Things in the behavioral health world aren’t perfect, but they are better than they used to be, according to Jeffrey A Lieberman, MD, president of the American Psychiatric Association (APA).
After years of work as a psychiatrist taking care of patients and conducting clinical research, Lieberman recently switched gears and began looking into issues relating to policy and administration. He said this shift is due mainly to his current role at the APA and also his role as chairman of psychiatry at Columbia University College of Physicians and Surgeons.
“The reason that I’ve seen those as desirable things to transition to and learn about is because it’s really critical that we be knowledgeable, strategic, and proactive at this point in time given where our country is at in terms of its policies and healthcare,” Lieberman explained at the 2014 National Association of Psychiatric Health Systems (NAPHS) annual meeting. “And, as anybody who spends any time in Washington or pays attention to Washington knows, you can’t have a tremendous amount of confidence in the politicians and policy makers to make the right decisions. Healthcare is too important to be left to the politicians.”
He feels that the problem with the current state of healthcare is that the United States hasn’t yet decided “how it wants to finance healthcare.” The nation, he asserts, must decide whether healthcare is a right or a commodity.
“If it’s a commodity then you get what you pay for and if it’s a right, then everyone gets it but the question is how much are you prepared to spend?”
“Nobody knows how this is going to end up,” he continued. “They just know that something has to happen because the current method is not sustainable.”
On the topic of the Affordable Care Act (ACA), Lieberman acknowledges that there are various opinions on the subject and shared his own thoughts about it: “My opinion is that it’s a terrible piece of legislation which I don’t pretend to even comprehend much of. On the other hand, I applaud the President for getting something done because something had to be done. We can’t live in this kind of alter universe of denying the fact that we have to figure out how we’re going to pay for healthcare.”
The stepchild of healthcare
Because of the “government policy ineptitude,” Lieberman said that the healthcare system has become sick, and when that happens, mental healthcare gets critically ill. “We suffer more,” he explained. “That’s been our lot in life.”
He said that historically, psychiatry has been the stepchild of healthcare for several reasons: Lacking hard outcomes to use to gather quality metrics, and not fully being able to understand the etiologies/mechanisms of many of the treatments – “we just know that they work.”
Even though mental healthcare may be “the sibling who’s disparaged, the one that the others make jokes about,” it certainly is a vital part of the family that the others don’t want to or can live without, he explained.
He lamented the fact that some neuroscience professionals – Tom Insel and Steve Hyman – have been very hard on the field due to the lack of science-based treatments. He spoke of his colleagues saying things like: “The field of psychiatry doesn’t know anything” and “We can’t treat anybody” and “We need to do better and throw out everything we know in terms of science to start over.” While he believes such sentiments are very unfair, they do represent real frustrations with the current state of psychiatry.
He said that the reality is that psychiatry – in terms of its therapeutic capability, the size of the population it treats, and the economic burden on the country and on the world measured by world bank metrics (disability adjusted life years) – is very consequential.
While the field may not yet have hammered down what exactly causes the illnesses it is treating and the specific mechanisms and actions of how they’re working, the treatments are generally effective. And although many give mental healthcare a hard time, Lieberman defended it by saying that it has made much more progress than its sister discipline, neurology.
For disorders such as Huntinton’s Disease and Amyotrophic lateral sclerosis (ALS), he suggested that there are no true treatments at this point. The mental health field gets much “unwarranted criticism because we’ve had a harder time learning, understanding, and explaining.” The reason it’s been hard, according to Lieberman, is because all of the work in the field deals with the brain – an organ that is “vastly more complex than any other organ in the body.”
He explained that if you took a small biopsy of a kidney or a liver and examined it under a microscope, it would look the same as any other part. However, the brain has more cells (100 billion cells), more connections (30 trillion synaptic connections), and each part is different from the next.
When the brainwork was divided into neurosurgery, neurology, and psychiatry, the other areas took the “easy stuff,” said Lieberman. “What we got were the most highly involved functions in the animal kingdom. There’s no animal model for many of these. There’s nothing to be apologetic about.”
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