The WPA- Lancet Psychiatry Commission on the Future of Psychiatry

Dinesh Bhugra, Allan Tasman, Soumitra Pathare, Stefan Priebe, Shubulade Smith, John Torous, Melissa R Arbuckle, Alex Langford, Renato D Alarcón, Helen Fung Kum Chiu, Michael B First, Jerald Kay (+29 others)
<span title="">2017</span> <i title="Elsevier BV"> <a target="_blank" rel="noopener" href="https://fatcat.wiki/container/fvhlvcs6vjf2vdrews4h3uvjtq" style="color: black;">Lancet psychiatry</a> </i> &nbsp;
Psychiatry has always been a medical discipline: but was this inevitable, and will it always be this way? The profession has changed so much since so-called alienists treated their "alienated" patients up to the 19th century when psychiatry as a term emerged. Changes in diagnostic practices, investigations and therapeutic interventions-pharmacological, psychological, and social-have brought psychiatric practice out of the asylums and into the community in many countries but not universally.
more &raquo; ... y intervention has gone from being an intriguing innovation to standard practice in many countries. However, delivery of these services depends upon resources available and in many countries around the world these remain aspirations. Psychiatry in the first quarter of the 21st century is at the cusp of major changes. We are beginning to understand more about the structures of brain and its development and function-and, more importantly, the impact of social factors on these processes. Recent investigations into the interactions between the immune system and the brain and optogenetics promise new knowledge of mechanisms and new treatments. Psychopharmacogenomics can enable clinicians and researchers to profile the pharmacodynamics and pharmacokinetics of individuals in order to develop and deliver more targeted interventions. The world is becoming more connected, and psychiatry is no exception to this. On the one hand, the rise of the global mental health movement has highlighted the importance of mental health but on the other hand, the movement's weakness lies in the perception that it is again an example of the so-called Western Anglo-centric countries dictating to the rest of the world what needs to be done, ignoring different cultural models of expressing distress and help-seeking. Another observation is that the global mental health movement needs to put much more emphasis on sharing examples of good clinical practice than it has done so far. For globalization and urbanization present not only challenges, but also an opportunity to share knowledge. Furthermore, this interconnectedness both fuels and is enhanced by the growth of digital technology, whose effect on mental health is uncertain, and whose impact on the delivery of treatment might be immense. It is time to look at where psychiatry has been, where it is now, and try to imagine its future. What will psychiatrists do, how will they do it, and what will they need to know in the next few decades? Who will psychiatrists treat? How will this be delivered and financed? How will psychiatry's relationship with society change? How must mental health laws adapt to accommodate this? Will psychiatry be able to go digital, and if so, how? And how will psychiatrists of the future be trained? To answer these questions, the World Psychiatric Association and The Lancet Psychiatry have commissioned a team of mental health professionals, researchers, and service users to write and review this new Commission on the Future of Psychiatry. The following pages are intended to stimulate thought, debate, and the change necessary for psychiatry to fulfil its potential as an innovative, effective, and inclusive medical specialty in the 21st century. Part 1: The Patient and Treatment Demographic and societal factors affecting the Patient The future of the psychiatric patient in the health care system will be influenced by many factors, several of which will be discussed in other sections of this report. One of the most critically important variables is the availability of and access to psychiatric care. WHO data 1 show vast discrepancies in resources across countries, with, for example, nearly 100-times variations in the per capita availability of psychiatrists. 2 Within specific countries, substantial geographic variations occur in availability of mental health clinicians and facilities as well as in specific treatment modalities such as pharmacological, psychotherapeutic or psychosocial interventions, or neuromodulation therapies. In the USA, with over 50,000 psychiatrists, the highest per capita ratio in the world, and an extensive array of government and privately supported programmes, many subpopulations have inadequate access to any aspects of clinical mental health care including medications. Owing to significant fragmentation compared with the general health system, access is constrained for those living in rural areas and poverty stricken urban cores, and the elderly, children, the homeless, victims of abuse, those in forensic facilities, and members of minority racial and ethnic groups. 3 Thus, it is uncertain whether many of the projections in this section concerning patient care changes in the coming decade will be available to the majority of the global population. While there is no evidence that the epidemiology of most psychiatric disorders is changing, largescale demographic and societal changes already underway will affect individual and population mental health. These are illustrated by four such changes, already occurring in Asia and major population centres elsewhere. First, ageing of the global population will continue due to improved nutrition and water supplies as well as advances in general medical care. 4 The growth in the elderly population means an increase in age-related diseases such as the dementias and late-life depression. Changes in social patterns, with multiple generations of families no longer living in the same houses or even towns, will alter the role of the elderly in the community and the way they are valued and cared for. The increased demands for caregiving by younger family members for the older generations will be less likely served when those younger generations live far away. These changes impair the quality of life of the elderly and can lead to poor mental health outcomes. 5 Moreover, the high prevalence of coexisting physical conditions, such as sensory loss, will exert a greater effect on mental health through the loss of self-esteem and independence. Second, an increasing percentage of the world's population will be living in urban areas. Urbanization affects mental health through the influence of increased stressors and factors such as an overcrowded and polluted environment, high levels of violence, access to illicit drugs, and reduced social support. 6 For example, lower paid urban workers often live in crowded spaces with poor basic sanitation, food supplies, and shelter, as well as a lack of basic governmental and social support services. Third, population disruption and migration due to natural and manmade disasters, are at the highest level in recorded history, 7 with associated adverse effects on mental health. 8 The stresses of forced emigration, physical, social, and psychological, have taxed all societal systems. 9 These stresses stem not only from factors directly related to migration or living in refugee camps, but also from living under the authority of individuals with, most often, a different culture, language, and traditions. Fourth, the rapidly expanding use of electronic communications in our "digital" world has led to concerns about the effect of more constant digital connectivity on individuals, such as a shorter attention span, interpersonal relationships, and society (see section on Psychiatry and the Digital World). Internet Addiction Disorder, while not listed in DSM-5, is of increasing concern in adolescents and young adults. There is a strong association between Internet Addiction Disorder and depression 10 though the causal relationship has not been determined. Culture and Patient Care Culture and Diagnosis With the vast migration of populations in recent decades, attention to cultural factors in understanding mental processes for both individuals and groups, and in psychiatric practice will continue to grow in importance. Diagnosis will continue to be among the most complex issues in psychiatry and will have to take increasing notice of the influence of culture. 11 Cultural variations must be taken into account in the clinician's understanding of the context and meaning of the language of patients, and this appreciation must be a basic component of every diagnostic interpretation. Understanding what patients are communicating to the clinician requires an awareness of the impact of the "cultural relativism" of language and other variables and will produce more effective decision making about normality and psychopathology. 12 The migration of human populations has modified local and regional cultures, but culture continues to be influenced by a multiplicity of factors, and global cultural diversity will persist. Assessment of race and ethnicity, language (verbal and non-verbal), religious beliefs, traditions, values and moral thought, family and gender issues, social relations, financial philosophies, and economic status will continue to be key elements to consider when formulating a diagnosis. 13 These and other cultural variables affect areas such as help-seeking patterns, causal attributions, explanatory models of illness, and severity assessment. The cultural elements inserted in several sections of DSM-5 are only the initial step in a conceptual and practical consolidation of culture in the diagnostic process. 14 The study of Idioms of Distress and Cultural Syndromes in various diagnostic schemes should continue to be refined and implemented in a way that can be used more effectively around the world. 15 DSM-5 developed the Cultural Formulation Interview as a novel 16-question measurement instrument of cultural diagnostic components to be used during an initial interview. This was field tested for utility, and is supported by 12 supplementary modules to broaden and deepen the collected data. 16 Thus, the Cultural Formulation Interview can serve as a platform for further development. Culture and the therapeutic alliance Understood as the common and shared effort of physician and patient aimed at the alleviation, healing or cure of ailments, the therapeutic alliance entails knowledge, attitudes and skills that, if appropriately used, will result not only in the stated objectives but also in the prevention of relapses, and the accomplishment of a better quality of life for the individual and the community. The therapeutic alliance is moderated by both the knowledge base and skills of the clinician, and the influence of culture on the system of care, and the cultural background of the physician and the patient. There is increasing attention to the role of these factors in the development and maintenance of a productive therapeutic alliance. 11, 17 As an individual, the physician absorbs the general principles and particular features of the culture of medicine as practised in his or her location and filtered through his or her own cultural background. The patient's cultural background brings with it conceptions of trust, respect for authority figures, dignity, self-image, self-esteem, and family-nourished beliefs and attitudes, that the physician needs to appreciate to develop a positive and productive therapeutic alliance. In psychiatry, the therapeutic alliance is also affected by prejudice, stigma, including selfstigmatization, 18 and discrimination-powerful cultural forces in most societies. Culture and psychiatric treatment Cultural competence is important not only in diagnosis and the therapeutic alliance but also in the formulation and execution of a treatment plan. 11 The patient's culture might influence his or her willingness to engage in the type of emotional self-disclosure that is essential for all forms of psychotherapy. Cultural and spiritual beliefs might influence the patient's perception that there is an internal locus of control of their thoughts, emotions, and behaviours. Both these factors would influence, for example, a prescription for psychotherapy and its implementation. Thus, the development and use of culturally sensitive psychotherapies and psychosocial interventions should be encouraged. In some cultures, pharmacotherapy prescription might be affected by traditional medicinal treatments and potential conflicts with traditional healers which must receive particular attention from the psychiatrist. 19 The cultural aspects of all components of the psychiatric care system should receive much more emphasis in the coming decade, with resources devoted to training, research, and clinical system development aimed to better equip clinicians to provide excellent culturally competent care. 20, 21 Culture and Stigma Culturally influenced discrimination against those with psychiatric illnesses, their families, and those who provide treatment for them has been known for centuries in essentially every society or culture. The discriminatory results of this stigmatization have influenced media portrayals of families of and patients with psychiatric disorders, and of both clinicians who provide mental health care and the settings in which they work. This stigmatization in modern times has affected not only the place of psychiatry in the health care system, but also governmental willingness to support adequate facilities, nondiscriminatory policies regarding access, training of clinicians, and reimbursement for psychiatric care compared with all other components of the health system, even in a well developed health care system as in the USA 3 . Further, there is good evidence that significant stigmatization exists at present among other physicians. 22 As Fink and Tasman wrote in 1992, "Patients' willingness or unwillingness to be treated, the inability to pay for treatment, and the unwillingness of people to have mentally ill persons living near them or working in their companies have combined to form the most powerful antitherapeutic forces that mentally ill individuals face." 18 While there is current impressionistic information from many clinicians around the world that stigma in the psychiatric sphere of concern has been diminishing in recent decades, there is little formal psychiatric research devoted to this topic. It still seems clear that culturally influenced stigma has an adverse impact on patients' willingness to seek care. 23 Programmes to reduce stigmatization have been implemented in many countries in academic institutions, by psychiatric and other mental health related organizations, and by governments, but these efforts are often local or regional in scope and impact, resulting in a dearth of study of national or cross national assessments of stigma reduction. This lack of data makes informal conclusions impossible to verify. Given the tumultuous state of the world, it is difficult to predict whether there will be available adequate resources to foster growth of sorely needed multifocal strategically targeted programmes in the coming decade. In addition, cultural change, which is necessary for widespread changes in attitudes and behaviour regarding mental health, comes at a very slow pace in most conditions. Both these factors suggest that a dramatic reduction in stigmatization is unlikely to occur in the near future, with most changes likely gradual, modest, and geographically diverse. Diagnostic Assessment Across medicine, diagnosis first involves gathering multiple types of information from different sources (eg, history, examination and investigations), which is then considered, weighted, and integrated by the clinician who makes a decision on the likely diagnosis. Changes in psychiatric diagnostic practice could involve alterations in the way initial information is collected, in the type of information that is gathered and used and the way data are integrated into a diagnostic decision. Typically, the diagnostic act begins with the clinician gathering information reported by the patient or others who know him or her well. Across medicine, the need to listen carefully, elicit relevant information, empathise and observe remains crucial for any successful diagnostic assessment. The psychiatric formulation is broader than diagnosis alone. It takes into account the social context, contributory risk and protective factors, and developmental change. These are relevant to devising the management plan, selecting appropriate treatments, and predicting adherence and prognosis. This approach is unlikely to be replaced by a purely biological or investigative approach and in its ideal form should continue to be based on an integrative bio-psycho-social-cultural formulation. Given the global scarcity of resources, the level of direct clinician contact with a patient is likely to change in the next decade; few if any places have sufficient clinicians with enough time to meet population demands and needs. Mobile, internet, and telemedicine technologies already enable remotely administered, online diagnostic interview (eg, www.dawba.info) and cognitive testing that are used in research and some clinical settings. Such approaches could enhance task-shifting from physician to health-care worker in LMIC. 24 One of the holy grails of clinical psychiatry is laboratory tests to assist in diagnostic assessment-a routine component of diagnosis in most other medical specialties. Our present definitions of mental disorders are based exclusively on subjective signs and patient-reported symptoms that are prone to recall error and misinterpretation. Laboratory tests have potential advantages, including being more objective 25 and facilitating the detection of mental disorders in primary care settings where the use of laboratory tests is routine. 26 Unfortunately, although one of the goals of the DSM-5 was to make the diagnostic system be based more on the underlying pathophysiology of mental disorders than on their symptomatic presentations, 27,28 no laboratory tests or other biomarkers were deemed to be sufficiently sensitive and specific to warrant their inclusion into the DSM-5 diagnostic criteria sets for any of the mental disorders.
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