Antonio Ventriglio

The WPA-Lancet Psychiatry Commission on the Future of Psychiatry

Background This Commission addresses several priority areas for psychiatry over the next decade, and into the 21st century. These represent challenges and opportunities for the profession to sustain and develop itself to secure the best possible future for the millions of people worldwide who will face life with mental illness. Part 1: The patient and treatment Who will psychiatrists help? The patient population of the future will reflect general demographic shifts towards older, more urban, and migrant populations. While technical advances such as the development of biomarkers will potentially alter diagnosis and treatment, and digital technology will facilitate assessment of remote populations, the human elements of practice such as cultural sensitivity and the ability to form a strong therapeutic alliance with the patient will remain central. Part 2: Psychiatry and health-care systems Delivering mental health services to those who need them will require reform of the traditional structure of services. Few existing models have evidence of clinical effectiveness and acceptability to service users. Services of the future should consider stepped care, increased use of multidisciplinary teamwork, more of a public health approach, and the integration of mental and physical health care. These services will need to fit into the cultural and economic framework of a diverse range of settings in high-income, low-income, and middle-income countries. Part 3: Psychiatry and society Increased emphasis on social interventions and engagement with societal expectations might be an important area for psychiatrys development. This could encompass advocacy for the rights of individuals living with mental illnesses, political involvement concerning the social risk factors for mental illness, and, on a smaller scale, work with families and local social networks and communities. Psychiatrists should therefore possess communication skills and knowledge of the social sciences as well as the basic biological sciences. Part 4: The future of mental health law Mental health law worldwide tends to be based on concerns about risk rather than the protection of the rights of individuals experiencing mental illness. The United Nations Convention on the Rights of Persons with Disabilities, which states that compulsion based in whole or in part on mental disability is discriminatory, is a landmark document that should inform the future formulation and reform of mental health laws. An evidence-based approach needs to be taken: mental health legislation should mandate mental health training for all health professionals; ensure access to good-quality care; and cover wider societal issues, particularly access to housing, resources, and employment. All governments should include a mental health impact assessment when drafting relevant legislation. Part 5: Digital psychiatry—enhancing the future of mental health Digital technology might offer psychiatry the potential for radical change in terms of service delivery and the development of new treatments. However, it also carries the risk of commercialised, unproven treatments entering the medical marketplace with detrimental effect. Novel research methods, transparency standards, clinical evidence, and care delivery models must be created in collaboration with a wide range of stakeholders. Psychiatrists need to remain up to date and educated in the evolving digital world. Part 6: Training the psychiatrist of the future Rapid scientific advance and evolving models of health-care delivery have broad implications for future psychiatry training. The psychiatrist of the future must not only be armed with the latest medical knowledge and clinical skills but also be prepared to adapt to a changing landscape. Training programmes in an age in which knowledge of facts is less important than how new knowledge is accessed and deployed must refocus from the simple delivery of information towards acquisition of skills in lifelong learning and quality improvement. Conclusion Psychiatry faces major challenges. The therapeutic relationship remains paramount, and psychiatrists will need to acquire the necessary communication skills and cultural awareness to work optimally as patient demographics change. Psychiatrists must work with key stakeholders, including policy makers and patients, to help to plan and deliver the best services possible. The contract between psychiatry and society needs to be reviewed and renegotiated on a regular basis. Mental health law should be reformed on the basis of evidence and the rights of the individual. Psychiatry should embrace the possibilities offered by digital technology, and take an active role in ensuring research and care delivery in this area is ethically sound and evidence based. Psychiatry training must reflect these multiple pressures and demands by focusing on lifelong learning rather than simply knowledge delivery.

Changes in medication practices for hospitalized psychiatric patients: 2009 versus 2004.

We tested the hypothesis that combinations and total daily doses of psychotropics for hospitalized patients diagnosed with major psychiatric disorders are rising.

Metabolic issues in patients affected by schizophrenia: clinical characteristics and medical management

Patients affected by psychotic disorders are more likely to develop high rates of co-morbidities, such as obesity, type 2 diabetes, dyslipidemias, hypertension, metabolic syndrome, myocardial infarction, stroke etc., in the long-term. These morbidities have a significant impact on the life-expectancy of these patients. Patients with chronic psychoses show a 2–3-fold increased risk of death mostly from cardiovascular and metabolic diseases. Although there may be an independent link, between schizophrenia and metabolic conditions the cardio-metabolic risk is mostly related to an unhealthy lifestyle and the usage of antipsychotic agents (especially Second Generation Antipsychotics or atypical) even when these remain effective treatments in the management of major psychoses. Recently, many international organizations have developed screening and monitoring guidelines for the control of modifiable risk factors in order to reduce the rate of co-morbidity and mortality among patients affected by schizophrenia. This paper is a review of current knowledge about the metabolic issues of patients affected by schizophrenia and describes clinical characteristics and medical management strategies for such conditions.

Suicide in the Early Stage of Schizophrenia.

Suicide is a relevant leading cause of death among patients affected by schizophrenia. Even if suicidal ideation may be present in different stages of disease, some differences have been described between the risk of suicide in patients experiencing first episode of psychosis and those with long-term schizophrenia. It is particularly higher during the first year of illness and reaches a steady decline over the following years. Suicidal ideation and attempts may also be common among subjects with subthreshold psychotic experiences. Factors associated with the risk of suicide in the early phase of schizophrenia are previous suicidal attempts and social aspects: the lack of social support and stable relationships, social drift after the first episode, and social impairment. Also, several psychotic symptoms (suspiciousness, paranoid delusions, mental disintegration and agitation, negative symptoms, depression and hopelessness, and command hallucinations) and substance abuse are associated with higher risk of suicide. It has been described that perfectionism and good levels of insight among individuals who have recently developed psychotic symptoms are significantly associated with higher numbers of suicidal attempts. Moreover, recent evidences show that prefrontal cortex-based circuit dysfunction may be related to suicide in the early stage of schizophrenia. This narrative review summarizes available evidences on suicide in the early stage of schizophrenia and deals with issues to be further studied and discussed.

Relevance of culture‐bound syndromes in the 21st century

Culture‐bound syndromes were first described over 60 years ago. The underlying premise was that certain psychiatric syndromes are confined to specific cultures. There is no doubt that cultures influence how symptoms are perceived, explained and from where help is sought. Cultures determine what idioms of distress are employed to express distress. Rapid globalization and industrialization have made the world a smaller place and cultures are being more influenced by other cultures. This has led to social and economic changes in parts of the world where such syndromes were seen more frequently. In this review we illustrate these changes using the example of dhat syndrome (semen‐loss anxiety). The number of syndromes in the DSM‐5 has been reduced, acknowledging that these syndromes may be changing their presentations. Clinicians need to be aware of social and economic changes that may affect presentation of various psychiatric syndromes.

Why do we need a social psychiatry

Human beings are social animals, and familial or social relationships can cause a variety of difficulties as well as providing support in our social functioning. The traditional way of looking at mental illness has focused on abnormal thoughts, actions and behaviours in response to internal causes (such as biological factors) as well as external ones such as social determinants and social stressors. We contend that psychiatry is social. Mental illness and interventions in psychiatry should be considered in the framework of social context where patients live and factors they face on a daily basis.

Tobacco smoking: From 'glamour' to 'stigma'. A comprehensive review.

In this narrative review, we explore the history of tobacco smoking, its associations and portrayal of its use with luxury and glamour in the past, and intriguingly, its subsequent transformation into a mass consumption industrialized product encouraged by advertising and film. Then, we describe the next phase where tobacco in parts of the world has become an unwanted product. However, the number of smokers is still increasing, especially in new markets, and increasingly younger individuals are being attracted to it, despite the well‐known health consequences of tobacco use. We also explore current smoking behaviors, looking at trends in the prevalence of consumption throughout the world, discrimination against smokers, light and/or intermittent smokers, and the electronic cigarette (e‐cigarette). We place these changes in the context of neuroscience, which may help explain why the cognitive effects of smoking can be important reinforcers for its consumption despite strong anti‐smoking pressure in Western countries.

Medical leadership in the 21st century.

Objective: Psychiatry as a discipline and as a profession stands at the cusp of major challenges in many areas including social, biological and psychological spheres. The practice of psychiatry is affected by ideologically driven policies by politicians, and the continuing long-lasting impact of the global economic downturn along with new developments in health care delivery. Changing biological factors include better understanding of brain structures and functioning and potential developments in psychopharmacogenomics. Social changes facing psychiatry include globalisation and rapid urbanisation. Psychological changes include therapies without therapists and the impact of social media and the information age. The current paper explores these challenges and the opportunities for psychiatrists to provide leadership in a number of settings. Conclusion: Leadership skills are essential skills for psychiatrists, and enable an individual to plan and deliver services, and also help them to lead not only clinical teams but organisations and institutions. Psychiatrists are best placed because of the breadth of the training they undergo and their communication skills. Leadership is markedly different from managerial skills, although there may be a small degree of overlap.

Characteristics and clinical changes during hospitalization in bipolar and psychotic disorder patients with versus without substance-use disorders.

BACKGROUND Co-morbid substance-use disorders (SUDs) are prevalent among patients with severe psychiatric disorders, but the characteristics of such patients remain incompletely defined, and their current treatments and responses, poorly documented. METHODS We evaluated the records of 481 consecutive inpatients diagnosed with DSM-IV bipolar or schizoaffective disorders, or schizophrenia, admitted to McLean Hospital in 2004 or 2009. Demographic and clinical characteristics, and treatments, were extracted from hospital and pharmacy records for bivariate and multivariate analyses. RESULTS SUD prevalence increased 1.84-times from 2004 (31.3%) to 2009 (57.6%). Patients with (n=204) versus without co-morbid SUDs (n=277) were similar in many respects, but in multivariate modeling, the following factors were more likely with SUD, in rank-order: co-morbid anxiety disorders > men more than women > greater prevalence in 2009 vs. 2004 > younger age > greater doses of mood-stabilizers > shorter hospitalization. CONCLUSIONS Hospitalized patients with severe primary psychiatric disorders, and comorbid SUD were more likely to be young and have anxiety disorders, to receive more combinations and higher doses of mood-stabilizers, and show more improvement in impulsivity and hostility, but otherwise differed little in treatment-responses. Prevalence of SUD rose substantially in the past five years, with increased but largely unproved use of mood-stabilizers.

Psychological Factors Affecting Medical Conditions in Consultation-Liaison Psychiatry

Consultation-liaison (C-L) psychiatry has an important role in the identification and management of psychological problems in patients with medical disorders in general hospitals. The diagnostic tools C-L psychiatrists are usually provided with may reveal to be limited because of particular psychosomatic syndromes and subthreshold psychopathology that are undetected by psychiatric diagnostic criteria. The Diagnostic Criteria for Psychosomatic Research (DCPR) were developed with the aim of providing clinicians with operational criteria for psychosomatic syndromes to overcome the limitations shown by the most often diagnosed disorders in medical settings as adjustment, somatoform, mood, and anxiety disorders. In a group of 66 consecutive C-L psychiatry inpatients, a consistent prevalence of 71% DCPR syndromes was found, particularly secondary functional somatic symptoms, persistent somatization, health anxiety, and demoralization. Their overlap rates with DSM-IV diagnoses showed that the DCPR syndromes were able to identify psychological dimensions (as somatic symptom clustering, anxiety triggered by the current health status, and a feeling state of hopelessness) that do not meet or are not detected by DSM-IV. Furthermore, the DCPR syndromes identified patients with clinically significant functional impairment. These results replicate previous findings in C-L psychiatry using the DCPR categories and pave the way for further research to clarify their mediating role in the course and the outcome variance of medical and psychological problems of hospital inpatients referred for psychiatric consultation.