Psychopathology, Life, and Society: On being a psychiatrist in the XXI century

Written by: Marsal Sanches, MD, PhD, FAPA

In a recent article published in Academic Psychiatry(1), the authors discuss the progressively increasing trend in applications for psychiatry residency over the last few years. Among United States medical graduates, applications rose 289% between 2013 and 2018.

This wasn’t always the case. For decades considered the “Cinderella” of medical specialties, psychiatry was often seen with weariness by physicians in other areas and the general public. The stigma associated with mental illnesses and, paradoxically, the denial of its own existence, as illustrated by the antipsychiatry movement in the 1960s, seems to have contributed to the misconception associated with psychiatrists themselves. Often regarded as sinister and mysterious, such as being portrayed in movies as experiencing more mental health issues than their patients, the picture of psychiatrists was distorted. It’s difficult not to hypothesize that these misconceptions about psychiatry might have, at least in part, contributed to the national shortage of mental health providers.

Nevertheless, the scenario seems to be changing. The last two decades have witnessed the remodeling of psychiatry as an attractive, indispensable and, in a certain way, a much more respected medical specialty. It’s difficult to pinpoint one single cause to this change, but some possible reasons can be listed:

• Mental disorders have clearly been incorporated by culture

Denying the existence of mental illnesses today would be denying the veracity of a huge amount of scientific evidence. Sound epidemiological data support the strong relationship between mental illness and disability. Suicide is currently listed among the leading causes of death in certain age groups. Several members of the show business have publicly spoken about their struggle with mental health issues, contributing to the decrease in the stigma and encouraging patients in similar situations to seek help. A constant focus on psychiatry from a public health standpoint and discussions aiming at how to increase access to mental health treatment for those who need it have been in progress.

• Better characterization of treatments and their effectiveness

Even though psychiatry, like other areas of medicine, continues to considerably rely on the individual experience of physicians and the peculiarities inherent to each patient, treatments in psychiatry have become less empiric and more evidence-based. Numerous clinical trials support the effectiveness of psychiatric treatments and any novel proposed treatments have to undergo rigorous tests before becoming available to the public.

• Biological-Psychosocial compromise

The classic debate involving a biological versus psychosocial basis for mental disorders has become less inflamed, and radical positions involving reductionist approaches in the etiology of psychiatric disorders have weakened. While strong evidence supports the involvement of biological factors in the pathophysiology of mental illnesses, the role of environmental/psychosocial issues cannot, and shouldn’t, be minimized, as it is supported by biological research itself. Studies on epigenetics of psychiatric disorders and the pathophysiological implications of the hyperactivation of the hypothalamus-pituitary axis (HPA) as a response to stress exposure are good examples.

In summary, this is a unique time psychiatry’s history, not only for professionals but also for those in need of psychiatric care. The next few decades will likely witness further expansion in the scope of psychiatric treatments and in the progressive consolidation of psychiatry as one of the most fascinating medical specialties.

Reference

1. Agapoff JR, Tonai C, Eckert DM, Gavero G, Goebert DA. Challenges and Perspectives to the Rise in General Psychiatry Residency Applications. Acad Psychiatry. 2018 Oct;42(5):674–6.

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