Has Medicine Lost Its Mind? Why Our Mental Health System Is Failing Us and What Should Be Done to Cure It

Book Title: Has Medicine Lost Its Mind? Why Our Mental Health System Is Failing Us and What Should Be Done to Cure It

Author: Robert C. Smith, MD

Publication Details: Prometheus Books, 2025, 200 pp., $28.95 hardcover

Although half of all patients presenting for health care have some mental health issue (either primary or concurrent with a medical condition), less than 5% of training during medical school is devoted to behavioral sciences. Robert C. Smith, MD, is a physician educator who has devoted his career to developing and teaching an evidence-based approach to communicating with patients about psychosocial and behavioral problems. He has conducted clinical trials and authored two textbooks in these areas.^1,2 In this new book, he has crafted a provocative manifesto addressing why and how health care professionals should better incorporate biopsychosocial care into their practice. Targeted at physicians, Smith’s treatise speaks to health care professionals of all disciplines. No clinician can spend a day in the office or hospital without coming across the problems highlighted in this book at least twice in the morning and twice in the afternoon.

Importantly, this is not a textbook about how to treat mental health conditions but instead an engaging discourse on caring for individuals with mental health concerns—reminiscient of Common Sense in which Thomas Paine made a concise yet impassioned callout for changing the old order.³ Even for readers with more than an average interest in mental health, this book’s teaching cases, facts about mental health care in the United States and the roller coaster history of the biopsychosocial model, and strategies to improve our training of students and our care of patients will be enlightening.

Chapters 1–3 blend selected but salient data about problems in mental health care with illustrative case vignettes drawn from Smith’s teaching and practice. While cases can be overused as a teaching tool, this book has the right number (eight) coupled with the poignant details to make the cases complementary to Smith’s major themes. Chapters 4–6 provide a historical perspective from Herodotus through Galen, Vesalius, Descartes, and Flexner, illustrating how medicine has seesawed between integrating and dividing the body and mind in terms of science, clinical care, and reimbursement. George Engel (with whom Smith trained) attempted to change the paradigm in 1977 by introducing the biopsychosocial model,⁴ which was initially met with enthusiasm but has seen only faltering progress in its adoption in the past five decades. Chapters 7–8 review the barriers to adoption and suggest specific steps for integrating mental health with medical care. The book is thoroughly referenced and has three appendices, including a particularly strong one on training health care providers.

Because of its brevity as well as its applicability to all health care professionals, Smith’s monograph could easily be assigned in an appropriate elective as a reading assignment (rather than a reference book) followed by a 60- to 90 minute discussion group 1 week later. This book could also find a receptive audience among the general public, wherein most have had some firsthand experience with mental health concerns for themselves, family, friends, neighbors, or coworkers. Notable is that the triad of mental health, substance use, and chronic pain conditions central to this book account for twice as much disability as the other 11 leading medical conditions combined (19.8 vs 8.8 million years lived with disability). The bit part allotted to mental disorders in clinical training despite their prevalence, impairment, and economic costs is as misplaced as it would be to give lip service to diabetes, heart disease, or cancer.

Whereas Smith attributes much of the problem to core issues such as inadequate clinician training in mental health and stigma, also important is that the listening to patients approach of his solution is inadequately reimbursed relative to procedures, imaging, and tests in modern medicine. Thus, allowing clinicians adequate time to listen as well as greater latitude for more frequent follow-up visits are also essential to optimizing this biopsychosocial approach. Smith does provide a NURS mnemonic (name, understand, respect, support) for making the process more efficient in busy clinical settings. In occasional places in the book, Smith’s message becomes slightly polemical. Realizing this (but not apologetically), he closes his book with

The eloquence with which Smith proclaims this message is relevant to clinicians of all stripes as well as educators, health care organizations, payers, and patients.