Point of view
THE CHANGING NATURE OF PSYCHIATRY Gavin Andrews
The traditional role of psychiatristas the central figure in the delivery of mental health services is changing. First, the advent of structured diagnostic interviews means that the diagnosis of mental disorders is no longer the exclusive preserve of psychiatrists; second, the growth of community mental health services staffed by non-psychiatrists means that psychiatrists now treat a minority of the patients with mental disorders; and third, the psychiatrists’ continued endorsement of dynamic psychotherapy means they are becoming identified with an unproven and very expensive treatment. These changes should be seen against the broader background of a profession that is welltrained, active inevaluatingperformance, supported by a burgeoning research base in cognitivescience and neuroscience,and delivering services efficiently and inexpensively. Australian and New Zealand Journal of Psychiatry 1991;25:453-459 In previous articles [ 1-31 we described the current state of Australian psychiatry and noted that it was, in world terms, informed, efficient and relatively inexpensive, an opinion shared by others [4].Further, in the the Tolkien Report IS], we described how current resources might be redeployed even more effectively. In this paper I will address three further issues concerning who diagnoses, who treats, and which treatments are used. All three issues could change the traditional role of the psychiatrist as the central figure in the delivery of psychiatrictreatment.The profession might like to think about these issues and discuss them if they appear to be salient.
Whodiagnoses3 Before the third revision of American Diagnostic and Statistical Manual was published in 1980, views Clinical Research Unit for Anxiety Disorders, University of New South Wales at St. Vincent’s Hospital Gavin Andrews MD, FRANZCP, Professor Based on the Organon Senior Research Award Address to the Annual Congress of the Australian and New Zealand College of Psychiatrists, Adelaide, May 1991
about the criteria for the diagnosis of particular mental disorders varied in subtle ways from country to country [ 6 ] ,and in quite marked ways between general psychiatrists and dynamic psychotherapists [7]. Given the lack of clarity in the diagnostic criteria, for the descriptions in DSM-I1 and ICD-9 were not precise, considerable training was required to ensure that such diagnoses could be made reliably, training that was largely confined to post graduate education in psychiatry. In contrast the specific diagnostic criteria established by DSM-I11 and ICD-10 respectively are being promulgated on a world wide basis and psychiatrists in Beijing and Brisbane increasingly use the same criteria to diagnose mental disorders. Clinical psychologists now learn about these criteria and have become proficient in applying them to the range of patients they see. Even some lawyers have become aware of which criteria need to be satisfied for each diagnosis. These diagnostic criteria are not cast in stone and while their advent has been resisted by dynamic psychotherapists [7] they now represent a growing internationalconsensus as to the criteria to be used for each diagnosis. It is of interest that Australians are contributing to the forthcoming DSM-IV and it is of
Downloaded from anp.sagepub.com at LAKEHEAD UNIV on March 14, 2015
454
THE CHANGING NATURE OF PSYCHIATRY
particular interest that both psychiatrists (Parker, depression) and clinical psychologists (Rapee, anxiety) are involved. In short, other professionals now make diagnoses using the new criteria and some are also playing a formative role in the further development of these criteria. Agreement about the criteria for each diagnosis has meant that structured diagnostic interviews, formerly confined to research, have now become applicable to clinical practice. Since 1980 my unit has routinely compared clinical diagnosis with the results of a structured diagnostic interview. We began by having a psychiatrist administer the Present State Examination [8], later we had a psychiatrist, clinical psychologist or psychologist administer the Composite International Diagnostic Interview [9], and we now use a computerised version of that interview [lo] for Axis 1 disorders and a clinician administers the Personality Disorder Examination [ 1 I ] for Axis 2 disorders. We have been providing training in these diagnostic interviews for a number of years. At the beginning training was only requested by research project staff. Now psychiatrists and clinical psychologists come for training so that they can use these interviews as a second opinion to enhance their clinical practice. Some structured diagnostic interviews lend themselves to being administered by computer. Many clinicians will use a computerised interview as a quick second opinion. A computerised interview will improve the accuracy of diagnosis in community clinics where manpower precludes a consultation with a psychiatrist, it will be an efficient way of training students about diagnosis, and it will considerably reduce the cost of making diagnoses in research studies. The World Health OrganisatiodADAMHA sponsored Composite International Diagnostic Interview [9] is a structured interview that appears to be of particular promise. It was derived from the Diagnostic Interview Schedule and refined in a series of international field trials. I t is constructed in modules which contain symptoms related to a particular diagnosis. A symptom is regarded as significant if, and only if, two conditions are satisfied. Firstly, the symptom must have caused the patient to seek professional advice, take medication or have “interfered with their life and activities a lot”. Secondly the symptom must not be solely attributable to physical illness, drugs or alcohol. Thus many symptoms fail to reach criteria for significance. The onset and offset of each significant
symptom is then recorded and a diagnosis is satisfied when a patient reports that the necessary symptoms occurred within the same time period. Such acomplete algorithm made the interview straightforward to computerise and for WHO we have developed a computerised version that generates both ICD- 10 and DSM-111-R diagnoses. At present test versions are operating in centres in Australia and in 12 other centres throughout the world. By January 1992 the computerised Composite International Diagnostic Interview should be available for distribution to clinicians. Patients accept both the interviewer administered and the computer administered versions of the interview very well. They seem to equate the comprehensive questioning to the clinician being thorough and caring. Both this interview and the computerised equivalent have been shown to be more reliable than any two clinicians in eliciting the same symptom, but the validity is limited by two factors. Like all diagnostic interviews it is limited by the validity of the DSM or ICD classification used to score the symptom profile. Validity is also limited by the extent to which the symptoms identified by the interview correspond to the symptoms that would have been identified by a skilled clinical psychiatrist. In broad terms the correspondence is good [ 121 and studies are in progress to demonstrate that the interview meets current standards for validity; that is, that diagnoses are consistent with longitudinal or history data, expert clinical judgement (the role of the expert diagnostician is still vital), and with other data about risk factors, co-morbidity, family history and response to treatment. These structured diagnostic interviews may seem irrelevant to many psychiatrists, especially those who are experienced diagnosticians. While the extra staff time involved in having someone administer an interview is probably not warranted, the minimal staff time involved in the computerised version of the interview changes this equation and makes the second opinion practical. For most patients the extra information is simply consistent with the psychiatrist’s opinion. However, in about 5% of patients the computerised diagnosis is different to the clinical diagnosis. Further clinical examination sometimes shows that the computerised interview was wrong, but sometimes it shows it to be both correct and important; for example, social phobia is revealed as schizophrenia, panic disorder as melancholia, or a difficult presentation is revealed as difficult simply because underneath the social veneer there is significant cognitive impairment
Downloaded from anp.sagepub.com at LAKEHEAD UNIV on March 14, 2015
GAVIN ANDREWS
that was missed on clinical interview. Granted that all this information should or could have been gathered at clinical interview, it is still possible to miss things and it is therefore helpful to have an automated consistent second opinion. Clinicians less well-trained in diagnosis, such as general practitioners, mental health nurses or psychologists, usually welcome these structured interviews, for too often in community health or in general practice they are forced into treating before a diagnosis can be established. The advent of these structured diagnostic interviews also means that persons who do not meet criteria for a mental disorder can be identified and referred to practitioners outside the mental health system who are interested in working with persons who wish to increase their personal well being.
Who treats? When surveyed, about 20% of the adult population will report significant emotional symptoms that day, but only half of these persons will have symptoms severe enough to meet criteria for a mental disorder. Many of this latter group will recover quickly without treatment. Some years ago we calculated that 3% of the population was a minimal estimate of those who warranted treatment [ 131. Not all people with a mental disorder want or will accept treatment, although the probability does rise in terms of the severity, chronicity and disability caused by the disorder. We have recently used the data from a series of epidemiological studies to estimate the treated prevalence by diagnosis. This was made possible because the Diagnostic Interview Schedule was used in a series of population surveys in nine sites in four countries. From these data [14] we calculated a one month treated prevalence for each disorder. In doing this we adjusted the one month prevalences for adults to a total population base, then discounted for co-morbidity and for not seeking treatment. In the light of the Christchurch survey we took the treated prevalence for the affective psychoses to be one fifth of all cases with major depressive episode, we arbitrarily estimated the treated prevalence of personality disorders, and we used other data [ 151 to estimate the treated prevalence for disorders of children and adolescents. Persons with primary drug and alcohol diagnoses were not included, for such persons are treated by other agencies in Australia and form a very small part of the workload
455
of Australian psychiatrists [ 11. Further, we assumed that treatment funded from the taxation base (i.e. state services and Medicare reimbursable services) should only be delivered to persons who met criteria for a mental disorder. Like Freud we do not think that psychiatry has any specific remedy for human unhappiness. Given all these assumptions we estimated that 2.75% of the population, or 2750 per 100,000, would currently be in treatment for a mental disorder (schizophrenia 0.19%, affective psychoses 0.14%, organic psychoses 0.15%, depressive neuroses 0.64%, anxiety disorders 0.79%, personality disorders 0.20%, disorders of children and adolescents 0.64%; all psychoses 0.48%,all non-psychotic conditions 2.27%; all disorders 2.75%). While these figures are estimates, they are in accord with our earlier calculations, and consistent with the evidence that 1.9% of the population see a psychiatrist in any one year [16]. A sensitivity analysis shows that the treated prevalence of mental disorders, excluding drug and alcohol disorders, lies between 2.5 and 3.0% of the population. The 2.75% or 2,750 persons per 100,000 head of population who are in treatment are too many to be managed by the nine psychiatrists per 100,000 who practise in Australia, for very few can manage a case load of 300 patients. There are no precise data on who takes responsibility for treating these 2750 people but we have estimated how their care is being shared between hospital, private psychiatrist, community mental health service and general practitioner, the components of the taxation funded health care system. It is not possible to estimate the contribution of private clinical psychologists and lay psychotherapists. We would estimate that within the organised health care system some 50 patients at any point in time will be in a private or public hospital bed, and a further 150 are being seen as outpatients by the hospital staff. The 7.5 full time equivalent private psychiatrists (many public sector psychiatrists have Medicare-funded private practices) will have a further 450 persons in treatment if we presume an average caseload of 60 patients per full time psychiatrist. The number of community mental health staff varies markedly within Australia. If the NSW figures of 17.2 per 100,000 are representative and these 17 are supplemented by some hospital staff who do outreach tasks then, given an average case load of 50 patients each, a further 1000 patients are accounted for. Finally, as general practitioners spend an estimated 10% of their time treating patients for men-
Downloaded from anp.sagepub.com at LAKEHEAD UNIV on March 14, 2015
456
THE CHANGING NATURE OF PSYCHIATRY
tal disorders they are responsible for treating the remaining 1 100 patients. Thus psychiatrists are directly responsible for only one in five patients in treatment, and the majority of persons with mental disorders will not be treated, directly or indirectly, by a psychiatrist. There is an assumption among psychiatrists that they should supervise community mental health staff and that general practitioners should consult them about the management of patients with mental disorders. Certainly neither group have had sufficient training to allow them to diagnose and treat in a competent fashion. Yet, as estimated above, they already treat the vast majority of persons with mental disorders. The practice of community mental health staff and general practitioners would be enhanced if they were trained to confirm their provisional diagnoses with one of the structured diagnostic interviews and to give treatment from detailed treatment protocols applicable to each diagnosis. We have developed such protocols for the anxiety disorders and are seeking to extend that work to all disorders, much in the same fashion that we were able to develop treatment outlines for Australian psychiatry. Even when such diagnostic and treatment tools are in place, psychiatrists and clinical psychologists may need to undertake less direct patient care and provide more supervision when general practitioners and community mental health workers realise that they need help with difficult cases. The federal and state governments will have to develop ways of paying for this supervision.
Which treatment? The Quality Assurance Project is completed. There are treatment outlines for schizophrenia, the depressions, the anxiety and somatoform disorders and for the personality disorders. Ten treatment outlines have been produced in ten years. Each treatment outline presents a review of the literature, a survey of current practice and advice from three or four elected experts. The project is a great credit to the College and to those from all over Australia who participated in it. It is very well regarded overseas. We are still the only professiond group in medicine that has made practice so explicit. On the basis of the literature reviews prepared for the Quality Assurance Project and the papers prepared for the World Health Organisation Scientific Group on Psychiatric Treatment [ 17,181 one can conclude that while non-specific aspects of treatment are very im-
portant there are specific treatments for most disorders which add considerably to these non-specific treatments. These specific treatments are medication and family intervention strategies in schizophrenia; medication in the affective psychoses; medication or cognitive-behavioural or interpersonal psychotherapy in the depressive neuroses; cognitive behaviour therapy in generalised anxiety, panidagoraphobia and social phobia; and medication or cognitive behaviour therapy for obsessive compulsive disorder. There are no proven specific treatments which add to the nonspecific or placebo treatment of the personality disorders. Long-term dynamic or developmental psychotherapy is not listed above despite the frequency with which it is practised [I], and as a profession we may have overestimated the probable benefits. The Quality Assurance Project experts recommended it for neurotic depression [ 191, generalised anxiety disorder [20], obsessive compulsive disorder [21], hypochondriasis [22], schizoid personality disorder [23], narcissistic, histrionic and borderline personality disorders [24], and for dependent, avoidant and passive aggressive personality disorders [25]. Dynamic psychotherapists in Australia expect their patients to require more than 300 hours of therapy on average before recovering (neurotic depression 178 hours, anxiety disorders 262 hours, personality disorders 520 hours, these three disorders being reported as constituting 75% of the cases seen in psychotherapeutic practice). Even though these patients were judged to require such long therapy, they did not appear to be a particularly ill group, at least as judged from demographic characteristics such as marital and occupational status [ 11. In the United States a study of psychotherapists [26] found that they reported success with very much shorter periods of therapy. Half the patients with these same three disorders were reported as improved after eight hours, three-quarters after 26 hours, and further therapy sessions produced progressively smaller and smaller gains. Neither the Australian nor U.S. study were planned as evaluations of psychotherapy, and depended on different criteria for improvement, but they do indicate very different styles of practising similar therapies. In Australia there is open-ended fee reimbursement from Medicare for psychotherapy, while such open ended reimbursement from a health insurer is very rare in the United States. Such factors may affect the number and frequency of consultations
Downloaded from anp.sagepub.com at LAKEHEAD UNIV on March 14, 2015
GAVIN ANDREWS
[2] and may in part be responsible for the heavy reliance on long-term psychotherapy in Australia. The issue of greatest importance however is not the cost or frequency of consultations but the efficacy of treatment. In 1981 we re-analysed the Smith, Glass and Miller data, restricting patient groups to those likely to have sought therapy. We found that the benefits of behaviour therapy were superior to dynamic psychotherapy and both seemed superior to the estimated effects of placebo therapy [27]. Prioleau et a1 [28] conducted another re-analysis of the Smith et a1 data, restricting themselves to the 32 placebo controlled trials of psychotherapy that involved “exploration and clarification of the emotional experiences of the patient within a transference relationship”. They failed to find any convincing evidence that psychotherapy was better than placebo in the treatment of psychiatric patients. None of these studies was representative of good dynamic psychotherapy practice so at this level the negative result could be dismissed. However the important consequence of this study was that none of the 23 scientists who wrote commentaries to that article, or the authors of the editorials that followed, mentioned placebo controlled trials that were representative and which showed that dynamic psychotherapy was superior to placebo [28]. In the intervening seven years the cognitive behaviour therapies have repeatedly been shown to be better than placebo in many studies of patients with anxiety and depressive neuroses [29]. They are effective treatments and in the anxiety disorders some studies have reported that the majority of patients treated are cured [30,3 11. The cognitive behaviour therapies have also been shown to produce reconstructive personality change that immunises against relapse [32,33] and to improve key features of two severe personality disorders [34,351. In the seven years since the Prioleau et a1 article neither psychoanalysis nor dynamic psychotherapy has been shown to be better than placebo or good clinical care [29], or for that matter to be different from the effects of advice from an untrained but kindly advisor [36], and given the number of negative studies I doubt that this finding will ever be reversed. These results refer to the treatment of adults with anxiety and depressive neuroses or with personality disorders, the three disorders that constitute 75% of the work of Australian dynamic psychotherapists. The literature contains a number of case reports and follow up studies that document improvement during dynamic
457
psychotherapy [23-2-51 but this improvement could be due to selective reporting of successful cases and would be need to be shown to be superior to the improvement expected from the combined effects of natural remission and the non-specific treatment effects of good clinical care. The natural history of the neuroses and personality disorders is for the disorders to improve with time. Emotionality reduces, ego defenses mature, and people become less distressed and more phlegmatic. Bergin and Lambert [37] estimated that 43% of patients with neurosis would recover in two years without any specific treatment. Even in anti-social personality disorder, the most intractable of all the disorders, the median patient will no longer meet criteria after the age of 29 [38]. As the median times to remission of the other personality disorders on which we have data appear to be comparable it remains to be shown that patients in psychotherapy recover more quickly than would be expected from natural remission alone. Given that the average duration of psychotherapy for personality disorder is five years this may be difficult to demonstrate. The progress of wait list control groups is usually attributed to regression to the mean and natural remission. Placebo treated groups serve to estimate another effect, that of considering oneself in therapy so that one is moralised by the placebo treatment to try and recover. In reply to Prioleau et a1 Frank [39] said that “the placebo is therapy” and we argued that a placebo treatment can be valuable when there is no specific treatment available [40]. The recent NIMH study of the treatment of depression [41] showed just how powerful one non-specific placebo condition, informed clinical care, could be. In that study the three specific treatments had difficulty demonstrating superiority over this very professional level of non-specific clinical care. If the dynamic psychotherapies are not of specific benefit then perhaps one of their greatest strengths is that they train doctors to have the patience and the theoretical interest in working with a disturbed patient year after year, using the factors common to all successful therapies (crisis resolution, empathy, support, non-possessive warmth and kindly advice) to encourage healthy behaviours and minimise damage while waiting for natural remission to occur. As such, the dynamic psychotherapies would technically be a sophisticated form of placebo therapy, superior to no
Downloaded from anp.sagepub.com at LAKEHEAD UNIV on March 14, 2015
4.58
THE CHANGING NATURE OF PSYCHIATRY
treatment but not necessarily superior to the less costly good clinical care. Specific treatments are available for most disorders, and in the United States courts have considered that it is malpractice to continue with psychotherapy when such specific treatments are available [42].Even when specific treatments are not available, as in the treatment of personality disorders, there is a further problem in that not all psychotherapists are kindly and supportive and non-specifically therapeutic. Indeed, p a t i e n t s in l o n g - t e r m t r a n s f e r e n c e - b a s e d psychotherapy are particularly vulnerable to therapist behaviours that impede recovery. There is both scientific and lay literature that demonstrates that psychotherapy can, and does, cause harm [43,44]. Treated patients do less well than control groups in 10% of research studies of psychotherapy, and even 10% of health professionals report having been harmed by their own therapy experiences 1431. Persons contemplating long term dynamic psychotherapy should realise that there are no data to support the efficacy of the therapy and choose their therapist with care. We would agree with Meares, Gold and Christie [24] that dynamic therapists should be specially trained and supervised.
Conclusions Who diagnoses? Diagnosis in DSM-111-R or ICD- 10 terms is now well accepted in Australia. The advent of the structured diagnostic interviews, and particularly the computerised versions, means that all who offer treatment to patients with mental disorders can be expected to make such diagnoses. Furthermore, as manpower is limited and the health and Medicare budgets are likewise limited, continued access to taxpayer funded treatment should now be restricted to patients who meet criteria for an ICD-I0 mental disorder. Who treats? It is now evident that the majority of persons who meet criteria for a mental disorder and who seek treatment will be treated by a health professional other than a psychiatrist. Treatment protocols should be developed for community mental health staff and for general practitioners in a similar way that treatment outlines were developed for psychiatry. Psychiatrists and clinical psychologists may need to spend more time in the training and supervision of these staff than they have been accustomed to. Appropriate methods for payment will have to be devised.
Which treatment? If we are to ensure that the treatments delivered are those that have been shown to be superior to placebo we will need to increase the emphasis on proven treatments and reduce the emphasis on dynamic psychotherapy in the training of psychiatrists. Changes in the training of psychiatrists such as not requiring the long case history to be an example of dynamic psychotherapy would be one important step. New graduates should be encouraged to focus on the biological and the cognitive behaviour t h e r a p i e s , s o m e of t h e y o u n g e r d y n a m i c psychotherapists should re-skill, and trainees should focus on other therapies, as is occurring in the United S t a t e s [45]. W e s h o u l d r e g a r d t h e d y n a m i c psychotherapies as one aspect of non-specific supportive psychotherapy and establish a 50 session review 1461 to end the present situation whereby 7% of all patients consume 50% of all consultation hours [ 11. While one cannot subscribe to the idea that only proven effective remedies should be reimbursed by the Health Insurance Commission, a prudent society would arrange that a limit is placed on expenditure from the health budget for unproven treatments. A validation as to the diagnosis before session 10 and a peer review of the patient’s history and the doctor’s treatment plan before session 50 would be one means of instituting such an expenditure limiting measure. These three issues of standardised diagnosis, other professions becoming clinically responsible, and data to allow evaluation of treatments -- are all indicators of how successful psychiatry in Australia has become. The basic problem of how to deploy comprehensive services for the mentally ill has been solved and is slowly being implemented. The College training program is excellent, there is quality assurance of practice standards, and basic and applied research is very productive. Only when the important problems are solved can one begin to see additional issues which need attention: three such additional issues have been the focus of this paper.
Andrews G, Hadzi-Pavlovic D. The work of Australian psychiatrists, circa 1986. Australian and New Zealand Journal of Psychiatry 1988;22: 153.165. Andrews G . Private and public psychiatry: A comparison of two health care systems. American Journal of Psychiatry 1989;146:881-886. Andrews G. Health services research and the future of Australian Psychiatry, Australian and New Zealand Journal of Psychiatry 1990;24:371-376,
Downloaded from anp.sagepub.com at LAKEHEAD UNIV on March 14, 2015
GAVlN ANDREWS
4. Sims A. Even better services: a psychiatric perspective. British Medical Journal 1991:302:1061-63. 5. Andrews G. The Tolkien Report. Sydney: Clinical Research Unit for Anxiety Disorders. 1991. 6. Kraemer M. Cross-national study of the diagnosis of mental disorders. American Journal of Psychiatry 1969; 124: I - I 1. 7. Klernian GL. Vaillant GE. Spitzer RL, Michaels R. A debate on DSM-Ill. American Journal of Psychiatry 1984; 141:539-553. 8 . Wing JK, Cooper JE, Sartorius N. The measurement and classification of psychiatric symptoms. London: Cambridge University Press, 1974. 9. Robins L, Wing J, Wittchen H-U et ul. The Composite International Diagnostic Interview. Archives of General Psychiatry 1989;45: 1069-1077. 10. Andrews G. Teesson M. A Computerised Version of the Cotnposite International Diagnostic Interview. Sydney: Clinical Research Unit for Anxiety Disorders, I09 I . 1 I . Loranger AW. Susrnan VL. Oldham JM. Russakoff LM. The Personality Disorder Examination: A preliminary report. Journal of Personality Disorders 1987: I : I - 13. 12. Wittchen H-U. Robins LN, Cottler L, er ul. Cross cultural feasibility. reliability and sources of variance of the Composite International Diagnostic Interview. British Journal of Psychiatry (in press). 13. Andrews G, Tennant C, Brodaty H. The need for psychiatric care. Medical Journal of Australia I98 I ; I :593-594. 14. Oakley-Browne MA, Joyce PR. Wells E. et ul. Christchurch psychiatric epidemiology study, part 11: Six month and other period prevalences of specific psychiatric disorders. Australian and New Zealand Journal of Psychiatry 1989;23:327-340. 15. Offord DR, Boyle MH, SLatamari MD, ct ul. Ontario child health study. 11. Six-month prevalence of disorder and rates of service utilization. Archives of General Psychiatry 1987:44:832. 16. Eisen P. Wolfenden K. A national health services policy. Canberra: Commonwealth of Australia, 1988. 17. World Health Organisation. The treatment of psychiatric disorders. Technical report. Geneva: WHO, July, 1991. 18. Sartorius N. Eisenberg L. Andrews G. et ul. The scientific ba\is for treatment in psychiatry. Berne: H. Huber, 1992. 19. The Quality Assurance Project. A treatment outline for depressive disorders. Australian and New Zealand Journal of Psychiatry 1983; 17: 129.148. 20. The Quality Assurance Project. Treatment outlines for the management of anxiety states. Australian and New Zealand Journal of Psychiatry 198.5; 19: 138- I5 I . 21. The Quality Assurance Project. Treatment outlines for the management of obsessive compulsive disorders. Australian and New Zealand Journal of Psychiatry 1985; 19240-253. 22. The Quality Assurance Project. Treatment outlines for the management of the somatoform disorders. Australian and New Zealand Journal of Psychiatry 1985; 19:397-407. 23. The Quality Assurance Project. Treatment outlines for the paranoid. schizotypal and schizoid personality disorders. Australian and New Zealand Journal of Psychiatry 1990:24:3393.50. 24. The Quality Assurance Project. Treatment outlines for the borderline, narcissistic and histrionic personality disorders. Australian and New Zealand Journal of Psychiatry, 1991; 25:392403. 25. The Quality Assurance Project. Treatment outlines for the avoidant, dependent and passive-aggressive personality disorders. Australian and New Zealand Journal of Psychiatry 199 I: 25:40441 I .
459
26. Howard KI. Kopta SM, Krause MS. et crl. The dose-effect relationship in psychotherapy. American Psychologist 1986:41: 159-164. 27. Andrews G, Harvey R. Does psychotherapy benefit neurotic patients'? A re-analysis ofthe Smith, Glas\ and Miller data. Archives of General Psychiatry I98 1 3 8 : 1203-1208. 28. Prioleau L. Murdock M. Brody N. An analysis of p5ychotherapy versus placebo studies. The Behavioral and Brain Sciences 1983;6:275-3 10. 20. Andrews G. The evaluation of psychotherapy. Current Opinion in Psychiatry 199 1;4:379-383. 30. Klosko JS, Barlow DH, Tassinari R, Cerny JA. A compariwn of alprazolatn and behaviour therapy in treatment of panic disorder. Journal of Consulting and Clinical Psychology 1990;58:77-84. 3 I . Michelson L, Marchione K, Greenwald M. Glanz L. e f ul. Panic disorder: cognitive-behavioral treatment. Behavior Research and Therapy 1990;28:141-151. 32. Andrews G. Moran C. Expowre treatment of agoraphobia with panic attacks: Are drugs essential? In: Hand 1. Wittchen H-U, eds. Panic and phobias 11. Treatments and variables affecting course and outcome. Heidelberg: Springer-Verlag. I YXX:X9-09. 33. Franklin J. Behavioural therapy for panic disorder. In: McNaughton N. Andrews G. eds. Anxiety. Dunedin: Otago University Press, I990:84-9 I . 34. Linehan MM. Dialectical behavioral therapy: A cognitive behavioral approach to parasuicide. Journal of Perwnality Disorder\ 1987; I :328-333. 35. Alden L. Short-term structured treatment for avoidant personality disorder. Journal of Consulting and Clinical Psychology l989:57:7.56-764. 36. Strupp HH. Hadley SW. Specific versus non-\pccific factors in psychotherapy: A controlled study of outcome. Archive\ of General Psychiatry 1978;36: I 125.1 136. 37. Bergin AE, Lambert MJ. The evaluation of therapeutic outcomes. In: Garfield s. Bergin A. eds. Handbook of Psychotherapy and Behavior Change. 2nd ed. New York: Wiley, 1978. 38. Robins LN, Tipp J, Przybeck T. Antisocial personality. In: Robins L, Regier D. eds. Psychiatric disorders in America. Glcncoe: Free Press, 1990. 39. Frank JD. The placebo in psychotherapy. The Behnvior;il and Brain Sciences 1983;6:291-292. 40. Andrews G. A wider view leads to different conclusions. The Behavioral and Brain Sciences 1983:6:285. 41. Elkin I. Shea T, Watkins JT. ct ul. National Institute of Mental Health treatment of depression collaborative research program. General effectiveness of treatments. Archives of General Psychiatry 1989;46:97 1-982. 42. Klerman GL. The psychiatric patient's right to effective trcatment: Implications of Osheroff vs Chestnut Lodge. American Journal of Psychiatry 1990: 147:409-418. 43. Lanibert MJ, Shapiro DA. Bergin AE. The effectiveness of psychotherapy. In: Garfield S. Bergin A, eds. Handbook of Psychotherapy and Behavior Change. 3rd ed. New York: Wilcy. 1986. 44. Masson J. Against therapy. London: Fontana, 1990. 45. Altshuler KZ. Whatever happened to intensive psychotherapy'? American Journal of Psychiatry 1990; 147:428-430. 46. Andrews G. Psychotherapy and health insurance. Australian and New Zealand Journal of Psychiatry 1983; 1768.72.
Downloaded from anp.sagepub.com at LAKEHEAD UNIV on March 14, 2015
THE CHANGING NATURE OF PSYCHIATRY Gavin Andrews
The traditional role of psychiatristas the central figure in the delivery of mental health services is changing. First, the advent of structured diagnostic interviews means that the diagnosis of mental disorders is no longer the exclusive preserve of psychiatrists; second, the growth of community mental health services staffed by non-psychiatrists means that psychiatrists now treat a minority of the patients with mental disorders; and third, the psychiatrists’ continued endorsement of dynamic psychotherapy means they are becoming identified with an unproven and very expensive treatment. These changes should be seen against the broader background of a profession that is welltrained, active inevaluatingperformance, supported by a burgeoning research base in cognitivescience and neuroscience,and delivering services efficiently and inexpensively. Australian and New Zealand Journal of Psychiatry 1991;25:453-459 In previous articles [ 1-31 we described the current state of Australian psychiatry and noted that it was, in world terms, informed, efficient and relatively inexpensive, an opinion shared by others [4].Further, in the the Tolkien Report IS], we described how current resources might be redeployed even more effectively. In this paper I will address three further issues concerning who diagnoses, who treats, and which treatments are used. All three issues could change the traditional role of the psychiatrist as the central figure in the delivery of psychiatrictreatment.The profession might like to think about these issues and discuss them if they appear to be salient.
Whodiagnoses3 Before the third revision of American Diagnostic and Statistical Manual was published in 1980, views Clinical Research Unit for Anxiety Disorders, University of New South Wales at St. Vincent’s Hospital Gavin Andrews MD, FRANZCP, Professor Based on the Organon Senior Research Award Address to the Annual Congress of the Australian and New Zealand College of Psychiatrists, Adelaide, May 1991
about the criteria for the diagnosis of particular mental disorders varied in subtle ways from country to country [ 6 ] ,and in quite marked ways between general psychiatrists and dynamic psychotherapists [7]. Given the lack of clarity in the diagnostic criteria, for the descriptions in DSM-I1 and ICD-9 were not precise, considerable training was required to ensure that such diagnoses could be made reliably, training that was largely confined to post graduate education in psychiatry. In contrast the specific diagnostic criteria established by DSM-I11 and ICD-10 respectively are being promulgated on a world wide basis and psychiatrists in Beijing and Brisbane increasingly use the same criteria to diagnose mental disorders. Clinical psychologists now learn about these criteria and have become proficient in applying them to the range of patients they see. Even some lawyers have become aware of which criteria need to be satisfied for each diagnosis. These diagnostic criteria are not cast in stone and while their advent has been resisted by dynamic psychotherapists [7] they now represent a growing internationalconsensus as to the criteria to be used for each diagnosis. It is of interest that Australians are contributing to the forthcoming DSM-IV and it is of
Downloaded from anp.sagepub.com at LAKEHEAD UNIV on March 14, 2015
454
THE CHANGING NATURE OF PSYCHIATRY
particular interest that both psychiatrists (Parker, depression) and clinical psychologists (Rapee, anxiety) are involved. In short, other professionals now make diagnoses using the new criteria and some are also playing a formative role in the further development of these criteria. Agreement about the criteria for each diagnosis has meant that structured diagnostic interviews, formerly confined to research, have now become applicable to clinical practice. Since 1980 my unit has routinely compared clinical diagnosis with the results of a structured diagnostic interview. We began by having a psychiatrist administer the Present State Examination [8], later we had a psychiatrist, clinical psychologist or psychologist administer the Composite International Diagnostic Interview [9], and we now use a computerised version of that interview [lo] for Axis 1 disorders and a clinician administers the Personality Disorder Examination [ 1 I ] for Axis 2 disorders. We have been providing training in these diagnostic interviews for a number of years. At the beginning training was only requested by research project staff. Now psychiatrists and clinical psychologists come for training so that they can use these interviews as a second opinion to enhance their clinical practice. Some structured diagnostic interviews lend themselves to being administered by computer. Many clinicians will use a computerised interview as a quick second opinion. A computerised interview will improve the accuracy of diagnosis in community clinics where manpower precludes a consultation with a psychiatrist, it will be an efficient way of training students about diagnosis, and it will considerably reduce the cost of making diagnoses in research studies. The World Health OrganisatiodADAMHA sponsored Composite International Diagnostic Interview [9] is a structured interview that appears to be of particular promise. It was derived from the Diagnostic Interview Schedule and refined in a series of international field trials. I t is constructed in modules which contain symptoms related to a particular diagnosis. A symptom is regarded as significant if, and only if, two conditions are satisfied. Firstly, the symptom must have caused the patient to seek professional advice, take medication or have “interfered with their life and activities a lot”. Secondly the symptom must not be solely attributable to physical illness, drugs or alcohol. Thus many symptoms fail to reach criteria for significance. The onset and offset of each significant
symptom is then recorded and a diagnosis is satisfied when a patient reports that the necessary symptoms occurred within the same time period. Such acomplete algorithm made the interview straightforward to computerise and for WHO we have developed a computerised version that generates both ICD- 10 and DSM-111-R diagnoses. At present test versions are operating in centres in Australia and in 12 other centres throughout the world. By January 1992 the computerised Composite International Diagnostic Interview should be available for distribution to clinicians. Patients accept both the interviewer administered and the computer administered versions of the interview very well. They seem to equate the comprehensive questioning to the clinician being thorough and caring. Both this interview and the computerised equivalent have been shown to be more reliable than any two clinicians in eliciting the same symptom, but the validity is limited by two factors. Like all diagnostic interviews it is limited by the validity of the DSM or ICD classification used to score the symptom profile. Validity is also limited by the extent to which the symptoms identified by the interview correspond to the symptoms that would have been identified by a skilled clinical psychiatrist. In broad terms the correspondence is good [ 121 and studies are in progress to demonstrate that the interview meets current standards for validity; that is, that diagnoses are consistent with longitudinal or history data, expert clinical judgement (the role of the expert diagnostician is still vital), and with other data about risk factors, co-morbidity, family history and response to treatment. These structured diagnostic interviews may seem irrelevant to many psychiatrists, especially those who are experienced diagnosticians. While the extra staff time involved in having someone administer an interview is probably not warranted, the minimal staff time involved in the computerised version of the interview changes this equation and makes the second opinion practical. For most patients the extra information is simply consistent with the psychiatrist’s opinion. However, in about 5% of patients the computerised diagnosis is different to the clinical diagnosis. Further clinical examination sometimes shows that the computerised interview was wrong, but sometimes it shows it to be both correct and important; for example, social phobia is revealed as schizophrenia, panic disorder as melancholia, or a difficult presentation is revealed as difficult simply because underneath the social veneer there is significant cognitive impairment
Downloaded from anp.sagepub.com at LAKEHEAD UNIV on March 14, 2015
GAVIN ANDREWS
that was missed on clinical interview. Granted that all this information should or could have been gathered at clinical interview, it is still possible to miss things and it is therefore helpful to have an automated consistent second opinion. Clinicians less well-trained in diagnosis, such as general practitioners, mental health nurses or psychologists, usually welcome these structured interviews, for too often in community health or in general practice they are forced into treating before a diagnosis can be established. The advent of these structured diagnostic interviews also means that persons who do not meet criteria for a mental disorder can be identified and referred to practitioners outside the mental health system who are interested in working with persons who wish to increase their personal well being.
Who treats? When surveyed, about 20% of the adult population will report significant emotional symptoms that day, but only half of these persons will have symptoms severe enough to meet criteria for a mental disorder. Many of this latter group will recover quickly without treatment. Some years ago we calculated that 3% of the population was a minimal estimate of those who warranted treatment [ 131. Not all people with a mental disorder want or will accept treatment, although the probability does rise in terms of the severity, chronicity and disability caused by the disorder. We have recently used the data from a series of epidemiological studies to estimate the treated prevalence by diagnosis. This was made possible because the Diagnostic Interview Schedule was used in a series of population surveys in nine sites in four countries. From these data [14] we calculated a one month treated prevalence for each disorder. In doing this we adjusted the one month prevalences for adults to a total population base, then discounted for co-morbidity and for not seeking treatment. In the light of the Christchurch survey we took the treated prevalence for the affective psychoses to be one fifth of all cases with major depressive episode, we arbitrarily estimated the treated prevalence of personality disorders, and we used other data [ 151 to estimate the treated prevalence for disorders of children and adolescents. Persons with primary drug and alcohol diagnoses were not included, for such persons are treated by other agencies in Australia and form a very small part of the workload
455
of Australian psychiatrists [ 11. Further, we assumed that treatment funded from the taxation base (i.e. state services and Medicare reimbursable services) should only be delivered to persons who met criteria for a mental disorder. Like Freud we do not think that psychiatry has any specific remedy for human unhappiness. Given all these assumptions we estimated that 2.75% of the population, or 2750 per 100,000, would currently be in treatment for a mental disorder (schizophrenia 0.19%, affective psychoses 0.14%, organic psychoses 0.15%, depressive neuroses 0.64%, anxiety disorders 0.79%, personality disorders 0.20%, disorders of children and adolescents 0.64%; all psychoses 0.48%,all non-psychotic conditions 2.27%; all disorders 2.75%). While these figures are estimates, they are in accord with our earlier calculations, and consistent with the evidence that 1.9% of the population see a psychiatrist in any one year [16]. A sensitivity analysis shows that the treated prevalence of mental disorders, excluding drug and alcohol disorders, lies between 2.5 and 3.0% of the population. The 2.75% or 2,750 persons per 100,000 head of population who are in treatment are too many to be managed by the nine psychiatrists per 100,000 who practise in Australia, for very few can manage a case load of 300 patients. There are no precise data on who takes responsibility for treating these 2750 people but we have estimated how their care is being shared between hospital, private psychiatrist, community mental health service and general practitioner, the components of the taxation funded health care system. It is not possible to estimate the contribution of private clinical psychologists and lay psychotherapists. We would estimate that within the organised health care system some 50 patients at any point in time will be in a private or public hospital bed, and a further 150 are being seen as outpatients by the hospital staff. The 7.5 full time equivalent private psychiatrists (many public sector psychiatrists have Medicare-funded private practices) will have a further 450 persons in treatment if we presume an average caseload of 60 patients per full time psychiatrist. The number of community mental health staff varies markedly within Australia. If the NSW figures of 17.2 per 100,000 are representative and these 17 are supplemented by some hospital staff who do outreach tasks then, given an average case load of 50 patients each, a further 1000 patients are accounted for. Finally, as general practitioners spend an estimated 10% of their time treating patients for men-
Downloaded from anp.sagepub.com at LAKEHEAD UNIV on March 14, 2015
456
THE CHANGING NATURE OF PSYCHIATRY
tal disorders they are responsible for treating the remaining 1 100 patients. Thus psychiatrists are directly responsible for only one in five patients in treatment, and the majority of persons with mental disorders will not be treated, directly or indirectly, by a psychiatrist. There is an assumption among psychiatrists that they should supervise community mental health staff and that general practitioners should consult them about the management of patients with mental disorders. Certainly neither group have had sufficient training to allow them to diagnose and treat in a competent fashion. Yet, as estimated above, they already treat the vast majority of persons with mental disorders. The practice of community mental health staff and general practitioners would be enhanced if they were trained to confirm their provisional diagnoses with one of the structured diagnostic interviews and to give treatment from detailed treatment protocols applicable to each diagnosis. We have developed such protocols for the anxiety disorders and are seeking to extend that work to all disorders, much in the same fashion that we were able to develop treatment outlines for Australian psychiatry. Even when such diagnostic and treatment tools are in place, psychiatrists and clinical psychologists may need to undertake less direct patient care and provide more supervision when general practitioners and community mental health workers realise that they need help with difficult cases. The federal and state governments will have to develop ways of paying for this supervision.
Which treatment? The Quality Assurance Project is completed. There are treatment outlines for schizophrenia, the depressions, the anxiety and somatoform disorders and for the personality disorders. Ten treatment outlines have been produced in ten years. Each treatment outline presents a review of the literature, a survey of current practice and advice from three or four elected experts. The project is a great credit to the College and to those from all over Australia who participated in it. It is very well regarded overseas. We are still the only professiond group in medicine that has made practice so explicit. On the basis of the literature reviews prepared for the Quality Assurance Project and the papers prepared for the World Health Organisation Scientific Group on Psychiatric Treatment [ 17,181 one can conclude that while non-specific aspects of treatment are very im-
portant there are specific treatments for most disorders which add considerably to these non-specific treatments. These specific treatments are medication and family intervention strategies in schizophrenia; medication in the affective psychoses; medication or cognitive-behavioural or interpersonal psychotherapy in the depressive neuroses; cognitive behaviour therapy in generalised anxiety, panidagoraphobia and social phobia; and medication or cognitive behaviour therapy for obsessive compulsive disorder. There are no proven specific treatments which add to the nonspecific or placebo treatment of the personality disorders. Long-term dynamic or developmental psychotherapy is not listed above despite the frequency with which it is practised [I], and as a profession we may have overestimated the probable benefits. The Quality Assurance Project experts recommended it for neurotic depression [ 191, generalised anxiety disorder [20], obsessive compulsive disorder [21], hypochondriasis [22], schizoid personality disorder [23], narcissistic, histrionic and borderline personality disorders [24], and for dependent, avoidant and passive aggressive personality disorders [25]. Dynamic psychotherapists in Australia expect their patients to require more than 300 hours of therapy on average before recovering (neurotic depression 178 hours, anxiety disorders 262 hours, personality disorders 520 hours, these three disorders being reported as constituting 75% of the cases seen in psychotherapeutic practice). Even though these patients were judged to require such long therapy, they did not appear to be a particularly ill group, at least as judged from demographic characteristics such as marital and occupational status [ 11. In the United States a study of psychotherapists [26] found that they reported success with very much shorter periods of therapy. Half the patients with these same three disorders were reported as improved after eight hours, three-quarters after 26 hours, and further therapy sessions produced progressively smaller and smaller gains. Neither the Australian nor U.S. study were planned as evaluations of psychotherapy, and depended on different criteria for improvement, but they do indicate very different styles of practising similar therapies. In Australia there is open-ended fee reimbursement from Medicare for psychotherapy, while such open ended reimbursement from a health insurer is very rare in the United States. Such factors may affect the number and frequency of consultations
Downloaded from anp.sagepub.com at LAKEHEAD UNIV on March 14, 2015
GAVIN ANDREWS
[2] and may in part be responsible for the heavy reliance on long-term psychotherapy in Australia. The issue of greatest importance however is not the cost or frequency of consultations but the efficacy of treatment. In 1981 we re-analysed the Smith, Glass and Miller data, restricting patient groups to those likely to have sought therapy. We found that the benefits of behaviour therapy were superior to dynamic psychotherapy and both seemed superior to the estimated effects of placebo therapy [27]. Prioleau et a1 [28] conducted another re-analysis of the Smith et a1 data, restricting themselves to the 32 placebo controlled trials of psychotherapy that involved “exploration and clarification of the emotional experiences of the patient within a transference relationship”. They failed to find any convincing evidence that psychotherapy was better than placebo in the treatment of psychiatric patients. None of these studies was representative of good dynamic psychotherapy practice so at this level the negative result could be dismissed. However the important consequence of this study was that none of the 23 scientists who wrote commentaries to that article, or the authors of the editorials that followed, mentioned placebo controlled trials that were representative and which showed that dynamic psychotherapy was superior to placebo [28]. In the intervening seven years the cognitive behaviour therapies have repeatedly been shown to be better than placebo in many studies of patients with anxiety and depressive neuroses [29]. They are effective treatments and in the anxiety disorders some studies have reported that the majority of patients treated are cured [30,3 11. The cognitive behaviour therapies have also been shown to produce reconstructive personality change that immunises against relapse [32,33] and to improve key features of two severe personality disorders [34,351. In the seven years since the Prioleau et a1 article neither psychoanalysis nor dynamic psychotherapy has been shown to be better than placebo or good clinical care [29], or for that matter to be different from the effects of advice from an untrained but kindly advisor [36], and given the number of negative studies I doubt that this finding will ever be reversed. These results refer to the treatment of adults with anxiety and depressive neuroses or with personality disorders, the three disorders that constitute 75% of the work of Australian dynamic psychotherapists. The literature contains a number of case reports and follow up studies that document improvement during dynamic
457
psychotherapy [23-2-51 but this improvement could be due to selective reporting of successful cases and would be need to be shown to be superior to the improvement expected from the combined effects of natural remission and the non-specific treatment effects of good clinical care. The natural history of the neuroses and personality disorders is for the disorders to improve with time. Emotionality reduces, ego defenses mature, and people become less distressed and more phlegmatic. Bergin and Lambert [37] estimated that 43% of patients with neurosis would recover in two years without any specific treatment. Even in anti-social personality disorder, the most intractable of all the disorders, the median patient will no longer meet criteria after the age of 29 [38]. As the median times to remission of the other personality disorders on which we have data appear to be comparable it remains to be shown that patients in psychotherapy recover more quickly than would be expected from natural remission alone. Given that the average duration of psychotherapy for personality disorder is five years this may be difficult to demonstrate. The progress of wait list control groups is usually attributed to regression to the mean and natural remission. Placebo treated groups serve to estimate another effect, that of considering oneself in therapy so that one is moralised by the placebo treatment to try and recover. In reply to Prioleau et a1 Frank [39] said that “the placebo is therapy” and we argued that a placebo treatment can be valuable when there is no specific treatment available [40]. The recent NIMH study of the treatment of depression [41] showed just how powerful one non-specific placebo condition, informed clinical care, could be. In that study the three specific treatments had difficulty demonstrating superiority over this very professional level of non-specific clinical care. If the dynamic psychotherapies are not of specific benefit then perhaps one of their greatest strengths is that they train doctors to have the patience and the theoretical interest in working with a disturbed patient year after year, using the factors common to all successful therapies (crisis resolution, empathy, support, non-possessive warmth and kindly advice) to encourage healthy behaviours and minimise damage while waiting for natural remission to occur. As such, the dynamic psychotherapies would technically be a sophisticated form of placebo therapy, superior to no
Downloaded from anp.sagepub.com at LAKEHEAD UNIV on March 14, 2015
4.58
THE CHANGING NATURE OF PSYCHIATRY
treatment but not necessarily superior to the less costly good clinical care. Specific treatments are available for most disorders, and in the United States courts have considered that it is malpractice to continue with psychotherapy when such specific treatments are available [42].Even when specific treatments are not available, as in the treatment of personality disorders, there is a further problem in that not all psychotherapists are kindly and supportive and non-specifically therapeutic. Indeed, p a t i e n t s in l o n g - t e r m t r a n s f e r e n c e - b a s e d psychotherapy are particularly vulnerable to therapist behaviours that impede recovery. There is both scientific and lay literature that demonstrates that psychotherapy can, and does, cause harm [43,44]. Treated patients do less well than control groups in 10% of research studies of psychotherapy, and even 10% of health professionals report having been harmed by their own therapy experiences 1431. Persons contemplating long term dynamic psychotherapy should realise that there are no data to support the efficacy of the therapy and choose their therapist with care. We would agree with Meares, Gold and Christie [24] that dynamic therapists should be specially trained and supervised.
Conclusions Who diagnoses? Diagnosis in DSM-111-R or ICD- 10 terms is now well accepted in Australia. The advent of the structured diagnostic interviews, and particularly the computerised versions, means that all who offer treatment to patients with mental disorders can be expected to make such diagnoses. Furthermore, as manpower is limited and the health and Medicare budgets are likewise limited, continued access to taxpayer funded treatment should now be restricted to patients who meet criteria for an ICD-I0 mental disorder. Who treats? It is now evident that the majority of persons who meet criteria for a mental disorder and who seek treatment will be treated by a health professional other than a psychiatrist. Treatment protocols should be developed for community mental health staff and for general practitioners in a similar way that treatment outlines were developed for psychiatry. Psychiatrists and clinical psychologists may need to spend more time in the training and supervision of these staff than they have been accustomed to. Appropriate methods for payment will have to be devised.
Which treatment? If we are to ensure that the treatments delivered are those that have been shown to be superior to placebo we will need to increase the emphasis on proven treatments and reduce the emphasis on dynamic psychotherapy in the training of psychiatrists. Changes in the training of psychiatrists such as not requiring the long case history to be an example of dynamic psychotherapy would be one important step. New graduates should be encouraged to focus on the biological and the cognitive behaviour t h e r a p i e s , s o m e of t h e y o u n g e r d y n a m i c psychotherapists should re-skill, and trainees should focus on other therapies, as is occurring in the United S t a t e s [45]. W e s h o u l d r e g a r d t h e d y n a m i c psychotherapies as one aspect of non-specific supportive psychotherapy and establish a 50 session review 1461 to end the present situation whereby 7% of all patients consume 50% of all consultation hours [ 11. While one cannot subscribe to the idea that only proven effective remedies should be reimbursed by the Health Insurance Commission, a prudent society would arrange that a limit is placed on expenditure from the health budget for unproven treatments. A validation as to the diagnosis before session 10 and a peer review of the patient’s history and the doctor’s treatment plan before session 50 would be one means of instituting such an expenditure limiting measure. These three issues of standardised diagnosis, other professions becoming clinically responsible, and data to allow evaluation of treatments -- are all indicators of how successful psychiatry in Australia has become. The basic problem of how to deploy comprehensive services for the mentally ill has been solved and is slowly being implemented. The College training program is excellent, there is quality assurance of practice standards, and basic and applied research is very productive. Only when the important problems are solved can one begin to see additional issues which need attention: three such additional issues have been the focus of this paper.
Andrews G, Hadzi-Pavlovic D. The work of Australian psychiatrists, circa 1986. Australian and New Zealand Journal of Psychiatry 1988;22: 153.165. Andrews G . Private and public psychiatry: A comparison of two health care systems. American Journal of Psychiatry 1989;146:881-886. Andrews G. Health services research and the future of Australian Psychiatry, Australian and New Zealand Journal of Psychiatry 1990;24:371-376,
Downloaded from anp.sagepub.com at LAKEHEAD UNIV on March 14, 2015
GAVlN ANDREWS
4. Sims A. Even better services: a psychiatric perspective. British Medical Journal 1991:302:1061-63. 5. Andrews G. The Tolkien Report. Sydney: Clinical Research Unit for Anxiety Disorders. 1991. 6. Kraemer M. Cross-national study of the diagnosis of mental disorders. American Journal of Psychiatry 1969; 124: I - I 1. 7. Klernian GL. Vaillant GE. Spitzer RL, Michaels R. A debate on DSM-Ill. American Journal of Psychiatry 1984; 141:539-553. 8 . Wing JK, Cooper JE, Sartorius N. The measurement and classification of psychiatric symptoms. London: Cambridge University Press, 1974. 9. Robins L, Wing J, Wittchen H-U et ul. The Composite International Diagnostic Interview. Archives of General Psychiatry 1989;45: 1069-1077. 10. Andrews G. Teesson M. A Computerised Version of the Cotnposite International Diagnostic Interview. Sydney: Clinical Research Unit for Anxiety Disorders, I09 I . 1 I . Loranger AW. Susrnan VL. Oldham JM. Russakoff LM. The Personality Disorder Examination: A preliminary report. Journal of Personality Disorders 1987: I : I - 13. 12. Wittchen H-U. Robins LN, Cottler L, er ul. Cross cultural feasibility. reliability and sources of variance of the Composite International Diagnostic Interview. British Journal of Psychiatry (in press). 13. Andrews G, Tennant C, Brodaty H. The need for psychiatric care. Medical Journal of Australia I98 I ; I :593-594. 14. Oakley-Browne MA, Joyce PR. Wells E. et ul. Christchurch psychiatric epidemiology study, part 11: Six month and other period prevalences of specific psychiatric disorders. Australian and New Zealand Journal of Psychiatry 1989;23:327-340. 15. Offord DR, Boyle MH, SLatamari MD, ct ul. Ontario child health study. 11. Six-month prevalence of disorder and rates of service utilization. Archives of General Psychiatry 1987:44:832. 16. Eisen P. Wolfenden K. A national health services policy. Canberra: Commonwealth of Australia, 1988. 17. World Health Organisation. The treatment of psychiatric disorders. Technical report. Geneva: WHO, July, 1991. 18. Sartorius N. Eisenberg L. Andrews G. et ul. The scientific ba\is for treatment in psychiatry. Berne: H. Huber, 1992. 19. The Quality Assurance Project. A treatment outline for depressive disorders. Australian and New Zealand Journal of Psychiatry 1983; 17: 129.148. 20. The Quality Assurance Project. Treatment outlines for the management of anxiety states. Australian and New Zealand Journal of Psychiatry 198.5; 19: 138- I5 I . 21. The Quality Assurance Project. Treatment outlines for the management of obsessive compulsive disorders. Australian and New Zealand Journal of Psychiatry 1985; 19240-253. 22. The Quality Assurance Project. Treatment outlines for the management of the somatoform disorders. Australian and New Zealand Journal of Psychiatry 1985; 19:397-407. 23. The Quality Assurance Project. Treatment outlines for the paranoid. schizotypal and schizoid personality disorders. Australian and New Zealand Journal of Psychiatry 1990:24:3393.50. 24. The Quality Assurance Project. Treatment outlines for the borderline, narcissistic and histrionic personality disorders. Australian and New Zealand Journal of Psychiatry, 1991; 25:392403. 25. The Quality Assurance Project. Treatment outlines for the avoidant, dependent and passive-aggressive personality disorders. Australian and New Zealand Journal of Psychiatry 199 I: 25:40441 I .
459
26. Howard KI. Kopta SM, Krause MS. et crl. The dose-effect relationship in psychotherapy. American Psychologist 1986:41: 159-164. 27. Andrews G, Harvey R. Does psychotherapy benefit neurotic patients'? A re-analysis ofthe Smith, Glas\ and Miller data. Archives of General Psychiatry I98 1 3 8 : 1203-1208. 28. Prioleau L. Murdock M. Brody N. An analysis of p5ychotherapy versus placebo studies. The Behavioral and Brain Sciences 1983;6:275-3 10. 20. Andrews G. The evaluation of psychotherapy. Current Opinion in Psychiatry 199 1;4:379-383. 30. Klosko JS, Barlow DH, Tassinari R, Cerny JA. A compariwn of alprazolatn and behaviour therapy in treatment of panic disorder. Journal of Consulting and Clinical Psychology 1990;58:77-84. 3 I . Michelson L, Marchione K, Greenwald M. Glanz L. e f ul. Panic disorder: cognitive-behavioral treatment. Behavior Research and Therapy 1990;28:141-151. 32. Andrews G. Moran C. Expowre treatment of agoraphobia with panic attacks: Are drugs essential? In: Hand 1. Wittchen H-U, eds. Panic and phobias 11. Treatments and variables affecting course and outcome. Heidelberg: Springer-Verlag. I YXX:X9-09. 33. Franklin J. Behavioural therapy for panic disorder. In: McNaughton N. Andrews G. eds. Anxiety. Dunedin: Otago University Press, I990:84-9 I . 34. Linehan MM. Dialectical behavioral therapy: A cognitive behavioral approach to parasuicide. Journal of Perwnality Disorder\ 1987; I :328-333. 35. Alden L. Short-term structured treatment for avoidant personality disorder. Journal of Consulting and Clinical Psychology l989:57:7.56-764. 36. Strupp HH. Hadley SW. Specific versus non-\pccific factors in psychotherapy: A controlled study of outcome. Archive\ of General Psychiatry 1978;36: I 125.1 136. 37. Bergin AE, Lambert MJ. The evaluation of therapeutic outcomes. In: Garfield s. Bergin A. eds. Handbook of Psychotherapy and Behavior Change. 2nd ed. New York: Wiley, 1978. 38. Robins LN, Tipp J, Przybeck T. Antisocial personality. In: Robins L, Regier D. eds. Psychiatric disorders in America. Glcncoe: Free Press, 1990. 39. Frank JD. The placebo in psychotherapy. The Behnvior;il and Brain Sciences 1983;6:291-292. 40. Andrews G. A wider view leads to different conclusions. The Behavioral and Brain Sciences 1983:6:285. 41. Elkin I. Shea T, Watkins JT. ct ul. National Institute of Mental Health treatment of depression collaborative research program. General effectiveness of treatments. Archives of General Psychiatry 1989;46:97 1-982. 42. Klerman GL. The psychiatric patient's right to effective trcatment: Implications of Osheroff vs Chestnut Lodge. American Journal of Psychiatry 1990: 147:409-418. 43. Lanibert MJ, Shapiro DA. Bergin AE. The effectiveness of psychotherapy. In: Garfield S. Bergin A, eds. Handbook of Psychotherapy and Behavior Change. 3rd ed. New York: Wilcy. 1986. 44. Masson J. Against therapy. London: Fontana, 1990. 45. Altshuler KZ. Whatever happened to intensive psychotherapy'? American Journal of Psychiatry 1990; 147:428-430. 46. Andrews G. Psychotherapy and health insurance. Australian and New Zealand Journal of Psychiatry 1983; 1768.72.
Downloaded from anp.sagepub.com at LAKEHEAD UNIV on March 14, 2015
