The need for specialist services for serious and recurrent mood disorders

To the Editor

The call for specialist services for serious and recurrent mood disorders (Berk et al., 2013) is a weird and distressing illumination of the gulf between ‘public’ and ‘private’ psychiatry. Nowhere in the article are private psychiatrists mentioned.

Private psychiatrists outnumber public psychiatrists and are saturated with experience. Serious and recurrent mood disorders are their bread and butter. They see people over years and through their recurrences. They tend not to ‘close’ patients’ files or force them through Byzantine re-entry paths or screen them through unfamiliar or inexperienced clinicians when they get sick again.

Private psychiatrists tend to carry their patients and remain the first call for general practitioners. They should not return sick patients to the GP with instructions beyond the GP’s competence any more than a surgeon should.

Private psychiatrists don’t see only the easy cases. If ECT is an indicator of seriousness, the use of ECT in private psychiatric hospitals far exceeds use in public hospitals.

Yes, there are barriers of cost and maldistribution and delayed access. (Private psychiatrists are always on luxury holidays from their expensive inner-city offices.) But 47–55% of people have private insurance (Private Healthcare Australia, 2013) and Medicare supports outpatient consultation for all. The barriers are real and high but different and often less forbidding than those thrown up by the public system.

Private psychiatrists are less constricted by the diagnostic labels which regulate inclusion and exclusion from public practice. Experience ‘out there’, where patients wander all over the diagnostic landscape, teaches us the inanity of the classificatory system (Malhi, 2013). That imprecision looks like unscientific stupidity or negligence but it is actually a release from the academic fiction of ‘accurate diagnosis’ and the simple-mindedness of ‘diagnostic instruments’. The skill in ‘up-skilling’ comes not from more theory but from the practical wisdom of experience – Aristotle’s phronesis.

The authors’ proposal to set up systems to deal with a discrete diagnostic group uses the same administrative structures and procedures and, worst, the objectifying language that have created the problems that they want to address. It writes off the actual positives of good private practice and re-installs the negatives of the existing systems. It looks like a proposal to create new clinical thickets with yet more barriers, dead ends and false paths.

What worlds are we living in where the gulf between public and private psychiatry is so wide that we have forgotten that each other exist?