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The Changing Landscape of Psychiatry

Marlene P. Freeman, MD

Published: April 15, 2014

The Changing Landscape of Psychiatry

The field of psychiatry, along with other fields of medicine, is constantly changing. In this first installment of the Early Career Psychiatrists special section of 2014, it is worthwhile to note that the context of our practice, research, and education is also rapidly changing. Because of several major recent developments in the professional milieu, today’s trainees and recent training graduates encounter an environment different than that faced by their senior colleagues at early career stages in a number of ways:

  • The Affordable Care Act. Obviously launched with controversy and a bumpy road, health care reform in the United States is underway. The end results have yet to be known, but over time we may see fewer uninsured, predicted and unpredicted consequences of legislation, and an evolution in the practice and administration of medicine.
  • Maintenance of Certification (MOC) requirements for board certification in psychiatry. New requirements include self-assessment continuing medical education and performance in practice evaluations. Requirements have been noted to be complicated and confusing among a generation of psychiatrists who are often spread quite thin already by productivity demands in almost every practice setting. By personal communication, I know that these requirements are seen often as daunting, unquestionably as expensive, and also as unfair, considering that those who made the rules are grandfathered out of having to adhere to them. It is unclear how many currently board-certified psychiatrists will remain certified.
  • The DSM-5. The DSM-5 is published and official, after years of debate about the necessity of its production. With it come some major and minor changes in psychiatric disorder classification. Perhaps now the field can take the time to decide a priori how much and what types of advancement will be needed to herald another DSM revision.
  • Marijuana laws. Medical marijuana is now legal in a number of states, and its recreational use is also now legal in a few. It remains to be seen how clinical practice and psychiatric research will go forward to incorporate this new status.
  • Research Domain Criteria (RDoC). The National Institute of Mental Health has launched this program to classify psychopathology for research purposes. Instead of using DSM-based definitions of disorders, this approach seeks to define dimensions of functioning that cut across disorders. Whether this will lead to effective treatments for individuals who have psychiatric disorders remains unknown. This initiative appears, however, to be in conflict, rather than in parallel, with the categorization of psychopathology as per the DSM-5 development process.

Within this evolving field, promising and dedicated early career psychiatrists continue to move research forward, and we are delighted to present some of their works in this issue.

Gonzalez and colleagues, in 2 online offerings, present original research and a review on bipolar disorder and rhythmicity. In the research report, the investigators assessed rhythm disturbances using actigraphy in patients with bipolar disorder for 1 week. In terms of rhythmicity, they assessed activity levels, circadian rhythm, sleep, and variability of activity. They found that manic states were in particular related to lower degrees of rhythmicity. The accompanying review article by Gonzalez systematically reviews the relationship between bipolar disorder and biological rhythms.

Graham et al present new research findings that build on the clinically important relationship between inflammation and psychiatric illness. Their study found a compellingly high association between individuals with psychotic episodes and presence of urinary tract infections, compared to controls.

Peyre and colleagues highlight one of the changes made in DSM-5 to the attention-deficit/hyperactivity disorder (ADHD) diagnosis. The authors present a study looking at diagnostic criteria for ADHD and age at onset in order to assess whether raising the age at onset from 7 years in DSM-IV to 12 years in DSM-5 changes the psychometrics of ADHD symptomatology. When they assessed psychometric properties of ADHD according to age at onset in 3 groups (onset ≤ 7 years, > 7 and ≤ 12 years, and > 12 and ≤ 18 years), they did not find significant differential item functioning between the groups.

In another timely study, Lydsdottir et al assess the specificity of the Edinburgh Postnatal Depression Scale (EPDS). While there have been recommendations to screen for perinatal depression, and the EPDS is commonly used in the obstetric setting, the emphasis has been primarily on depression and not on other disorders. However, it is underrecognized that positive answers on the 10-item EPDS may be indicative of disorders other than major depressive disorder (MDD). Therefore, the authors assessed screenings of pregnant women who were consecutively administered the EPDS and applied diagnostic criteria. They found that 48% of those who screened positive (score > 11) met criteria for MDD; however, another 13% met criteria for bipolar disorder; 61%, for anxiety disorders; 2%, for an eating disorder; 5%, for substance abuse; and 5%, for dysthymia. Notably, the authors discuss that a comprehensive clinical assessment is warranted following administration of the EPDS in women who are noted to screen positive for perinatal depression.

In our final article, Perez-Rodriguez and coworkers address a considerably and increasingly relevant topic for US health care, the relationship between acculturation, discrimination, and suicidal ideation and attempts among Hispanics in the United States. Using data from the National Epidemiologic Survey of Alcohol and Related Conditions, the authors found a relationship with dimensions of acculturation and lifetime ideation and attempts, as well as an association between discrimination and ideation and attempts. In particular, acculturation and discrimination play roles in diminishing the protective aspects of Hispanic cultures, such as social support, coping methods, and moral objections to suicide, and will hopefully be addressed in future studies as targets for intervention.

With decided pleasure, we offer these contributions of early career psychiatrists as they seek to advance our field.

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