Yogi Berra once said, “It’s tough to make predictions, especially about the future.” It is particularly difficult to talk about the future of psychiatric care and the profession of psychiatry given the current state of affairs and the dysfunction of the mental health services system in America today.
The current system is broken. Needs are not being met. Care is underfunded and uncoordinated. Patients fall through the cracks and are criminalized or homeless. And although there are some early signs of reform, such as the push for integration of psychiatry in medical care systems, it is unclear with the potential repeal of the Affordable Care Act and the undoing of parity whether the situation for our patients and the profession might get even worse.
Dr. Steven F. Sharfstein
In the year 2067, most physicians will be employees of one out of four major health care nonprofit corporations that are vertically or horizontally integrated systems of care. All Americans will be enrolled through a government-financed universal single payer plan of care, as employer-based health insurance will have disappeared for the last 25 years. Americans will choose which of the four health systems they wish to join during an annual open season and be able to select their primary and specialty care physicians. Many of the services provided will be in the home or workplace through broad and interactive computing and telemedicine capacity and high-tech centers. Hospitals will provide sophisticated gene therapy, organ transplantation, and biomedical engineering. Approximately 30% of the gross national product will be spent on health care.
Americans will live to an average age of 125 years, but it would not be unusual to find some individuals living to age 150. These Americans will have had many of their organs replaced by either genetically programmed animal organs or harvested organs from special banks. However, the brain is the only irreplaceable organ, and psychiatrists will be prominently involved in the interface of brain and behavior as they have been for the past 200 years.
In the year 2067, an expanded specialty of psychiatric physicians will be certified in one of four major categories of practice. Those certifications will be in neuroscience, medical psychiatry, psychotherapy, and social psychiatry.
The neuroscience psychiatrists will combine an MD with a PhD, and will be the most highly technical and specialized and the most highly compensated psychiatrists. They will be the clinician scientists. The neuroscience psychiatrist will be an expert on the human genome, sophisticated brain imaging and mapping, and the differential use of a variety of neurochemicals, as well as the application of technology such as magnetic fields for the treatment of mental illness and direct intervention into the brain with psychosurgery.
The medical psychiatrists will most resemble the early 21st century psychiatrists with subspecialties in geriatrics, adult, child and adolescent, and substance use. The medical psychiatrists will be integrated with other medical colleagues in many ambulatory as well as residential settings. Geriatrics will be the specialty for the treatment of the very old working with the neuroscience psychiatrist in the treatment of dementias and similarly, the child psychiatrist will work with the neuroscience psychiatrists in early preventive interventions at the intrauterine level with genetic abnormalities being corrected before birth. The medical psychiatrist will be a very popular area for all physicians, with more than 20% of all medical graduates specializing in medical psychiatry.
The psychotherapy psychiatrists will combine the MD degree with psychology education, religion, and the humanities. This psychotherapist will work one to one and in group settings on the age-old problems of individuation, separation, grief, loss, insight, and self-actualization.
The social psychiatrists will combine the MD degree with a degree in sociology or criminology and/or a law degree. They will focus on the social control issues of the day. Forensic prisons will be an area of government-sponsored treatment and will dominate the criminal justice system with interventions in an effort to reduce criminal behavior.
Managed care will not exist 50 years from now. It will be perceived as a regrettable experiment of the late 20th century ending in the first part of the 21st century. With the enactment of a universal single payer system of care, the high-cost intrusive middle management of carve-out behavioral health care companies will become moot.
Human progress comes in many forms. By the year 2067, psychiatry will have made significant advances that will make the prior 200 years of psychiatric care seem crude, quaint, and absurd.
Dr. Sharfstein, a past president of the American Psychiatric Association, is president emeritus of the Sheppard Pratt Health System, Baltimore. This essay is based on a presentation he made in February 2017 at the annual meeting of the American College of Psychiatrists in Scottsdale, Ariz.