Has Psychiatry Drifted Away from Its Core Business?

There is a growing demand for mental health services across the world. Almost 1 billion people live with a mental disorder with the vast majority of them living in low- and middle-income countries. Several studies have identified the prevalence of common mental disorders, with approximately 1 in 5 meeting criteria for a mental disorder in the preceding 12 months.^1,2 The figures jump to around 44% when lifetime prevalence is considered and around 5% of the population is estimated to have a severe mental illness. ² Although the prevalence rates vary based on geographic areas, the rates are more or less consistent across countries. There remains a significant challenge in providing treatment to almost 20% of the world’s population unless we focus on prevention efforts. Even in high-income countries access to care and treatment is poor with only about half of those with severe mental illnesses able to access treatment.

People with severe mental illnesses continue to have poor outcomes. The life expectancy gap for Schizophrenia remains almost 20 years compared to the general population and there is evidence it might be increasing. Physical health causes are an important contributor to this gap. There is also evidence that this gap can be reduced by addressing several modifiable factors including treatment with medications. ³

The most recent amendment of mental health legislation in the state of Victoria in Australia has incorporated “wellbeing” in its title and commonly refers to “psychological distress” without providing a definition for it. ⁴ This essentially further widens the scope of psychiatry and mental health capturing the essential human emotion of distress in its realms raising questions about medicalizing or psychologizing the common human experience. We also continue to expand to newer issues relevant for mental health, for example, climate crisis, impact of digitization on mental health and well-being, etc.

Providing treatment is an outcome of a multitude of factors. This includes availability of appropriately skilled workforce, availability of appropriate treatments both physical and psychological, affordability, and a support system to facilitate that treatment including addressing various psychosocial factors. There is a significant shortage of mental health workforce across the world especially in low- and middle-income countries. The migration of health professionals from low- and middle-income to high-income countries continues to drain the limited resources in those countries. Essential medications are not available in many countries and lack of affordability is a key barrier in accessing help. Socioeconomic status has a significant impact on psychological problems, those having a lower socioeconomic status have more psychological problems but are less able to access help. ⁵

In summary, we continue to expand the scope of psychiatry to incorporate a range of problems that are significantly impacted by social factors and further continue to delve into well-being. We also have limited resources at hand and are not able to provide treatment to those who have the most severe illness and the outcomes for these groups are not better. Further, we are also not able to demonstrate the effectiveness of our prevention efforts as evident by the continuing mental health crisis. In addition, there is an array of social factors which cause psychological problems and socioeconomic issues underpin the development as well as maintenance of these problems.

What is psychiatry? “Psychiatry is the branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional and behavioural disorders. Psychiatrists are specialist medical doctors who are experts in mental health.”^6,7 These two definitions are from the American Psychiatric Association and The Royal Australian and New Zealand College of Psychiatrists. The Royal College of Psychiatrists states “Psychiatry is a branch of medicine dealing with people with a huge range of mental health conditions. Psychiatrists help people to manage, treat or recover from these.” ⁸

Preventing, diagnosing, and treating mental disorders is essentially our core business. These definitions do not restrict us from providing these services to only those with severe disorders, but there is an ethical need to provide treatment to those who are in the greatest need. There is no doubt that psychiatry has some of the most effective treatments available despite the fact that some of them have been around for decades with limited further innovation and newer developments.

The need to provide treatment to a large proportion of the population raises many questions. Can we provide treatment to 20% of the world’s population in context of workforce shortages, lack of availability of treatments, and affordability as a key issue? Are we overestimating the prevalence of common mental disorders with ever-expanding categories in diagnostic systems further blurring the boundary between pathology and normality? While psychiatry is subsumed under the umbrella term mental health, our further expansion into well-being and distress raises questions, especially when we are not even able to provide appropriate care and treatment to those who have the greatest need. ⁹ Are we constantly expanding our scope of practice despite the lack of evidence-based treatments for many of the problems the population faces? Does this make us vulnerable to medicalize normal human emotions and the potential for the use of restrictive interventions? Are there solutions that we can apply or adapt, to help us navigate this issue? Can we learn from other fields of medicine such as cancer services where there has been a massive effort in prevention as well as treatment?

There are some obvious solutions to some of these questions. Reviewing the prevalence data is probably one of the most important issues especially in light of evidence during COVID-19 when there seemed a surge of increase in prevalence of common mental disorders, although the evidence suggests that the increase was modest. ¹⁰ There was also evidence that levels of distress in the population increased during periods of lockdowns and it returned to the baseline levels when restrictions were lifted. There is a question mark over the validity of the prevalence data from surveys about depression and anxiety disorders especially in light of evidence around variance in how the severity of disorders is defined. That might mean we are overestimating the prevalence of several disorders based on the various social and cultural issues prevalent at the time when such surveys were conducted. A reduction in the number of people who need treatment might itself be a significant advancement. While there are several limitations in defining the severity of mental illness, there is some agreement about what is considered a severe mental illness based on symptom presentation, diagnosis and the chronicity of illness, and level of impairment. ¹¹ Treatment response based on the severity of the condition is well known, especially for depressive disorders with a high rate of placebo response in those with mild to moderate presentations. This does not necessarily mean that those with milder problems are not worthy of any help, but it means that the help they need might be very different than what psychiatry can offer. The impact of universal basic income as a prevention strategy is well known. Similarly, there are several measures at the population level that can reduce rates of suicide, which is impacted significantly by several social issues. Of course, suicidal behavior in those with a mental illness requires intervention appropriate to their presentation.

So here are a few approaches which can help us going forward.

Provide Treatment for People with Severe Mental Illnesses

Psychiatry needs to reinvest its focus on providing treatment for those with the greatest need, people with severe mental illnesses. The ethical principles of beneficence and justice are important in this regard. Providing the most effective treatments to those who would benefit the most from them in an equitable manner is important to utilize the limited resources. While there is a lot of talk about early intervention, its benefits have been limited without the focus on sustained intervention for those with chronic conditions. Early intervention is only effective if there is appropriate effort on relapse prevention and early intervention in future relapses given the chronic and recurrent nature of many psychiatric conditions. Treatment is not only effective in reducing mortality, but it is also helpful in recovery leading to more meaningful participation in the society. Psychosocial support using evidence-based approaches is another pillar of intervention. There are several evidence-based strategies in reducing the treatment gap for mental disorders. ¹²

Imagine if every skin mole was considered to be a sign of skin cancer—we would be overwhelmed with demand for services. Hence, the focus is on early detection of a cancerous mole but also in informing the public about prevention efforts as well as when to seek help. Similarly, we need to refrain from diagnosing every symptom of depression or anxiety as disorders and rather focus on evidence-based public health approaches to prevent these issues and also when professional help is needed. That brings us to the second point.

Develop and Influence a Strong Prevention Agenda Led by Public Health Experts

There is significant evidence for the effectiveness of public mental health approaches as well as the implementation gap in the prevention of many common mental health problems. ¹³ While it is important that psychiatry and psychiatrists are engaged in prevention, we must engage the public health experts in our efforts. Psychiatry’s role should be to provide leadership and expertise to the prevention agenda but not necessarily drive it solely. Public health has never owned public mental health, and it has been left to psychiatry to address this issue sometimes to the detriment of our profession. Incorporating public mental health in public health teaching and sharing the ownership of prevention in mental health is the way forward as has happened in infectious diseases and cancer services.

During COVID-19, generally, the public health experts led the prevention efforts. Infectious disease physicians provided input but maintained their focus on treatment. Psychiatry was left to carry both the burdens spreading our resources further. We also potentially created a problem by continually emphasizing on negative impacts of the pandemic on mental health rather than focusing on the resilience of the community in dealing with challenges and other preventative strategies in a difficult uncertain situation. We must also work with public health experts to drive home messages that are effective and simpler. Although there is significant evidence of the public mental health approaches in the prevention of common mental health problems and conditions, our messaging is too vague compared to many other preventative strategies for other medical problems. The other major issue is that many of the interventions require high-level policy interventions rather than action from the individuals, and hence, they need to be targeted appropriately for their effectiveness. For example, universal basic income or many interventions during childhood require commitment from governments rather than individuals.

Research for Newer Treatments for Psychiatric Disorders

There is no progress without research. Research in psychiatry has been lagging behind compared to many other medical specialties. Cardiovascular medicine, cancer treatment, joint replacement, etc., have all made significant developments in the last few decades. In psychiatry some of our most effective treatments remain as old as almost half a century—ECT, lithium, clozapine, and tricyclic antidepressants to name a few. There have been some new developments with antidepressants, depot medications, and neurostimulation interventions, but their impact is still limited and has not resulted in the kind of improvements seen in other spheres of medicine.

We must also focus on translational research which can help improve retention in treatment for those with chronic and severe illnesses as treatment is known to improve outcomes. A specific focus on the physical health of those with mental illness deserves a special mention as it is a disgrace for our profession that the most unwell of our patients still die more than 20 years earlier than the general population most of it contributed by poor physical health. Effective treatment is also a key element of stigma reduction. One of the most effective ways to reduce stigma is to provide effective treatments and keep people well. Stigma reduction for HIV and cancer has not only been the result of public health education campaigns but quite remarkably due to innovations in treatment. Similarly, further research on effective treatments that help people recover and stay well is important if we are to reduce stigma and improve access to treatment. Again, a comparison with cancer services is relevant in all aspects including treatment and outcomes as well as research into newer treatments.

Restrict “Mission Creep”

“Mission creep is the gradual or incremental expansion of an intervention, project or mission beyond its original scope, focus or goals.” ¹⁴ Expanding the scope of psychiatry to mental health was a form of mission creep, and expanding it further to well-being and distress is rather irresponsible. While the expansion from psychiatry to mental health was an important step in trying to reduce stigma, it has had some impact in reducing stigma for those with anxiety and depressive disorders but not much change for those with psychotic disorders.

Continuing expansion of our scope or mission creep has meant that we are losing our focus on providing effective treatments while embarking on trying to address other issues which have limited evidence. Interventions for several milder problems including psychological distress is a good example for that. Many of those issues are self-limiting or can be addressed by the individual within their community context with appropriate support and guidance including digital resources. An important element of restricting mission creep would be to put a curtain on the ever-expanding diagnostic categories as well as better prevalence data rather than just relying on surveys. It is almost akin to having two separate issues—those with moderate to severe illnesses where there are effective treatments, and those which fall under milder problems which might be self-limiting or where there is limited evidence of the effectiveness of individual treatments but greater benefit from preventative approaches or where some of the treatments may do more harm than provide any benefit. Someone presenting in distress or even depressive symptoms in context of financial issues requires assistance to address those issues rather than a pill. Farmer suicide and the strategies to reduce farmer suicide is a very good example from an Indian perspective. ¹⁵

With almost a quarter of the 21st century gone and no sight of addressing the mental health crisis we face, we need to refocus and revisit some of our priorities. We must focus on what is our core business and prioritize to provide effective treatments to those who need them the most. Our obsession to treat everyone with some anxiety and depression must end especially when these words are so commonly used to express normal human emotions. We must work with the public health experts to develop strategies that are effective for population health if we are to somehow contain this ever-expanding mental health crisis. We need to invest in research to develop more effective treatments as has happened in other spheres of medicine.