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Comments and Controversies

Focus on change

Vol. 10, No. 08 / August 2011

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.”

Forget about judges and lawyers “telling us how to practice.” What about “Big Pharma” manipulating us and advertising on television, urging viewers to “talk to their doctor” about medication X? Dr. Nasrallah is preaching to the choir here. What we need is less breast-beating and more constructive action.

Edward W. Darell, MD
Psychiatrist, Private Practice
New York, NY

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