by Gerald D. Klee, MD
[Spring 1997; Vol. 24 No. 1]
The cottage industry era of psychiatry is ending as profit driven corporations take over. Psychiatry is rapidly undergoing industrialization, while simultaneously being thrust into the information age. Office based, solo private practitioners are disappearing. Standardization and productivity are emphasized, as technology replaces art. The artisan is being replaced by the assembly line. There may soon be few traces left of the previous system. Before this era is entirely lost, let’s look back to a pivotal time in the history of Maryland psychiatry. In 1965, I conducted a survey of private psychiatric practice in Maryland with the assistance of Jean Warthen, PhD. An American Psychiatric News summary of the findings will be presented, but first I will provide a context.
This was the time of “THE GREAT SOCIETY". America was attempting to forge a new world. The defense industry prospered, as we fought a war in Viet Nam. Social consciousness was rising at home. Medicare legislation was passed. Private health insurance had begun paying for a significant share of psychiatric treatment. The “War Against Mental Illness" had begun. In psychiatry, we were confident that we had the necessary weapons to win the war. The psychoanalytic movement was strong and many other forms of psychotherapy were developing. The psychopharmacology revolution had begun over a decade earlier and mental hospitals were being emptied of long term patients.
Neuroscience was rapidly developing. With generous federal funding, the community mental health movement was taking shape.
During that time, the Maryland Psychiatric Case Register, an NIMH sponsored program, collected data on psychiatric admissions and discharges from psychiatric treatment programs, for planning purposes. In order to supplement this information, the MPS conducted a survey of private office practice. Although private practice was then only a tiny segment of psychiatric care, it was thought necessary to have some of this information to round out the total picture of psychiatric care in Maryland. I was Chairman of the MPS research committee at that time, as well as psychiatric consultant to the Case Register. Then, as now, the MPS covered the entire state except for Prince George and Montgomery Counties. At that time, however, the population, as well as psychiatric practice, were heavily concentrated in the Baltimore area. The results were summarized by the American Psychiatric Association News in July, 1968. The following is a condensation of the APA news article:
The majority of psychoanalysts’ patients in the Baltimore, Maryland area are not in psychoanalysis, according to a study which was conducted under the auspices of the Maryland Psychiatric Society. The survey found that analysts have more varied practices than is generally assumed. They see fewer patients than nonanalysts, use drugs less frequently, and conduct
intensive psychotherapy more often than traditional psychoanalysis.
The authors enlisted the aid of 60 psychiatrists in the area, who reported on 922 patients seen during a one-week period in March 1965. Of the psychiatrists surveyed, one-third were psychoanalysts and two-thirds non-analysts; 32 were in full-time private practice and 28 in part-time private practice. It was found that analysts spend more hours per week seeing patients (median 45 hours) than nonanalysts (median 35 hours). The analyst sees a median of 15 patients a week and 32 a year, while the nonanalyst sees 32 patients a week and 93 a year.
There were about an equal number of males and females in all forms of treatment, in contrast to Dr. Anita Bahn's 1965 study that found females outnumbering males by three to two. The median age was 34 for females and 32 for males, with few patients over 55 and few children.
Forty-five percent of all patients were not married (that is, never married, separated, divorced, or widowed). More than one-third were never married, in contrast to 15 percent of the general population who never marry.
The patients wore highly educated, 22 percent having college degrees and 19 percent graduate degrees; however, the analysts' patients were more highly educated than patients of nonanalysts. Similarly, the total patient population had a high occupational status; 30 percent were professionals, and only five patients worked as laborers or household workers. The authors say that this reflects to some extent the expense of seeing a private practitioner, but not entirely, since 27 percent of the patients seen were treated at reduced fees. They suggest it is more likely a reflection of the fact that the poorly educated seek short-term or palliative therapy, while the more highly educated seek intensive psychotherapy.
The patients were diagnosed as 16 percent psychotic, 50 percent neurotic, an 28 percent character disorders. Eleven percent of the patients had been hospitalized within a year prior to the time of the survey, and six percent had been seen in clinics.
For the majority, treatment consisted of some form of individual psychotherapy. Seven hundred and seven patients received individual psychotherapy, and in 82 percent of these cases no other form of therapy was used. Only 91 patients were in psychoanalysis, with 92 percent of the analysts’ patients receiving individual psychotherapy, either analysis or intensive psychotherapy. There were fewer females in analysis and twice as many women as men receiving chemotherapy.(1) (2) Only two patients diagnosed psychotic were in analysis, and 35 percent of those diagnosed psychotic were receiving chemotherapy.
It is a safe guess that today, all of the numbers will be different from those of the 1965 study. We will find more psychiatrists and more patients. Patients will differ demographically and by diagnostic distributions. Diagnostic labeling will have changed as we have moved from DSM I to DSM IV. There will be far more pharmacotherapy and much less psychotherapy.
In the 1960s, as the war against mental illness was launched, the future of psychiatry seemed bright. We have come a long way since then. Where are we now? Is the war being won? Many believe that it is being won by managed care, and lost by psychiatry and the mentally ill. Whatever flaws there may have been in the past, the high rate for psychotherapy in 1965 suggests that psychiatrists listened to patients. The listening was part of psychotherapy. There is less and less time for that now as psychotherapy gives way to brief, infrequent "med checks". This is a serious mistake, which may contribute to the rising numbers of malpractice suits. Drugs are not a substitute for listening. Even clinical psychopharmacology requires a thorough knowledge of the patient and an ongoing therapeutic relationship. If it’s just a matter of writing prescriptions, someone else can do it as well. “Parity for Mental Health" is of little value unless the psychiatrist is in charge of treatment and spends time with the patient.
The psychiatrist who is no more than an assembly line worker is easily dispensable. We were told in medical school that the patient is our best teacher. Before reaching for the prescription pad, listen to the patient. Listen and learn.
(1)The term "chemotherapy" which was often used in the past in psychiatry has been replaced by other terms, such as pharmacotherapy.
(2)The greater frequency of pharmacotherapy for women is one of many findings that deserve further study.