Psychiatry: time for change

Psychiatry has changed. The terrific increase in neuroscientific research, which has occurred in the recent past few decades, has permitted the spread of the notion that the mind corresponds in part to the brain, and that psychiatric symptoms are also the results of disturbances of the brain. In addition, it has provided us sharpened instruments, ie, psychotropic drugs that, far from being specific, at least are not “big bullets,” as they used to be in the beginning of the psychopharmacological era. Moreover, neuroscientific research has opened (and will open increasingly) new horizons to more focused psychiatric interventions and, therefore, has reduced the stigma related to mental disorders, as well as to decrease the gap between common people and psychiatry. Therefore, we can affirm that we know much about the pathophysiology of mental disorders, and that we can control most psychiatric disorders and symptoms, and, in some cases, we can even restore normal equilibrium by means of chemical compounds. Besides drugs, psychological practice has also become more scientifically oriented, with some techniques showing reliable effectiveness, so that the combination of drugs and focused psychological treatment can be extremely beneficial in some patients. This is also possible because diagnostic instruments have become more appropriate, widely applied, and constitute a sort of common language which undergoes continuous refinements, on the basis of the feedback arriving from the bedside and the eventual support of biological correlates. The link between research and clinical practice has undoubtedly become stronger in psychiatry than in any other medical field. However, it is likely that the equation brain +mind is not so absolute: are we really sure that the brain will be able to accomplish the goal of understanding itself, and therefore to reveal the mystery of its self-consciousness? Are we sure that when we have dissected all psychiatric disorders into distinct symptoms or symptom clusters, and we have understood all their molecular and/or neurological bases or genetic underpinnings, will we have then reached a crucial point in psychiatry? Although it is true that the mind is rooted in the brain, and that the understanding of the brain in molecular terms will promote great advancements, it is also plausible that the mind is something more complex and will escape even our current attempts at definition or delimitation. There is a shared impression that if we proceed in this way, that is to say, toward progressive dissections of complex phenomena, such as psychiatric symptoms, we shall never arrive at the end. Different concepts have been introduced to overcome this bias, such as comorbidity, dimensions, subthreshold phenomena, and psychopathological continuum, to the extent that even the schizophrenia subtypes are not considered reliable. Indeed, at this point, we need to incorporate all data deriving from neuroscientific research (which cannot be neglected nowadays even by most traditionally oriented psychoanalysts), in more exhaustive and comprehensive models, including the challenges deriving from the environment, which, through learning and/or epigenetic mechanisms, has had a profound effect on brain development. If this is true for almost all branches of medicine, there can be little doubt that psychiatry especially is a discipline that is linked to and a reflection of social urges, demands, problems, and fears, since the individual may be considered to be the result of a constant interaction between the brain and its environment. For this reason, when applied in the diagnosis, treatment, and, when successful, resolution of specific disturbances or disorders, psychiatrists restore not only a deranged brain equilibrium, but, in addition, an individual’s attitudes and behaviors and, consequently, the effects that a single individual may have upon society. It may equally be concluded that the particular society or environment by which an individual is surrounded, together with any conflicts that may exist therein, can affect the functioning of that individual and induce mental disorders or, at the very least, act as a triggering First published online 10 September 2014