the analogy introduced in Katschnig’s titular question (“Are psychiatrists an endangered species?”). It is our view that psychiatry is currently at risk of going on the endangered species list. There are many species competing within the same habitat. If psychiatrists do not pass on their optimal qualities to the future generations of psychiatrists they will – and indeed should – become extinct. There is only a point in having psychiatrists if they provide a costeffective advantage to patients. We believe very strongly that patients can derive major advantages from psychiatric contributions to care and that they would be disadvantaged and put at risk without such contributions 1.

Perhaps we are entering a period of intense natural selection from which are likely to emerge medical practition ers that specialize in psychiatric illness and use their medical and biological expertise and diagnostic skills effectively within the context of an appreciation of the psychosocial factors and available treatment modalities. It seems to us that Reil would recognize such physicians as worthy members of the medical specialty of psychiatry that he described two centuries ago 6.