Psychiatry in the future
The prognosis and the vision
Stefan Priebe

Modern psychiatry is approximately 200 years old. The term ‘ psychiatry’ was first published in 1803, and the 19th century witnessed the rise of large asylums and the establishment of psychiatry as an academic discipline within medicine. During the second half of the 20th century, major reforms of mental health care led to various forms of community services, and a widening range of psychological treatments and drugs was introduced for a continuously increasing clientele. Yet, what future can we expect for psychiatry?

Beginning with this issue, the Psychiatric Bulletin is publishing a series of brief papers on specific aspects of the future of psychiatry. They are intended to contribute to a currently almost non-existent debate on how psychiatry might and should develop. One might argue that an idea about the direction of travel and a sense of purpose are essential for the specialty of psychiatry to shape its future and, possibly, survive for decades to come.

Mental health care in the United Kingdom has been overwhelmed with white and green papers, a National Service Framework, a National Health Service (NHS) Plan and a wide range of further policy documents and strategies, all of which are intended to influence the immediate future. The papers in this series will not deal with current Government policies or other guidelines of today. They take a wider perspective and go beyond the topical issues of the year 2004.

How far can one reasonably look into the future and anticipate changes? If one takes only the span of half a generation, i.e. 15 years, this can be seen as a very long period of time. The past 15 years witnessed the collapse of the Communist Bloc, the rise of neo-capitalism and neo-conservatism in parts of the Western world, and significantly more globalisation of markets with decreasing cultural diversity and increasing disparity between rich and poor, both between and within countries. It appears questionable whether all these developments could have been anticipated 15 years ago. In any case, they now influence our world with a more or less direct impact on mental health care. These processes are likely to continue. There are other predictable changes that may influence psychiatric practice in this country. The trend towards a more ageing population will continue over the next 15 years, and more immigration will be required to compensate for this. Thus, the challenges to provide mental health care in a multi-ethnic environment will probably increase rather than decrease. There is a reasonable probability that we will have at least one change of government within the next 15 years and experience an economic recession within that time. Whether the NHS will still exist - and, if so, in what form - appears more difficult to predict. All these factors have to be considered within a vision for the medium-term future of psychiatry.

However, in historical terms 15 years may also be seen as a relatively short period of time, enabling us to come up with realistic expectations and prognoses. Most practitioners in mental health care today will still be within working age, most of the current treatment methods will still be practised, and many of the services that are established now will still be around. Also, experience tells that psychiatric textbooks are unlikely to change completely within 15 years. So, psychiatry is likely to survive the next 15 years in one form or another, but it might be subject to significant changes.

The papers exploring these issues are very short, and only state hypotheses and ideas without elaborating them. Each paper deals with a different and specific aspect. In this issue, Tom Burns considers the changes that the United Kingdom has experienced in the last 15 years, and Frank Holloway takes a personal perspective to explore the impact that research and scientific publications have had on clinical practice. These papers discuss factors that have shaped psychiatry up until today, which might allow some extrapolation into the future.

In the next issue, three papers will address specific issues with a potential relevance for future developments. Richard Laugharne discusses whether the concept of postmodernism might be useful to understand changes, particularly in the light of the increasing importance of the notions of choice and power within mental health care. Isaac Marks applies the potentials of new information technologies to psychological treatments. I look at changes on an international level and speculate on how common processes in Europe might influence the future of mental health care. Finally, there will be three papers predicting how research and general adult psychiatry might develop. Peter Tyrer presents options for the future of mental health service research, and Peter Fonagy outlines how research in psychological treatments might be linked to more biological research. Three different scenarios for mental health care in about 15 years time will be characterised by Trevor Turner in the last paper of this series.

All papers focus on mental health care for adults of working age. This does not suggest that other fields are - or indeed will be - of less importance for the future of psychiatry. The papers reflect personal views of the authors and do not claim to be representative for any group of the psychiatric profession. Yet, they will hopefully be interesting reading and, as a whole, provide a range of stimulating ideas on prognoses and visions for the future of our specialty. In order to take psychiatry forward, both a realistic prognosis and a more aspirational, possibly dreamy, vision might be required.