55.

3 PSIKIATRI MASA DEPAN

Kursus psikiatri klinikal Amerika untuk abad yang lalu akan merendahkan
sebarang prognosticator.

The course of American clinical psychiatry for the last century would have humbled any
prognosticator. Every one of its major developments was surprising. First, the rise to
dominance of Sigmund Freud's talking cure, followed by the splintering of psychoanalysis
into competing schools. Then, the development at the height of psychoanalytic influence, of a
biopsychosocial paradigm, the transformation of military psychiatry into the community
mental health movement. Antihistamine-based antipsychotic and antidepressant medications;
the lithium revolution; the resurgence, beginning when psychoanalytic influence was at its
peak, of a Germanic diagnostic system, the acceptance of the therapeutic milieu as a standard
for hospital care was followed by the large-scale deinstitutionalization of the chronically
mentally ill, the influence of outcome studies, bringing popularity for simple cognitive and
behavioral therapies, and the erosion of many forms of mental health care delivery under
pressure from insurers, just as these same outcome studies had bolstered the case for
psychotherapy.

The course of change in psychiatry is especially hard to predict because the field is so
responsive to external influence. Freud turned to physics to give shape to his
metapsychology, and subsequent theorists have borrowed from systems theory and
cybernetics. Progress in the science of psychiatry has relied on advances in a variety of
disciplines, from engineering to genetics. Meanwhile, the practice of psychiatry is reshaped
constantly by the ambient social, political, and economic organization. The very substrate of
psychiatry, the object it acts upon and intends to influence, has an erratic history. The self or
person is a concept constantly reshaped by changes in technology, social organization, and
spiritual belief. To foretell the course of psychiatry would entail knowing the future of
humankind and its achievements.

Even contemporary trends are hard to gauge. For most of the twentieth century, the core
discipline in psychiatry was psychoanalysis. Today, cutting-edge discoveries arise most often
from biological psychiatry. Perhaps the profession is in the midst of a paradigm shift. In that
case, psychotherapy may disappear while psychiatry merges with neurology to form a
uniform medical specialty based on brain sciences. Alternatively, if current changes are
incremental, psychiatry may continue for some time to embrace both physiological and
psychological interventions.

PSYCHOPHARMACOLOGY

Perhaps the safest prediction as the century closes is that the coming decades will see a
continued proliferation of biological therapies for disorders of brain and mind. Clinically,
psychiatry has been transformed in recent years by the availability of more potent and more
specific medications. Conditions long considered refractory are approached routinely with
medication: clomipramine (Anafranil) and the selective serotonin reuptake inhibitors (SSRIs)
often ameliorate obsessive-compulsive disorder and the negative symptoms of schizophrenia
sometimes respond to clozapine (Clozaril) or other serotonin-dopamine antagonists.
Medications such as the SSRIs are now mainstays in the treatment of conditions such as
dysthymic disorder and the minor mood disorders, that were once the exclusive province of
psychotherapy.

The scope of psychopharmacology has been further expanded by three concomitant

developments: the incorporation into psychiatric practice of medications traditionally
associated with other specialties (e.g., antiepileptic agents including valproate [Depakene]
and carbamazepine [Tegretol]), the legitimation of medications previously out of favor
(notably the psychostimulants); and a renewed interest in polypharmacy, especially the
augmentation of antidepressant drugs.

Barring a series of therapeutic disasters, certain trends will continue. New medications will
be introduced, especially medications specific to receptor subtypes or particular brain
pathways or regions. Existing medications will find broadened application and the indications
for psychopharmacology will be expanded. The pace may accelerate as advances in
computing and molecular biology (especially techniques for characterizing receptors)
facilitate drug development. These changes will be accompanied by the development of novel
biological interventions, perhaps including transplantation of brain elements, introduction of
psychoactive genetic fragments into adult cells, and innovations in the ways medications are
delivered to parts of the brain. The flowering of psychobiological therapeutics may combine
with advances in the basic sciences to affect every aspect of psychiatry, from therapeutics to
metapsychology.

Diagnosis A new range of choices for clinicians will create a demand for biologic markers of
illness and for ways to predict and monitor treatment success. In psychiatry as in the rest of
medicine, genetic profiles may be used to predict liability to illness and responsiveness to
specific interventions. Brain imaging may move into the clinical arena as an aid to guiding
treatmentperhaps supplemented by chemical or electrophysiological tests or other
biological or psychological indicators yet unknown. The field may yet see the secular
analogue of the ontological lapsometer imagined by the novelist Walker Percy, a hand-held
brain imager that could diagnose the state of the soul.

The increased scope of biological treatment will create pressures on the diagnostic system. In
the latter half of this century, acceptance of lithium (Eskalith) for the prophylaxis of manic-
depressive illness (bipolar I disorder) gave an important spur to the predominance of what
Walter Menninger called the Linnean tradition of diagnosis, that is, division of illness into
ever finer subcategories. Recent trends indicate a continued proliferation of diagnostic
categoriesperhaps to the point where computers become necessary diagnostic aids.

Many of the newer medications already available have broad-spectrum utility. The SSRIs are
variously reported to have roles in the treatment of obsessive-compulsive disorder, depressive
disorders, bulimia nervosa, impulsive aggression, premenstrual syndrome, and the personality
disorders, to mention only a few of many indications. A tension has thus developed between
the diagnostic system and the commonest tools of psychiatry. The medications seem to cry
out for a different sort of taxonomic system, one based on the state of neuroreceptors or
neural pathways.

Perhaps the discovery of biologic markers of the relevant brain states will give rise to a new
axis of psychiatric diagnosis or a new grouping of syndromes. In the interim, theorists have
speculated that medications typically affect functions or dimensions of mind (e.g.,
aggression) rather than illness, and one can imagine a taxonomy that would address the
relevant functions or dimensions. The future may even include a return to a diagnostic
tradition that is (in Menninger's terms) Hippocratic, expressing the clinician's assessment of
the complex state of the individual patientbut from a psychopharmacologic perspective
rather than, or in addition to, a psychotherapeutic one. Such a system might require that
clinicians exercise the subtlety and attention to detail that once characterized the anamnesis
preparatory to psychoanalytic treatment.

Prophyaxis New psychiatric tools may revitalize another dream, mental illness prevention.
Clinicians are already debating whether to use medication prophylactically in defined
situations (e.g., just after delivery by a mother with a history of postpartum psychosis). As the
pathology of psychic trauma is further elucidated, much broader forms of medication-based
prevention may become possible, such as interrupting the cascade of stress hormones
produced in response to important stressors. The death of a parent predisposes a child to
future depression, but perhaps the profession will find pharmacological interventions to avert
that association. Such capabilities would evoke profound ethical challenges; is prevention of
illness always humane or can it be dehumanizing?

Treatment Similar issues are bound to arise in response to the broadened scope of
pharmacological treatment of existing conditions. Researchers have already turned their
attention to formes frustes of psychiatric disorderslevels of mood disorder, autistic
disorder, and attention-deficit disorders that would previously have been deemed
subsyndromal. Emerging evidence indicates that available medications can mitigate
subsyndromal states. At the same time, the field is witnessing a resurgence of Darwinism, in
the guise of evolutionary psychology. In the Darwinian perspective, much of what otherwise
would be labeled illness is reconceptualised as an adaptive response, perhaps to bygone
challenges. More popularly, learning disabilities have been reframed as learning
differenceswhat was once called minimal brain dysfunction is now deemed a normal
variant. These trends will demand reconsideration of the definition of health and illness. For
the moment, the tendency in psychiatry is to expand the realm of pathology, for example, by
conceptualizing subsyndromal symptomatic depression as an illness. The field may have to
choose between, on the one hand, recognizing an ever-expanding domain of illness and, on
the other, acknowledging that psychiatric interventions can be applied appropriately in the
treatment of variant normal states.

Indeed, the field will most likely find itself facing the ethical questions raised by the ability to
enhance normal functioning. Preliminary research indicates that SSRIs can affect the social
behavior of people who suffer no psychiatric disorder whatsoever, perhaps in an adaptive
fashion. And the greatly increased prescribing of methylphenidate (Ritalin) for
underperforming schoolchildren has underlined the need to distinguish treating defect from
heightening performance.

Since drug development largely targets neural receptors and pathways and since the receptors
and pathways implicated in illness are presumed to underlie normal temperament, issues of
what has been called cosmetic psychopharmacology (the use of medication to change normal
but undesirable or unrewarded traits for normal and desired or rewarded ones) will likely
become real and even common in the profession. The use of psychotherapy to improve the
mood or social functioning of healthy people is widely accepted. As the scope of
psychopharmacology becomes indistinguishable from that of psychotherapy, the profession
will need to grapple with the use of medication for enhancement and with the distinction
between such use and drug abuse. Issues of prevention, definition of illness, and enhancement
may elicit a comprehensive conceptual resolution that will be part of the process of self-
definition of the psychiatric profession.

TRENDS

Of course, progress in psychopharmacology will come in tandem with developments in basic

and clinical research. These are even harder to foresee, but to the extent that psychiatry
mimics the rest of medicine, researchers will search for causes of mental illness in such
disciplines as genetics, infectious disease, endocrinology, and immunology.

Surprises may include a new overarching theory of mind and mental illness, such as Sigmund
Freud elaborated at the turn of the twentieth century, but for the moment, the future seems to
hold a varied collection of explanations. This eclecticism may result in further
subspecialization within psychiatry or in the transfer to other disciplines of illnesses
previously considered psychiatric, as occurred in the past with tertiary syphilis, the vitamin
deficiencies, and endocrine disorders. Regarding subspecialization, recent years have seen
increased interest in sex-related aspects of pharmacology, a development with vague parallels
to the feminist psychotherapy movements of the 1960s. The future likely holds an increased
interest in the role of gender, race, and ethnicity in optimal psychiatric care. At the same time,
computer-assisted consultation, either by algorithm or with colleagues at distant sites, may
sustain the viability of general psychiatric practice.

PSYCHOTHERAPY
Perhaps the greatest mystery is the future of psychotherapy. Particularly in the last half of the
twentieth century, psychotherapies proliferated to include treatments based on behavioral and
cognitive principles, strategic and systems theory approaches, and many others. Although
outcome research is limited in its findings, it has gained in influence, so that although
research rarely shows distinctions in efficacy between psychotherapies, treatments that are
most easily manualized and tested have become increasingly popular. These include
cognitive psychotherapy, the interpersonal approach of Gerald Klerman, and (most recently)
dialectical-behavioral therapies.

Within the line of therapies that begins with classical psychoanalysis, the recent movement
has been away from approaches that attempt to remedy unconscious conflict and toward
those (e.g., self psychology and the intersubjective school) that attempt to remedy posited
deficits in personality structure, in part by applying empathy as a diagnostic and therapeutic
instrument. A series of therapies take into account the research on attachment pioneered by
John Bowlby and others. These treatments are more in tune with current theories of mind and
of child development than were their predecessors, and they hold forth the possibility of a
conceptual and clinical integration of psychotherapeutic and psychopharmacologic
approaches. Meanwhile, research of the most preliminary sort points to the possibility of
documentingand in the future perhaps quantifying or monitoringthe central
physiological effects of psychotherapy.

Considering scientific and intellectual opportunity only, the future of psychotherapy in

psychiatry might look bright. But this view ignores other trends. Psychotherapy has suffered
a decline in reputation and status for various reasons including a harsh reassessment of the
character and achievements of many of the founders of psychotherapy, a series of scandals
involving undue intimacy and other abusive behaviors on the part of practitioners, and
controversy regarding the efficacy and scientific integrity of the discipline. At the same time,
psychotherapy within psychiatry has been vulnerable to changes in health care delivery
systems, notably cost-cutting measures on the part of third-party payers and fourth-party
reviewers of health care. The result is a reliance in all disciplines on brief and unambitious
treatments, marginalization of psychotherapy within training programs, and widespread
discouragement about the ability of psychiatry to maintain psychotherapy as a central element
in its identity. One notable dissenter from this pessimism is Leston Havens, who argues that
members of a growing and vigorous middle- and upper-middle class throughout the world
will ask themselves, What's for me? a question best answered by psychotherapy.
This debate reveals the extent to which the future of psychiatry rests on social and economic
forces external to the discipline. Even progress in psychopharmacology depends on continued
financial opportunities for drug manufacturers, a circumstance that was briefly called into
doubt during the health care policy debates of the early 1990s. Other areas of the field, such
as public-sector psychiatry, including community mental health care, are particularly at the
mercy of shifts in public policy.

Despite multiple sources of uncertainty, a picture of a possible future psychiatry emerges. It is

more closely allied with the rest of medicine through the basic sciences and biologically
based treatments. Yet, it maintains a distinctive character, both because of its particular
requirements for Hippocratic diagnosis and its ongoing use of a distinctive technology,
psychotherapy (whether or not primarily administered by psychiatrists). It continues to
comprehend tensions between mind and brain, while continuing its theoretical work to
minimize that division. It remains intimately tied to a host of human interests, from its sister
sciences to philosophy to the social forces it lives amidst. There is even the possibility that
psychiatry, with its insistent dialectical attention to mind and brain, will become a model for
the rest of medicine, so that psychiatry will not so much respond to its environment as
reshape it.