The last 60 years: Selected advances

Progress in psychiatry may be looked for in three domains: scientific knowledge, clinical services and health outcomes. The writer has now seen Psychiatry for 60 years, providing an opportunity to consider what may have advanced. That task has been astutely proposed by the Editor. What follows is inevitably a highly selective account but one that nevertheless counts because of its time span.

Knowledge

None could doubt that scientific knowledge in psychiatry has expanded greatly, even if unevenly. There is a much better understanding of the brain and its interaction with the social and physical environment, how it develops over time and how it functions in health and in mental disorders. Most remarkably, this knowledge now applies to events extending from the human population level down to molecules. Indeed, there is now a journal called Molecular Psychiatry, a title that would have previously evoked incredulity. This is partly because, until recently, direct access to the brain has been extraordinarily difficult, but technological advances in recent decades have led to neuroimaging tools which allow us to examine its morphology and function in unimaginable detail. For example, using diffusion tensor imaging we can track axonal organisation and by employing functional imaging we can see the mind at work.

Sixty years ago, registrars were typically invited to believe that schizophrenia, one of the worst diseases afflicting humankind, was caused by alterations in how the libido was deployed, and it was the family who could make some persons regress and become psychotic, while paranoia was due to unconscious homosexual im-pulses. Thus, in the 1960s, RD Laing was a hero among students. Now, schizophrenia is viewed altogether differently as a neurodevelopmental syndrome with many interacting causes.

Some of this progress is due to the manner in which research has developed. Psychiatric research is now conducted on a large scale with immeasurably better funding, often undertaken by teams who are part of large-scale international collaborations. For knowledge about causation, the findings now consistently point to a common aetiology for many disorders, with epigenetic effects eclipsing the unhelpful contrast previously drawn between nature and nurture. In an update on psychiatric genomics, one influential consortium says we have entered a phase of accelerated genetic discovery for multiple psychiatric disorders. Investigators no longer see themselves dealing solely with specific psychiatric disorders, but instead as grappling with ‘a myriad of processes distributed across multiple levels of the biological hierarchy, from genes to molecules to cells to circuits to human behavior’ (^{Senthil and Lehner, 2020).}

Critics of psychiatry frequently assert that the advances in neurobiology and molecular genetics have done nothing for patients. And while, presently, this may be somewhat true, it will not continue. It is inconceivable that advances in neurobiology will fade away, leaving no benefit for clinical practice. Readers may ask themselves whether progress in the treatment of mental illness is commensurate with the remarkable successes seen elsewhere in general medicine, such as in immunology, cardiology or oncology. The answer is clearly no, but the comparison is not just, because such specialities are not dealing with the most complex piece of matter in the known Universe.

In the psychosocial domain, much more is known about harmful exposures such as childhood abuse or trauma and their longitudinal consequences. What is harmful and what is beneficial in human interaction is also much better understood. Meanwhile, the psychological foundation of psychiatry has burgeoned, exemplified by the development of attachment theory and learning theory. Both of these have generated advances in psychotherapy for anxiety, depression and personality disorders. It is now firmly established that some psychological interventions are effective. The general public in many countries now has much better knowledge about mental disorders – partly because mental health is indisputably more visible in the media, in social conversation and in health policy.

Epidemiology

We now know about the prevalence and principal correlates of mental disorders as they occur on all continents, and not just in the few people who have reached health services and who are thereby familiar to clinicians. For research on aetiology, patients are now seen as an incomplete representation of the true denominator. Importantly, an acceptably valid method for case ascertainment in general populations has been achieved, using a standardised instrument, which is administered not by psychiatrists but by trained lay interviewers: the Composite International Diagnostic Interview. Consistent regional variation has been found for the prevalence of the so-called common or high prevalence disorders (anxiety, depression and substance misuse). North and South East Asian, and Sub-Saharan African countries have consistently lower 1-year and lifetime prevalence estimates than other regions, while the highest lifetime prevalence estimates are in English speaking countries. In a large study of over 60,000 adults across 14 countries, the number of mild and subthreshold cases receiving treatment was found to far exceed the number of untreated serious cases. So globally, available resources are inappropriately deployed ^{(World Health Organization (WHO), 2004).} In the United States, in the decade between 1990–1992 and 2001–2003, the prevalence of mental disorders did not change, but the rate of treatment increased ^{(Kessler et al., 2005).}

In some diagnostic groups, the volume of cases who reach services has changed greatly. General practitioners are now better equipped to recognise people with anxiety and depression. Morbidity from alcohol and substance misuse, particularly opiates and psychostimulants, has sharply increased, not least in the young. In the 1960s in the West, opiate dependency oc-curred mainly in doctors or others who had access. Now our Emergency Departments and acute mental health services are often overextended by casualties from psychostimulants and opiates. Any advance in knowledge attributable to this increase in morbidity has yet to emerge.

For better or for worse, there are more diagnoses to offer patients, obvious examples being attention deficit hyperactivity disorder, borderline personality disorder and post-traumatic stress disorder, none of which were recognised in the early 1960s. But not all would agree these represent an advance in knowledge. It remains uncertain whether the psychoses and mood disorders have changed in incidence. Although this question is often asked, it cannot be answered with confidence. The numbers reaching services have certainly greatly increased, but these are unsatisfactory estimates of the true prevalence at the population level, and there are no adequate epidemiological data on the psychoses or mood disorders in earlier times for comparison. An advance of profound significance for clinicians is that comorbidity, at least in treated populations, is now known to be pervasive across all diagnostic groups. It is also bidirectional over the lifespan. These findings emerge from the remarkable work by ^{Plana-Ripoll et al. (2019)} in Aarhus.

Data obtained by the World Health Organization show surprisingly that global suicide rates have been decreasing in recent decades, dropping from about 15 per 100,000 in 1990 to about to 10 per 100,000 in 2017. Any explanation for this can only be speculative because so many plausibly causal factors have changed in the same period – the unpredictability of such trends exemplified by the effects of the current pandemic, which seems to be increasing suicide rates once again.

Medication

Knowledge in psychopharmacology has made modest progress. The present armamentarium of drugs is an advance on 60 years ago where there was essentially only paraldehyde, the barbiturates and then chlorpromazine. The tricyclics had just arrived. Australia has given the world the use of lithium for mood disorders. The introduction of clozapine has been a true advance, but overall the efficacy and safety of antipsychotic drugs is still far from ideal. Expenditure on antidepressants has vastly increased, with commensurate profits, yet with no decrease in morbidity at the population level.

The Internet

Knowledge is now much more easily communicated. In all of medical science and across health services, information technology has transformed what can be accessed or transmitted, with a volume and rapidity that can even become uncomfortable. It is now familiar to clinicians, administrators and researchers to become overloaded with information. The challenge nowadays is not how to get hold of knowledge but how to determine what is real and what to use.

Services

Advances in services can be considered in two fields: the workforce available to deliver them; and how that workforce is deployed. In developed countries, there has been a massive increase in the numbers of people working in mental health, both in clinics and in the community. In 1962, the Australasian College of Psychiatrists had a mere 360 members, one for every degree on a protractor. Now, in 2020, the Royal Australian and New Zealand College has nearly 5000 Fellows (4943 to be exact). This is an almost 14-fold increase, much greater than the national populations. One encouraging statistic is that the College currently has 1836 trainees. And a similar expansion in the workforce has taken place for nurses, psychologists and social workers. Our Universities and teaching hospitals now have training programmes for each of these professions to an extent that would have been unthinkable six decades ago. At that time, university departments of psychiatry and chairs were just being established in both our countries. Now, psychiatry has a secure place in the medical curriculum alongside other disciplines. In marked contrast to the 1960s, medical students now rarely come straight from school, but typically have degrees in other disciplines or experience far from medicine. Some have even acquired a familiarity with the humanities. The result is that in the writer’s experience, today, many trainees have more broadly educated minds than before. An advance of immeasurable value, albeit still incomplete, is the number of women who now have chairs in psychiatry in Australia and New Zealand. In all our professions, there is now much greater variety in country of origin, as there is in patients. There are now many more community clinics, general hospital beds, community services, non-governmental organisations (NGOs) and much more legislation. General practitioners on average have had much better training in mental health. The number of private psychiatric clinics and hospitals has risen, while mental hospitals have essentially disappeared. Some may see these changes as an advance, but that needs to be weighed across many variables: the numbers of people now seeking treatment, the lamentable unmet need in those disabled by severe and persistent disorders, the national expenditure on mental health and its overall benefit to the community.

Attention must be drawn to one significant development in Australia and New Zealand for ensuring long-term progress. In 1978, a research society was formed in Australia, shortly joined by New Zealand. With some close colleagues, we established the Australian (and later New Zealand) Society for Psychiatric Research, now the Society for Mental Health Research (SMHR) (https://www.smhr.org.au/history-of-aspr-and-smhr). From the outset, and in contrast to the Royal Colleges, a major emphasis has been to encourage younger investigators from psychiatry, psychology, the social sciences and biostatistics. The Society’s contribution is evidenced by its growing membership and its influential role in the promotion of research in both countries. Further advances depend on what is done now at a national level to develop the structure for promising young psychiatrists to pursue a research career. Without such a structure, our most gifted young will have no choice but to go elsewhere, caught in the insatiable demand for services and administration. One advance is that the National Health and Medical Research Council (NHMRC) in Australia and the Health Research Council (HRC) in New Zealand now fund much more for mental health than in the 1960s, but too many high-quality applications continue to be declined.

An admirable Australian initiative, to be seen as a major advance for service policy and further progress, has been the National Mental Health Strategy, which commenced in 1993 with the first in a series of 5-year reform plans (^{Department of Health and Ageing, 2013)} and continues to the current time. This contribution is the product of exceptional insight and political skill. A fundamental question will be what factors will determine its success

Outcomes

It seems that people in distress are now much more likely to seek help. But in the end, the most fundamental question is whether there has been a change in the prevalence of any of the mental disorders, not in those who reach services, but in the general population. We may never know with certainty, because there are no data on prevalence then and now, obtained by exactly the same measures. One statistic we do have is data on national suicide rates. In Australia in 1960, it was 11.7 per 100,000. In 2018, the latest year available, it was 12.2. One interpretation of this is that, insofar as suicide rates are one indicator of a country’s mental and social health, advances in knowledge and services have not yet brought about any demonstrable change.

A final development to note is the advancing disuse of the word ‘psychiatry’. Over the years, this word, derived from Classical Greek for a doctor of the mind, has sadly come to have distinctly unpleasant connotations in the eyes of the public and many non-medical health professionals. It is seen to be dominated by what the incompletely informed like to call ‘the medical model’. In its place, the wider expression ‘mental health’ has become more acceptable. This change may in the end prove beneficial in some ways, provided our contribution as physicians is allowed to continue across the entire field. Psychiatry, as we have known it, has never had such exhilarating prospects.