The Rationalization of Psychiatrists
What is Rationalization?
George Ritzer, an American sociologist, defines rationalization through four objectives:
- Efficiency - the best way to get from one point to another
- Calculability - the quantitative aspects, where mathematical reasoning can be used to improve processes
- Predictability - the assurance that a product or service remains consistent over time and space
- Control - exerted over both the customers and the workers to improve accuracy
The Beginnings of Psychiatry
The beginnings of mental health care focused primarily on patients in asylums or hospitals as opposed to day-to-day mental health struggles. Many cultures actually viewed mental illness as demonic possession, and treatment often included exorcism, execution, putting a hole in the person’s skull to release the spirits, or imprisonment. In asylums, patients were often beaten or chained to their beds in dark, windowless rooms. It was only after efforts from reformers in the late 18th century and 19th century that slow progress was made. Even then, housing conditions and treatments were inhumane, such as the rooms being so cold that a glass of water would be frozen by morning. However, in the 1900s, legislation was passed that began deinstitutionalization and paved the way for modern psychiatric care.
Psychopharmacology vs. Psychotherapy - Is Rationalization Possible?
Psychopharmacology is the study of the use of medications in treating mental disorders and its effects on the mind and behavior. On the other hand, psychotherapy is a process used to treat mental disorders through verbal communication. Recently, psychiatric practitioners have been gravitating toward psychopharmacology in general. In addition, prescription medication is more sought out than psychotherapy because of time and cost benefits. Medication is also easier to access than meeting with a psychotherapist.
Psychopharmacology - Three Generations of Innovation
- Late 1950s - 70s: This period included the introduction of many psychotropic drugs. By the end of the 1950s, at least one agent from each major class of psychotropic drugs was known. These discoveries changed the categorization, diagnosis, and treatment of psychiatric disorders.
- 1980s and 90s: This second generation of discovery included "atypical" drugs, meaning that the drugs behave in ways unlike most other antidepressants. Two major classes of antidepressants were also introduced: selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs). They increase serotonin and norepinephrine levels in the brain, which are hormones and neurotransmitters that help with mood and energy regulation. This marked a shift towards greater calculability and predictability in treatment.
- 2000s - present day: This generation has emphasized finding new therapeutic mechanisms that enhance efficiency and calculability. Improving the effectiveness of drugs and developing new methods to stimulate or block receptors in the brain are two central focuses with the intention of finding optimum treatments for stable recovery. One such example is the induction of neurogenesis to treat depression. Neurogenesis refers to the production of nerve cells in the brain. Blocking NMDA glutamate receptors is associated with rapid neurogenesis, and this has shown to help patients recover from depression.
Psychotherapy - Implementation of Control
- Health Insurance Portability and Accountability Act (HIPAA): It was passed in 1996 with a goal of making healthcare more accessible in terms of insurance as well as improving efficiency. In 2003, a Privacy Rule was established under HIPAA that included guidelines on what information clients should have access to. With greater usage of technology in psychiatry comes more need for confidentiality regulations to protect personal information.
- The American Psychiatric Association, first founded in 1844 under the name the Association of Medical Superintendents of American Institutions for the Insane (AMSAII), has regulations that also demonstrate control over the occupation. Under the APA, there are record keeping guidelines and ethics codes that are to be followed by all members. They follow the American Medical Association’s Principles of Medical Ethics and APA has its own Ethics Committee as well.
Telepsychiatry and Clinical Decision Support Systems (CDSS)
Telepsychiatry is the use of video conferencing to connect patients to psychiatrists, advanced practice nurses, physician assistants, and psychologists. Although it was introduced in the 1950s, telepsychiatry grew in America mainly during the 1970s and 80s before spreading to other continents in the 90s. Telepsychiatry can be connected to Ritzer's dimension of efficiency, as it saves both money and time in comparison to in-person interactions. This is especially applicable for patients living in rural areas who would have to drive long distances to find a psychiatrist in person. Furthermore, telepsychiatry has helped in erasing the stigma that is associated with getting professional help for mental health. Patients can be in a comfortable and private environment, avoiding common feelings of shame for going to therapy.
Clinical decision support systems (CDSS) combines a patient’s data and psychiatrist’s knowledge to determine the best treatment available. It aims to improve consistency across diagnoses and treatments, as the psychiatrist can check off boxes of the patients’ symptoms and the symptoms can be matched to an illness that already has a specific treatment listed for it. CDSS limits the time needed for a patient-psychiatrist interaction (efficiency), divides each diagnosis into checkboxes of symptoms that associate with it and corresponding treatments (predictability), and reduces the options provided to both psychiatrists and patients in the diagnostic process (control). However, this can have negative implications as the treatment becomes focused on the population rather than the individual. It is almost dehumanizing to reduce a patient to checkboxes on a list and compromise on the genuineness of the interaction between the patient and psychiatrist.
Technology Continued: Virtual Reality and Artificial Intelligence
Virtual reality has been used to help patients overcome fears. Psious, a behavioral health technology company, offers virtual reality treatments for phobias such as a fear of flying, needles, public speaking, and more. Virtually Better, a VR company, has exposure therapy for anxiety disorders, phobias, and post-traumatic stress syndrome. These are just two of many examples where the immersive environment re-creates a situation that scares patients in a safe space.
Artificial intelligence is also rapidly growing in psychiatry. For example, a health technology company named Sonde Health trained machine learning models that provide cues when people begin experiencing symptoms of depression. They did so by utilizing six vocal biomarkers that measure aspects of the way a person speaks. The product is available as an app for consumers or integrated into applications that are used by clinical psychiatrists while a patient is speaking. Another example is a machine-learning algorithm created by data scientists at Vanderbilt University Medical Center that can predict the likelihood of a person taking their own life. The algorithm uses hospital admissions data such as medication and diagnostic history to do this with the hope of being implemented in all medical settings. In terms of Ritzer's four dimensions, technology is more efficient than humans and can produce more consistent and accurate results across trials (calculability and predictability). Finally, it controls the scope of the psychiatrist’s role by giving artificial intelligence a part in the diagnosing and treatment process.
Irrationalities: Lack of Access
Many people with mental disorders do not receive treatment due to the high cost and issues with insurance coverage. The National Comorbidity Study recorded that 47 percent of respondents with a mental disorder who felt that they needed treatment stated that they did not seek care due to high costs or a lack of health insurance. Even for those with insurance, it isn’t always accepted: About 45% of psychiatrists don’t accept private health insurance or Medicaid (Rowan et. al. 2013). Apart from insurance, the lack of access to mental health care has been exacerbated by a shortage of psychiatrists. As of 2017, 60% of US counties have no practicing psychiatrists with rural areas suffering the most. Consequently, there have been shorter doctor visits, longer-running prescriptions for medications with less monitoring, and long wait times in hospital emergency rooms. The shortage has gotten worse due to COVID-19 and demand for psychiatrists has risen significantly. In just the first year of the pandemic, global prevalence of anxiety and depression increased by 25% according to the World Health Organization (WHO 2022). The pandemic has had negative impacts on many people's mental health, such as feelings of loneliness or isolation, grief from losing loved ones, financial worries and fear of infection. More people are seeking care but there are not enough professionals available to meet this demand. Advanced practice nurses, physician assistants, and prescribing psychologists have had to take over to meet patient demand. Furthermore, hospitals have had to deal with a reduction in inpatient psychiatric beds available to comply with social distancing requirements.
What Does the Future Hold?
- A focus on advanced techniques in psychopharmacology that can be used in both diagnosis and treatment
- Growth of artificial intelligence and telehealth: might be a tool to bridge the gap between the developing and developed worlds
- Advanced technology for brain stimulation to manipulate certain pathways in the brain to evoke desired responses
- More personalized care through the incorporation of pharmacogenomics (the study of variability in drug response due to genetics): genetic screening becoming more common as an individual's genetic makeup can determine how they respond to drugs
References:
Allen, Summer. “Artificial Intelligence and the Future of Psychiatry.” EMB, IEEE Engineering in Medicine and Biology Society, 29 June 2020, www.embs.org/pulse/articles/artificial-intelligence-and-the-future-of-psychiatry/.
Baldessarini, Ross J. “The impact of psychopharmacology on contemporary psychiatry.” Canadian journal of psychiatry. Revue canadienne de psychiatrie vol. 59,8 (2014): 401-5. doi:10.1177/070674371405900801
Covid-19 Pandemic Triggers 25% Increase in Prevalence of Anxiety and Depression Worldwide. World Health Organization, 2 Mar. 2022, www.who.int/news/item/02-03-2022-covid-19-pandemic-triggers-25-increase-in-prevalence-of-anxiety-and-depression-worldwide.
Donald, A. The Wal-Marting of American Psychiatry: An Ethnography of Psychiatric Practice in the Late 20th Century. Cult Med Psychiatry 25, 427–439 (2001). https://doi.org/10.1023/A:1013063216716
“Ethics.” Psychiatry.org - Ethics, American Psychiatric Association, www.psychiatry.org/psychiatrists/practice/ethics#:~:text=All%20APA%20members%20are%20bound,Psychiatry%20(%22Principles%22).
Friedman, Richard A. “Psychiatry's Identity Crisis.” The New York Times, The New York Times, 17 July 2015, www.nytimes.com/2015/07/19/opinion/psychiatrys-identity-crisis.html?searchResultPosit ion=19
“The Future of Psychiatry: Telehealth, Chatbots, and Artificial Intelligence.” The Medical Futurist, 13 Aug. 2021, medicalfuturist.com/future-of-psychiatry/.
Harrar, Sari. “Inside America's Psychiatrist Shortage (Special Report).” Psycom, 2 Feb. 2022, www.psycom.net/inside-americas-psychiatrist-shortage.
Hillhouse, Todd M, and Porter, Joseph H. “A brief history of the development of antidepressant drugs: from monoamines to glutamate.” Experimental and clinical psychopharmacology vol. 23,1 (2015): 1-21. doi:10.1037/a0038550
“History of Telepsychiatry.” Psychiatry.org - History of Telepsychiatry, www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/history-of-telepsychiatry.
Institute of Medicine (US) Committee on Health Research and the Privacy of Health Information: The HIPAA Privacy Rule. Beyond the HIPAA Privacy Rule: Enhancing Privacy, Improving Health Through Research. Edited by Sharyl J Nass et. al., National Academies Press (US), 2009. doi:10.17226/12458
Kravets, Alla, et al. “The Development of Medical Diagnostics Module for Psychotherapeutic Practice.” Communications in Computer and Information Science, 2017, pp. 872–883., doi:10.1007/978-3-319-65551-2_63.
“Introduction to Psychology.” Lumen Learning, courses.lumenlearning.com/wmopen-psychology/chapter/introduction-to-mental-health/.
“New Mental Health Trends and the Future of Psychiatry.” Maryville University, 23 May 2019, online.maryville.edu/blog/future-psychiatry/.
Ofer, Zur. “Trends and Changes in Psychotherapy and Counseling.” Zur Institute, 8 July 2021, www.zurinstitute.com/trends-in-psychotherapy/.
Ritzer, George. The McDonaldization of Society into the Digital Age. SAGE, 2021.
Rapoport, Roger. “'Every Day Is an Emergency': The Pandemic Is Worsening Psychiatric Bed Shortages Nationwide.” STAT, 23 Dec. 2020, www.statnews.com/2020/12/23/mental-health-covid19-psychiatric-beds/.
Rowan, Kathleen, et al. “Access and Cost Barriers to Mental Health Care, by Insurance Status, 1999-2010.” Health Affairs (Project Hope), U.S. National Library of Medicine, Oct. 2013, www.ncbi.nlm.nih.gov/pmc/articles/PMC4236908/.
Stahl, Stephen M., and Segal, Sabrina. “The Third Generation of Therapeutic Innovation and the Future of Psychopharmacology.” Current Psychiatry, vol. 20, no. 12, 2021, doi:10.12788/cp.0199.
Stout, Chris E. “An Automated Method of Psychiatric Treatment Planning.” Behavior Research Methods, Instruments, & Computers, vol. 24, no. 2, 1992, pp. 326–327., doi:10.3758/bf03203515.
U'ren, Richard C. “The Rationalization of Psychotherapy.” Perspectives in Biology and Medicine, vol. 30, no. 4, 1987, pp. 586–589., doi:10.1353/pbm.1987.0024.
Vieta, Eduard, et al. “Psychiatry in the Aftermath of Covid-19.” Revista De Psiquiatria Y Salud Mental, 2020, www.ncbi.nlm.nih.gov/pmc/articles/PMC7833677/.
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