Barriers to Patient Care in Psychiatry

This is an essay about some of the problems facing psychiatrists currently.  There are a host of difficulties.  I will only enumerate below the matters I think are relatively uncontroversial, and comparatively serious.  

The first is the problem of commitments. Civil commitment laws have been changed periodically since the 1960s. They are still far too limited, leading to unnecessary crime, homelessness, emergency rooms packed with violent, psychotic patients, and flooded family practitioners’ offices.

The second problem is the lack of psychiatric hospital beds. Many of the homeless should be hospitalized for long periods of time so they can be taken care of humanely, so they do not suffer, and so the public does not suffer either. 

Again, in the 1960s and 70s, psychiatric hospitals were closed due to concerns about a “least restrictive environment” associated with patients’ civil rights. Civil rights are still important, but the pendulum has swung too far, and for this reason, all doctors, including psychiatrists, are hamstrung in being able to help very severely ill people and to protect the public. The laws need to be changed to give psychiatrists and lawyers more capacity to institute civil commitments. 

The third matter has to do with insurance. Most insurance coverage for any kind of psychiatric care pays the physician less than a plumber, handyman service or an Uber driver. There’s something wrong with that picture. This problem may be impossible to rectify since “the horse has left the barn.” Nevertheless, it is almost universally agreed among psychiatrists that spending a max of 15 minutes with a patient and prescribe a psychotropic medication is far too limiting. Psychiatrists cannot get paid enough for a 45- or 50-minute psychotherapy session to survive in the United States economic environment. 

The final matter that disturbs psychiatric practice in 2023 concerns malpractice liability. As it stands now, psychiatrists are responsible if any of their patients kill themselves or kill other people. It has been proven over and over for the past 50 years that psychiatrists cannot predict with any degree of certainty which patients are going to kill themselves (or kill other people), and who are not. We have a large amount of literature concerning how to try to assess suicidality in some sort of reasonable way, but all psychiatrists know that accuracy is not measurable. The laws should reflect this widely understood reality. 

Professional liability for any patients who kill themselves or other people should be erased. This will allow many more psychiatrists than now to try to treat suicidal patients; as it stands, many psychiatrists have stopped accepting referrals of severely suicidal people because of the malpractice risk.

Those are some of the problems psychiatrists and their patients face. Life is full of challenges, and all of us need to live with them. But the bureaucratic difficulties impinging on the practice of Psychiatry seem to have become excessive.

Jerome S Blackman, MD 

Board certified, Psychiatry

Board certified, Psychoanalysis

Virginia Beach, Virginia 

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