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Carolyn B. Robinowitz, MD, On the Common Concerns of Neurology and Psychiatry

Stump, Elizabeth

doi: 10.1097/01.NT.0000314560.28012.ed
IN THE FIELD

Carolyn B. Robinowitz, MD, professor of psychiatry at Georgetown University School of Medicine and clinical professor of psychiatry and behavioral sciences and child health and development at George Washington University School of Medicine in Washington, DC, has a remarkable history of firsts during her 44 years of practicing medicine. She became the first woman dean of Georgetown University School of Medicine in 1998, the first director of the American Psychiatric Association (APA) Office of Education in 1976, and became the first woman president of the American Board of Psychiatry and Neurology (ABPN) in 1985. She serves as president of the APA — a 38,000-member organization of psychiatrists — through May.

Among her honors, she received the First Educator of the Year Award from the Association for Academic Psychiatry in 1988 and the Distinguished Service Award of the American College of Psychiatrists in 2001.

Dr. Robinowitz spoke with Neurology Today in a telephone interview about the state of modern psychiatry and common issues faced by both psychiatrists and neurologists.

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What are some of the APA's priority concerns?

Our top priority has been improving non-discriminatory access to patient care over the past decade. More than 45 million Americans have no insurance at all and another 25 million or so are severely underinsured by discriminatory coverage for treatment for mental illness, including substance abuse. Barriers to care include higher co-payments, coverage for fewer physicians' visits for days in the hospital, and higher deductibles than those that apply to other medical illnesses.

We've advocated for repealing the Medicare discriminatory co-pay. Medicare recipients who usually pay 20 percent co-pay for most medical care pay a 50 percent co-payment for psychiatric care, a major difference. And it is quite a disincentive — not to the physician, whose Medicare compensation is the same in either case — but for the patient who must bear a greater burden for psychiatric care.

There is also a stigma associated with psychiatric care. People don't like to talk about needing or going for help. We have been working with the National Alliance of Mental Illness and Mental Health America to help policymakers and the general public to understand the impact of illness on patients and families and to diminish the stigma. We want to address the myths and stereotypes propagated by groups like the Church of Scientology, which has gone on record as being opposed to psychiatric care.

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What are some of the APA legislative priorities?

Among priorities, we want to protect patient privacy-confidentiality, particularly pertaining to health records. In addition, we are concerned about legislation that grants non-physician providers, such as psychologists, prescribing rights. In New Mexico and Louisiana, psychologists can prescribe psychotropic medications, for example. We are concerned about the effect of these practices on patient safety, because these non-physicians lack training in pathophysiology and pharmacology, as well as how psychiatric disorders and their treatment affect medical illnesses and their treatment.

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In some rural states, there is only 1 child psychiatrist per 20,000 residents. How is the APA addressing this shortage?

We need to partner more with pediatricians and family physicians in terms of initial diagnosis and management, and use telepsychiatry and visiting consultants to help our colleagues in general medicine. In addition to offering education programs to help family physicians with general psychiatry, the APA works with the American Academy of Child and Adolescent Psychiatry to improve general psychiatrists' knowledge and skills in child and adolescent psychiatry, as well as to assist pediatricians in addressing psychiatric aspects of care.

The APA is also trying stimulate interest in child psychiatry among medical students and residents, and we're working with policymakers to encourage loan forgiveness programs for medical students.

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Legislation proposed in the Senate last June would create financial incentives for medical students and child psychiatrists. How was the APA involved in this?

The Child Health Care Crisis Relief Act of 2007 is a companion to a bill sponsored by Rep. Edward Kennedy. An APS member serving a six-month fellowship in Congress authored the legislation. The bill would increase the number of well-trained mental health service professionals, including those based in schools providing clinical mental health care to children and adolescents. This would help the shortage and it also means that kids who need access to mental health service are more than likely to receive care.

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Tell us more about the APA Committee on Mental Health Care for Veterans and Military Personnel and Family.

We established the committee because we're seeing a major influx of military veterans and their families with mental disorders, particularly depression, anxiety, traumatic brain injury, and post-traumatic stress disorder (PTSD). With PTSD, an acute stress disorder may occur right on the battlefield, or it may emerge months after — so that in initial screenings, returning veterans may show a lower rate of symptoms than if you re-screen a month or six weeks later.

The committee addresses everything from how soldiers shift psychologically from combat to home in 48 hours, often with minimal system support or community resources, to treatment and long-term care. We also have worked with the VA in improving access to care, for example aiding veterans who may be self-treating their depression, anxiety, or PTSD with alcohol or other substances, and whose substance abuse may make them ineligible for certain treatment programs.

The APA helps advocate for funding, for personnel, and for better access to care. We're also working with TriCare — the Department of Defense health care program for members of the uniformed services, their families, and survivors — to make it easier for family members to receive care in the private sector, particularly when there may be insufficient resources in the military sector to serve their needs. Tri-Care is viewed as a less than user-friendly system for providers, and we would like to remedy the problem.

The APA has a great public information Web site, HealthyMinds.org, which has information on veterans' mental health and other resources on mental health issues.

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Are there as many opportunities now for women in psychiatry as when you started in the field?

The good news is that we're seeing more women in medical school and new leadership positions in hospitals. On the other hand, women's compensation remains below that of their male colleagues, and women are not promoted as rapidly as their male colleagues.

I've been fortunate because the APA has a good track record for enhancing women and minority representation in leadership. This year, for example, all the APA officers are women, and they're all excellent. There have been several APA-based programs to increase the number of women and minority participants in psychiatry, and we promote family awareness issues, as well.

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In what ways do you envision closer collaboration between neurology and psychiatry?

Although diagnosis and treatment options have developed in different pathways, neurologists and psychiatrists have both benefited by the tremendous advances in neuroscience and brain research. We share interest in the same neurotransmitters in Parkinson disease, in geriatric care, and in the need to provide both biological and behavioral treatments.

We would benefit from increased collaboration and integration of clinical care of our patients. The ABPN keeps much separated but we do expect grounding in the basic scientific understanding for each discipline by physicians being certified in the other discipline.

The APA Annual Meeting will be held this year from May 3–8 in Washington, DC. For more on the APA and its annual meeting highlights, visit www.psych.org.

©2008 American Academy of Neurology