Alcohol
& Drug
Addiction for a New Marc Richard
Galanter, Frances,
Abuse
Psychiatry: Challenges Psychiatric Subspeciaky M.D. M.D.
The American Board of Psychiatry and Neurology(ABPN) will conduct its first examination for a certificate of added qualifications in addiction psychiatry on March 30, 1993. Addiction psychiatry is the first addiction treatment subspecialty to receive formal approval from the American Board of Medical Specialties (ABMS), of which ABPN is a member organization. Recertification will be required every ten years. Formal certification clearly legitimates the role of addiction psychiatry within the mainstream of medical subspecialties, and it is likely to generate greater interest in the field among psychiatric residents. The official establishment of the field of addiction psychiatry as a subspecialty and the creation of a means of distinguishing properly trained and experienced addiction psychiatrists are the culmination of several major steps taken by professional organizations in the field over the course of the last decade. This column summarizes the recent history of the field of addiction psychiatry,
presents a rationale for the development of added qualifications, and discusses some ofthe advantages and disadvantages of subspecialization.
Galanter is professor of psychiatry and director of the division of alcohol and drug abuse at the New York University School of Medicine, 550 First Avenue, New York, New York 10016. Dr. Frances is vice-chairman of the department of psychiatry and professor of clinical psychiatry at the University of Medicine and Dentistry of New Jersey in Newark. He is also editor of this column.
Establishing a subspecialty Substance abuse is the psychiatric disorder with the highest prevalence and greatest cost. Lifetime prevalence rates are 1 5 percent for alcohol abuse and 6 percent for drug abuse (1). The actual dollar cost of addiction in the United States is $144 billion annually, more than that of general mental illness (2). Most peopie suffering from addiction go untreated. Because ofthese compelling facts, the medical profession has increasingly recognized the need to provide specialized training in treatment of addiction. In psychiatry in recent years, curricula on addiction treatment have been instituted at the undergraduate medical level, and lectures and clinical rotations focusing on addiction are available to psychiatric residents. Departments of psychiatry also realize the need to recruit and train experts to provide leadership in this area for primary care physicians and for psychiatrists of the future. How did this subspecialization come about? Certification of medical specialties was described as far back as the Renaissance in the Republic of Venice, where the state required ongoing medical certification and surgeons, acknowledged as a specialty group, were obliged to prove their competence (3). In this century in the United States, the concept of specialty certification was first implemented in 1917, when the American Medical Association established a board to monitor the qualification of
Hospital
November
Dr.
and
Community
Psychiatry
1992
Vol.43
No.
11
practitioners in ophthalmology. Today, its successor, the American Board ofMedical Specialties, oversees certification in 23 specialties. With the emergence ofthe disease concept of addiction in the 1950s, and concomitant studies on the pathophysiology of intoxication and withdrawal, it became clear that the addiction field had its own epidemiologic, psychological, and biomedical body of knowledge. Expansion of this knowledge base was bolstered by a number of developments, including an enhanced Understanding ofunderlying pathology and the development ofeffective modalities of care. During the 1960s and 1970s, several scholarly organizations dealing specifically with research and clinical issues in the area of addictions, including the Amencan Society on Addiction Medicine, were created; a large number of professional journals presenting extensive new findings were launched; and the federal Institutes for Drug Abuse and Alcoholism were established. Teaching expertise in addiction was also formalized in 59 medical schools under the federally sponsored Careen Teacher Program ofthe 1970s. Most medical schools now have at least one senior faculty member who is knowledgeable in the field of alcohol and drug abuse. One of the first attempts to formalize expertise in addiction medicine was undertaken by the Amencan Society on Addiction Medicine, which established a procedure for certifying its members in the mid 1980s. The first applications were accepted in 1986, and 735 physicians were certified that year. The most frequently represented specialties in that year were general and family practice (32 percent), psychiatry (28 percent), and internal medicine (24 percent) (4). This process, however, lay outside the established ABMS procedures for certification. An important development for psychiatry and the medical establishment was the emergence of medical fellowship training in addiction treatment. A recent survey (5) of fellowship programs revealed growth in the number of addiction fellowships in recent years, from 27 in 1987 to
1067
48 in 1990-91. Altogether the programs have graduated a total of 161 fellows to date. A majority of the programs surveyed listed their fellowship as an extension ofan existing residency program. These residency programs were typically based in departments of psychiatry, sometimes in conjunction with another specialty. Psychiatry clearly played the key role in postgraduate training in the addiction field. In 1980 the Consortium for Mcdical Fellowships in Alcoholism and Drug Abuse was established to promote fellowship training of high caliber. Its primary sponsors are the American Academy of Psychiatrists in Alcoholism and Addictions, the Association for Medical Education and Research in Substance Abuse, and the American Society of Addiclion Medicine; other sponsors indude a wide range ofmedical specialties. Its goal has been to assure the availability of clinical research and teaching specialists in the addiction field and to develop and organize effective training programs. In 1987, the Center for Medical Fellowships in Alcoholism and Drug Abuse, sponsored by the American Academy of Psychiatrists in Alcoholism and Addictions and the Association for Medical Education in Substance Abuse, was established to promote postgraduate medical training in addiction treatment. The center has developed an advisory group of leaders in education of medical specialists in alcoholism and drug abuse, worked to develop guidelines for medical training in addictions, disseminated information on fellowship programs, and promoted establishment of new programs in qualified medical training centers. Certification Psychiatry also took the lead in establishing an addiction subspecialty certification process through ABMS. The American Academy of Psychiatrists in Alcoholism and the Addictions (AAPAA) spearheaded this effort. From its inception in 1985 after a careful assessment of the professional activities of American psychiatrists (6), AAPAA has actively promoted subspecialty certification. The goals and objectives of AAPAA are to im-
1068
prove education, prevention, treatment, and research in the field of alcoholism and addictions; to strengthen the training of psychiatrists in the addiction field; and to provide public information about the role of addiction psychiatrists. Its current membership is 1 ,200 psychiatrists. In 1990 AAPAA collaborated with the ABPN in formulating statements of need for issuing certificates of added qualification in addiction psychiatry. AAPAA helped influence the American Psychiatric Association (APA) to increase its attendon to alcohol and drug issues and to establish the council on addiction psychiatry in 1990. These efforts ultimately led in 1990 to APA’s giving its support to an examination for added qualifications in addiction psychiatry. The council now has an education committee and a treatment task force and is forming a work group to develop practice parameters for addiction psychiatry. As a result of this effort, the ABPN is implementing procedures to award the certificate of added qualifications in addiction psychiatry, placing the subspecialty firmly within the medical mainstream. The first group ofdiplomates will be certified in 1993. Criteria for certffication are experience in the field (25 percent of the applicant’s time must be spent in addiction psychiatry) and passing the added qualifications cxamination. The ABPN’s psychiatric residency review committee is currently engaged in a five-year process to formalize requirements for fellowships in addiction psychiatry. Once the requirements are established, applicants for the certificate of added qualifications will be expected to complete a one-year approved fellowship program before taking the exam. Challenges of specialization This is a time of challenge and opportunity in addiction psychiatry as well as psychiatry as a whole. The services of addiction psychiatrists are greatly needed. As mentioned above, persons with addictions constitute the largest and most undertreated group of psychiatric patients. There is a major shortage of specialists in the field and
November
1992
Vol.43
No.
11
growing need for clinicians, researchers, and teachers. This is also a time ofgreat opportunity for researchers interested in the biopsychosocial underpinnings of addictive disorders. From important developments in neuroscience, including advances in knowledge about cell membranes, receptors, neuroanatomical structures, and pharmacological effects, to increasing interest in comorbidity, clinical treatment outcome studies, and efforts to locate a gene for addictive disorders, an enormous amount of scientific data is being generated about the effects ofalcohol and other substances. In addition, recognition of addiction psychiatrists by organized psychiatry is ofgreat importance to their place in organized medicine and to the provision ofcare for addicted patients. But this relationship is also very significant for the welfare of psychiatry itself. For example, the integrity of the APA is in no way ensured for the future unless psychiatry as a field grows along with its new expertise. The emergence of subspecialties in psychiatry could undermine psychiatrists’ working together with a shared clinical and theoretical onentation if efforts are not made to strengthen the subspecialties’ links with the overall discipline. These efforts are needed because specialties such as treatment ofaddictions often draw practitioners from many mcdical disciplines. Internal medicine has encountered similar trends, and intennists have divided themselves into a variety ofsubspecialty groups, each operating relatively autonomously. The American College of Physicians (ACP) represents internal medicine but has only a modest portion of certified internists among its members. Cardiologists, diabetologists, endocninologists, and the like each have their own subspeciaky organizations that operate independent of the ACP. One way to avoid the potential dissociation between subspecialists and general psychiatry is for subspecialty groups like AAPAA to become voting components of APA. (Continued
Hospital
and Community
on page 1072)
Psychiatry
tional mental health services during hospital closing programs. Such services, and clearly formulated guidelines for their use, should be made available. For example, the Department of Health should identify specific institutional functions that require closure and should work with social service departments to develop alternative facilities in the community (21). At the district level, a fundamental barrier to rational planning and evaluation of services has been the lack of an infrastructure for storage and retrieval of computerized information (22,23). Strategic guidance in this area from both the regional and national levels has been minimal. Although local management of such information
systems
is crucial,
the
assistance of national expert consultants could expedite the development of systems that are more useful for planning during the current era ofdeinstitutionalization (24). Our proposals go far beyond the single target set for mental health services in Britain’s Health of the Nation draft law. The recommendations require commitment at all levels of health care organization to accord mental health and mental illness services a priority they have never enjoyed in England. As such, the planning process offers an unrivalled opportunity to create a strategic framework for the development of mental health services into the 21st century.
Year 2000. ganization,
6.
7.
Allebeck
4. Raftery J: Social policy and community psychiatry in the United Kingdom, in Community Psychiatry: The Principles. Edited by Bennett D, Freeman H. London, Churchill Livingstone, 1991 5. Global
1072
Strategy
for Health
for All by the
P:
disease.
15:81-89,
Alcohol
Camberwell. 561-579,
Schizophrenia: Schizophrenia
a life-shorBulletin
1989
8. Bebbington Epidemiology
P, HurryJ, Tennant C, et al: of mental disorders in Psychological Medicine 11: 1981
9. Mann A: Public health and psychiatric morbidity, in Indicators for Mental Health in the Population. Edited byJenkins R, Griffiths S. London, Her Majesty’s Stationery Office, 1991 10.
Goldberg
D: Filter
to care: a model,
ibid
B, Lesage
A, Brewin C, et al: care among the relatives of long-term users ofday care. Psychological Medicine 19:725-736, 1989
1 1 . MacCarthy Needs for
12.
Croft-Jeifreys C, Wilkinson G: Esticosts of neurotic disorder in United Kingdomgeneral practice, 1985. Psychological Medicine 19:549-5 58, 1989 mated
13.
Davies L, Drummond M: The economic burden ofschizophrenia. British Journal ofPsychiatry 154:522-525, 1990
14. Thomicroft
G,
health. British 410-412, 1991
15.
Abuse
E: Community mental services: a vision for the future. MedicalJournal 302:1064-1065,
icine 83:222-225,
health British 1991
They would then play a role in establishing APA policy. Psychiatry must also address the fragmentation of the Alcohol, Drug Abuse, and Mental Health Admiistration and the entry ofits respective institutes into the National Institutes of Health. An inadequate response could lead to the loss of a coherent perspective from psychiatry in relation to alcohol, drug abuse, and mental health. For psychiatry to meet the needs ofits patients, new subspecialties and related expertise are necessary. In taking this opportunity to address the addiction problem, one of major national priority, psychiatry can further develop the leadership role it has played in the last decade. Fortunately, psychiatry has demonstrated historically its capacity to adapt to such new circumstances. It will, no doubt, continue to do this in the future.
959-967,
1990
18.
Census 1981. London, Stationery Office, 1983
19.
Thompson C: The Instruments chiatric Research. Chicester,
1510-1512
Her
Majesty’s
1989
Strathdee G, Thornicroft G: Establishing needs within routine clinical practice, in Measuring Mental Health Needs. Edited by Thomicroft G, Brewin C, Wing J. London, Gaskell, 1992
22.
Wing J (ed): Health Services Planning and Research: Contributions From Psychiatric Case Registrars. London, Gaskell, 1989
23.
Implications for the Field of Mental Health of the European Targets for Attaming Health for All. Copenhagen, World Health Organization, 1991
24.
Thornicroft G, Bebbington P: Deinstitutionalisation: from hospital closure to service development. British Journal of Psychiatry 155:739-753, 1988
Vol.43
No.
11
1984
2. Rice DP, Kelman 5, Miller IS, et al: Economic Costs ofAlcohol and Drug Abuse and Mental Illness, 1985. San Francisco, Institute for Health and Aging, University
of PsyEngland,
Wetzler 5: Measuring Mental Illness. Washington, DC, American Psychiatric Press, 1989
1992
1068)
1. Myers JK, Weissman MM, Tischler GL, et al: Six-month prevalence of psychiatric disorders in three communities: 1980 to 1982. Archives ofGeneral Psychiatry 41:
Patmore C, Weaver T: Rafts on an open sea. HealthServiceJournal,Oct 1990, pp
November
(Continuedfrompage
References
Murphy
17.
21.
& Drug
Strathdee G: Mental Medical Journal 303:
16. Strathdee G: The delivery of psychiatric care.Journalofthe Royal Society of Med-
2. Marks I, Thornicroft G: Private psychiatric inpatient care. British Medical Journal 300:892, 1990 3. Sharp D, Morrell D: The psychiatry of general practice, in Scientific Approaches in Epidemiological and Social Psychiatry: Essays in Honour of Michael Shepherd. Edited by Williams P, Wilkinson G, Rawnsley K. London, Routledge, 1989
Or-
5: Introduction to annual reports ofpublic health, in Indicators for Mental Health in the Population. Edited by Jenkins R, Griffiths S. London, Her Majesty’s Stationery Office, 1991 tening
20.
1. Department of Health: The Health of the Nation. London, Her Majesty’s Stationery Office, 1991
Health
Farrow
Wiley,
References
World
Geneva,
1981
3.
of California,
1990
ElI SR: Five hundred years of specialty certification and compulsory continuing medical education. JAMA 251:752-753, 1984
4. Galanter
M,
Bean-Bayog
M:
Physician
certification dence.JAMA
in alcohol and drug depen259:354, 1988 5. GalanterM, BurnsJ: The status of medical fellowships in addiction. American Journal of Addictions, in press 6. Miller SI, Frances R: Psychiatrists and the treatment of addictions: perceptions and practices. American Journal of Drug and Alcohol Abuse 12:187-197, 1986
Hospital
and
Community
Psychiatry
& Drug
Addiction for a New Marc Richard
Galanter, Frances,
Abuse
Psychiatry: Challenges Psychiatric Subspeciaky M.D. M.D.
The American Board of Psychiatry and Neurology(ABPN) will conduct its first examination for a certificate of added qualifications in addiction psychiatry on March 30, 1993. Addiction psychiatry is the first addiction treatment subspecialty to receive formal approval from the American Board of Medical Specialties (ABMS), of which ABPN is a member organization. Recertification will be required every ten years. Formal certification clearly legitimates the role of addiction psychiatry within the mainstream of medical subspecialties, and it is likely to generate greater interest in the field among psychiatric residents. The official establishment of the field of addiction psychiatry as a subspecialty and the creation of a means of distinguishing properly trained and experienced addiction psychiatrists are the culmination of several major steps taken by professional organizations in the field over the course of the last decade. This column summarizes the recent history of the field of addiction psychiatry,
presents a rationale for the development of added qualifications, and discusses some ofthe advantages and disadvantages of subspecialization.
Galanter is professor of psychiatry and director of the division of alcohol and drug abuse at the New York University School of Medicine, 550 First Avenue, New York, New York 10016. Dr. Frances is vice-chairman of the department of psychiatry and professor of clinical psychiatry at the University of Medicine and Dentistry of New Jersey in Newark. He is also editor of this column.
Establishing a subspecialty Substance abuse is the psychiatric disorder with the highest prevalence and greatest cost. Lifetime prevalence rates are 1 5 percent for alcohol abuse and 6 percent for drug abuse (1). The actual dollar cost of addiction in the United States is $144 billion annually, more than that of general mental illness (2). Most peopie suffering from addiction go untreated. Because ofthese compelling facts, the medical profession has increasingly recognized the need to provide specialized training in treatment of addiction. In psychiatry in recent years, curricula on addiction treatment have been instituted at the undergraduate medical level, and lectures and clinical rotations focusing on addiction are available to psychiatric residents. Departments of psychiatry also realize the need to recruit and train experts to provide leadership in this area for primary care physicians and for psychiatrists of the future. How did this subspecialization come about? Certification of medical specialties was described as far back as the Renaissance in the Republic of Venice, where the state required ongoing medical certification and surgeons, acknowledged as a specialty group, were obliged to prove their competence (3). In this century in the United States, the concept of specialty certification was first implemented in 1917, when the American Medical Association established a board to monitor the qualification of
Hospital
November
Dr.
and
Community
Psychiatry
1992
Vol.43
No.
11
practitioners in ophthalmology. Today, its successor, the American Board ofMedical Specialties, oversees certification in 23 specialties. With the emergence ofthe disease concept of addiction in the 1950s, and concomitant studies on the pathophysiology of intoxication and withdrawal, it became clear that the addiction field had its own epidemiologic, psychological, and biomedical body of knowledge. Expansion of this knowledge base was bolstered by a number of developments, including an enhanced Understanding ofunderlying pathology and the development ofeffective modalities of care. During the 1960s and 1970s, several scholarly organizations dealing specifically with research and clinical issues in the area of addictions, including the Amencan Society on Addiction Medicine, were created; a large number of professional journals presenting extensive new findings were launched; and the federal Institutes for Drug Abuse and Alcoholism were established. Teaching expertise in addiction was also formalized in 59 medical schools under the federally sponsored Careen Teacher Program ofthe 1970s. Most medical schools now have at least one senior faculty member who is knowledgeable in the field of alcohol and drug abuse. One of the first attempts to formalize expertise in addiction medicine was undertaken by the Amencan Society on Addiction Medicine, which established a procedure for certifying its members in the mid 1980s. The first applications were accepted in 1986, and 735 physicians were certified that year. The most frequently represented specialties in that year were general and family practice (32 percent), psychiatry (28 percent), and internal medicine (24 percent) (4). This process, however, lay outside the established ABMS procedures for certification. An important development for psychiatry and the medical establishment was the emergence of medical fellowship training in addiction treatment. A recent survey (5) of fellowship programs revealed growth in the number of addiction fellowships in recent years, from 27 in 1987 to
1067
48 in 1990-91. Altogether the programs have graduated a total of 161 fellows to date. A majority of the programs surveyed listed their fellowship as an extension ofan existing residency program. These residency programs were typically based in departments of psychiatry, sometimes in conjunction with another specialty. Psychiatry clearly played the key role in postgraduate training in the addiction field. In 1980 the Consortium for Mcdical Fellowships in Alcoholism and Drug Abuse was established to promote fellowship training of high caliber. Its primary sponsors are the American Academy of Psychiatrists in Alcoholism and Addictions, the Association for Medical Education and Research in Substance Abuse, and the American Society of Addiclion Medicine; other sponsors indude a wide range ofmedical specialties. Its goal has been to assure the availability of clinical research and teaching specialists in the addiction field and to develop and organize effective training programs. In 1987, the Center for Medical Fellowships in Alcoholism and Drug Abuse, sponsored by the American Academy of Psychiatrists in Alcoholism and Addictions and the Association for Medical Education in Substance Abuse, was established to promote postgraduate medical training in addiction treatment. The center has developed an advisory group of leaders in education of medical specialists in alcoholism and drug abuse, worked to develop guidelines for medical training in addictions, disseminated information on fellowship programs, and promoted establishment of new programs in qualified medical training centers. Certification Psychiatry also took the lead in establishing an addiction subspecialty certification process through ABMS. The American Academy of Psychiatrists in Alcoholism and the Addictions (AAPAA) spearheaded this effort. From its inception in 1985 after a careful assessment of the professional activities of American psychiatrists (6), AAPAA has actively promoted subspecialty certification. The goals and objectives of AAPAA are to im-
1068
prove education, prevention, treatment, and research in the field of alcoholism and addictions; to strengthen the training of psychiatrists in the addiction field; and to provide public information about the role of addiction psychiatrists. Its current membership is 1 ,200 psychiatrists. In 1990 AAPAA collaborated with the ABPN in formulating statements of need for issuing certificates of added qualification in addiction psychiatry. AAPAA helped influence the American Psychiatric Association (APA) to increase its attendon to alcohol and drug issues and to establish the council on addiction psychiatry in 1990. These efforts ultimately led in 1990 to APA’s giving its support to an examination for added qualifications in addiction psychiatry. The council now has an education committee and a treatment task force and is forming a work group to develop practice parameters for addiction psychiatry. As a result of this effort, the ABPN is implementing procedures to award the certificate of added qualifications in addiction psychiatry, placing the subspecialty firmly within the medical mainstream. The first group ofdiplomates will be certified in 1993. Criteria for certffication are experience in the field (25 percent of the applicant’s time must be spent in addiction psychiatry) and passing the added qualifications cxamination. The ABPN’s psychiatric residency review committee is currently engaged in a five-year process to formalize requirements for fellowships in addiction psychiatry. Once the requirements are established, applicants for the certificate of added qualifications will be expected to complete a one-year approved fellowship program before taking the exam. Challenges of specialization This is a time of challenge and opportunity in addiction psychiatry as well as psychiatry as a whole. The services of addiction psychiatrists are greatly needed. As mentioned above, persons with addictions constitute the largest and most undertreated group of psychiatric patients. There is a major shortage of specialists in the field and
November
1992
Vol.43
No.
11
growing need for clinicians, researchers, and teachers. This is also a time ofgreat opportunity for researchers interested in the biopsychosocial underpinnings of addictive disorders. From important developments in neuroscience, including advances in knowledge about cell membranes, receptors, neuroanatomical structures, and pharmacological effects, to increasing interest in comorbidity, clinical treatment outcome studies, and efforts to locate a gene for addictive disorders, an enormous amount of scientific data is being generated about the effects ofalcohol and other substances. In addition, recognition of addiction psychiatrists by organized psychiatry is ofgreat importance to their place in organized medicine and to the provision ofcare for addicted patients. But this relationship is also very significant for the welfare of psychiatry itself. For example, the integrity of the APA is in no way ensured for the future unless psychiatry as a field grows along with its new expertise. The emergence of subspecialties in psychiatry could undermine psychiatrists’ working together with a shared clinical and theoretical onentation if efforts are not made to strengthen the subspecialties’ links with the overall discipline. These efforts are needed because specialties such as treatment ofaddictions often draw practitioners from many mcdical disciplines. Internal medicine has encountered similar trends, and intennists have divided themselves into a variety ofsubspecialty groups, each operating relatively autonomously. The American College of Physicians (ACP) represents internal medicine but has only a modest portion of certified internists among its members. Cardiologists, diabetologists, endocninologists, and the like each have their own subspeciaky organizations that operate independent of the ACP. One way to avoid the potential dissociation between subspecialists and general psychiatry is for subspecialty groups like AAPAA to become voting components of APA. (Continued
Hospital
and Community
on page 1072)
Psychiatry
tional mental health services during hospital closing programs. Such services, and clearly formulated guidelines for their use, should be made available. For example, the Department of Health should identify specific institutional functions that require closure and should work with social service departments to develop alternative facilities in the community (21). At the district level, a fundamental barrier to rational planning and evaluation of services has been the lack of an infrastructure for storage and retrieval of computerized information (22,23). Strategic guidance in this area from both the regional and national levels has been minimal. Although local management of such information
systems
is crucial,
the
assistance of national expert consultants could expedite the development of systems that are more useful for planning during the current era ofdeinstitutionalization (24). Our proposals go far beyond the single target set for mental health services in Britain’s Health of the Nation draft law. The recommendations require commitment at all levels of health care organization to accord mental health and mental illness services a priority they have never enjoyed in England. As such, the planning process offers an unrivalled opportunity to create a strategic framework for the development of mental health services into the 21st century.
Year 2000. ganization,
6.
7.
Allebeck
4. Raftery J: Social policy and community psychiatry in the United Kingdom, in Community Psychiatry: The Principles. Edited by Bennett D, Freeman H. London, Churchill Livingstone, 1991 5. Global
1072
Strategy
for Health
for All by the
P:
disease.
15:81-89,
Alcohol
Camberwell. 561-579,
Schizophrenia: Schizophrenia
a life-shorBulletin
1989
8. Bebbington Epidemiology
P, HurryJ, Tennant C, et al: of mental disorders in Psychological Medicine 11: 1981
9. Mann A: Public health and psychiatric morbidity, in Indicators for Mental Health in the Population. Edited byJenkins R, Griffiths S. London, Her Majesty’s Stationery Office, 1991 10.
Goldberg
D: Filter
to care: a model,
ibid
B, Lesage
A, Brewin C, et al: care among the relatives of long-term users ofday care. Psychological Medicine 19:725-736, 1989
1 1 . MacCarthy Needs for
12.
Croft-Jeifreys C, Wilkinson G: Esticosts of neurotic disorder in United Kingdomgeneral practice, 1985. Psychological Medicine 19:549-5 58, 1989 mated
13.
Davies L, Drummond M: The economic burden ofschizophrenia. British Journal ofPsychiatry 154:522-525, 1990
14. Thomicroft
G,
health. British 410-412, 1991
15.
Abuse
E: Community mental services: a vision for the future. MedicalJournal 302:1064-1065,
icine 83:222-225,
health British 1991
They would then play a role in establishing APA policy. Psychiatry must also address the fragmentation of the Alcohol, Drug Abuse, and Mental Health Admiistration and the entry ofits respective institutes into the National Institutes of Health. An inadequate response could lead to the loss of a coherent perspective from psychiatry in relation to alcohol, drug abuse, and mental health. For psychiatry to meet the needs ofits patients, new subspecialties and related expertise are necessary. In taking this opportunity to address the addiction problem, one of major national priority, psychiatry can further develop the leadership role it has played in the last decade. Fortunately, psychiatry has demonstrated historically its capacity to adapt to such new circumstances. It will, no doubt, continue to do this in the future.
959-967,
1990
18.
Census 1981. London, Stationery Office, 1983
19.
Thompson C: The Instruments chiatric Research. Chicester,
1510-1512
Her
Majesty’s
1989
Strathdee G, Thornicroft G: Establishing needs within routine clinical practice, in Measuring Mental Health Needs. Edited by Thomicroft G, Brewin C, Wing J. London, Gaskell, 1992
22.
Wing J (ed): Health Services Planning and Research: Contributions From Psychiatric Case Registrars. London, Gaskell, 1989
23.
Implications for the Field of Mental Health of the European Targets for Attaming Health for All. Copenhagen, World Health Organization, 1991
24.
Thornicroft G, Bebbington P: Deinstitutionalisation: from hospital closure to service development. British Journal of Psychiatry 155:739-753, 1988
Vol.43
No.
11
1984
2. Rice DP, Kelman 5, Miller IS, et al: Economic Costs ofAlcohol and Drug Abuse and Mental Illness, 1985. San Francisco, Institute for Health and Aging, University
of PsyEngland,
Wetzler 5: Measuring Mental Illness. Washington, DC, American Psychiatric Press, 1989
1992
1068)
1. Myers JK, Weissman MM, Tischler GL, et al: Six-month prevalence of psychiatric disorders in three communities: 1980 to 1982. Archives ofGeneral Psychiatry 41:
Patmore C, Weaver T: Rafts on an open sea. HealthServiceJournal,Oct 1990, pp
November
(Continuedfrompage
References
Murphy
17.
21.
& Drug
Strathdee G: Mental Medical Journal 303:
16. Strathdee G: The delivery of psychiatric care.Journalofthe Royal Society of Med-
2. Marks I, Thornicroft G: Private psychiatric inpatient care. British Medical Journal 300:892, 1990 3. Sharp D, Morrell D: The psychiatry of general practice, in Scientific Approaches in Epidemiological and Social Psychiatry: Essays in Honour of Michael Shepherd. Edited by Williams P, Wilkinson G, Rawnsley K. London, Routledge, 1989
Or-
5: Introduction to annual reports ofpublic health, in Indicators for Mental Health in the Population. Edited by Jenkins R, Griffiths S. London, Her Majesty’s Stationery Office, 1991 tening
20.
1. Department of Health: The Health of the Nation. London, Her Majesty’s Stationery Office, 1991
Health
Farrow
Wiley,
References
World
Geneva,
1981
3.
of California,
1990
ElI SR: Five hundred years of specialty certification and compulsory continuing medical education. JAMA 251:752-753, 1984
4. Galanter
M,
Bean-Bayog
M:
Physician
certification dence.JAMA
in alcohol and drug depen259:354, 1988 5. GalanterM, BurnsJ: The status of medical fellowships in addiction. American Journal of Addictions, in press 6. Miller SI, Frances R: Psychiatrists and the treatment of addictions: perceptions and practices. American Journal of Drug and Alcohol Abuse 12:187-197, 1986
Hospital
and
Community
Psychiatry
