Abstract
McNamara replied to the letter by McQueen [1]. McQueen is critical of the way psychiatrists manage patients who are on methadone maintenance therapy and who require additional psychiatric input.
McNamara is correct when he passionately points out that as well as there being high rates of substance use disorders among people with identified mental illnesses, there are even higher rates of mental illnesses in those diagnosed with a substance use disorder. The physical, and at times philosophical, separation between substance use disorders, treatment services and psychiatric services has not helped patients with these conditions. Service planners made bad decisions in the past.
It is also true that until recently, apart from a handful of psychiatrists, the majority of those in the profession have felt that the management of patients with drug and alcohol problems has not been part of their core business. One Australian survey reported that Royal Australian and New Zealand College of Psychiatrists (RANZCP) fellows described spending 13.8% of their clinical time on drug and alcohol psychiatry [2]. Is this adequate for the second most common mental disorder by 12-month prevalence according to the National Survey of Mental Health and Wellbeing and one that affects at least between one in six to one in three patients with other mental illnesses per year [3]? This point could well be debated in terms of disability and costs to the community and a variety of other factors. However, it is easy to conclude that as psychiatrists we are well equipped professionally but we do not do enough for our patients with these problems.
McNamara is critical of the College, among others, in its failings to do more. Many are to blame if we were looking to do this. The College as a whole has done little in the past to further the area of Addiction Psychiatry although there have been individual psychiatrists who have made major contributions to the field in Australia and New Zealand. Politicians have made mistakes. Individuals in our profession have also tended to work in what may have been seen to be more appealing areas or to focus on what appeared to have been more conspicuous problems.
Members of the Committee of the Section on Addiction Psychiatry (previously known as the Section on Alcohol and Other Drugs) have worked hard to address the area in some way and improve the plight of patients with these problems. With much effort, there have been important achievements but the focus of the RANZCP in the past has really been on other areas, and addiction has received little ‘air play’.
Many others within the College are beginning to echo the views expressed by McNamara. There is now a welcome change happening within our profession and College. Many of these changes are not visible yet ‘at the coalface’. The College Executive has been very supportive of the section and of change. It has been assertively facilitative of psychiatrists playing a greater role in the field again. Encouragement, rather than resistance, is the reaction among the wider population of psychiatrists to these transformations. One could readily criticise this of course, saying that it is overdue, but nevertheless it is now occurring and much has happened in a relatively short space of time.
The latest draft of the Basic Training in Psychiatry stipulates that Addiction Psychiatry is now a mandatory training experience. McNamara requested a six-month term in drug and alcohol/comorbidity. At this stage, there are not enough appropriately supervised terms to allow this. Hopefully, in the future this will be achievable. For those trainees unable to complete approved training in Addiction Psychiatry areas, they are required to manage a representative range of patients with substance use disorders and pathological gambling while being appropriately supervised.
The section is currently developing an advanced training curriculum in Addiction Psychiatry for RANZCP trainees that is planned also to be accredited as part of the Addiction Medicine Specialty Training Programme. College members have been very active in the establishment of the Chapter of Addiction Medicine within the College of Physicians and will continue to be involved with this speciality.
There are significant changes starting to take place within our profession in this area. The College is moving once again to ensure that psychiatrists are expert in the assessment and management of addictive disorders and have a place in the field which matches public expectation. Psychiatrists have always needed to remain nonjudgemental in dealing with their patients, which include patients with substance use disorders, and advocate, like McNamara, on their behalf.