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A
way through which the evolution of psychiatry and its future trends
can be pinpointed is by analysing the increase in the number of scientific
publications in the various areas of psychiatric interest over the last
few years. Since the 60s, the number of articles on psychiatric genetics
has increased tremendously and has simply soared in the last decade
(FIG. 2).
A
lot of these studies concern molecular genetics and are focused on identifying
genic vulnerability complexes with respect to single psychiatric problems.
Special importance is given, within these genetic studies, to identifying
"endophenotypes" (phenotypes related to specific encephalic problems),
to the isolation of new psychiatric phenotypes no longer based on categorial
diagnostics, but on psychopathologic dimensions, and on the relationship
of these new phenotypes to genic vulnerability complexes (FIG.
3). These new approaches to psychiatric genetics are the
foundations for the creation of a new epidemiology, of a new prevention
of the risk of illnesses and, finally, they open the road to future
genic therapy of psychiatric ailments (FIG.
4) Another area of study in which there has been an exponential
growth in research works published is the sector of biochemical psychiatry
(FIG. 5).
Biochemical
psychiatry has been progressively gaining importance over the last ten
years, largely because of the progress made in psychopharmacology. We
have witnessed a growing interest in animal models for psychiatric disorders.
Today, we have quite precise animal models available, as far as some
areas of psychopathology is concerned (for example, emotional disorders).
These animal models allow scientists to make more complete and precise
biochemical hypotheses about mental illness than they could have made
in the past. The increased precision in the dosages of cerebral neurotransmitters
and the use of pharmacological stimulation tests have allowed for either
a confirmation or denial of the biochemical hypotheses, based on animal
models.
The
results of these biochemical studies, addressed toward mental disorders,
have been clearly supported by the studies in clinical pharmacology.
By understanding the mechanisms of the pharmocodynamic action of the
drugs used in therapy, the observation of the results of treatment allow
doctors to perfect the pathogenic hypotheses formulated on the basis
of the animal studies and the studies on the dosage of the neurotransmitters.
The current limits of the biochemical psychiatry studies are associated
with the fact that the data collected from these studies refers to the
global nature of the cerebral functioning (or malfunctioning) and do
not provide, except in rare cases, specific information on the circuits
and structures involved in the specific disorders. Another area of research
undergoing intense development is that of the cerebral visualisation.
Again in this case, the exponential increase in the scientific publications
on this subject bear witness to this development (FIG.
6).
The techniques of visualisation and cerebral mapping of the encephalitic
functions are today able to demonstrate how the various cognitive activities,
the various emotional states, and psycho-pathological conditions are
associated with functional activation and deactivation of groups of
cerebral areas both cortical as well as subcortical (7,8) (FIG.
7). Some of these techniques have an elevated complexity
(for example the PET), other techniques have become more easy to execute
and at the reach of many well-equipped clinical laboratories (for example,
the fRMN) (9). The combined use of the morphological investigations
(RMN) with the functional techniques (PET, SPECT, fRMN) allows today
to have a direct and sequential vision over time of cerebral functioning
in areas localisable with significant precision.
Furthermore,
the cerebral visualisation techniques applied to the receptor occupation
of substances and drugs under both normal (10,11) (FIG.
8) and pathological (12 - 14) conditions have allowed for
a greater understanding of the functioning mechanism of the psychoactive
substances used in treatment and have offered the ability to construct
new interpretational models of psychiatric disorders (15). Naturally,
as in all sectors in science, this augmented understanding has created
new problems even as far as cerebral visualisation is concerned. For
example, the activation - deactivation of the multiple cerebral areas
has posed the problem of the possible coincidental relationship existing
between the various phenomena observed. In addition to the more conceptual
level, the cerebral visualisation has emphasised the risk of a new "phrenology"
where individual disorders are associated with individual dysfunctional
areas, as happened in the past on a specific anatomical area level.
One might naturally ask if an analogous development has occurred in
the more traditional framework of psychopathology and clinical psychiatry.
In this broad-based area, one sector that has witnessed a dramatic and
exponential increase is the one of the psychometry and the scales of
evaluation (FIG.
9). The need to carry out a measurement of the variable psychopathologies
has been increasing, especially in the past ten years. It is important
to note that for a long time, in psychiatry, there was a tendency to
consider the variables characterising psychiatric profiles impossible
to measure by quantitative instruments. Progressively, and in greater
and greater degree, clinical psychiatrists have come to understand that
not only is it possible, but also indispensable to give a numeric measurement
to the object of their observations. Today, no work of clinical research
is accepted into the international journals unless accompanied by some
measure of the variables observed by means of scales of evaluation and
by an adequate statistical processing of the results. But even in terms
of daily operational practice, clinics have come to learn that the use
of these evaluation scales allows for a more precise and dependable
objectivity of the state of the patients and the efficacy of the treatment.
However, the sector where the greatest increase in the works published
has been found, both in terms of absolute numbers as well as in terms
of trends, has been in psychopharmacotherapy (FIG.
10).
On the basis of this observation, there has been a progressive increase
in the introduction of new psychoactive molecules onto the market as
well as their respective studies, prepared both so that the drug might
be approved for use and to attain greater precision in its use on a
clinical level (efficacy and safety). In fact, the interest in psychopharmacology
has been increasing simultaneously with the ever greater efficacy of
the treatments and the better and better control over the primary and
secondary side effects. In increasing degree, drug therapy has seen
its fields of application broaden, and today include the extreme ages
of life (16,17), the differences in type, and the entire area of co-morbidity
and somatic psychiatry (20). On a more analytical level, it is interesting
to observe how the application of the drugs to psychiatric disorders
has been moving from a "categorical" point of view to a "dimensional"
standpoint (FIG.
11).
This
means that rather than associating a drug with a specific illness (defined
symptomatically by classification systems) the trend is moving towards
the use of drugs, or combinations of drugs, which act on associations
of symptoms which imply specific pathophysiological mechanisms. In addition,
a tendency already underway and destined to have progressive development,
is the research into the correlation between the observable clinical
effect and the action of the drug on a level of genic neuronal transcription.
The molecular psychiatrist thereby finds a connection to the clinic.
Beyond psychopathology and the pharmacological treatments, other areas
of psychiatry appear to be in growth phases. One of these areas is represented
by social assistance and psychosocial interventions
(FIG. 12). There has been a collective
new awareness that the treatment for psychiatric disturbances must necessarily
be multidimensional. Especially as far as serious psychiatric disorders
are concerned, such as major psychosis, even if the pharmacological
intervention represents the basis of the treatment, a complete recovery
by the patient and his/her reinsertion into the social structures must
be subjected to rehabilitation interventions which are the responsibility
of specialised assistance structures. The current trends, as far as
the non-drug treatments are concerned, are seeing a progressive increase
in the brief and minimally structured psychotherapies, the multidimensional
team interventions, and programmed rehabilitation.
A sector in continual expansion and destined to enjoy a growth in interest
over the next few years is ethical psychiatry (FIG.
13). The problems of ethical psychiatry involve the doctor
on a research level as well as a clinical level and have three important
aspects. The first is of a more strictly legal nature and regards the
doctor understanding and adapting his practice to the regulations guiding
his profession. The second aspect concerns the application of the deontological
code when dealing with the psychiatric patient who demonstrates more
complex problems compared with any other medical patient. The third
aspect is of a more strictly moral character and concerns the operative
decisions of the psychiatrist, even once he has observed the legal regulations
and the deontological standards that preside over his profession. We
should expect to see growing attention paid to ethical, deontological,
and legal problems over the coming years, both in terms of clinical
activity as well as in the research by the psychiatrist and the problem
of getting consent for treatment will be a crucial point in this discussion.
Clinical
research in psychiatry is destined to be ever more regulated, complex
and expensive, while the human rights of the mentally ill will be increasingly
protected. In this continual rise in understanding, the change in the
conceptual models, and the constantly multiplying requests for help
and assistance by larger and larger groups of the population, it is
not be easy to foresee that will await us over the next few years. One
thing is certain and that is that psychiatry is destined to assume an
increasingly important role among the medical professions, filling the
gap which still today partly exists, between the traditional image and
its real impact on the complex modern society in which we live.
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