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‘Progress’ in psychiatry
I have practiced community mental health in Fayetteville, NC for 12 years and have observed every point Dr. Nasrallah made in “A skeptical view of ‘progress’ in psychiatry” (From the Editor, Current Psychiatry, June 2011, p. 18-19). As psychiatrists, we share a great deal of the blame. We handed over leadership of community mental health centers to social workers and allowed ourselves to be “carved out” of community hospitals. State hospitals are dysfunctional at best.
Dr. Nasrallah is correct in asking who is the “genius” behind these decisions. Many new psychiatric practices are based on family practice models of herding 60 to 80 patients per day. I’m not sure I will even recognize the practice of psychiatry in 10 to 20 years. Perhaps with obstinate rigor we can restore what we’ve lost.
Mark Chandler, MD
Medical Director
Cumberland County Mental Health Center
Fayetteville, NC
Missed progress
I, too, am concerned with the lack of recent progress in psychiatry. Nevertheless, Dr. Nasrallah is missing some of the progress he downplays (“A skeptical view of ‘progress’ in psychiatry,” From the Editor, Current Psychiatry, June 2011, p. 18-19). For instance, the discovery of chlorpromazine brought about concomitant serious side effects and homelessness, but many patients gained a life in society, which allowed some to become peer specialists, helping others with mental illness. Sure, insurance hassles for state hospitalization did not exist and hospitalization stays today often are much too short, but 40 years ago, state mental hospitals were so-called “snake pits” of overcrowding with excrement on the floor, and precious little treatment. Yes, in psychiatry we have more legal constraints, but in part this is a reflection of past coercive and unneeded hospitalizations.
I agree funding reductions have broken public mental health systems, but psychiatrists generally have preferred private practice with mentally healthier patients and sat quietly while other disciplines took over psychotherapies. I also don’t like the term “behavioral health,” but behavior can be measured, and we have precious few ways to measure progress and outcomes in psychiatry. Maybe pharmaceutical companies are abandoning drug development because they have been unsuccessful in developing novel medications in the last few decades, instead benefitting from serendipitous discoveries such as chlorpromazine. We may need new approaches to biologic treatments to progress any further, but this should not be surprising, given how difficult it is to access and study the brain
Steven Moffic, MD
Professor of Psychiatry
Medical College of Wisconsin
Milwaukee, WI
Focus on change
Dr. Nasrallah’s editorial (“A skeptical view of ‘progress’ in psychiatry,” From the Editor, Current Psychiatry, June 2011, p. 18-19) is intriguing because it summarized concerns I have seen frequently expressed in publications catering to psychiatrists. Since the advent of managed care, these kinds of “poor psychiatry” articles have appeared regularly.
Instead of bemoaning the lack of “progress” in psychiatry, perhaps Dr. Nasrallah would have been better served by focusing on change and its inevitability. I found it ridiculous he contrasted the “asylum era” with current practices in order to focus on length of stay. At that time, the mentally ill were—except for well-intentioned attempts at “cure” via “milieu therapy”—warehoused for years, if not lifetimes, under filthy conditions.
Dr. Nasrallah then segues into the expected attacks upon insurance companies, lack of parity, and drastically shortened lengths of stay. It is obvious 3 to 4 days of acute care generally is not sufficient for serious psychiatric conditions. As an experienced managed care and independent reviewer, I can assure Dr. Nasrallah such strict criteria sets are the minority. What about psychiatrists who keep patients until their insurance runs out or let relatively benign patients languish because they did not call attention to themselves and kept a bed filled? Contrary to Dr. Nasrallah’s assertion, judges and lawyers do not tell us how to practice medicine; they are part of a necessary system of checks and balances that, in a highly imperfect world, help prevent inappropriate or abusive practices by incompetent, uninvested, or morally deficient physicians, of which there are plenty.
Dr. Nasrallah should be aware terms such as “behavioral health” are largely the result of efforts to destigmatize mental illness, leading society to coin more politically correct and palatable terms for just about everything.
At no point does Dr. Nasrallah even hint at offering solutions. For example, psychiatrists have done next to nothing to educate the public about their profession. Meanwhile, a substantial number of prominent psychiatrists are more than happy to accept steak dinners and honoraria from drug companies, along with going out and speaking at free CME events, in order to oh-so-subtly hawk a medication that just happens to be manufactured by the company paying for the “free lunch.”
