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From the Editor

Let me tell you how I feel… (Things that nag at me)

Why have mentally ill outpatients become ‘clients,’ as if mental healthcare was a business transaction?

Vol. 8, No. 8 / August 2009

Every psychiatrist and mental health professional encourages patients to “express your feelings.” Venting produces a cathartic effect, especially if frustrations have been harbored for a while. So I thought I should practice what I preach and tell you some things that annoy me about the contemporary state of psychiatry, which might bother some of you as well.

  • Why have we allowed our patients to be relocated from hospitals to jails and prisons? How were the mentally ill transformed from “patients” to “felons?” State hospitals have been shuttered, but correctional facilities are a growth industry.
  • Why have community-based mentally ill patients become “clients,” as if mental healthcare was a business transaction? Would cardiologists or oncologists accept labeling their patients as “clients?” No chance!
  • Why did psychiatrists shed their white coats and psychiatric nurses replace their professional uniforms with street clothes? Medical attire used to serve as an important environmental cue that an inpatient ward was a “therapeutic facility.” Nowadays, hospitalized psychotic and bipolar patients think they are in a hotel (or, as one of my psychotic patients said recently, in a spaceship).
  • Why is it that the more powerful the evidence that mental illnesses are brain disorders with neurobiological roots, the more “demedicalized” the community mental health system has become?
  • Why don’t practitioners actively support research when they know that every treatment in clinical practice today was once a research project? The breakthrough treatments of tomorrow are being researched today. One simple way clinicians can help accelerate treatment discoveries is to refer patients to therapeutic clinical trials at local academic institutions.
  • When are we going to overcome bureaucratic obstacles and give our public sector seriously mentally ill patients the continuity of care they need and deserve? Changing psychiatrists frequently puts patients at risk for diagnostic and treatment errors, repeated mistakes, and difficulties building rapport and therapeutic alliances.
  • Why aren’t more psychiatrists collaborating actively with primary care providers? Up to 50% of chronically mentally ill individuals have serious medical conditions,1 and up to 50% of primary care patients have mental health problems.2 We desperately need an integrated, collaborative approach to mind-body illnesses.
  • Why have psychiatrists in community mental health settings been reduced to writing prescriptions and doing “med checks” during sessions too brief to allow for the optimal approach of integrating psychotherapy with psychopharmacology?
  • Why are politicians so callous about citizens’ health that they even consider granting the privilege to prescribe powerful, sometimes high-risk psychotropics to persons who have had no professional medical training?
  • Why is there so much criticism about off-label use of antidepressants, mood stabilizers, and atypical antipsychotics, when 85% of DSM-IV-TR psychiatric disorders do not have any FDA-approved drug treatment?3 Do “armchair critics” have a better idea for treating serious psychiatric disorders?
  • Why is there such a scarcity of long-term psychiatric beds for patients who need that type of supervised care? And why do we psychiatrists tolerate managed care policies that dictate discharging psychotic or suicidal inpatients after only 5 or 6 days of treatment?
  • Why does the stigma of mental illness persist, even though 75 million (1 in 4) Americans has a diagnosable mental disorder in any given year?4
  • Finally, why are we standing still when the dysfunctional public mental health system was declared “in shambles” in 2003 by the final report of the President’s New Freedom Commission on Mental Health?5

So there, I feel better sharing a few things that bug me. Feel free to share your gripes with me. Better still, let’s try to develop some solutions to these problems.


1. Toft T, Fink P, Oernboel E, et al. Mental disorders in primary care: prevalence and co-morbidity among disorders. Results from the functional illness in primary care (FIP) study. Psychol Med. 2005;35(8):1175-1184.

2. Koranyi EK. Somatic illness in psychiatric patients. Psychosomatics. 1980;21:887-891.

3. Devulapalli K, Nasrallah HA. An analysis of the high psychotropic off-label use in psychiatric disorders: the majority of psychiatric diagnoses have no approved drug. Asian J Psychiatry. 2009;2:29-36.

4. Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627.

5. President’s commission offers prescription for broken mental health system. Bazelon Center, NAMI, NASMHPD, NMHA call on Bush and Congress to take action. Available at: Accessed July 6, 2009.

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