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Today
psychopharmacology has made it possible to cure many psychiatric complaints,
very often completely, and this currently represents the fastest growing
pharmacological sector. Psychiatric diagnostics, using increasingly
more sophisticated empirical and statistical methods, has managed to
paint a very precise syndromic picture indeed of psychiatric complaints
and is close to the final goal of diagnostics based on aetiopathogenic
criteria. Finally, the exponential growth of neuro-sciences has led
to a growing knowledge of the pathophysiological brain mechanisms behind
psychiatric complaints. In the light of new discoveries and new treatment
methods, the way of considering psychiatric complaints has changed completely
in just a few years. The old mental homes have been shut once and for
all. New and more agile hospital structures have sprung up which have
helped see "mental illnesses" in a new light, more similar to other
illnesses. The diagnosis and cure of psychiatric complaints have become
an increasingly bigger priority in terms of state and private investments
in the field of medicine. Today, psychiatry has greatly extended its
areas of competence following a growing awareness that emotional complaints,
anxiety and an addiction to substances result in high morbidity and
are among the major causes of temporary or permanent invalidity among
all world populations (1,2). The greater knowledge of operating possibilities
in the psychiatry field at both diagnostic and therapeutic level has
resulted in a growing number of people who suffered from psychiatric
complaints (and did not realise this) turning to psychiatrists in order
to alleviate their suffering. The development of neuro-sciences has
made psychiatric complaints more explainable or understandable. The
language of psychiatrists, in terms of aetiology, pathogenesis, symptomatology
and therapy is now the same as that used in all the fields of medicine
and above all "psychic suffering" is no longer grounds for marginalisation
and social rejection. This increase in knowledge has, on the other hand,
also deeply changed the conceptual models of psychiatry. The dominant
model until just a few years ago had its roots in the historical dichotomy
of "mind" and "brain", "organic" and "non-organic", "biological and
"psychic", "neurology" and "psychiatry". Within the field of competence
of neurology came demonstrated brain damage with possible psychic consequences.
Within the field of competence of psychiatry came emotional, cognitive
and behavioural changes, where no structural alteration of the brain
could be demonstrated. Molecular biology and brain display have profoundly
changed this model. Molecular biology techniques applied to brain functions
have shown how events, emotions, memories and thoughts can change both
neurone structure and function through a chain of post-synaptic biochemical
events that link the neurone environment with genic transcription mechanisms
(FIG. 1). In turn, molecular changes
can radically condition emotions, behaviours and cognitive processes.
Drugs and psychoactive substances, emotional stressors, events in life,
personal interactions, intrapsychic events interact at neuronal DNA
transcription level (neuronal plasticity) affecting the metabolism of
the neurotransmitters, the sensitivity and density of the ceptors, the
number and arborization of the synapse, and intraneuronal proteine synthesis
procedures (3-6). The brain display techniques (PET, SPECT, and fRMN)
have also highlighted how emotional states extended over time can functionally
trigger a series of related brain areas and how the extended or repeated
triggering over time of specific brain structures causes changes to
the biochemical environment in those areas. Changes in the biochemical
environment, in turn, trigger a chain of post-synaptic events that cause
persistent changes in nuclear genic transcription. This way, events
usually considered of "psychological" type actually change the molecular
structure of the brain, which in turn becomes the cause of the persistence
of the emotions caused by the events. In this new context, the borderline
between "organic" and "psychic" obviously loses its original meaning
and one enters a new dimension, where structure, function and intrapsychic
events appear as different aspects of an identical brain continuum.
This conceptual revolution has also been based on the extrapolation
of the way the brain works from notions obtained from information technology
applications. The concepts of "hardware" and "software", immediately
understandable for any PC operator, have, when applied to brain functions,
shown how psychiatric complaints can be caused either by "hardware faults"
(structure) and "software faults" (information management programs).
The difference between our data processing tools and the brain is that
software alterations (management programs) can, in the brain, affect
the structure, while obviously this is not the case as regards our daily
"artificial intelligence" tools. A new discipline has thus seen the
light over recent years within psychiatry which has taken the name of
"molecular psychiatry". Molecular psychiatry studies are currently centred
on identifying molecular substrates (for instance, individual genes
and proteins) through which various types of genetic and environmental
factors associate to produce alterations in the processing procedures
of the information that could be at the bottom of specific psychopathologic
situations. Molecular psychiatry thus covers a broad spectrum of knowledge
relating to the interaction between external environment, management
programs and molecular changes at neurone level. Neurotransmission,
neuronal plasticity, relationship between environmental factors, genic
transmission and finally molecular genetics are the main subject of
this area of research (TAB. I) 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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