Unresolved questions about the specialty lurk in the cortex of psychiatrists

But many of our own questions await an answer. The fact is that psychiatrists have serious, nagging questions—in every cortical fold of their collective brain—about patients’ welfare, psychiatric practice, and professional matters. Their questions about frustrations of daily practice deserve an honest and convincing response, yet go begging—expressed so well in songwriter Bob Dylan’s lyric, “The answer is blowin’ in the wind.”

What follows are long-standing “Why?” questions whose answers are still blowin’ in the wind. (Dylan didn’t specify which wind is blowin’, so I’ve provided the names of 22 atmospheric movements of air molecules in the Box. Take your pick!)

Why is a jail OK for the mentally ill but an asylum is not? Why is it necessary to put armed guards in charge of psychiatric patients instead of a multi­disciplinary team of psychiatrists, primary care providers, nurses, social workers, psychologists, and pharmacists? Why has a brain disease, such as psychosis or bipolar disorder, become a punishable felony instead of a treatable illness?

Why did the system of mental health care degenerate to the point that a severely depressed or suicidal, or acutely psychotic, patient can be hospitalized for only 4 or 5 days, then must be discharged before her (his) illness has been fully controlled? Why do health care insurers exhibit that atrocious combination of maximum greed and minimal compassion?

Why does a completely unjustified and hurtful stigma continue to plague mental brain disorders, patients who suffer from them, mental health professionals, and the very discipline of psychiatry?

Why do otherwise intelligent people show compassion toward people with a brain disorder such as stroke, Parkinson’s disease, multiple sclerosis, myasthenia gravis, or migraine, but express aversion and even disdain for psychiatric brain disorders such as schizophrenia, depression, obsessive-compulsive disorder, and panic disorder?

And why does this prejudice persist despite advances in psychiatric neuroscience that have used neurogenetics, neuroimaging, and molecular studies to establish, without a doubt, the neurobiological basis of all psychiatric disorders.

Why are there still no objective diagnostic criteria for psychiatric disorders? Why do we persist in using defining symptoms that have been volunteered by patients—symptoms that can be subject to distortion or malingering? Why aren’t the hundreds of established biomarkers being incorporated into the diagnostic formulation, to lessen subjectivity and improve reliability and validity?

Why is off-label prescribing, the judicious clinical repurposing of psychotropic medications, criticized and panned, even though there are no approved drugs for 88.5% psychiatric diagnoses?¹ Why allow insurers to refuse to pay for a medication that can help a patient, just because the patient has not been given the “official” diagnosis for which the FDA approved that drug?

And why doesn’t the FDA solve this problem by revising its requirements that registration trials for new medications test their efficacy for a single symptom, rather than a diagnosis comprising multiple symptoms?

Why do people not accept the fact that all drugs have benefits and risks, and that it is impossible to have pure efficacy without side effects? Why empower lawyers to make clinical care adversarial? Why do lawyers refrain from suing oncologists or manufacturers of life-saving chemotherapy drugs because of terrible adverse effects, but pounce on other medications that might cause a serious side effect in a tiny percentage of patients that is clearly spelled out in the package insert?

Why do people demonize the pharmaceutical industry far more than other industries? No other entity discovers and develops life-saving medications.

Why don’t people realize that, without medications, massive numbers of patients would be hospitalized and the death rate would rise? Why can’t people weigh risks and benefits of having a pharmaceutical industry, just as they assess the risk-benefit ratio of everything in life?

Should the government impose a massive ($1 or $2 trillion) tax hike to establish infrastructure for drug research and development, for the benefit of psychiatry and all other medical specialties?

Why is there a severe shortage of psychiatrists but a glut of lawyers? Why doesn’t society rationally deploy its resources to meet urgent social needs and priorities? And why do lawyers bill us for every minute we talk to them, while we field telephone calls and e-mail messages from patients without compensation?

Why did the FDA allow the pharmaceutical industry to develop direct-to-consumer advertising? Why do they not realize how that decision has complicated the doctor–patient relationship, and how it preempts physicians’ evidence-based decision-making by encouraging consumers to demand a drug that they saw on television—a contorted version of prescribing by proxy?

Why (speaking of prescribing without a license), do politicians pass laws allowing people who do not have required medical training to take a short-cut to becoming a prescriber? Why not mandate that politicians, and their families, receive medical care exclusively from unqualified practitioners on whom they bestow prescribing privileges without requisite comprehensive medical training?Why do some psychiatrists resist changing their practice patterns despite continuous advances that update the care they provide? Why do reports of exciting therapeutic breakthroughs, published in top-tier journals, go unread by so many practitioners? Why do they say they are too busy to read journals or peruse PubMed?

Why don’t people realize that today’s research is tomorrow’s treatment? That research is not a luxury but an ongoing necessity? Why don’t more freshly minted, young psychiatrists pursue a career in research to accelerate the pace of progress about the biological causes and treatments of serious psychiatric disorders? Why aren’t there more incentives to grow the next generation of psychiatric discoverers and Nobel laureates? Why don’t clinicians support research by referring patients to clinical trials of medications or to National Institutes of Health-funded investigations of the neurobiology of psychiatric disorders?

Are these just rhetorical questions?
Some might sound that way. But they are not. These questions are brewing inside the hearts and minds of many psychiatrists, although only a few seem determined to relentlessly seek answers on which medical science and society can act.

We should collectively pose these “why” questions and not accept long-winded, hollow answers. We need to foster the winds of change—not resign ourselves to winds in which answers blow about but, ultimately, disappear.

But many of our own questions await an answer. The fact is that psychiatrists have serious, nagging questions—in every cortical fold of their collective brain—about patients’ welfare, psychiatric practice, and professional matters. Their questions about frustrations of daily practice deserve an honest and convincing response, yet go begging—expressed so well in songwriter Bob Dylan’s lyric, “The answer is blowin’ in the wind.”

What follows are long-standing “Why?” questions whose answers are still blowin’ in the wind. (Dylan didn’t specify which wind is blowin’, so I’ve provided the names of 22 atmospheric movements of air molecules in the Box. Take your pick!)

Why is a jail OK for the mentally ill but an asylum is not? Why is it necessary to put armed guards in charge of psychiatric patients instead of a multi­disciplinary team of psychiatrists, primary care providers, nurses, social workers, psychologists, and pharmacists? Why has a brain disease, such as psychosis or bipolar disorder, become a punishable felony instead of a treatable illness?

Why did the system of mental health care degenerate to the point that a severely depressed or suicidal, or acutely psychotic, patient can be hospitalized for only 4 or 5 days, then must be discharged before her (his) illness has been fully controlled? Why do health care insurers exhibit that atrocious combination of maximum greed and minimal compassion?

Why does a completely unjustified and hurtful stigma continue to plague mental brain disorders, patients who suffer from them, mental health professionals, and the very discipline of psychiatry?

Why do otherwise intelligent people show compassion toward people with a brain disorder such as stroke, Parkinson’s disease, multiple sclerosis, myasthenia gravis, or migraine, but express aversion and even disdain for psychiatric brain disorders such as schizophrenia, depression, obsessive-compulsive disorder, and panic disorder?

And why does this prejudice persist despite advances in psychiatric neuroscience that have used neurogenetics, neuroimaging, and molecular studies to establish, without a doubt, the neurobiological basis of all psychiatric disorders.

Why are there still no objective diagnostic criteria for psychiatric disorders? Why do we persist in using defining symptoms that have been volunteered by patients—symptoms that can be subject to distortion or malingering? Why aren’t the hundreds of established biomarkers being incorporated into the diagnostic formulation, to lessen subjectivity and improve reliability and validity?

Why is off-label prescribing, the judicious clinical repurposing of psychotropic medications, criticized and panned, even though there are no approved drugs for 88.5% psychiatric diagnoses?¹ Why allow insurers to refuse to pay for a medication that can help a patient, just because the patient has not been given the “official” diagnosis for which the FDA approved that drug?

And why doesn’t the FDA solve this problem by revising its requirements that registration trials for new medications test their efficacy for a single symptom, rather than a diagnosis comprising multiple symptoms?

Why do people not accept the fact that all drugs have benefits and risks, and that it is impossible to have pure efficacy without side effects? Why empower lawyers to make clinical care adversarial? Why do lawyers refrain from suing oncologists or manufacturers of life-saving chemotherapy drugs because of terrible adverse effects, but pounce on other medications that might cause a serious side effect in a tiny percentage of patients that is clearly spelled out in the package insert?

Why do people demonize the pharmaceutical industry far more than other industries? No other entity discovers and develops life-saving medications.

Why don’t people realize that, without medications, massive numbers of patients would be hospitalized and the death rate would rise? Why can’t people weigh risks and benefits of having a pharmaceutical industry, just as they assess the risk-benefit ratio of everything in life?

Should the government impose a massive ($1 or $2 trillion) tax hike to establish infrastructure for drug research and development, for the benefit of psychiatry and all other medical specialties?

Why is there a severe shortage of psychiatrists but a glut of lawyers? Why doesn’t society rationally deploy its resources to meet urgent social needs and priorities? And why do lawyers bill us for every minute we talk to them, while we field telephone calls and e-mail messages from patients without compensation?

Why did the FDA allow the pharmaceutical industry to develop direct-to-consumer advertising? Why do they not realize how that decision has complicated the doctor–patient relationship, and how it preempts physicians’ evidence-based decision-making by encouraging consumers to demand a drug that they saw on television—a contorted version of prescribing by proxy?

Why (speaking of prescribing without a license), do politicians pass laws allowing people who do not have required medical training to take a short-cut to becoming a prescriber? Why not mandate that politicians, and their families, receive medical care exclusively from unqualified practitioners on whom they bestow prescribing privileges without requisite comprehensive medical training?Why do some psychiatrists resist changing their practice patterns despite continuous advances that update the care they provide? Why do reports of exciting therapeutic breakthroughs, published in top-tier journals, go unread by so many practitioners? Why do they say they are too busy to read journals or peruse PubMed?

Why don’t people realize that today’s research is tomorrow’s treatment? That research is not a luxury but an ongoing necessity? Why don’t more freshly minted, young psychiatrists pursue a career in research to accelerate the pace of progress about the biological causes and treatments of serious psychiatric disorders? Why aren’t there more incentives to grow the next generation of psychiatric discoverers and Nobel laureates? Why don’t clinicians support research by referring patients to clinical trials of medications or to National Institutes of Health-funded investigations of the neurobiology of psychiatric disorders?

Are these just rhetorical questions?
Some might sound that way. But they are not. These questions are brewing inside the hearts and minds of many psychiatrists, although only a few seem determined to relentlessly seek answers on which medical science and society can act.

We should collectively pose these “why” questions and not accept long-winded, hollow answers. We need to foster the winds of change—not resign ourselves to winds in which answers blow about but, ultimately, disappear.

But many of our own questions await an answer. The fact is that psychiatrists have serious, nagging questions—in every cortical fold of their collective brain—about patients’ welfare, psychiatric practice, and professional matters. Their questions about frustrations of daily practice deserve an honest and convincing response, yet go begging—expressed so well in songwriter Bob Dylan’s lyric, “The answer is blowin’ in the wind.”

What follows are long-standing “Why?” questions whose answers are still blowin’ in the wind. (Dylan didn’t specify which wind is blowin’, so I’ve provided the names of 22 atmospheric movements of air molecules in the Box. Take your pick!)

Why is a jail OK for the mentally ill but an asylum is not? Why is it necessary to put armed guards in charge of psychiatric patients instead of a multi­disciplinary team of psychiatrists, primary care providers, nurses, social workers, psychologists, and pharmacists? Why has a brain disease, such as psychosis or bipolar disorder, become a punishable felony instead of a treatable illness?

Why did the system of mental health care degenerate to the point that a severely depressed or suicidal, or acutely psychotic, patient can be hospitalized for only 4 or 5 days, then must be discharged before her (his) illness has been fully controlled? Why do health care insurers exhibit that atrocious combination of maximum greed and minimal compassion?

Why does a completely unjustified and hurtful stigma continue to plague mental brain disorders, patients who suffer from them, mental health professionals, and the very discipline of psychiatry?

Why do otherwise intelligent people show compassion toward people with a brain disorder such as stroke, Parkinson’s disease, multiple sclerosis, myasthenia gravis, or migraine, but express aversion and even disdain for psychiatric brain disorders such as schizophrenia, depression, obsessive-compulsive disorder, and panic disorder?

And why does this prejudice persist despite advances in psychiatric neuroscience that have used neurogenetics, neuroimaging, and molecular studies to establish, without a doubt, the neurobiological basis of all psychiatric disorders.

Why are there still no objective diagnostic criteria for psychiatric disorders? Why do we persist in using defining symptoms that have been volunteered by patients—symptoms that can be subject to distortion or malingering? Why aren’t the hundreds of established biomarkers being incorporated into the diagnostic formulation, to lessen subjectivity and improve reliability and validity?

Why is off-label prescribing, the judicious clinical repurposing of psychotropic medications, criticized and panned, even though there are no approved drugs for 88.5% psychiatric diagnoses?¹ Why allow insurers to refuse to pay for a medication that can help a patient, just because the patient has not been given the “official” diagnosis for which the FDA approved that drug?

And why doesn’t the FDA solve this problem by revising its requirements that registration trials for new medications test their efficacy for a single symptom, rather than a diagnosis comprising multiple symptoms?

Why do people not accept the fact that all drugs have benefits and risks, and that it is impossible to have pure efficacy without side effects? Why empower lawyers to make clinical care adversarial? Why do lawyers refrain from suing oncologists or manufacturers of life-saving chemotherapy drugs because of terrible adverse effects, but pounce on other medications that might cause a serious side effect in a tiny percentage of patients that is clearly spelled out in the package insert?

Why do people demonize the pharmaceutical industry far more than other industries? No other entity discovers and develops life-saving medications.

Why don’t people realize that, without medications, massive numbers of patients would be hospitalized and the death rate would rise? Why can’t people weigh risks and benefits of having a pharmaceutical industry, just as they assess the risk-benefit ratio of everything in life?

Should the government impose a massive ($1 or $2 trillion) tax hike to establish infrastructure for drug research and development, for the benefit of psychiatry and all other medical specialties?

Why is there a severe shortage of psychiatrists but a glut of lawyers? Why doesn’t society rationally deploy its resources to meet urgent social needs and priorities? And why do lawyers bill us for every minute we talk to them, while we field telephone calls and e-mail messages from patients without compensation?

Why did the FDA allow the pharmaceutical industry to develop direct-to-consumer advertising? Why do they not realize how that decision has complicated the doctor–patient relationship, and how it preempts physicians’ evidence-based decision-making by encouraging consumers to demand a drug that they saw on television—a contorted version of prescribing by proxy?

Why (speaking of prescribing without a license), do politicians pass laws allowing people who do not have required medical training to take a short-cut to becoming a prescriber? Why not mandate that politicians, and their families, receive medical care exclusively from unqualified practitioners on whom they bestow prescribing privileges without requisite comprehensive medical training?Why do some psychiatrists resist changing their practice patterns despite continuous advances that update the care they provide? Why do reports of exciting therapeutic breakthroughs, published in top-tier journals, go unread by so many practitioners? Why do they say they are too busy to read journals or peruse PubMed?

Why don’t people realize that today’s research is tomorrow’s treatment? That research is not a luxury but an ongoing necessity? Why don’t more freshly minted, young psychiatrists pursue a career in research to accelerate the pace of progress about the biological causes and treatments of serious psychiatric disorders? Why aren’t there more incentives to grow the next generation of psychiatric discoverers and Nobel laureates? Why don’t clinicians support research by referring patients to clinical trials of medications or to National Institutes of Health-funded investigations of the neurobiology of psychiatric disorders?

Are these just rhetorical questions?
Some might sound that way. But they are not. These questions are brewing inside the hearts and minds of many psychiatrists, although only a few seem determined to relentlessly seek answers on which medical science and society can act.

We should collectively pose these “why” questions and not accept long-winded, hollow answers. We need to foster the winds of change—not resign ourselves to winds in which answers blow about but, ultimately, disappear.