Landscapes of tomorrow: Precision psychiatry and beyond

The authors have known psychiatry for more than 50 years. In this period, it has made impressive progress in knowledge and undergone many changes in the delivery of services, some of great attraction and others less welcome. Katschnig (2010) set out where he sees changes having taken place, pointing out that some have come from within psychiatry, others from outside. His paper has been useful in indicating what may lie ahead for all professionals dealing with mental disorders, not only psychiatrists.

One must ask if psychiatry itself has any control over its future, or if forces external to it are the sole determinants. Through vehicles such as the ANZJP, we see no reason why psychiatrists should not have more influence over further developments, not least by acting on what comes from outside. Psychiatry itself must also advance as part of medicine. With this in mind, we want to identify some of the key issues and look at what lies ahead for practitioners. We focus on three major fields: the human population, health services and technology. There are others, but these three are a sufficient base on which to build.

The human population

At present, psychiatrists typically attend to only a very small fraction of the general population who need treatment. Most go untreated, while many reach primary care or go to other ‘providers’. There is reason to believe that more people are seeking treatment than in the past. This increase is because the threshold for help-seeking has probably dropped, accompanied by a lowering of the hurdle to meet the diagnosis of a ‘mental health problem’, rather than any true increase in the prevalence of morbidity among the clearly defined disorders. Evidence for such an increase is lacking. There are now many more non-medical staff working in the field. Mental health literacy continues to improve, leading to greater public expectations from services. Associated with better literacy is a reduction of public stigma towards persons with mental disorders. One hopes for less stigma towards psychiatry itself, not least from other doctors. However, much of the reduction in stigma is associated with the common mental disorders through widely used euphemisms such as ‘mental health issues’ and ‘mental health problems’. These terms, unfortunately, run the risk of undermining the pain and suffering associated with the more severe psychotic disorders. We see further reduction of stigma as crucial for progress in services. This calls for action, with psychiatrists themselves as major participants.

The demographic structure of the population will continue to change in line with global trends, as with migration, greater life expectancy, urbanisation, social mobility and an increase in the proportion of older persons. At the same time, there is now greater socioeconomic inequality and a reduction in social cohesion, both of which have impacts on mental wellbeing. This will in turn be reflected in the characteristics of persons coming to services. We should advocate for strategies that minimise inequality and promote community cohesion and social capital as protective factors

Misuse of so-called recreational drugs is likely to continue to increase, and their variety will expand. In this way, morbidity that is determined by personal choice of lifestyle will compete with morbidity associated with factors independent of the individual. Personal responsibility for mental health, unlike physical health, has yet to become socially expected. Unlike cardiovascular disease, cancer, infectious diseases or trauma, interventions at the level of the general population such as immunisation, compulsory seatbelts, smoking, diet and lifestyle are not yet available for mental disorders or are at best in a very early stage of development.

There is also the prospect of an expanding range in the types of morbidity available to the general population. There are more psychiatric diagnoses in the lexicon now than 50 years ago, as exemplified by the advent of posttraumatic stress disorder (PTSD) and attention-deficit hyperactivity disorder (ADHD) and the pathologising of aberrant behaviours. Furthermore, the numbers of cases in the general population who have hitherto been unrecognised has apparently expanded, as with bipolar affective disorder and ADHD. These secular changes over the decades have come largely from within psychiatry itself, particularly in America, albeit welcomed by some of the public and the pharmaceutical industry. It seems likely that these trends will continue. Psychiatry needs to be vigilant about its proper role in this expansion. On one hand, having even more disorders seems something to resist, but on the other, it is likely that syndromes such as schizophrenia are in fact heterogeneous and deserve differentiation. The social consequences of further changes in classification are hard to anticipate.

Mental health services

It is useful to consider what changes have been taking place in mental health services in higher income countries and what changes have taken place in the work of psychiatrists. This may give some notion of what can be expected in the future. In many countries, those in the general population seeking psychiatric services presently have a choice, if they can afford it, between public and private practice. In 2011, 32% of Australian psychiatrists were in private practice. By 2014, this had increased to 40%, with a concomitant drop in the proportion of psychiatrists who work in both the private and public sector from 36.2% to 26.7%. One can only speculate on the ratio of private and public practitioners in the future. Among the driving forces at play, here is dissatisfaction with excessive managerialism in the public sector. In addition, psychiatry graduates are increasingly liable to finish training still with substantial university debts.

Greater affluence or Government policy may bring further change to the absolute numbers reaching mental health services. In terms of what actually happens in treatment, private practice almost invariably involves direct transactions between a psychiatrist and the patient or family, with less involvement of other professionals. In the public system, the much-championed multi-disciplinary team seems likely to persist or even expand. No one knows if these operational differences matter in terms of clinical outcome, but the overall contrast seems unlikely to change.

In high-income countries, recent decades have seen a very large increase in overall expenditure on services for mental disorders, but little new money going to the core services that look after those with chronic and psychotic disorders. This increase has been both in the numbers and diversity of personnel and in the prescription of psychotropic drugs. Yet Jorm et al. (2017) show that this increase has not been accompanied by a drop in the prevalence of common mental disorders at the community level. Despite this observation, further expansion of mental health services is likely driven by public demand and hopefully an increasing awareness of unmet need in the severely disabled. Because of this expansion in the total workforce denominator, psychiatrists will become less visible, as has been happening since the middle of the 20th century. We anticipate that the role of psychiatrists in both policy and practice will continue to decrease. Lay administrators and non-medical clinicians such as nurses, psychologists and social workers are likely to have an increasing influence on what happens at the coal face. These changes in the psychiatrist’s role in mental health teams is well illustrated by a common request that a psychiatrist examine a patient ‘for review of medication’ (sic). Is this what we have come to? It is a regrettable misunderstanding of our training. Such a perception needs to be corrected by further education of staff. As members of a team engaged in comprehensive care, psychiatrists should not be seen merely as pharmacological technicians.

The overall situation in mental health services is an attractive opportunity for psychiatrists to make much better use of their general education, medical training, knowledge of clinical psychiatry and interpersonal skills. These attributes have to be more clearly recognised within health services and the community. It is these that enable psychiatrists to contribute to the organisation of services, but most of all to the examination and treatment of patients in a way that other mental health professionals cannot. So, one comes back full circle to the centuries-old role of being a highly observant physician, skilled at eliciting the necessary information about a person and their illness, then assembling it in a formulation to guide treatment. This is preferable to a cookbook approach, ticking off the required Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria and applying a simplistic remedy. Because of the increasing expansion of allied health professionals, psychiatrists will also need exceptional interpersonal skills in working effectively as members of a team.

Without doubt, we will increasingly use information technology, where machines will contribute to diagnosis and treatment. But even this needs to be balanced with clinical wisdom. We will have to be well-informed about the interpretation of neuroimaging and have a deep knowledge of neuroscience and psychopharmacology. While many patients will be referred to psychologists for one of the behaviour therapies, this trend should not prevent many psychiatrists from conducting psychotherapy themselves with a good understanding of the therapeutic relationship. It is this diversity of competence that will ensure survival of the discipline. What psychiatry offers is irreplaceable. But there is a further force at work, outside the domain of health services, one which will further strengthen its position. Knowledge in psychiatry itself will not remain static. It is here that we have both influence and responsibility for the future.

Clinical science and technology

Clinical skills such as interviewing an unwell person, taking a history and making a formulation are unlikely to alter any more than they have in the last 200 years; there is unlikely to be an algorithm to supplant the pattern recognition displayed by a skilled clinician. But in comparison with general medicine, the level of knowledge available to us in clinical psychiatry is still at an early stage. We have a limited understanding of why only some individuals become unwell or what underlies relapse of symptoms. In contrast to the rest of medicine, our diagnostic groups are defined only by their clinical attributes. There is not one laboratory test for any psychiatric disorder. Although there has been impressive progress in unravelling the aetiology of schizophrenia and the affective disorders, this knowledge has not yet been translated into clinical utility. Although this absence of translation is now frequently asserted, the situation is unlikely to persist. For example, there are unprecedented advances in knowledge about the effect of the social and physical environment on the developing human brain and on activity levels in specific brain areas in the mood disorders or schizophrenia. Further progress in such neuroscience will inevitably take place. It may be some decades away, but this will have a profound effect on clinical practice, analogous to the difference between general medical practice in 1900 and today. For example, the findings on palpation, percussion and auscultation are no longer given the same weight by today’s physician. In an analogous way, psychiatrists are likely to go about their work with new tools. The changes will lie in the following areas: diagnostic technology to investigate brain function, metabolism and immunology; psychopharmacology; genomics; and non-invasive physical treatments. As in other areas of medicine (Williamson et al., 2018) precision (or personalised) psychiatry will make it possible to select interventions that are much better fitted to a person’s genes and past environmental exposures. It is even conceivable that precision psychiatry may extend beyond pharmacology. Already, in a remarkable development, brain imaging is being used to determine who may respond to particular types of psychotherapy.

But who will bring about these scientific advances? In the research domain, we anticipate a situation where psychiatrists will again have a diminishing role, just as has been slowly taking place over the last 100 years. It is our impression that for research projects on mental disorders, non-medical scientists are playing an increasing role among recipients of grants from Research Councils. This applies in Australasia and elsewhere. Unsurprisingly, it is the same for authorship in publications. Academic psychiatry is being overshadowed by other professions. Unlike most psychiatrists, our non-medical researchers have been exposed to highly relevant science and methodology since they left school. So, it is understandable and perhaps inevitable that psychiatrists will often play only a secondary role in research teams. The situation is compounded by the currently available career paths and salaries. It is of grave concern to us there are no clear pathways or job opportunities for budding academic psychiatrists and there has been limited succession planning. Salaries in the earlier stages are a serious disincentive. Throughout academic medicine, the drop in recruitment and funding for junior academic posts has become a matter of great concern for several Royal Colleges and Academies. Attention has been drawn to this critical situation in an earlier Editorial (Henderson et al., 2015). It is far from certain that a new generation of academic psychiatrists is emerging in sufficient numbers, individuals with an outstanding research record to replace the present ageing cohort.

We have a bold proposal to put forward for consideration: suppose academic physicians, including psychiatrists, were to have a substantial loading to their salaries on the grounds that they are now seriously scarce, yet are essential for scientific progress and for training the next generation. In addition, while working alongside other clinicians, they must be outstandingly competent across three fields: clinical practice, teaching and, above all, research.

In clinical practice, we are confident that the clinical psychiatrist will retain one irreplaceable role: as an interlocutor between neuroscience and the patient. It is here, in the construction of a formulation, integrating all the elements in a person’s total life, that the psychiatrist can be exemplary to all other professionals. At some stage later this century, a person presenting with symptoms suggesting a psychiatric disorder will be examined clinically and then have diagnostic tests as indicated above. These will hopefully be used only to complement what has already been ascertained from the clinical assessment. But non-invasive technology will produce information unlike anything available today. Special investigations will guide treatment specific for that individual. This will be the advent of precision or personalised psychiatry. Further developments in computing and information technology may give rise to prostheses for mental activity. Because psychiatry, unlike the rest of medicine, considers the mind as well as its brain, it will be the psychiatrist who collaborates with the patient in using these unprecedented advances towards recovery. This means the psychiatrist will have to acquire another skill, this time in what amounts to the hermeneutics of neuroscience with a human face, all the while relating to a person who is unwell. We should also enthusiastically anticipate new knowledge, biological and social, that leads to prevention. In its leadership role, here is an agenda that the Royal Australian and New Zealand College of Psychiatrists (RANZCP) could so usefully tackle by convening a Working Group. The wider community needs to know what psychiatrists can and will do.

Writing on the future of psychiatry 45 years ago, Eisenberg (1973) put it this way: ‘… comprehensive evaluation and effective therapeutic planning require the physician to be as knowledgeable about psychosocial (factors) as about molecular biology’. Contrary to what Katschnig (2010) proposed, psychiatrists will not become a threatened species. The diversity of their capacities ensures their ecological niche. They cannot be replaced by others. Apart from neurosurgeons, no other medical specialty addresses itself to the most complex piece of matter in the known universe.