Intervene or Innovate: a Dilemma for Psychiatrists-in-Training
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THE LEARNER'S VOICE
Intervene or Innovate: a Dilemma for Psychiatrists-in-Training Nathaniel P. Morris 1 & Neir Eshel 1 Received: 12 December 2019 / Accepted: 7 February 2020 # Academic Psychiatry 2020
As trainees about to graduate from psychiatry residency, we believe that budding psychiatrists face a key dilemma when considering how to spend our careers: whether to prioritize intervention or innovation. To make the biggest impact, should we focus on applying what is known in psychiatry, delivering care to patients who need it now, expanding access to treatments that work? Or should we devote our resources to advancing our understanding of mental disorders, to discovering novel treatments, to pushing the field in new directions? Perhaps nowhere is this dilemma more obvious than in the San Francisco Bay Area. Every day, we go to work next to space-age laboratories, where researchers use tools like optogenetics, functional magnetic resonance imaging, and transcranial magnetic stimulation to develop new insights into mental disorders. As part of our training, we receive teaching at the forefront of psychiatry, whether grand rounds about ketamine infusions, lunch talks about the default mode network, or didactics about pharmacogenomics. Yet, beyond the walls of our academic medical center, we too often see people muttering to themselves, wandering the streets in the throes of psychosis. We see tent encampments dotting sidewalks, where people openly inject substances into their necks, and the flashing lights of police cars as officers try to calm someone screaming in the park. We see how far psychiatry has to go. Psychiatrists-in-training have compelling reasons to focus on intervention. According to the 2018 National Survey on Drug Use and Health, approximately 4.1 million US adults with serious mental illness, out of a total 11.4 million, did not receive any mental health services in the past year [1]. Among an estimated 20.3 million US adults who needed substance use treatment in 2018, just 3.5 million received any in the year prior [1]. More than 47,000 individuals died by suicide in the USA during 2017. Meanwhile, the list of
* Nathaniel P. Morris [email protected] 1
Stanford University School of Medicine, Stanford, CA, USA
underutilized, evidence-based treatments in psychiatry is far too long. For instance, research suggests clozapine can decrease psychotic symptoms, suicidality, and mortality among patients with schizophrenia, yet a 2014 study of nearly 80,000 antipsychotic treatment episodes for Medicaid-insured adults with treatment-resistant schizophrenia found just 5.5% included clozapine initiation over a 4-year period [2]. Electroconvulsive therapy is among the most effective treatments for treatment-resistant mood disorders, yet a study of approximately 1 million privately insured US adults with mood disorders found just 0.3% had received electroconvulsive therapy in 2014 [3]. Opioid agonist therapy can decrease mortality by half or more for patients with opioid use disorders (OUDs); however, in 2017,
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