My take as a mental health and heart patient (not a doctor):
I think it's just the way the cards are dealt by the fates. Psychiatry like many areas of medicine is medication driven. But compare it to cardiology which has procedures, and you might conclude psychiatry in comparison is almost entirely medication driven (although I know there is TMS, ECT, etc). The strength of psychiatry then lies in large part on the strength of its medications. They just have so many side effects and heterogeneous efficacy compare to cardiology, for example. It's rare that an ACE inhibitor wouldn't lower blood pressure. And rather than possibly causing TD like FGAs or possibly causing metabolic syndrome like SGAs, they actually improves other biomarkers of health. And if it doesn't work, you can add on a second drug, also usually with a fairly favorable side effect profile. Multiple medications in psychiatry is also common, but trickier and with more room for problems. Sometimes the most effective medications in the short term are also ones that are ineffective and harmful in the long-term (e.g., benzos), or can stop working over time and cause prolonged as-of-yet not-understood permanent changes (e.g., SSRIs), or are undesirable for any number of side effects or interactions and require lab testing. In cardiology, the mechanism of the disease is understood and the mechanism of the treatment is understood. And those treatments tend to be more predictable in their effects. I don't know if there are breakthroughs in cardiology pharmaceuticals or not, but they seem less needed.
It's a much more herculean task to understand human behavior than human hemodynamics. There's normal human behavior, maladaptive human behavior, and obviously frank disease like severe autism or schizophrenia. It's harder to distinguish the grey areas, where functioning is not optimal and distress is experienced for the current demands of work and family. What is that even? That's something people have tried to suss out from the beginning of time with religion, philosophy, etc. And then there was an idea to apply medicine to it, along with applying medicine to the more obviously frank behavioral diseases. The problems psychiatry addresses are much older than the problems cardiology addresses, or rather people have been trying to address them for much longer; therefore, it seems reasonable to assume they would be more intractable or they wouldn't still be problems seeking better solutions.
This might be unpopular to say, but I would assert that psychiatry in the way it's practiced will not change much in the near future and that any significant changes to outcomes would result from drug companies discovering new drugs that are an improvement over existing offerings. I base that on having been a patient of a psychiatrist or another since 1997, at which point the main offerings are remarkably similar to what they are today--identical in many cases. And if anything, I've seen psychiatrists embrace their role as medication managers. It used to be that a psychiatrist might tell me not to bother with therapy as if they saw it as a competing methodology to their medication treatment. Now I find it's encouraged and am told that psychiatry is medication management and for help with other issues you need to look elsewhere. Of course, that's not true for everyone. There are psychiatrists who are "full service." Most are not.
I mean this in no way as a dig at the very bright minds here, who I see practice in very good ways and find unique problems (diagnosing biological medical issues other have missed) and coming up with unique solutions. And I actually look forward to being corrected in what I have missed. This is from a single point of view. Sometimes I learn the most by saying what I think I know and then finding out how it is wrong.
