Crystal Ball Gazing

Editor in Chief

I’ve written before about the importance of self-reflection in our clinical practices and in teaching our residents and students to enhance their own skill and to help foster it in their patients. As hectic as the world is today, and with our increasingly busy schedules (as if they weren’t already), we often have little opportunity to consider the future of our profession. So, I’m pleased to suggest you spend a bit of time reading The Lancet Psychiatry Commission on the Future of Psychiatry. The target future selected was a decade from now -far enough that changes would likely be apparent, but not so far into the future that the conclusions would be almost completely speculative.

Many of us have been aware that The Lancet has been since the early 1800s one of the most prestigious medical journals in the world. But some may not be as aware that several years ago The Lancet established a number of specialty journals including The Lancet Psychiatry. I was honored to be asked to serve as a member of the Lancet Psychiatry Commission. (This was a volunteer academic effort, a collaboration of The Lancet and the World Psychiatric Association, so I receive no benefit from suggesting you read the report.) After a year of work, the final report will have been released by the time you are reading this in early October, timed to coincide with World Mental Health Day.

The report has 6 sections: (1) The Patient and Treatment, (2) Psychiatry and the Health Care System, (3) Psychiatry and Society, (4) The Future of Mental Health Law, (5) Digital Psychiatry Enhancing the Future of Mental Health, and (6) Training the Psychiatrist of the Future. Let me briefly highlight some of the critical issues highlighted in the report. Since most of our readers live in the US, many of the issues of concern will be well known though unsolved.

In the The Patient and Treatment section, one of the key issues addresses the tremendous global disparities in treatment resources, including psychiatrists, other clinical personnel, and treatment facilities. We are aware in the US that although we have among the most extensive treatment availability of any country, substantial segments of our population have limited access to quality care. These groups include those living in urban cores and rural areas; members of many minority groups, including recent immigrants; the elderly; children; and those with significant medical comorbidity.

While recent decades have seen little change in our treatment armamentarium, the development of biomarkers, etiologically based diagnostic classification, and pharmacogenetics hold out promise of dramatic breakthroughs which nonetheless are difficult to predict. How we can maintain the centrality of the therapeutic relationship is an issue we will need to address in the face of increased demand, the rise of telepsychiatry, and the increasingly culturally diverse population.

The Health Care Systems section addresses several important areas familiar to all of us. Given the geographic maldistribution of clinical personnel and resources, how can we engineer a new system that will substantially increase access? The integration of physical and mental care must counter centuries of separation in essentially every country including our own. While collaborative care was a keystone principle when the Affordable Care Act was passed, implementation has been lacking. And who knows how the coming year in Congress will affect our efforts toward integration?

The sections on psychiatry and society and the future of mental health law address thorny issues related to the intersection of individual rights versus societal concerns about safety of individuals with mental illness and those close to them. The United Nations Convention on the rights of persons with disabilities addresses mental health issues and concludes that any compulsory treatment is inherently discriminatory. Since for decades courts in the US have trended toward ruling in this direction -and because we are very aware of how involuntary psychiatric treatment has been used in some countries to suppress political dissent -these matters are very familiar. Another important area involves the social determinants of illness and the amelioration of those types of risks -an issue we have discussed in the US, but for which we have so far found few, if any solutions.

The pace of change in digital communication and the use of digital technology in research and clinical care are highlighted in the section on digital technology. (See the New York Times article from September 10, 2017, that discusses the currently publicized IBM Watson project on cancer treatment for a cautionary view.) We already know that widespread use of electronic medical records storage has fostered great risks of identity theft and revelation of personal health information. Figuring out how to maximize the benefits and minimize the risks will take a great deal of work.

Finally, in light of the issues raised by all of the above, the report discusses how we will train the psychiatrist of the future. Certainly we know that in a country like Tanzania, with its 12 million people and fewer than 10 psychiatrists, the role of the psychiatrist is vastly different than one working in London or New York. Thus, training needs to consider both the need to adapt to an increasingly complex body of knowledge and skills, but also to the roles of psychiatrists in very diverse settings in the face of ongoing health care systems changes.

I haven’t tried to address the details of any of these issues in this column as my aim has been to highlight some of the key matters addressed in The Lancet Psychiatry Commission report and, I hope, to pique your interest in reading all 40 pages. I hope, too, that you will take a little time to read it for yourself, and more important, to reflect on how we’ll address these critically important issues for the future of our profession in the US.