Yale Textbook of Public Psychiatry

In psychiatry’s diverse and colorful family of subspecialties, public psychiatry has always been the “plain Jane” cousin who shows up at all the reunions but keeps quiet and off to the side. It’s neither the flashy young neurobiologist nor the sophisticated depression specialist, and it has certainly never resembled the refined, matronly psychoanalyst. Indeed, public psychiatry seems to have been content with its place in the background. But with widespread health care reform taking hold with its emphasis on person-centered care and attention to meaningful outcomes, public psychiatry’s time in the shadows may be ending. One gets that sense when reading the recently published Yale Textbook of Public Psychiatry. Editors Selby Jacobs and Jeanne Steiner collaborated with their department colleagues to publish a text that creates a coherent narrative for public psychiatry by weaving together history, the current landscape, training priorities, and key best practices and competencies. The Yale group’s profile is impressive, as each chapter is coauthored by a faculty member with a national or international reputation in the area. This is a text worth reading.

The text features four sections. Part I describes the public psychiatry service system by outlining the discipline’s origins in community and public health initiatives from the last century. A highlight is chapter 3, “Recovery and Recovery-Oriented Practice,” which relates the evolution of the recovery movement and provides a succinct review of person-centered concepts, recovery-oriented services, and the nature and impact of peer services. Part II is anchored in the present and rightfully asserts that today’s public psychiatrists must be competent to provide integrated (general medical and behavioral health) care, to apply a public health perspective to understand diseases and modifying factors at the population level, and to serve the ever-increasing number of patients with serious mental illness who are also involved in civil and criminal justice systems. This section lays out the foundation of the public psychiatrist’s current clinical identity.

Part III drills down into core clinical skills, focusing on children and young adults, hospital and outpatient service settings, and the importance of outreach and engagement strategies. Chapters throughout the text are similarly structured to provide history and context leading to a description of current best practices and required clinical competencies. For example, a chapter on services for children and adolescents includes a brief review of psychoanalytic theory and practice for children beginning with Sigmund Freud and tracing the evolution of Anna Freud’s clinic, which currently provides services in London’s publicly funded care system. Chapter 10, “Early Intervention and Prevention for Psychotic Disorders,” begins in Melbourne, where the first Early Psychosis Prevention and Intervention Centre was established in 1992. This background provides context that is interesting and greatly enhances the reader’s understanding of the material.

Consecutive chapters describe the shift from inpatient to outpatient care for individuals with serious mental illness that has taken place over the past half-century. A thorough review of state hospital inpatient care is necessary given that public psychiatry’s early identity was forged in large state asylums. Subsequent chapters trace the shift to outpatient care and describe the comprehensive array of community-based services that are the backbone of today’s public psychiatry. Chapter 13, “Clinical Competence in Outreach and for Special Populations,” stands out for its description of key outreach strategies used by public psychiatrists to ensure that high-need, high-risk patients are effectively engaged and served. This chapter also details unique needs and challenges encountered when working with patients with traumatic brain injuries; with those with co-occurring substance use disorders; and with the elderly, homeless, and the lesbian, gay, bisexual, and transgender populations.

The final section of the text takes a step back and examines public psychiatry’s administrative structure with chapters devoted to workforce issues, training needs and priorities, and future challenges. Public psychiatrists’ roles as medical and clinical directors, teachers, and practitioners are defined, emphasizing the many leadership opportunities and potential for public psychiatrists to meaningfully affect clinical- and system-level policies. The final chapter outlines key future challenges in the field, including the increasing focus on risk and quality management, practitioner accountability, and our nation’s continuing and often chaotic approach to reforming the organization of and funding for health care. Indeed, a section heading near the end of the final chapter is “The Road Ahead is Unclear.” This brings the story full circle, ending with the acknowledgment made in the text’s introductory chapters that public psychiatry’s foundation always has and always will be anchored in the unsteady realm of social and safety-net services for the truly disadvantaged.

But the story is well told. One comes away feeling that public psychiatry has grown in stature and deserves greater recognition in psychiatry’s broad family of subspecialties, no longer the shrinking violet. The editors are commended for recognizing the breadth of talent and experience at Yale and for organizing a succinct and informative text that is very much worth reading.