The future of psychiatry

The evidence base for common interventions within psychiatry is expanding

Mental health is rarely out of the media spotlight. There are radio discussions, websites, newspaper articles, and any number of social media influencers who focus on mental health wellbeing and conditions such as depression and anxiety. This is broadly a positive development, although media coverage tends to neglect disorders such as schizophrenia and bipolar disorder. Hopefully, this will rebalance over time and the media will expand its role in promoting mental health and providing information about mental illness.

In parallel with these developments, psychiatry is changing in various ways. The discipline reflects an evolving combination of person-centred care and system-level changes that are ideally compassionate, evidence-based, and developed in partnership with people with mental illness and their families. Mental health services require considerably more resources to realise this vision, but a collaborative model of care can emerge when such resources are provided.

The evidence base for common interventions is expanding, especially for medications such as antipsychotics, which are proving more beneficial than imagined. Inevitably, deciding which treatment to use depends on a range of factors including a person’s presenting symptoms, other conditions or illnesses they have, their past history of treatment (if any), and personal preferences for one form of treatment over another.

Mental health needs change over time, so treatments and supports that are offered at one point might not prove equally effective at another time. Communication and flexibility are essential to optimise outcomes and realise the potential benefits of treatments.

Psychiatry has further developed its bio-psycho-social model of care, which acknowledges biological, psychological, and social dimensions to health, illness, and treatment. While each condition might have a physical cause (known or unknown), there are also psychological and social aspects to causation, symptoms, and outcomes. This is reflected in treatments which, ideally, look at biological, psychological, and social aspects of care.

Growing evidence affirms the value of cognitive-behaviour therapy (CBT) in the management of a range of conditions, including depression, generalised anxiety disorder, panic disorder, social phobia, and post-traumatic stress disorder. CBT is the form of psychotherapy that is best supported by evidence. Other therapies include interpersonal psychotherapy, mindfulness-based approaches, psychoanalysis, and various others.

While there have been few novel medications for mental illnesses in recent years, the evidence-base for existing medications has deepened and expanded. For example, cumulative data strongly support the effectiveness of antipsychotic medication for conditions such as schizophrenia. Long-term antipsychotic use does not increase risk of serious physical illness requiring hospitalisation and is associated with substantially decreased mortality among people with schizophrenia.

Growing evidence supports the effectiveness of antidepressants for many people with depression. Variations between antidepressants are small, so choice of antidepressant (if medication is used) depends on the severity of the depression, treatment history, and the patient’s preference. Other approaches are also needed, but the value of antidepressants as an option has been strongly reaffirmed over recent years.

Potential new treatments, such as ketamine and psilocybin, often in combination with psychotherapy, have attracted a great deal of attention and hold substantial promise for the future. This should not, however, distract from the requirement for a sound evidence base before such substances come into widespread use (if they do). Initial results are promising, but more data are needed before they can be recommended in day-to-day practice.

Looking to the future, key issues include the continued development of diagnostic methods in psychiatry, with hopefully greater input from biological research over the coming decades. It is also essential to advance the idea of a “right to mental healthcare”, possibly through mental health legislation. Ireland’s new Mental Health Bill 2024 signals significant reform in this area. Psychiatry has unique potential to act as a transformative movement to advance rights and promote the wellbeing of people with mental illness, so hopefully that legislation will be revised in a pragmatic, productive way.

Human rights require firm protections in law, but other approaches are also needed to realise rights in practice. These are approaches which remain deeply aware of human rights, but find their fundamental roots in an ethics of interpersonal care, evidence of benefit, service development, and political activism. Human rights are essential to protect in law, but law alone is not enough. Good clinical care promotes rights.

It is also essential for psychiatry to engage with the potential roles and risks of artificial intelligence. People with mental illness have the right to enjoy the benefits of technological advances on an equal basis with others, so it is essential that issues of access, ethics, and evidence of benefit are managed appropriately.

Overall, the future of psychiatry lies in further deepening the evidence base for psychiatric treatments, inviting critics to examine this systematic evidence for themselves, combining this with knowledge from direct experience of mental illness, and continually reshaping psychiatry as both a discipline within medicine and a transformative movement to promote the rights of people with mental illness and their families.

Prof Brendan Kelly is Professor of Psychiatry at Trinity College Dublin. His new book, The Modern Psychiatrist’s Guide to Contemporary Practice: Discussion, Dissent, and Debate in Mental Health Care, is available online free of charge: www.taylorfrancis.com/books/oa-mono/10.4324/9781003378495/modern-psychiatrist-guide-contemporary-practice-brendan-kelly