‘Shifting priorities’ vital to future of psychiatry

NEW YORK — A session dedicated to discussing the future of psychiatry concluded that the new times make it necessary to shift to new priorities, which — above all — depend on mental health professionals to invent, promote and execute them.

“The time to do this is now,” Norman Sartorius, MD, PhD, FRCPsych, former director of the Division of Mental Health of the WHO, and former president of the World Psychiatric Association and of the European Psychiatric Association, said during his presentation

Context of health care

In the first part of his talk, Sartorius discussed the context of health care and reviewed the impact of globalization, of the horizontalization of culture, of commodification and of other social changes on the practice of psychiatry and the management of mental health services.

“When globalization was first announced having the idea that there would be a global, open world in which we would be able to work together and freely communicate was just fantastic, but as time went by, I became less and less enthused by what was happening under the name of globalization,” Sartorius said. “It was not only the more powerful industry that was imposing itself on the less developed, feebler industry of other countries, it was also that value systems and ideas were being imposed — thus for example, that people should strive for independence and autonomy rather than seek interdependence — which has been and still remains the strategy of survival in difficult times.

The culture is now defined horizontally — meaning that we experience people of the same social class as very close even when they are from different cultures while at the same time feeling distant from people of different professions and different social classes living in our country and culture — representing a change of the sense of belonging, which can have many consequences for the creation and function of communities. Sartorius also discussed the impact of commodification — the tendency to consider and measure all as if it were a commodity such as timber or iron. Commodification has significantly affected the provision of health care.

“Providing health care in the past was, for a long time, an ethical imperative to society. It has now become an economic opportunity,” Sartorius said. “And this change from an ethical imperative to an economic opportunity is dangerous for health care and for the functioning of society.”

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The middle class is becoming smaller in high-income countries, meanwhile becoming larger in the poorer countries, according to Sartorius. The middle class has always been the protector of morals of a society, and as its size is reduced so does the attention to the morals of a society, according to Sartorius.

Change of morbidity patterns

Sartorius also discussed the epidemic of comorbidity, which is, in part, due to the successes of medicine. People are living longer, but that does not mean they are living longer in good health.

“Although you live 20 years longer, you don’t necessarily live 20 healthy years longer. You may live 19 sick years longer,” Sartorius said. “That notion that we’re living in a society with an increasing number of people who have an impairment or a disease, changes the nature of health care.”

The relationship is also changing between patients and doctors. Physicians do not often spend enough time with patients, which makes personalizing their care difficult. In addition to knowledge of patients about their disease has also changed — and patients often research their illness on the internet before coming to see the doctor which also changes the medical encounter.

Transformations in health services

Medicine is also becoming more fragmented partly because the increasing amount of knowledge and partly for financial reasons. Doctors are becoming more specialized while patients are more and more often suffering from several comorbid conditions.

He also discussed the changes of ethics of medicine. He recalled that when he started practicing, there were two main rules to be observed: to save life and to diminish pain. The tendency to accept the legality of physician-assisted suicide, exemplifies that there are changes in the previously generally held rules

Shifting priorities

An analysis of the functioning of health care and the of the experience of patients and their families indicates that it is becoming necessary to change some of the paradigms which were considered immutable. Thus, for example, instead of making community care the central goal of providing care, psychiatrists should develop a variety of options for patient care including, hospital beds, protected housing, day care facilities and other forms of care, Sartorius said.

Collaborating with primary care physicians is vital to the future of psychiatry and it is time to change the strategy of involving them in the provision of care. Psychiatrists should focus on the education of those general practitioners who want to learn about psychiatry; they should not provide intensive courses on the whole of psychiatry but focus on the provision of skills and knowledge that will help general practitioners to deal with mental health problems which they frequently see. Experienced general practitioners who have learned how to deal with mental health problems should participate in such teaching. He also spoke about addressing stigma and discrimination.

“Stigma is the main obstacle to everything that you want to do in psychiatry,” Sartorius said and fighting stigma should be an essential part of all health care efforts. Since it will take time to remove stigma or prevent it is important to start by removing discrimination, resulting from stigma — discrimination which people who have mental illness and their families find in all walks of life — in finding a place to live, a job or anything else. Discrimination is much more identifiable and easy to define as a target for prevention.

He concluded by emphasizing that it is important to develop global rules, but that it is just as important to seek locally relevant solutions

“We will have to think about ways of shifting and changing some of the priorities which we considered to be very important and useful in the beginning of the last century,” Sartorius said.

Reference:

Sartorius, N. The future of psychiatry. Presented at: American Psychiatric Association Annual Meeting; May 5-9, 20178; New York.

Disclosures: Sartorius reports no relevant financial disclosures.