From the Editor

Your vote, please: What’s ailing psychiatry?

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Rank 17 challenges to psychiatry on a scale from 10 (highest importance) to 1 (lowest importance)


Psychiatry has become a mature neuroscience discipline and medical specialty, helping millions of Americans suffering from mental illness. Neurobiologic and psychosocial research into causes of and treatments for psychiatric brain disorders is booming, and molecular genetic discoveries promise unprecedented insights into the neural mechanisms of thought, feeling, emotional, behavioral, and cognitive disturbances.

As psychiatry’s promise grows, however, so do its frustrations. I list here 17 challenges psychiatrists face, and I would like to know how important you feel each challenge is to our profession.

Please visit the HTML version of this article to rank each challenge from 10 (highest importance) to 1 (lowest importance). To add other challenges not on my list, simply use the comments field at the bottom of the survey. We will share the results with you in Current Psychiatry, and you can compare your opinions with those of your colleagues.

  1. Still-elusive pathophysiology of psychiatric disorders, despite the abundance of new knowledge.
  2. Lack of an objective diagnostic schema, including laboratory tests to confirm diagnoses.
  3. High rates of off-label psychotropic use because >80% of DSM-IV-TR psychiatric disorders have no approved medications and practitioners have few options.
  4. Tightening regulations, suffocating litigation, and a demoralized drug-discovery industry that have blunted innovation and threaten drug development.
  5. Limited evidence-based psychotherapy research, compared with controlled FDA trials for drug therapy or medical devices.
  6. Persistent stigma of mental illness interfering with prevention and early intervention.
  7. Lack of full parity for mental illness with physical illness.
  8. Excessive, harmful intrusion of the courts into psychiatric care, more than any other medical specialty.
  9. A “broken” public mental health system with red tape, inadequate funding, nonevidence-based treatments, homelessness, drug abuse, and lack of primary care.
  10. Far less private philanthropy bestowed on psychiatry compared with cancer, cardiology, or other medical specialities.
  11. Shrinking funds for psychiatric research because of National Institutes of Health belt-tightening and dwindling of unrestricted pharmaceutical industry research grants.
  12. Atrociously low compensation for psychiatrists, with hourly earnings a fraction of those for procedural specialists (such as surgeons or radiologists), although the years of training are similar.
  13. Unreimbursed time spent on paperwork or phone calls related to patient care.
  14. Little time to read journals or attend continuing medical education meetings to keep up with rapid advances in psychiatry.
  15. Lack of primary care for the seriously mentally ill because of barriers to collaborative care between psychiatrists and primary care providers.
  16. Shortage of psychiatric beds, both acute and longterm, and a ridiculously brief length of stay for psychotic or suicidal patients.
  17. Too few academic psychiatrists to train and mentor young clinicians, researchers, and educators who represent the cutting edge of the speciality.

I am very interested in knowing your opinions. Ranking the importance of these challenges may be a sobering task, but problem solving always starts by assessing the challenges and developing strategies to address them in a targeted, systematic manner.

Finally, it is interesting that while there is a serious national shortage of psychiatrists, there is certainly no shortage of challenges. Psychiatrists, patients, families, and advocates should combine their efforts to find effective solutions, one challenge at a time.

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