Damian Sendler: Assessment, treatment, and prevention of mental illnesses such as bipolar disorder, anxiety, schizophrenia, developmental disorders (such as autism), and neurodegenerative diseases are all part of the field of psychiatry (e.g., Alzheimer dementia). A major percentage of the worldwide burden of illness-related incapacity is attributable to these illnesses, which are the primary focus of the organization’s work. Clinical neuroscience is the foundation of psychiatry. Since breakthroughs in the evaluation, treatment, and prevention of brain disorders are most likely to come from research of etiology and pathophysiology based on clinical and translational neuroscience, its main purpose is best fulfilled in this setting today and in the future. Psychiatry must also guarantee that those who require the advantages of its research are also its beneficiaries in order to maintain its wide public health relevance in the future. Clinical neuroscience in psychiatry, encompassing epidemiology, community and behavioral health science, and health economics, must increase their collaborations to achieve this successfully.
Damian Jacob Sendler: A SWOT analysis of psychiatry is presented by the writers, who offer solutions for enhancing psychiatry’s future and enhancing its significance in public health and the rest of medicine. Some of these strategies include new ways to strengthen the relationship between psychiatry and neurology, to finance it, to focus on early and sustained multidisciplinary training (research and clinical), to strengthen the academic infrastructure, to reorganize mental health services both for preventive intervention as well as cost-effective chronic disease management, to strengthen the academic infrastructure.
Damian Sendler
Dr. Sendler: In the medical speciality of psychiatry, the goal is to assist patients and their families who are affected by a wide range of complicated brain illnesses, including depression, bipolar disorder, anxiety disorders, schizophrenia and drug misuse disorders. When researchers have discovered the genesis of certain illnesses, such as those affecting the central nervous system, they have frequently relocated them to the domain of neurology rather than psychiatry. (A excellent historical illustration of this transition is tertiary syphilis.) As a result of advances in contemporary neuroscience, the boundaries between psychiatry and neurology are becoming more blurred, making the distinction between the two disciplines increasingly meaningless. 1 There are substantial consequences for the future of psychiatry because of the artificiality of this barrier. That the two fields, which were formerly linked by a common interest in clinical neuroscience, should be brought back together again is our central premise (Figure 1). So even while psychiatrists and neurological specialists both study the brain, we admit that their interests might differ, leading to a need for professional affiliations. Medical sociology has a core belief in the importance of this identity. Re-integrating psychiatry and neuroscience in medical education and research might benefit both fields. We are not asking that psychiatrists or neurologists give up their passions. Psychiatry and neurology are both rife with arbitrary and historically based elements. Psychiatry and current clinical neuroscience address problems in anatomical circuits and connections, while conventional neurology has concentrated on specific anatomical abnormalities (e.g. stroke or tumors). These are not absolutes, as we will show in the following examples.
It’s an exciting time to be a psychiatrist. As a conceptual map, it shows how psychiatry has evolved through time and how it relates to other fields of medicine, neurology, and public health in the future.
Approximately 20 percent of the worldwide burden of illness-related impairment is attributed to neuropsychiatric illnesses, which the WHO describes as “complex brain dysfunction.”
Damian Jacob Markiewicz Sendler: Like neurology, psychiatry is built on a solid scientific basis. This includes a wide spectrum of fundamental biological and social disciplines, as well as various techniques (e.g., brain imaging, genetics and neuropsychopharmacology) that may be used to build innovative evaluation and treatment methods that are anchored in knowledge of etiology and pathophysiology.
It is our goal to look at the future of psychiatry as a clinical neuroscience and identify solutions in several settings to promote this future: (1) education and training, (2) policy, (3) institutional challenges, (4) research, and (5) clinical practice at medical schools and training hospitals. As a starting point for future debate, we want to give a synthesis of the most pressing problems currently affecting the field of psychiatry and to serve as an educational tool.
This is why we suggest first to give a psychiatric SWOT analysis, which examines a field’s strengths, weaknesses, opportunities, and threats (positive and negative). We have almost 200 years of combined expertise in academic psychiatry, encompassing fundamental and clinical research, teaching (including mentoring academic careers programs), clinical work, and administration (medical school dean and academic health center [AHC] president, department chair, and large research group leader). In our roles as NIH reviewers, grantees, and National Institute of Mental Health (NIMH) national advisory council members, as well as in our roles as leaders of professional associations and the Institute of Medicine (IOM), each of us brings a wealth of knowledge to the table (American Psychiatric Association [APA], the American College of Neuropsychopharmacology, and the American College of Psychiatrists). We want to be clear that the opinions expressed here are solely those of the authors and do not necessarily represent those of any professional organizations with which we are connected. That being said, our primary goal was to synthesize the many different viewpoints that exist on the current state of psychiatry’s conceptual and social issues, to broaden participation of academic medicine leaders in this conversation and to make what we believe are strategic recommendations for dealing with the tipping point where psychiatry currently stands. In our opinion, there is a pressing need to continue this discussion and take action on it. Surgeon General’s3 and IOM’s4 as well as the APA’s4 resources are only a few examples of the wealth of information available in the literature.
Damian Jacob Sendler
Damien Sendler: Psychiatry’s diagnostic and therapeutic tools, such as structured diagnostic instruments and maintenance medication to avoid relapse and recurrence, are adequate, but not exceptional, in our view. The vast majority of patients make significant progress, although many never completely recover. Experts and practitioners now recognize the need to incorporate multiple dimensions (e.g., severity, distress, impairment) into their assessment procedures in order to better accommodate advances in relevant basic brain and behavioral sciences and to enhance clinical relevance in the diagnosis of mental illness. Indeed, the Diagnostic and Statistical Manual (Fifth Edition) task committee has made this multidimensional evaluation a primary priority.
This field of medicine now has an evidence base that is at least as good as or better than the rest in terms of rigorously controlled randomised clinical trials (RCTs), including those testing theoretically based, disorder-specific psychosocial treatments, which is another strength that psychiatric treatment can use (e.g., cognitive behavior therapy for depression). Personalized therapy for people with mental illnesses is a top priority in the profession, as seen by the recently released NIMH Strategic Plan. 6 Because of their commitment, mental health professionals and general practitioners alike are increasingly turning to studies into treatment response moderators and models of care organization (such as depression care management), which allow for the implementation of evidence-based practices in both mental health specialties and general practice settings alike. More and more attention is being paid to multicomponent interventions that take into account the burdens of concurrent medical, neurological, and psychosocial problems as well as stepped-care approaches with public health relevance (e.g., using watchful waiting before intervention and using simple strategies before more complex ones) (e.g., care-giving burden). Many of these therapies are geared on improving people’s quality of life. The use of targeted, presyndromal screening to identify people at high risk of developing a mental illness is also becoming more common in primary care and specialized settings; these screenings often identify people who are already exhibiting symptoms of depression before they become clinically depressed. 7 For adults with macular degeneration, psychosocial therapies like problem-solving therapy may help prevent or postpone depression.8, whereas psychopharmacological interventions like antidepressant medicines can help post-stroke patients who are at risk of depression.9
Psychiatry’s biggest asset is the large number of young individuals who are joining the profession and its allied fields of study. 4 percent of medical school graduates in the United States choose to practice psychiatry. 10
Finally, the many and significant advancements that are occurring in the fields of molecular, developmental, and systems neuroscience represent a fundamental and rising strength of psychiatry as clinical neuroscience. Neuronal foundations for cognitive and emotional skills that are disrupted in psychiatric diseases are becoming more well understood, enabling a more comprehensive and nuanced database for the production of testable hypotheses about the biological basis of mental illness. Neuroscientists are now in the early stages of developing innovative pharmaceutical therapies based on pathophysiologically-based sickness models rather than random finds. Psychiatrists are now better able to anticipate treatment response variability using pharmacogenetic information and to quantify risk for mental disease. Psychiatry and neurology are merging in this way, blurring the line that has traditionally existed between the two fields.
A lack of clinical neuroscience perspectives is limiting psychiatry’s assessment and treatment tools, even though they are good, because the findings of psychiatric genetics, brain imaging, cognitive and affective neuroscience and psychometric theory can be used to define etiology and pathophysiology, as well as treatment-relevant phenotypes, and to personalize treatment (i.e., which therapy for which patient at what point in the illness trajectory?) Optimizing therapy necessitates a greater focus on the discovery of biological and psychological characteristics that predict or influence short-term and long-term treatment response, in our view. Psychiatry, compared to other medical specialities, is a newcomer to this venture. People with complex brain illnesses face a significant barrier to advancement because of the schism that separates neurology and psychiatry, the two primary clinical neuroscience practice arms, on a conceptual and structural level.
Research into the causes of mental illness, as well as the development of treatments and approaches to mental health that are tailored to the unique needs and circumstances of each individual, are just a few of the many opportunities that psychiatry as a clinical neuroscience discipline offers to improve the health of the general population. Progress in psychiatry is now possible thanks to the instruments developed in the fundamental and behavioral sciences. It’s also a good time to think about how to improve the public health effect of contemporary psychiatric therapy by developing targeted and targeted preventative treatments for persons at high risk of developing mental illness. Understanding genetics, pathophysiology, functional neuroanatomy and neuropsychopharmacology may also help psychiatry enhance evaluation and treatment procedures. This allows for the creation of more tailored therapies. Psychiatry will be able to overcome stigma towards the mentally ill if it has the chance to create and implement public health-relevant forms of mental health care delivery. Partnerships with patients and families affected by mental illness are critical in the fight for equity in the financing of mental health treatments, as is increasing the financial incentives for young people to work in the sector via advocacy and consumer health information projects. It is up to psychiatry to help medical students and doctors who are seeking mental health care to transform the culture of academic medicine in a manner that helps them get the help they need. Teaching medical students and doctors to better detect depression in themselves and their colleagues may lead to lower rates of physician incapacity and suicide—and enhance the probability that nonpsychiatrist physicians would notice depression in their own patients.
Psychiatry, as a branch of clinical neuroscience, has numerous advantages, but it also confronts threats to its long-term viability. Several of these issues are pecuniary in nature, such as the disparity in Medicare’s copayment requirement of 50% and the absence of parity in reimbursement systems. In general practice and pediatrics, the adoption of evidence-based mental health treatments is hampered by structural hurdles (e.g., a lack of electronic health records, declining institutional support, and an emphasis on acute rather than chronic care). Furthermore, the profession’s future is jeopardized by social realities such as the continuing of stigma towards people with mental illnesses and health/science policies (such as a lack of resources for psychologically health research and a lack of support for mentorship). We also face serious challenges in recruiting high-quality students and their workforce consequences (e.g., lack of child/adolescent and elderly psychiatrists), as well as a low proportion of trainees who go on to pursue research careers in psychiatry. Finally, the infrastructural demands of psychiatric and mental health research—from basic labs to community-based collaborations, particularly with poor, underserved people—require continuing, planned investment. Because the NIMH/NIH appropriations’ purchasing power has declined dramatically over the last five years, the philanthropic community in the United States and appropriate partnerships with industry are becoming increasingly important if psychiatry is to have a bright future as a branch of clinical neuroscience.
