Psychiatry of the Future – 2030 and Beyond
- Posted by Editor JPR
- Posted in Editorials & Commentary
Vol 8 #6
James A. Bourgeois OD, MD,1,✉ Ana Hategan MD,2 Alan B. Eppel, MB, FRCPC3
1 Clinical Professor (Affiliated), CL Psychiatrist, Chair, Department of Psychiatry, Baylor Scott & White Health, Central Texas Division; College of Medicine, Texas A&M University Health Science Center, Temple, TX, USA. ✉ [email protected]
2 Clinical Professor, Geriatric Psychiatrist, Department of Psychiatry and Behavioural Neurosciences, Michael G. DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
3 Professor, Psychiatrist, Department of Psychiatry and Behavioural Neurosciences, Michael G. DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
Psychiatry, like all medical specialties, is in the process of major changes. Psychiatrists and other clinicians must work together to ensure that the future practice of psychiatry will be relevant and useful to the population of tomorrow’s world. It is time to look at where this medical specialty is now and to try to imagine its future over the next decade. This can be partially addressed by a series of targeted rhetorical questions:
1. What will psychiatry look like then?
2. How will this medical specialty be structured?
3. How will psychiatrists of the future be trained to practice?
4. Will psychiatric care go substantially “virtual”?
5. How will psychiatry’s relationship with other medical specialties evolve?
6. Can diagnostic phenomenology, medical diagnostic technology, somatic interventions, and psychotherapy keep the pace with adapting our therapeutic cultures to reflect scientifically-grounded, evidence-based, and cost-effective clinical practices?
On Futurism and the Limitations of this Paper
All futuristic pieces, of which this is a relatively modest example, necessarily reflect the opinions and preferences of the authors. In addition, such pieces must take the “present state” as the basis for future speculation. Even futuristic situational descriptions which seem to reflect fundamental, discontinuous change from the present must (with rare exceptions attributable to rare, large macro-level changes in the social-political environment, which are themselves a priori unpredictable) be actuated in an incremental, sequential process of change adoption. Futuristic pieces are thus necessarily at least somewhat “idealistic” and “aspirational” and may, for purposes of stimulating needed discussion and consensus-building, set aside external matters such as political acceptability, details on financial modeling, and broader social acceptance of the speculated changes. It is impossible to predict all possible opposition to even “obviously needed” changes by those who seek to preserve the status quo, or even revert to a less desirable future state than the current.
It is in the spirit of generation of healthy debate over the future of psychiatry that the authors have written this paper. For purposes of focus on the evolution of the practice of psychiatry as a medical specialty in the year 2030, we do not emphasize several clearly important areas pertinent to psychiatry that are under active debate by others and must rely on basic core assumptions as the intellectual substrate of this work. Areas which we will not directly address, but which we acknowledge are important to consider, include the following:
1. Psychiatric diagnosis. For our purposes, we will not address methodology by which a psychiatric diagnosis is rendered, maintaining use of the DSM concepts and nomenclature. We acknowledge that subsequent revisions of the DSM series will have important implications for the diagnosis and management of psychiatric illness. However, we support the “broadly inclusive” view of psychiatric illness; e.g. inclusive of delirium, major neurocognitive disorder, traumatic brain injury as clearly within the realm of psychiatric scholarship and practice.
2. Financing models. We will not directly address critical debates about health care financing models, which are under significant pressure and thus evolution worldwide. It will be essential, obviously, for the specialty to earn its proper place at the table in all health care systems.
3. Our core assumption is that systems of care have at least a “reasonable” number of psychiatrists for a given population. Systems with a grossly inadequate psychiatric workforce (e.g., in low- and middle-income countries ) will likely need to concentrate psychiatric resources for specific populations (e.g., hospital care for severe schizophrenia), so would not be able to fully explore our proposed model.
4. There will be a continuing tension among a triangle of clinicians providing what are now considered to be “psychiatric” or “mental health” services among psychiatrists (including psychiatric subspecialists), other physicians (most of whom work in primary care), and various mental health professionals from other disciplines. The relative division of labor and responsibility among these groups will be subject to incremental adjustment and changes in definition of professional boundaries and other matters.
5. We will not primarily focus on larger, macro-level social/political matters that clearly impact the human experience and are of importance in the provision of psychiatric care. These include international relations, race, gender and other social matters, poverty vs affluence, and distribution of social resources such as housing, employment, and education. These critical areas will, of course, impact the clinical practice of psychiatry, but our focus is on the direct provision of clinical services.
6. We will mention, but not discuss in great detail, critical supportive matters such as medical (and other health professional) educational and other workforce management issues.
7. We will assume that actual psychiatric clinical services delivered will remain some combination of psychotherapy, psychopharmacology, and non-pharmacology medical intervention (including neuromodulation services). The relative balance among these three broad categories of interventions will be developed further.
The Three Neurosciences: Scientific Advancement Leading to Clinical Convergence
The three “brain specialties” of psychiatry, neurology, and neurosurgery will necessarily work more closely together. The advancements in structural and functional neuroimaging, quantitative electroencephalography, clinical genetics and genomics, and neuromodulation interventions have rendered the anachronistic distinction between “functional” and “organic” illness to be meaningless, along with the obsolete and highly clichéd Cartesian distinction between “mind” and “brain” .
For illustration, it is a source of great puzzlement how attributionally “functional” illnesses (e.g., depressive , bipolar, and, psychotic disorders) are primarily treated with “organic” interventions (e.g., psychotropic medication, ECT, rTMS). Progress in the neurosciences, which proceeds increasingly rapidly, necessarily transcends historical and habitual medical specialty boundaries. It is both more intellectually honest and clinically pragmatic to acknowledge that the brain is a complex organ, and its illnesses demand the attention of (at least) these three, ultimately more complementary than competitive, medical specialties.
Many brain illnesses render patients symptomatic in “both” the “psychiatric” and “neurologic realms” (as historically, if somewhat arbitrarily, distinguished). Common examples include multiple sclerosis and Parkinson disease; these are “not just neurologic” and “not just psychiatric” but, in fact “both” or “neuropsychiatric” . A typical patient with these illnesses is managed with both “neurologic” and “psychiatric” medications; indeed, many of these medications themselves have both “neurologic” and “psychiatric” effects and side effects. Therefore, closer collaboration among brain specialties to co-manage these admittedly challenging disorders allows for optimized functional outcomes, and less patient suffering.
Many chronic illnesses of the central nervous system (CNS) benefit from neurosurgery (e.g., deep brain stimulation (DBS) for movement disorders), so a collaborative approach among psychiatry, neurology, and neurosurgery offers both comprehensive clinical care as well as richer understanding from multiple perspectives for patients with particularly complex chronic CNS illness. So that all medical specialists can work at the “top of their license” by focusing their medical specialty skills on the most complicated clinical problems, clinical services structures need to be designed to accommodate this necessity. For optimum clinical efficiency, greater use of advanced practice professionals (nurse practitioners and physician assistants) for team-based care is a highly desirable model of clinical integration and an important developmental goal .
It is plausible that allied health care professionals, such as nurses, dieticians, pharmacists, paramedics, and others, will become more common access points to the health care system in general as they continue to improve the quality of care that they provide, and will learn some of the skills to access the evidence based medical literature and practice as physicians do. These professionals will potentially provide specialty consultation to their patients, through appropriate access to diagnostic facilities and prescribing evidence-based therapeutics similar to the practice of primary care physicians. Ultimately, this can serve to improve the quality of care that physicians provide to their patients by increasing the number of capable practitioners, thus releasing pressures on the medical system.
Psychiatrists and Psychodynamic Psychotherapy: An Ongoing Priority for Certain Patients
The broader evolution of modern psychiatry is clearly in the direction of ever-greater integration of scientific/medical concepts, and more closely alignment of psychiatry with other medical specialties. This convergence is multi-faceted and includes illness conceptualization, diagnostic evaluation, and psychopharmacology and other somatic therapies, but there remains a need for psychiatric expertise in psychodynamic psychotherapy . This psychotherapy approach is highly personalized to the specific patient experience, relies on depth understanding of the patient’s developmental experiences and current functioning, and has as its definitive clinical goal “character change” [6, 7]. In general terms, the difference between general psychiatry and “psychodynamic psychiatry” may lie in how psychodynamic psychiatrists clinically evaluate patients and propose psychodynamic treatment vs. when to withhold, depending on the application of test or timing interpretations .
Phenomenologically, psychodynamic psychotherapy is a preferred intervention for many patients with narcissistic, avoidant, obsessive-compulsive, and borderline personality disorders . As these patients often experience significant psychiatric co-morbidity (and even tri-morbidity), their management by a psychiatrist who can manage the multimorbid psychiatric illnesses and integrate various somatic therapies into the psychodynamic psychotherapy facilitates lasting improvement. These patients will often have completed other, more symptom- and/or behaviorally directed psychotherapy approaches with partial improvement before referral for psychodynamic psychotherapy when the limitations of the improvements attributable to these other psychotherapies have become clinically evident.
Psychiatrists practicing psychodynamic psychotherapy will continue to accept and welcome referrals from other professional disciplines in the practice of psychotherapy. The utility of psychiatrists as the psychodynamic psychiatry expert as well as expert at somatic interventions for CNS disease is illustrated well by a patient with multiple sclerosis, recurrent depressive disorder, and avoidant personality disorder. Such a patient would be best served by an integrated neuropsychiatry approach wherein the physician can combine psychodynamic psychotherapy using psychotherapy metrics and feedback systems algorithms as part of the approach to psychotherapy, combined with state-of-the-art psychopharmacological and other somatic interventions.
Psychiatry as a Consultative Specialty
Psychiatry in the next decade and beyond will be primarily a consultative specialty (both to other physicians and to allied mental health professionals) with a substantial neuromodulation and advanced psychopharmacology focus. Longer-term care offered directly by the psychiatrist will be primarily reserved to psychodynamic psychotherapy for selected patients likely to benefit from this intervention and patients with complex psychiatric co-morbidity. “Community mental health” interventions will be, appropriately, primary social, with the psychiatrist involved in a focal and specific role for medical management.
The role of psychiatrist as consultant to primary care and other physicians has its genesis in consultation-liaison psychiatry, where the fundamental role is to provide consultation so as to facilitate the overall medical management of patients by advising primary physicians on psychiatric diagnosis and “first line” medical management [10, 11]. Given the demonstrated advantages to both primary care physicians and primary care patients experiencing mild to moderate psychiatric illnesses that may be well-managed in primary care settings, the role of psychiatrists as consultants to primary care clinics and other outpatient medical and surgical clinics is likely to continue to grow rapidly. Embedded psychiatry services in primary care medical clinics may eventually reach an endpoint where having access to psychiatric consultation in primary care becomes normative. The benefit to patients receiving primary care-based initial clinical care for milder cases of psychiatric illness are intuitive and measurable.
The broader adoption across the health care system of a population health/risk-based financing model may well continue to demonstrate the high rate of psychiatric co-morbidity in primary care patients, thus facilitating the greater recognition of the need for psychiatric care to primary and specialty care medicine . At present, much embedded psychiatric care in primary and specialty care medical clinics is provided on a part-time basis by consultation-liaison psychiatrists, many of whom spend their other time on hospital practice.
A component of the primary care consulting relationship will increasingly be in the psychiatric assessment of complex patients/high utilizers. This group is identified by excessive and generally clinically wasteful and inappropriate medical care utilization, especially excessive emergency and inpatient care. These patients have a high risk of co-morbid psychiatric illness (notably including personality disorders and substance use disorders), and have poor clinical outcomes for their primary care medical problems as well as a poor prognosis for social and employment function. Early psychiatric evaluation of these patients for diagnostic clarity and formulation with clinical interventions can lead to greater clarity on the common psychiatric co-morbidity and facilitate these patients receiving targeted mental health services in concert with appropriately supported comprehensive primary care medical as well as social services.
Evidence-based medicine will continue to grow. Techniques applying artificial intelligence will enhance the tools of strengthening the science of medicine, and its application in the patient care. Whereas patients will continue to seek the advice of primary care physicians, they will also increasingly seek the advice of many different types of allied health professionals, such as complementary medicine clinicians, for the management of chronic conditions (including less severe psychiatric disorders). Many of these modalities will be integrated in the applications of evidence-based medicine principles.
Psychiatric Subspecialties: Differentiation of Services Paralleling Advances in Clinical Research
There is likely to be a need for greater degrees of psychiatric sub-specialization, as clinical and research knowledge creates a greater range of therapeutic options for specific patient groups. Currently, in the U.S., there are formal, board-certified subspecialties in child and adolescent, addictions, consultation-liaison (recently psychosomatic medicine), geriatric, and forensic psychiatry. There are informal “sub-subspecialties” of consultation-liaison psychiatry, including HIV, transplant, and cancer psychiatry; physicians working in these subsubspecialty areas commonly deliver services both in hospital and outpatient clinic areas. Consultation-liaison psychiatry, in general, has evolved from a primary inpatient/medical center based practice to include more opportunities in outpatient models, including consultative services to primary care medicine [13, 14]. While the boundaries between currently existing psychiatric subspecialties can be a bit “permeable” (e.g., consultation-liaison psychiatrists see a large number of geriatric patients in hospital practice), the clinical and research literature and logical boundaries among patient groups argues for maintenance of the distinct clinical roles of the current subspecialties. It is unlikely that the “subsubspecialties” will eventually require additional yearlong fellowships for qualification, but will likely remain interest- and experience-based areas of consultation-liaison psychiatry for the near-term future.
Plausible areas of greater subspecialty differentiation that can be anticipated include neuropsychiatry, neuromodulation (including ECT, rTMS, and ketamine), and emergency psychiatry. The development of these areas as formal sub-specialties may depend on two broad areas in convergence: increasing literature differentiating these clinical areas from general psychiatry and other current subspecialties, and the practical challenges of developing training models and attracting applicants for one-year fellowships for subspecialty training. It is plausible that large psychiatry groups (including university departments) specializing in the care of more complicated patients will find a competitive advantage in having fellowship-trained and certified neuromodulation psychiatrists to focus on providing these clinical services. Major academic medical centers may also find it advantageous to have neuropsychiatrists for co-location with neurology and neurosurgery, and emergency psychiatrists for positions in emergency department of major academic medical centers/trauma centers with formal board subspecialty certification for their specific and highly specialized clinical missions.
Technology Adoption: Multiple Advances, Great Opportunities for Clinical Services Delivery
Whether growth and differentiation of psychiatry along primary technical dimensions (e.g., telemedicine, use of patient-friendly mobile apps for improving communication, remote monitoring through wearable devices, other extensions of technology such as integration of big data and artificial intelligence in medicine) eventually leads to a widespread adoption of formal subspecialty status emphasizing these advances is less clear [15, 16]. On the one hand, adoption of these technologies is proceeding at an increasingly brisk pace, and seems certain to have a significant and persistent presence in clinical practice. However, it may well evolve that greater technology adoption and deployment becomes so common in clinical practice that it merely becomes an advancement in what has heretofore been considered the practice of general psychiatry.
The opportunity to conduct psychiatric care substantially by telemedicine has an important additional benefit in facilitating care to patients living in rural environments, reaching patients with significant mobility difficulties, and as an alternative to travel to the physician’s office leading to less consumption of fuel for avoidable vehicular travel. It is plausible to imagine that in the next decade or so, a broad adoption of telehealth technology may enable the bridging of the health access gaps for those not only living in rural and remote settings, but also to provide a means for partnerships and collaborations in health care delivery between developed and developing nations. Physicians will learn to manage the distraction of technology efficiently while reinforcing the role of a compassionate and humanistic approach of the physician.
Residency Training: Preparing Residents for the Modern Models
The basic model of medical school followed by medical specialty residency to achieve full qualification is likely to endure. The move proposed for residency training towards competency-based (rather than time-based) qualification is likely to continue to develop . A modified, hybrid model between time and competency based qualification may be a reasonable and manageable compromise. In such a model, the normative time to complete a psychiatry residency (meeting normative competency milestones) could be three years (minimum) for a very highly achieving psychiatry resident, the familiar four years for the majority of competently performing residents, and five years for those needing the benefits of remedial instruction and experience to master the common competencies.
Beyond the time-based model considerations in residency programming, psychiatry residency training will need to evolve to cover the changing areas of clinical practice resulting from the rapid progress in clinical and basic science research. While it is plausible that more general psychiatry graduates will pursue subspecialty fellowships in response to this incentive, it is equally imperative that the general psychiatry residency evolves to didactically and experientially address these rapidly growing areas. It is unlikely that there would be a broad push to extend a standard psychiatry residency by an additional year (although in Canada, psychiatry residency currently is 5 years). However, it will be necessary to restructure the residency model to emphasize newer areas such as functional neuroimaging, neuromodulation, embedded and collaborative care service to primary care, and telemedicine and other technology adoption. Those clinical activities that are primarily outpatient clinic-delivered could be creatively integrated into the third (full time clinical) year, while standardized fourth year experiences in neuropsychiatry, neuromodulation, and embedded psychiatry services could become requirements in order to graduate.
For the more distant future, technology will play a role in decentralizing medical training. The basics of psychiatry will be learned in any location with access to Internet. World expert educators will have the capacity to deliver principles of human psychology and psychiatric conditions to medical trainees from anywhere in the world. Clinical year medical students will learn basic psychiatry in their community of choice with skilled preceptors who equally excel in teaching as the large academic centers. Moreover, “classmates” will not only be other medical students, but physician assistant students, nursing students, psychology students, pharmacy students, paramedic trainees, physiotherapists, acupuncturists, and other groups. Specialty and subspecialty experience for medical residents will be acquired in academic centers to enhance the basics of medicine. Because quality health care can be viewed as an economic “reflection” of macroeconomic status among nations, the gross inequity between the developed and developing countries will get closer to closing the gap. For this, medical educators will contribute beyond local community, to the national and ultimately international communities through physically or virtually travelling to developing countries to participate in the medical education and delivery of health care in these growing communities.
Moreover, there already is an increased acknowledgement of the impact of burnout across the medical profession and we anticipate an even greater focus in the future on physician wellness and residency programs that promote resilience and provide emotional support to residents during their training .
Legal and Regulatory Issues: Modernization to Catch Up with the New Realities
An additional area that is important to change is the regulatory and legal status of psychiatry. Regarding patient record privacy, it is problematic to have a different level of “secrecy” for psychiatric medical records compared to other medical records (especially in health care systems using electronic medical record (EMR) systems). This is both an ethical and safety issue. It is very problematic if other physicians cannot readily access psychiatric medicine records, especially in emergency settings. More broadly, the insistence on “psychiatric exceptionalism” adds to psychiatric stigma, by communicating that there is something so “extreme” and “esoteric” about these illnesses that other physicians are not allowed to review psychiatric treatment records . This sets up a cycle of completely unnecessary boundaries with adversely impacting physician to physician communication.
Regarding psychiatric commitment orders executed by civil authorities to detain patients and force them to receive psychiatric evaluation, the illogical and intellectually dishonest definitions of “psychiatric illness” supporting a commitment order need significant revision. In some U.S. jurisdictions, delirium, major neurocognitive disorders, traumatic brain injury, and substance-related illnesses are considered exclusionary from the narrow definition of “psychiatric illness”, making legal commitment of patients with these primary clinical problems very difficult to accomplish, with resultant risks of poor patient outcomes and professional liability. Rewriting of all psychiatric commitment statutes to allow a broad range of psychiatric illness (e.g., any illness listed in the current DSM) will be necessary to allow for broad uniform standardization of clinical practice.
Putting it All Together: An Illustrative Scenario for Psychiatry Clinical Services
It is clear that successfully achieving the required changes in psychiatric practice will likely depend on how well clinicians, organizational leaders, stakeholders, and policy makers leverage existing resources and redefine the role of psychiatry in an increasingly interconnected medical world. To illustrate this, imagine the following scenario of an explanatory announcement for a future psychiatry service within a department of neurosciences. This scenario is intended to stimulate the discussion necessary for psychiatry to fulfill its potential as an inclusive and efficient medical specialty in the 21st century, and beyond.
Welcome to the department of neurosciences. This multispecialty department includes physicians from psychiatry, neurology, and neurosurgery, who practice collaboratively to care for a wide range of CNS illnesses. Clinical services include diagnostic interviews, neuroimaging, EEG, other instrumental testing, and pharmacological, psychodynamic psychotherapy, neuromodulation, digital wearable devices, and neurosurgical interventions. Patients are seen on referral from primary care and specialty medicine as well as from the psychotherapy department. The primary care physician has ready access to the neurosciences’ EMR and is encouraged to regularly review records of patient care in the department.
Patients referred to this clinic are initially seen for an intake appointment by one of our neurosciences-qualified advanced practice professionals (physician assistants (PAs) and nurse practitioners (NPs)), who will also review all referral clinical information and perform a thorough protocol-derived review of past and present treatment information. All new cases seen by the PAs and NPs are then screened by natural learning processing tools and machine learning, as subfields of artificial intelligence, which help predict the course of disease in the given patient. This information will be further presented in case conference format to a clinical team of psychiatry, neurology, and neurosurgery to determine who is the most appropriate primary physician in the department for the patient’s care. The other specialty physicians remain available to consult as needed at a later time depending on the complexity of the patient’s CNS illness and need for interventions. For ongoing clinical care, the advanced practice professionals typically are the main point of face-to-face and virtual contact for patient questions between regular appointments. They are also responsible for monitoring of digital wearable devices between appointments, which assess patient behavioral activation and other biomarkers and deliver interventions. The department also employs clinical pharmacists with subspecialty expertise in neurosciences. All patients who receive medication have a standard medication reconciliation and consultation with a pharmacist. The pharmacists supervise pharmacogenomics assessment and therapeutic drug monitoring on all patients.
To maximize patient comfort and convenience, decrease environmental and travel costs, and minimize risk of communicable diseases, all initial consultations can be accomplished by video using computers, tablets, and other mobile-powered devices. Clinical administrative staff will assist patents in obtaining the appropriate computer software and apps to complete all video visits. As much as possible given the clinical needs, subsequent physician visits will be available by video as well unless there is a clinical need for the patient to present for in-person care (e.g., diagnostic or therapeutic procedures).
Mobile apps for virtual medicine
Patients seen in this clinic are required to download and use the clinic app, which is used for all o scheduling, communication to patients, and check-in procedures. Virtual clinic staff are available to facilitate patients’ learning how to access the clinic app and to troubleshoot any accessibility problems. Mobile apps will also be used to connect virtual care patients’ wearable devices and home therapeutic monitoring systems. Through the use of home therapeutic monitoring devices and wearable technologies, the department is proud to announce initiative to minimize the need for centralized care within the hospital setting.
Referrals from psychology/social work
The department of neurosciences does not directly employ non-medical mental health professionals. Patients seeking non-medically supported psychotherapy services are referred to the psychotherapy service. Patients being seen in the Psychotherapy Service may be referred to the neurosciences department for medical evaluation and management with additional coordination with the patient’s primary care physician. Therefore, all patients seen in the neurosciences department must also be under the ongoing medical care of a primary care physician.
When patients need inpatient admission for management of neuropsychiatric illness, they are admitted to a neurosciences unit, which is managed by psychiatrists, neurologists, and neurosurgeons with consultation support by internal medicine hospitalists. Inpatient care is typically needed for suicidal or homicidal crisis, severe psychotic illness, substance intoxication or withdrawal, or other complex clinical situations requiring inpatient care with 24 hour nursing supervision and a comprehensive care model.
Crisis stabilization units
When patients are in acute clinical crisis and likely to improve within 72 hours, they are admitted to a crisis stabilization unit, which focuses on detoxification, restart of medications, and establishment of outpatient care; if a crisis stabilization unit (CSU) patient does not stabilize within 72 hours, he/she is transferred to the inpatient neurosciences unit.
The department has facilitated access to neuroimaging for MRI, fMRI, SPECT, and PET scanning from the department of radiology. Neuroradiologists regularly meet with the psychiatrists, neurologists, and neurosurgeons to review neuroimaging interpretations and to recommend appropriate use of follow-up neuroimaging.
Neuromodulation (electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), direct current stimulation (DCS), ketamine, esketamine)
The neuromodulation group is a subspecialty part of the psychiatry division of the neurosciences department. All neuromodulation psychiatrists are specially trained and credentialed in ketamine administration, rTMS, and ECT. The group sees patients only on referral from other neurosciences physicians. The neuromodulation focuses on the “brain-repair” strategy aiming to reverse neuroplastic changes that impair connectivity and function.
Neurosurgery and deep brain stimulation (DBS)
For rare cases; e.g., treatment refractory obsessive-compulsive disorder and depression, the neurosurgery group offers stereotactic microablation and gamma knife radiation. In some cases, DBS is offered in lieu of ablative procedures and is used as implantable electrodes to perform minute ablative procedures on selected targets.
Intensive outpatient program and partial hospitalization program
The Psychotherapy Department offers both intensive outpatient group therapy and partial hospitalization programs as the preferred treatment for acute crisis and/or personality-disordered patients. Admission to these programs is open every day on acute referral and saves admissions to the CSU. Many patients seeing the psychiatrist for psychodynamic psychotherapy can concurrently be referred to participate in the intensive outpatient program or partial hospitalization program. Patients should know that our programs use artificial intelligence software systems for administering scales regarding scoring outcomes and session rating for real-time data collection.
In summary, as illustrated in this vignette, psychiatry’s future is already here in many respects. Psychiatrists of the future must leverage the emerging challenges and opportunities for this medical specialty to sustain and develop itself and secure the best possible future for the many individuals in need worldwide who will face life with psychiatric illness. The simplistic notion of “chemical imbalance” will continue to shift into models of progressive neuroplasticity with both gray and white matter changes impairing brain connectivity and functioning. With a multitude of advances on the susceptibility genes associated with psychiatric diseases in human populations, there will continue to be a shift beyond the overly simplistic Mendelian “one gene-one disease” paradigm.
Clinical practice using pharmacogenetic screening will become routine in psychiatry, and will enable psychiatrists to customize pharmacotherapy to achieve better efficacy and tolerability for their patients. This is particularly important given the genetic variations across societies. With the molecular pathophysiological advances of major psychiatric disorders will come the new developments of specific disease-modifying treatments rather than simply symptom-controlling pharmacotherapeutics. The focus will be on early intervention and treatment during the prodromal phase (before the clinical syndrome of major psychiatric disorder manifests) with the aim to modify emerging severe psychiatric illness by using both pharmacotherapy/somatic therapies and psychotherapy. The optimal psychiatric practice will be an integrated collaborative model of care among psychiatrists, primary care physicians, and other specialized services, so that patients receive comprehensive treatments.
Genetic technologies in the next decades will probably bring about the most controversy. Antenatal selection and embryo building, prenatal genetic testing for psychiatric disorders, and genetic therapies, will all be possible. Ethical dilemmas in this domain will continue to push boundaries. However, cutting-edge health care will be possible due to genetic technologies. It will be fascinating to see where these technologies take us by mid-century.
While we do not know precisely what the next couple of decades have in store for the field of psychiatry, we do make the future. The possibilities for a better future for health care are unlimited. Fantasizing about the future is at best intriguing and thought provoking, at worst dull and amateurish. Nonetheless, it is probably safe to iterate that the fundamental physician-patient relationship will remain a constant that will preserve the integrity of medicine as a profession.
Conflict of Interest:
The authors report no conflicts of interest concerning the subject matter of this article.
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