Abstract
The first edition of Introduction to Psychiatry is a textbook designed to reach medical students, house staff, primary care clinicians, and early-career mental health practitioners. It is the editors’ hope that this text will enable its readers to understand the neuroscientific basis of psychiatry, best practices in the psychiatric assessment and treatment of the patient, the current understanding of core psychiatric diagnoses, and the important underlying issues of population health, public policy, and workforce recruitment and training that must be tackled to bring these advances to all.
Why create a textbook of psychiatry specifically for clinicians not trained for the mental health field? To answer this question, one must understand the troubling challenges facing the mental health workforce, the changing face of mental health care delivery, the enormous comorbidity between psychiatric illnesses and other health conditions, and the impact on non-psychiatric medical illnesses when a comorbid psychiatric disorder is present.
Introduction
The essence of global health equity is the idea that something so precious as health might be viewed as a right.
Without mental health there can be no true physical health.
The first edition of Introduction to Psychiatry is a textbook designed to reach medical students, house staff, primary care clinicians, and early-career mental health practitioners. It is the editors’ hope that this text will enable its readers to understand the neuroscientific basis of psychiatry, best practices in the psychiatric assessment and treatment of the patient, the current understanding of core psychiatric diagnoses, and the important underlying issues of population health, public policy, and workforce recruitment and training that must be tackled to bring these advances to all.
Why create a textbook of psychiatry specifically for clinicians not trained for the mental health field? To answer this question, one must understand the troubling challenges facing the mental health workforce, the changing face of mental health care delivery, the enormous comorbidity between psychiatric illnesses and other health conditions, and the impact on non-psychiatric medical illnesses when a comorbid psychiatric disorder is present.
The Prevalence and Impact of Psychiatric Disorders
Across the globe, no category of human suffering equals that of mental illness. Mental disorders are highly prevalent, have their onset beginning in childhood through early adulthood, and are stubbornly chronic. One in five people annually have a diagnosable mental disorder, and a staggering one in two people will suffer from a mental illness during their lifetime. (Kessler, 2005; Steel et al., 2014). Though the prevalence of mental disorders is approximately equivalent among non-Hispanic whites, Hispanics, and non-Hispanic blacks, access to treatment and treatment intensity is lower among Hispanics and non-Hispanic blacks, leading to poorer outcomes (Alegria et al., 2008; US Dept of HHS, 2001).
Suicide is a frequent outcome of the more severe presentations of the most serious mental illnesses and is the second most common cause of death globally in young adults (Arensman, et al., 2020). Ninety percent of suicides are associated with a diagnosable psychiatric disorder. Substance abuse and death by drug overdose are a worldwide scourge.
Psychiatric disorders hit the child and adolescent population especially hard. Meta-analyses have found that the worldwide prevalence of mental disorders in children and adolescents is 13 percent (Polancyzk, 2015). Approximately half of all serious psychiatric disorders encountered in adults have their onset in childhood. Psychiatric disorders that have their onset in childhood and become chronic have a myriad of serious sequelae, following these young people through development and thus impacting their emerging identity, ability to learn, social development, and overall health and life expectancy.
Psychiatric disorders impede access to medical care and worsen clinical outcomes of medical illness. Virtually all medical problems have a poorer prognosis when accompanied by a comorbid mental illness. Individuals with mental illness in the United States and globally have a severely shortened life expectancy due to the mental illnesses as well as the poor overall health that accompanies them.
In spite of these staggering realities, the majority of individuals with psychiatric illness do not receive care.
Why Is This the Case?
The global population is growing. In 2021, the US population is projected to grow by 2,000,000 people from a combination of new births and immigration United Nations World Population Prospects U.S. Population Growth Rate 1950–2021. www.macrotrends.net. Retrieved 2021-03-29. Given this growing population, it can be predicted that the number of people needing mental health treatment will continue to increase.
Yet this growing demand for mental health care is not being met.
There is a severe workforce shortage in mental health globally, and indeed, in many cases that shortage may be expected to increase. For example, between 2003 and 2013, while the US population grew, the number of practicing psychiatrists declined (Bishop et al., 2016). A novel study analyzing data from the Association of American Medical Colleges (AAMC), American Board of Psychiatry & Neurology (ABPN), and US Census Bureau projected the psychiatrist workforce through 2050 (Satiani, et al., 2018). The study concluded that this workforce will continue to contract through 2024 if no interventions are implemented. In the United States, these shortfalls will continue to be felt most heavily in rural areas, among the poor and non-white population.
The shortfall of mental health clinicians who treat children and adolescents is especially severe. Most areas of the United States are in “severe shortage” for child and adolescent psychiatrists. Inequity worsens this lack of care and the shortfall is severe in the developing world (Shatkin, 2018; Bruckner et al. 2011).
What to Do
Integration of Primary Care and Behavioral Health
Traditionally, mental health and primary care have been isolated from one another, housed in separate clinical locations, often with no access to a shared medical record and with separate insurance and administrative/regulatory governance. A movement to integrate behavioral health care into primary care pediatric and internal medicine settings has gained momentum in recent years (Ramanuj, et al., 2019). The provision of behavioral health in these settings has a number of clear advantages over the current siloed approach, in which behavioral health care settings are institutionally separate from other medical settings. The evidence base for improved overall health outcomes when integrated mental health care is provided is growing. Integrated care allows for seamless transitions of care from the primary care provider (PCP) to the behavioral health provider (BHP); overall improvements in health care costs and the efficient leveraging of scarce psychiatric resources are additional benefits of this approach.
The significant global treatment gaps for mental health problems is another powerful rationale for the integration of mental health into the primary care setting. Integrated care improves access to care and overall health outcomes on both the individual and population scale.
The integrated care approach includes on-site collaborative models, as well as telepsychiatry. Telepsychiatry has been shown to be effective in settings where in-person access is limited, such as rural areas, high population urban areas, geographically difficult-to-reach areas, and in times of disaster when access is blocked.
Significant stigma accompanies a mental health diagnosis in most cultures. An advantage of the integration of mental health treatment into the primary care setting is the decreased isolation of patients being treated for mental health disorders. Eliminating this isolation will not only improve the care of the mentally ill, but also allow the larger medical community to increase their exposure to these patients, promoting greater understanding and, ideally, reducing stigma.
In addition to integrating behavioral health into primary care medical settings, integration of primary care medical services into mental health settings (sometimes referred to as “reverse integration”) has also gained ground as an effective model, particularly for individuals with serious mental illness and substance use disorders whose closest and most frequent health care contacts may be with mental health clinicians. In addition, such individuals often have difficulty navigating general medical settings in which clinicians may have less familiarity with evaluating and treating general medical illness in individuals with significant psychiatric conditions and complex psychiatric treatment regimens. It is hoped that behavioral health integration into primary care as well as primary care into mental health settings will help address the substantial health disparities related to mental illness and substance use disorders.
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