Swedish psychiatry needs a restart
- Linda van Paaschen
- Dec 12, 2020
- 4 min read
Updated: 9 hours ago
The clinical gaze and medical assessment have gradually been pushed aside in favor of manual-guided diagnostics - often performed by professional groups without medical training. When criterion-based questionnaires replace the physician’s diagnostic work, psychiatry loses its medical foundation. For psychiatry to provide quality healthcare, a restart is needed where medical competence, clinical judgment, and resource efficiency are the guiding principles, writes psychiatrist Linda van Paaschen.
“No, as a psychiatrist you cannot determine whether a patient has bipolar disorder. A psychologist must first be involved,” my department head - also a fellow psychiatrist - explained to me at a general psychiatric clinic in the Stockholm region.
This was last year. For more than a decade, I have observed psychiatry in free fall, but at times the downward movement appears especially astonishing. Now I was truly taken aback.
“It’s probably for the best that you don’t have to examine the patient,” he continued. “You only need to be responsible for the diagnostic classification.”
My then-department head is convinced that this setup is the most efficient way to conduct diagnostic work. I, however, see it as a manifestation of a flawed diagnostic methodology, a misuse of the diagnostic concept, and above all - a senseless waste of resources.
The development of Swedish psychiatry away from clinical observation and the art of medicine has been ongoing for some time. It has been replaced by tests, questionnaires, rating scales - and above all, by counting diagnostic criteria. One might think that such a mathematical approach is handled by AI, but in fact, it is psychologists doing the counting. At least for now.
Yet diagnostics in all branches of medicine is a physician’s task, the very core of which consists of clinical judgment and medical practice. A specialist physician’s twelve-year training includes extensive and broad clinical experience primarily aimed at building competence in differential diagnosis within a specific medical field.
The department head believes it is clever to let psychologists examine patients instead of psychiatrists. But the Swedish psychology degree is neither medical nor even a healthcare education. A newly graduated psychologist can work as an organizational psychologist. The only thing distinguishing such a psychologist from one employed in healthcare is one year of clinical service, usually at a general psychiatric clinic.
In my experience, neither psychologists nor psychiatrists in Sweden always have a clear understanding of what differentiates our areas of expertise. Laypeople also have difficulty telling us apart, but that is less problematic. Within psychiatry, however, it is crucial if we are to work efficiently with available resources. It requires a good understanding of the competencies at our disposal.
Today, Swedish psychiatry devotes a vast number of psychologist hours to diagnostic assessment. My point is not that psychiatrists should do this instead - because regardless of how many hours are spent on questionnaires and criterion-counting, a diagnosis is never a truth, an answer, or an explanation. A diagnosis is merely descriptive - a description. No matter how careful or time-consuming the diagnostic process is, a diagnosis can never be proven, since we lack reliable and objective examination methods.
A psychologist or psychiatrist may reach one conclusion, and another may reach the opposite - both assessments are equally valid. Diagnoses should not be defined as right or wrong. They are qualified guesses intended to be used as working hypotheses in a treatment plan, and they should always be reconsidered when necessary. But that is not how we work today.
Swedish psychiatry prioritizes diagnostic classification over clinical relevance, guided by a superficial and literal interpretation of the diagnostic manual DSM-5. Existing competencies are used suboptimally, and the waste of resources is evident - with the full knowledge of department heads.
The most remarkable feature of psychiatry’s fragile structure is that we meet the enormous demand for care with an ever-growing production of psychiatric diagnoses, an increasing prescription of psychotropic medication, and high rates of sick leave. At the same time, waiting lists are long for all interventions, and psychotherapeutic treatments are effectively deprioritized as resources are increasingly tied up in diagnostic assessments and administration.
In my experience, this disheartening situation is explained by medicalization. It is a well-known problem throughout healthcare, but psychiatry holds an unchallenged first place. Psychologists and psychiatrists - as well as several other professional groups within psychiatry - now diagnose normal and healthy individuals and treat them with psychotherapy, psychopharmaceuticals, and other interventions. These unnecessary medical measures continue to escalate relentlessly.
Specialist psychiatric care in Sweden needs a restart. Hand over today’s psychiatry to psychologists to run as a non-medical operation. It is time for the medically trained professions within psychiatry to abandon the criterion-counting diagnostic chase and begin rebuilding a specialist psychiatric healthcare system that centers on the individual’s actual care needs. □
