The changing doctor–patient relationship in psychiatry: observations on recent trends in autism, attention-deficit hyperactivity disorder, gender dysphoria and mental distress

Abstract

This editorial highlights increasing prevalence and treatment rates of apparently disparate disorders. We ask whether cross-disorder factors including greater mental health literacy, social media and a shift to psychiatric explanations for distress contribute to these trends. We highlight a consequence: the changing doctor–patient relationship and its impacts.

There is something afoot in the world of psychiatry. Its presence is clear: it is discussed in office tearooms and in homes, but evades description. We refer to links between rising rates of apparently disparate conditions including autism, attention-deficit hyperactivity disorder (ADHD), gender dysphoria and mental distress. In this article, we suggest these longitudinal trends have similar underpinnings. We also aim to highlight a consequence: a fundamental shift in the doctor–patient relationship in psychiatry.

A traditional doctor–patient relationship exists when doctors are regarded as a repository of expertise.¹ This expertise is sought by individuals (or sometimes their family or other members of society) to address issues and explain unformulated concerns. In psychiatry, a traditional relationship is often present for so-called major mental illnesses including schizophrenia, bipolar disorder and depression. Rates of these disorders are fairly consistent, and when psychiatrists are consulted, treatments are offered (despite their limitations) and illnesses are addressed.

In other conditions, prevalence and treatment rates are rising. These include autism spectrum disorder, ADHD, gender dysphoria and a new category called mental distress. The early conceptualisations of these disorders had little impact on the doctor–patient relationship. The term autism described a severe category of neurodevelopmental disorder. Although it was apparent that this category was overly restrictive, subsequent dimensional approaches were recognised as useful. Unexpectedly however, rates of autism spectrum disorder have been rising rapidly over the past 10 years with some claiming there is an ‘autism epidemic’.²

For ADHD there is debate about whether it is prevalence or treatment rates that are rising. Polanczyk et al³ evaluated ADHD prevalence surveys over three decades and reported that prevalence rates for young people are relatively consistent: approximately seven per cent of the general population, and not impacted by year of evaluation. However, treatment rates for ADHD are clearly on the rise, and for adults with ADHD in New Zealand, increased ten-fold over a 16-year period.⁴ Despite these rapid increases in ADHD treatment, there remains a treatment gap and a limited capacity of mental health services to complete assessments. Similarly to autism, other factors appear to be at play.

A more contentious diagnosis is adolescent gender dysphoria. A recent systematic review reported that there are no population studies, so the prevalence of gender dysphoria is unknown.⁵ However, the authors reported consistent evidence of marked increases in presentations to services and a shift in the natal gender of referral cases; those assigned female at birth are now in the majority. They concluded that while improvements in availability of services and diagnostic practices have contributed, there has undoubtedly been a shift in cultural attitudes leading to gender non-conformity becoming more acceptable. A recent editorial by Hilary Cass in this journal outlines key dilemmas faced in reviewing this area.⁶ In addition to the challenge of understanding the nature of the population with gender dysphoria, she also highlights the limited evidence base for puberty-blocker medications (which have become widespread and applied later in puberty than initially intended) and the weak evidence base for both medical and non-medical interventions offered to those presenting. Withers⁷ questions whether the medicalisation of transgender identification is an attempt to avoid psychological distress and the need to address underlying trauma by trans-individuals, their clinicians and society.

The concept of psychological distress, usually measured by psychometric instruments, has a long history. In New Zealand we have recently observed the emergence of a related category: mental distress which results in presentations to clinicians. Similar categories associated with low psychological well-being are emerging in other countries. Mental distress is more often described in consumer and advocacy domains,⁸ and there are calls for better access to mental health and addiction services for people with mental distress. Interestingly, population rates of psychological distress (measured by psychometric scales) may not be changing, but more people are reporting poor mental health and accessing mental health treatment over time.⁹ Clearly, rising rates of treatment-seeking by people with mental distress are a factor in mental health services becoming overwhelmed, alongside other factors such as failure to properly fund mental health services and adjust service capacity to increases in population.

What is causing the rapid increase in diagnosis and treatment rates described above? When disorder trends are considered individually, it is unclear if there is an overarching issue. For the groups described, there is a need to identify previously unrecognised morbidity and improve access to appropriate treatment. In our view, these and other factors at play are contributing to fundamental shifts in the doctor–patient relationship in psychiatry.

One factor is increased mental health literacy. There has been an important mental health literacy campaign over two decades aiming to reduce stigma towards those with mental illness. More recently, social media and online forums have become the primary source of mental health knowledge for many, so that doctors are no longer the major repository of information and expertise. Examples of missed diagnoses support the benefits of greater health literacy among the public, especially when these occur within historically excluded groups. However, social media as the primary source of medical information is fraught because of the potential for misinformation and unbalanced information to be prevalent.

The rise in social media has also supported a shift of many domains of society – work, education and socialisation – to an online format. This may fuel isolation and loneliness. There are many reports of social media's role in anxiety, low self-esteem, body dysmorphia and feelings of inadequacy through comparisons with carefully curated images online. Social media also provides an accessible support network for those with similar issues. Individuals now publicly share and discuss their mental health diagnoses and treatment journeys online.

It is natural for people to seek explanations for symptoms and distress. When these occur alongside greater mental health literacy and social media support networks, the result may be that non-specific distress and low psychological well-being is channelled into diagnostic categories. This contributes to the increased prevalence and treatment rates observed, and potentially over-medicalisation. Because of treatment inadequacy and poorly targeted treatment, it is common for people to receive multiple diagnoses. There is also a risk that broad psychosocial interventions (that may better target distress) are used less frequently than medical interventions as a result.

When medical knowledge is easily accessed outside of traditional domains, it is easier for doctors’ expertise to be disputed. This broadening of this knowledge base contributes to a fundamental shift in the social contract between doctors and society. Doctors are placed in a gate-keeping role to be passed for access to treatment and services. There are numerous ‘rate my doctor’ websites. Their purpose is to alert people to sub-standard doctors. A risk is that doctors are rated poorly if they offer an opinion counter to those formed by the patients. A further risk is that doctors modify opinions to preserve good ratings, and the benefit of medical expertise is lost. When this occurs, a fundamental shift in the power dynamic between doctors and patients has occurred.

In the new form of doctor–patient relationship, patients may pre-diagnose their condition prior to the consultation. This approach challenges the traditional medical process of history-taking and examination to inform diagnosis. It can be difficult for psychiatrists to disagree with what is self-evident for the individual, particularly when histories are sought from people with considerable background knowledge of their presumed disorder. There is much at stake for the patient. Diagnosis provides validation, explain disability and provide an avenue to additional support. Pharmacotherapy is assumed to follow diagnosis, and the traditional skills of formulation and comprehensive treatment planning may be dismissed. If the doctor disagrees with the patient's formulation, it is challenging for both and negatively affects any therapeutic relationship to be formed.

A shared feature of the disorder groups described above is vocal consumer bodies. Previously, these did not exist because of the power imbalances that were present between doctors and patients. Consumer bodies advocate for attention and call for greater access to diagnosis and treatments. They provide a sense of collectivity for patients and validation of suffering. Unfortunately, the benefits of psychiatric treatments are often limited and may fail to address the drivers underpinning mental illness and distress. Paradoxically, a drive for greater access to diagnosis and treatment may be associated with frustration and distress when promised treatments do not alleviate presenting symptoms.

Are there advantages to the changing doctor–patient relationship? We support earlier shifts away from a paternalistic relationship and recognise more work is needed. A marked power-imbalance between doctors and patients is problematic and a more equal partnership is a foundation for good clinical outcomes. However, if medical opinion is dismissed out of hand, issues such as poorly targeted treatment and therapeutic conflicts arise. By raising these issues, we hope to contribute to a discussion that reconsiders the balance within the doctor–patient relationship.

There is the potential for even discussion on these matters to be interpreted as being dismissive of the distress experienced by individuals and the need for timely, accessible psychiatric input. That is not our intention. We acknowledge the importance of timely psychiatric input and are aware of many individuals who have benefited from assessment and treatment of the conditions we highlight. However, a consequence of the social factors we focus on is that psychiatric frameworks are being applied in increasing frequency, and the risks and benefits of this approach need consideration. An understanding of the social underpinnings to distress such as trauma and inequity risk being lost when transactional roles are applied to healthcare.

In conclusion, when disorder trends are considered individually, issues such as rising pathology, illness burden and unmet need are highlighted. These factors are important and deserve attention. We contend there is something additional at play. A cross-disorder ‘meta-trend’ results from factors such as the impact of greater mental health literacy, the role of social media and a shift to psychiatric explanations for distress. These factors are driving a fundamental shift towards consumerism within the doctor–patient relationship. The consequences are multifaceted but harms may accrue as a result. We raise these issues to actualise what is frequently discussed, to share our perspective and to prompt discussion so that trends may be checked.