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Saturday, June 4, 2011

The State of Psychiatric Treatment: Then and Now

The following is an article that was posted on the site's forum and then will follow some of the discussion that took place. What is your take on this question?

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A skeptical view of ‘progress’ in psychiatry
Henry A. Nasrallah, MD
Editor-in-Chief “Current Psychiatry”
Editorial from June 2011 issue

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


One of the forum's participants responded with the following comment:

...what a depressing article from such an unexpected source. I'm not even sure where to start.

1) I do not believe we would be better back in the "asylum days". I think the abandonment of the asylum was a good thing.
2) Anti-psychotic drugs help people more than the author will admit.
3) I think an insurance system designed to keep you away from being hospitalized for "months to years" is a good thing.
4) The local hospital is designed to cover the crisis a patient is going through. It's not for long term treatment.
5) There are more legal constraints on a psychiatrist because they aren't dealing with visible physical injuries like a broken leg.They're also dealing with incarceration and often treatment against a patent's wishes. People with broken legs don't refuse treatment.

Jeez, I could go on because I disagree with almost ever thing this guy says. It's not that bad out there and people are getting better. Good lord is it better than the days of the asylums.

And here were my thoughts:

I agree with you...asylums aren't the answer....but if it takes a person longer than exactly 30 days to come out of an episode, there should be more options available....

I agree with you that long term hospitalization is not always necessary or desirable. When I was 19 I spent 14 months in a hospital and had, I think, two or three other 6 month long stays. The 14 month one was a waste of taxpayer's money...but actually, both of the 6 month-ers were pretty much who's to say what the limit of time spent in hospital should be? There's a difference between receiving treatment and expensive housing. And it is a tough call for the insurance companies to make to determine which is taking place on an individual level. So I believe that rather than struggle with that question and the abuses and insurance fraud that I'm sure took place, they erred on the "safe" side (safe for them, note) and just said 30 days max. Period.

And yeah for some people, it sucks. And it puts pressure on social workers etc in the hospitals, often to arrange for living and treatment situations quickly...and I think that because of the difficulty of that, they just don't even really try to do that any more or to get heavily involved with the aftercare plan. And unfortunately, this may have resulted in a greater percentage of homelessness and suicides than would have occurred should adequate plans have been in place.

You're right , a lot can be said about it...on both sides of the argument (between long and short term care.) As far as "asylums" : I don't think ANYONE is arguing for that to return....except this article.

And as far as medical advances:? I had been treated on EVERY single antidepressant and antipsychotic drug available back in the 80's at unbelievably high no avail....The drugs simply weren't available then which would help me. Thank God for the advances in this area....while not ideal, they are a far cry from the misery I was in back then.

However I do agree that the term "Behavioral Health" is misleading in a very negative sense. It relegates a serious mental and physical illness to a matter of mere behavior, implying that perhaps all that's needed is a "smack on the hand" or retraining and the problem will resolve or go away. This is a fallacy; and a dangerous one.

It will not be until Schizophrenia is seen as a serious brain disease, that funding, research and a cure will be found....Too many people call mental illness "emotional illness" or "emotional problems " and think that it is an equivalent term. No amount of effort, therapy, or rehabilitation is going to cure schizophrenia or reverse it's damage. This is a common misconception and is reiterated by such terms as "behavioral health" and it perpetrates and perpetuates a common public misunderstanding of a devastating illness leading to even greater misery among the population who suffer from it.
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