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A broken system
I was relieved to see your article “I have a dream … for psychiatry” (From the Editor,
Psychiatry does need better treatments. On the other hand, we do have many effective treatments that simply are not available to many.
This brings me to ask, how is it that overall psychiatric care is actually worse now than in, say, the late 20th century? There might have been fewer psychopharmacologic treatments available back then, but there was overall better access to care, and a largely intact system. For lower-functioning patients, such as those who are homeless or in jail, I do believe this is the case, as I will explain. But even higher-functioning private practice patients are affected by the shortage of psychiatrists.
In 2022, the system is broken. Funding is abysmal, and numerous psychiatric hospital closures across the United States have led to simply no reasonable local access for many.
Prisons and jails are the new treatment centers! As you have rightly pointed out, by being housed in prisons with violent criminals, severely mentally ill patients are subjected to physical and sexual abuse daily.
Laws meant to protect mentally ill individuals, such as psychiatric holds, are often not implemented. Severely mentally ill patients can meet the criteria to be categorized as a danger to self, danger to others, or gravely disabled, but can’t get crisis intervention. Abandoning these patients to the streets is, in part, fueling homelessness and drug addiction.
In my opinion, the broken system is the fundamental problem that needs to be solved. Although I long for novel treatments, if there were such breakthrough treatments available—as exciting as that may be—how could they be delivered effectively in our current broken system? In other words, how can these patients be treated with neuroscientific breakthrough treatments without the necessary psychiatric infrastructure? We are at such an extreme, I worry for our specialty.
In Karl Menninger’s The Crime of Punishment, one passage stuck with me: “I suspect that all the crimes committed by all the jailed criminals do not equal in total social damage that of the crimes committed against them.”1 I have often wondered how that relates to the criminalized mentally ill, who are punished daily by being in horrific, abusive, unsafe settings. What truly is their crime? Being mentally ill?
Given how the system is now engineered to throw these patients in prison and allow them to be abused instead of admitting them to a psychiatric hospital, one must wonder: How did this come to be? Could it go beyond stigma to actual hatred and contempt for these people? After all, as psychiatrists, the abuse is in plain sight.
Finally, I have often wondered why there has not been a robust psychiatric organizational response to the breakdown in access to patient care. I can only hope that one day there can be.
Dr. Nasrallah responds
Thank you for your comments on my editorial. I sense that you are quite frustrated with the current status of psychiatry, and are longing for improvements.
I do share some of your concerns about: 1) society turning a blind eye to the mentally ill (and I have written about that from the angle of tragically high suicide rate1); 2) the hatred and contempt embedded within stigma of serious mental disorders; 3) the deplorable criminalization and trans-institutionalization of our patients from state hospitals to jails and prisons; 4) the shortage of acute psychiatric beds in many communities because the wards were converted to highly lucrative, procedure-oriented programs; 5) the dysfunctional public mental health system; and 6) the need for new and novel treatments.
However, despite those challenges, I remain optimistic that the future of psychiatry is bright because I keep abreast of the stunning neuroscience advances every day that will be translated into psychiatric treatments in the future. I envision a time when these brain research breakthroughs will lead to important clinical applications, such as a better diagnostic system using biomarkers (precision psychiatry), not just a cluster of clinical symptoms, and to brave new therapeutic interventions with superior efficacy and better safety. I would not be surprised if psychiatry and neurology will again merge after decades of separation, and that will certainly erase much of the stigma of disorders of the mind, which is the virtual brain.
Please hang in there, and do not let your patients perceive a sense of resignation and pessimism about psychiatry. Both our patients and psychiatrists need to be uplifted by hope for a better future.
1. Menninger K. The Crime of Punishment. Viking Adult; 1968.
2. Nasrallah HA. The scourge of societal anosognosia about the mentally ill. Current Psychiatry. 2016;15(6):19,23-24.
A broken system
I was relieved to see your article “I have a dream … for psychiatry” (From the Editor,
Psychiatry does need better treatments. On the other hand, we do have many effective treatments that simply are not available to many.
This brings me to ask, how is it that overall psychiatric care is actually worse now than in, say, the late 20th century? There might have been fewer psychopharmacologic treatments available back then, but there was overall better access to care, and a largely intact system. For lower-functioning patients, such as those who are homeless or in jail, I do believe this is the case, as I will explain. But even higher-functioning private practice patients are affected by the shortage of psychiatrists.
In 2022, the system is broken. Funding is abysmal, and numerous psychiatric hospital closures across the United States have led to simply no reasonable local access for many.
Prisons and jails are the new treatment centers! As you have rightly pointed out, by being housed in prisons with violent criminals, severely mentally ill patients are subjected to physical and sexual abuse daily.
Laws meant to protect mentally ill individuals, such as psychiatric holds, are often not implemented. Severely mentally ill patients can meet the criteria to be categorized as a danger to self, danger to others, or gravely disabled, but can’t get crisis intervention. Abandoning these patients to the streets is, in part, fueling homelessness and drug addiction.
In my opinion, the broken system is the fundamental problem that needs to be solved. Although I long for novel treatments, if there were such breakthrough treatments available—as exciting as that may be—how could they be delivered effectively in our current broken system? In other words, how can these patients be treated with neuroscientific breakthrough treatments without the necessary psychiatric infrastructure? We are at such an extreme, I worry for our specialty.
In Karl Menninger’s The Crime of Punishment, one passage stuck with me: “I suspect that all the crimes committed by all the jailed criminals do not equal in total social damage that of the crimes committed against them.”1 I have often wondered how that relates to the criminalized mentally ill, who are punished daily by being in horrific, abusive, unsafe settings. What truly is their crime? Being mentally ill?
Given how the system is now engineered to throw these patients in prison and allow them to be abused instead of admitting them to a psychiatric hospital, one must wonder: How did this come to be? Could it go beyond stigma to actual hatred and contempt for these people? After all, as psychiatrists, the abuse is in plain sight.
Finally, I have often wondered why there has not been a robust psychiatric organizational response to the breakdown in access to patient care. I can only hope that one day there can be.
Dr. Nasrallah responds
Thank you for your comments on my editorial. I sense that you are quite frustrated with the current status of psychiatry, and are longing for improvements.
I do share some of your concerns about: 1) society turning a blind eye to the mentally ill (and I have written about that from the angle of tragically high suicide rate1); 2) the hatred and contempt embedded within stigma of serious mental disorders; 3) the deplorable criminalization and trans-institutionalization of our patients from state hospitals to jails and prisons; 4) the shortage of acute psychiatric beds in many communities because the wards were converted to highly lucrative, procedure-oriented programs; 5) the dysfunctional public mental health system; and 6) the need for new and novel treatments.
However, despite those challenges, I remain optimistic that the future of psychiatry is bright because I keep abreast of the stunning neuroscience advances every day that will be translated into psychiatric treatments in the future. I envision a time when these brain research breakthroughs will lead to important clinical applications, such as a better diagnostic system using biomarkers (precision psychiatry), not just a cluster of clinical symptoms, and to brave new therapeutic interventions with superior efficacy and better safety. I would not be surprised if psychiatry and neurology will again merge after decades of separation, and that will certainly erase much of the stigma of disorders of the mind, which is the virtual brain.
Please hang in there, and do not let your patients perceive a sense of resignation and pessimism about psychiatry. Both our patients and psychiatrists need to be uplifted by hope for a better future.
A broken system
I was relieved to see your article “I have a dream … for psychiatry” (From the Editor,
Psychiatry does need better treatments. On the other hand, we do have many effective treatments that simply are not available to many.
This brings me to ask, how is it that overall psychiatric care is actually worse now than in, say, the late 20th century? There might have been fewer psychopharmacologic treatments available back then, but there was overall better access to care, and a largely intact system. For lower-functioning patients, such as those who are homeless or in jail, I do believe this is the case, as I will explain. But even higher-functioning private practice patients are affected by the shortage of psychiatrists.
In 2022, the system is broken. Funding is abysmal, and numerous psychiatric hospital closures across the United States have led to simply no reasonable local access for many.
Prisons and jails are the new treatment centers! As you have rightly pointed out, by being housed in prisons with violent criminals, severely mentally ill patients are subjected to physical and sexual abuse daily.
Laws meant to protect mentally ill individuals, such as psychiatric holds, are often not implemented. Severely mentally ill patients can meet the criteria to be categorized as a danger to self, danger to others, or gravely disabled, but can’t get crisis intervention. Abandoning these patients to the streets is, in part, fueling homelessness and drug addiction.
In my opinion, the broken system is the fundamental problem that needs to be solved. Although I long for novel treatments, if there were such breakthrough treatments available—as exciting as that may be—how could they be delivered effectively in our current broken system? In other words, how can these patients be treated with neuroscientific breakthrough treatments without the necessary psychiatric infrastructure? We are at such an extreme, I worry for our specialty.
In Karl Menninger’s The Crime of Punishment, one passage stuck with me: “I suspect that all the crimes committed by all the jailed criminals do not equal in total social damage that of the crimes committed against them.”1 I have often wondered how that relates to the criminalized mentally ill, who are punished daily by being in horrific, abusive, unsafe settings. What truly is their crime? Being mentally ill?
Given how the system is now engineered to throw these patients in prison and allow them to be abused instead of admitting them to a psychiatric hospital, one must wonder: How did this come to be? Could it go beyond stigma to actual hatred and contempt for these people? After all, as psychiatrists, the abuse is in plain sight.
Finally, I have often wondered why there has not been a robust psychiatric organizational response to the breakdown in access to patient care. I can only hope that one day there can be.
Dr. Nasrallah responds
Thank you for your comments on my editorial. I sense that you are quite frustrated with the current status of psychiatry, and are longing for improvements.
I do share some of your concerns about: 1) society turning a blind eye to the mentally ill (and I have written about that from the angle of tragically high suicide rate1); 2) the hatred and contempt embedded within stigma of serious mental disorders; 3) the deplorable criminalization and trans-institutionalization of our patients from state hospitals to jails and prisons; 4) the shortage of acute psychiatric beds in many communities because the wards were converted to highly lucrative, procedure-oriented programs; 5) the dysfunctional public mental health system; and 6) the need for new and novel treatments.
However, despite those challenges, I remain optimistic that the future of psychiatry is bright because I keep abreast of the stunning neuroscience advances every day that will be translated into psychiatric treatments in the future. I envision a time when these brain research breakthroughs will lead to important clinical applications, such as a better diagnostic system using biomarkers (precision psychiatry), not just a cluster of clinical symptoms, and to brave new therapeutic interventions with superior efficacy and better safety. I would not be surprised if psychiatry and neurology will again merge after decades of separation, and that will certainly erase much of the stigma of disorders of the mind, which is the virtual brain.
Please hang in there, and do not let your patients perceive a sense of resignation and pessimism about psychiatry. Both our patients and psychiatrists need to be uplifted by hope for a better future.
1. Menninger K. The Crime of Punishment. Viking Adult; 1968.
2. Nasrallah HA. The scourge of societal anosognosia about the mentally ill. Current Psychiatry. 2016;15(6):19,23-24.
1. Menninger K. The Crime of Punishment. Viking Adult; 1968.
2. Nasrallah HA. The scourge of societal anosognosia about the mentally ill. Current Psychiatry. 2016;15(6):19,23-24.