The future of psychiatry: psychiatrists of the future

OBJECTIVE: The authors' goal was to examine the changing demographic trends in psychiatry manpower. These changes have important implications for the practice of the profession in the future. METHOD: Each year, the APA Office of Membership, in collaboration with the American Association of Directors of Psychiatric Residency Training, conducts a census of all residents in psychiatry. A survey instrument is sent to the director of residency training in each U.S. program accredited by the Accreditation Council for Graduate Medical Education. Using data from this survey and from the American Medical Association, the authors conducted a study of the changes in the number of psychiatric residents over the last decade, particularly the increases in the number and percentage of women in medicine and psychiatry. RESULTS: They found that the number of psychiatric residents has grown from 4,674 in academic year 1978-1979 to 5,829 in 1987-1988, an increase of 25%. The percentage of women has increased from 32% of all psychiatric residents in 1978-1979 to 41% in 1987-1988. The largest proportions of female physicians and psychiatrists were found in the age groups younger than 35. CONCLUSIONS: Previously documented gender differences that affect practice patterns and career opportunities may very well change as a function of the increasing representation of women in the profession of psychiatry, and these changes need to be taken into account in planning for future patient care and research needs.     

The future of psychiatry

The author reviews the vicissitudes of psychiatry's history over the past 50 years and urges the profession to abandon false boundaries between mind and brain and to make a commitment to the scientific validation of prevailing theories of the etiology of psychiatric disorders. He argues that the separation of psychiatry and neurology is no longer justified. He calls instead for a carefully conceived new career path leading to specialization in clinical neuroscience and further urges that psychiatric training programs be restructured to focus on the critical examination of problem solving and validation methods.     

The future of psychiatry

There is widespread concern among psychiatrists that the profession is in crisis and that it faces an array of external and internal challenges. Indeed, some observers have questioned whether the psychiatrist is an endangered species. This paper argues that medical specialties can become extinct as the case of the apothecaries exemplifies. The training template for psychiatry in the UK was put in place 40 years ago and there is a need to carefully examine whether it is still fit for purpose. Advances in theoretical knowledge and in basic understanding of psychiatric disorders have not significantly influenced the structure of clinical placements; rather it is service developments and administrative demands that have been the determinants of changes in training. Urgent action is required to address the need for reform of training that will ensure the future of psychiatry as a profession.     

Genomics and the future of pharmacotherapy in psychiatry

Pharmacogenetic studies of psychotropic drug response have focused on determining the relationship between variation in specific candidate genes and the positive and adverse effects of drug treatment. Preliminary evidence exists for a significant relationship between a promoter region polymorphism in the serotonin transporter gene and antidepressant response, as well as for associations between candidate neurotransmitter receptor genes and second generation antipsychotic drug response. More recent work in schizophrenia has focused on the use of first episode, antipsychotic na?ve subjects, which may provide greater study power as suggested by studies examining dopamine receptor genetic variation and clinical response measures. An emerging body of literature suggests that pharmacogenetic strategies may be especially useful in the prediction of drug-induced adverse effects, in particular for the important side effect of antipsychotic-induced weight gain. New developments in genomics, including whole genome genotyping approaches and comprehensive information on genomic variation across populations, coupled with large-scale clinical trials in which DNA collection is routine, now provide the impetus for a next generation of pharmacogenetic studies. These increasingly comprehensive approaches should provide informative data on the genes associated with psychotropic drug response, a critical step towards the ultimate goal of 'personalized' medicine.     

Genomics and the future of pharmacotherapy in psychiatry

Pharmacogenetic studies of psychotropic drug response have focused on determining the relationship between variation in specific candidate genes and the positive and adverse effects of drug treatment. Preliminary evidence exists for a significant relationship between a promoter region polymorphism in the serotonin transporter gene and antidepressant response, as well as for associations between candidate neurotransmitter receptor genes and second generation antipsychotic drug response. More recent work in schizophrenia has focused on the use of first episode, antipsychotic naïve subjects, which may provide greater study power as suggested by studies examining dopamine receptor genetic variation and clinical response measures. An emerging body of literature suggests that pharmacogenetic strategies may be especially useful in the prediction of drug-induced adverse effects, in particular for the important side effect of antipsychotic-induced weight gain. New developments in genomics, including whole genome genotyping approaches and comprehensive information on genomic variation across populations, coupled with large-scale clinical trials in which DNA collection is routine, now provide the impetus for a next generation of pharmacogenetic studies. These increasingly comprehensive approaches should provide informative data on the genes associated with psychotropic drug response, a critical step towards the ultimate goal of ‘personalized’ medicine.     

The biopsychosocial paradigm and the future of psychiatry

Although hazardous, prediction is necessary for sensible programing for the future of psychiatry. Because of the multitude of variables essential for comprehending normal and abnormal behavior, a complex, all-encompassing model takes on increasing importance. Dualism and reductionism have had a chilling effect on progress in developing psychiatric models. The biopsychosocial model as elaborated by Dr. George Engel would appear to be a major step in moving toward an adequate workable model. Dr. Engel rejects the biomedical or Newtonian model in favor of the biopsychosocial model, basing his conception in part on developments in the past century, particularly the contributions of Einstein, Heisenberg, and Planck. The implications and relevance of these advances, including the work of Niels Bohr, are presented. Other ideas such as Chaos Theory and the work of Roger Penrose are also discussed, together with the new thinking that arises from them. This work reinforces notions of holism, leading to a more humanitarian psychiatry and medicine.     

The future of consultation-liaison psychiatry

OBJECTIVE: To review the status of consultation-liaison psychiatry and the factors shaping it, and suggest strategies for its future development. METHOD: In addition to searches of the main computerized psychiatric databases and review of relevant Commonwealth of Australia publications, the author drew on discussions with national and international colleagues in his role as convenor of the International Organization for Consultation-Liaison Psychiatry. RESULTS: Physical/psychiatric comorbidity and somatization, the conditions in which consultation-liaison psychiatry specializes, are the commonest forms of psychiatric presentation in the community. They are as disabling as psychotic disorders, and comorbid depression in particular is a predictor of increased morbidity and mortality. Acknowledging this, the Second Australian National Mental Health Plan called for consultation-liaison psychiatry to be allowed to participate fully in the mental health care system. It stated that failure to define the term 'severe mental health problems and mental disorders' in the First Plan had led to some public mental health systems erroneously equating severity with diagnosis rather than level of need and disability. The call has been largely unheeded. The implication for patient care is both direct and indirect; the context created for psychiatry training by such a restricted focus is helping to perpetuate the neglect of such patients. This is a worldwide problem. CONCLUSIONS: Proactive involvement with consumers is required if the problem is to be redressed. At a service level, development of a seamless web of pre-admission/admission/post-discharge functions is required if patients with physical/psychiatric comorbidity and somatoform disorders are to receive effective care, and consultation-liaison psychiatry services are to be able to demonstrate efficacy. Focus on comorbidity in the Australian Third National Mental Health Plan may force resolution of the current problems.     

The future of community psychiatry

As our understanding of post-traumatic stress disorder (PTSD) improves, so too should our psychopharmacological approaches to treating this common and sometimes disabling condition. Treatment with drugs can lead to improvement in PTSD. The most effective drugs seem to be those that have their action on the serotonergic system, such as the selective serotonin reuptake inhibitors and the monoamine oxidase inhibitors. Higher dosages and longer periods of treatment seem to be required in many cases for adequate therapeutic response. Here we examine the main groups of agents used in the pharmacological treatment of this disorder. With a background of relatively few randomized therapeutic trials and others beset by limitations, it remains difficult currently to draw confident conclusions in the approach to drug management.