From the Editor
A skeptical view of ‘progress’ in psychiatry
For psychiatry, progress isn’t what it used to be
Everybody loves progress. People feel uplifted by the notion of progress, by the dynamic feeling it evokes of “moving forward,” of achieving new milestones and reaching new heights. Progress implies improvement in the human condition and an upgrade in quality of life. In medical disciplines such as psychiatry, it connotes less suffering, better treatments, more hope, improved social and vocational functioning, and full restoration of wellness.
But let’s be realistic. Overall evolution of psychiatry is not as “progressive” as we like to believe. Yes, there are thrilling breakthroughs in basic neuroscience research and understanding brain structure and function at the cellular and molecular levels. However, in many other areas of psychiatric practice, I feel we have moved backward since I began my career 3 decades ago. Egress, not progress, appears to be the state of psychiatry. In a tango-like fashion, psychiatry seems to take 1 step forward on 1 level (science and discovery) and 2 steps back on another level (practice realities). As an optimistic person, it pains me to admit that we have moved backward in several aspects of psychiatry:
- The discovery of chlorpromazine, the first antipsychotic, was a miraculous event for our field, but was it “progress” for our patients? Their symptoms improved partially but they developed serious side effects and remained functionally disabled throughout their lives. Patients were “freed” from locked hospital wards, then hurled into a poorly prepared and under-resourced community mental health care system, resulting in revolving door relapses, extensive drug abuse, rampant stigma, abject poverty, physical neglect, early death, homelessness, and for many psychiatric patients, incarceration in jails and prisons, an environment more restrictive than the reviled asylums. Our patients who were medically ill individuals cared for by doctors, nurses, and other health professionals are now lowly felons. It seems that those unfortunate enough to suffer from a psychotic brain disorder are destined to be further punished for it, a great injustice in the name of “progress.”
- Insurance hassles for serious mental illness did not exist in the asylum era. If an individual developed a psychotic disorder, he or she was admitted to the nearest state hospital without hesitation and provided medical and psychosocial care, even if the stay lasted months or years. Now, the same patient cannot afford psychiatric hospitalization even if he or she has “health insurance” (a euphemism for “restricted health coverage”). Equality of psychiatric disorders with other medical and surgical disorders remains a farce, and the lack of parity for mental illness has deprived millions of patients from adequate care. How many victims of mental illness have suffered or died in the name of “progress” in the health insurance industry?
- Who is the “genius” who stipulated that a psychotic, bipolar, suicidal, or homicidal patient could be effectively treated after 3 to 4 days of hospitalization? How did patients become widgets on an assembly line? Medical students and residents on inpatient wards no longer have the rewarding experience or witnessing full improvement in their patients. Is it progress when a patient with schizophrenia or severe depression is discharged after barely 30% to 40% improvement in symptoms? No wonder relapse, suicide, and homicide rates are very high in the 3 weeks after discharge. Long-term hospitals, the last refuge for severely disabled patients who cannot care for themselves, now are rare. Is that progress?
- Why are psychiatrists shackled by more legal constraints than physicians in other medical specialties? Why should lawyers and judges tell us how to practice medicine and who, when, and how to treat? Legal progress sounds like an oxymoron to me.
- Why is the public mental health system so broken in every state? Why is it so ineffective, chaotic, underfunded, hard to navigate, and demedicalized? Why have psychiatrists—the traditional leaders in mental health—been marginalized to sign prescriptions instead of being executives and policy-setters for mental illness? Respiratory and physical therapists have important roles but the pulmonologist or the orthopedist runs the clinic. Why is it not so in public psychiatry? This is not progress, but a travesty.
- Why is psychiatry now referred to as “behavioral health”? Who decided to fix the name of psychiatric care when the original term is much more comprehensive, factual, and inclusive and uses medical terminology (iatros = “healer” or “medicine”). It is not progress to reduce to “behavior” psychiatric illnesses that involve a broad spectrum of pathologies, including thought disorders, mood disorders, perceptual disorders, cognitive disorders, pain, addictions, and many general medical conditions that manifest with psychiatric signs and symptoms. Redefining psychiatric care with inaccurate terminology certainly is not progress.
- Why are pharmaceutical companies, the only source of drug development, abandoning CNS research? Is it because cardiovascular, oncologic, and GI drugs are more profitable and less “challenging” to develop? Is it progress to turn away from the most critical medical frontier, the human brain, and its diseases? At a time when 80% of psychiatric disorders have no approved medication, it is inexcusable to shirk from discovering drugs that trigger hope for recovery for patients with untreatable mental illness.
Ogden Nash once wrote: “Progress might have been all right once, but it has gone on too long.” I will add to that for psychiatry, progress isn’t what it used to be.