You don’t need to be a prophet to predict the future of psychiatry. Just look at the direction in which modern medicine is developing in general.
The main focus in psychiatry of the future will be on the development of biomedical technologies aimed at studying the material basis of mental disorders. In the psychiatry of the future, the main role will be played by genetic, neuroimaging and laboratory studies of the brain in the context of the environment. Today, technology does not yet allow us to fully understand the complex nature of mental disorders. No laboratory tests or other biological markers were found to be sensitive or specific enough for experts to include them as diagnostic criteria for mental disorders in the leading psychiatric classifications (ICD-10/11, DSM-5).
One of the reasons for the failures in the search for diagnostic biomarkers is the erroneous assumption that all mental disorders are independent nosologies, and not diagnostic constructs introduced on the basis of expert agreement. Mental disorders are biologically and clinically very heterogeneous in nature, and, in addition, they can overlap with each other at all possible levels (from common genes to common symptoms). The famous psychiatrist and geneticist Kenneth Kendler noted in one of his articles that “our genes do not seem to have read psychiatric classifications,” hinting at the multiple interweaving of the most complex biological mechanisms of mental disorders.
Future classifications of mental disorders based on genetics, neuroscience, and behavioral sciences will require new systematic data. However, the scientific literature with such data cannot appear as long as the research depends on the current psychiatric classifications. It turns out to be a vicious circle.
Attempts are already being made to get out of this classification trap and take a different path — not from diagnoses to understanding the biological nature of diseases, but, on the contrary, from biology to psychopathology. In 2008, the National Institute of Mental Health of the United States set a strategic goal: “To create new approaches to the classification of mental disorders for scientific research based on neurobiological indicators.” The traditional approach used by the World Health Organization and the American Psychiatric Association involves this sequence: first, based on the clinical manifestations, it is determined what kind of disease it is, and then the biological mechanisms of the onset of symptoms are investigated. The proposed new algorithm looks different: first, you need to understand what the work of the psyche looks like in a normal state; second, you need to find the brain systems that support normal mental processes; third, you need to find out the causes of the dysfunctions of these systems. With this approach, more basic research will be involved in the study of mental disorders. The draft of the new classification has only just begun to be developed, but it is already clear that it will become a platform for the research of mental disorders from a completely new perspective.
We expect the future of psychiatry to provide objective criteria for mental disorders that will complement and refine diagnostic criteria based on clinical symptoms. The ” Commission on the Future of Psychiatry “(and this also exists), created by the authoritative medical journal Lancet, is confident that the current clinical approach is unlikely to be replaced by a purely biological one and in its ideal form will be based on an integrative biopsychosocial model.
When in the beautiful psychiatry of the future, psychiatric clinics that resemble closed cities for madmen today will gradually close, and most psychiatrists will begin to conduct appointments in ordinary clinics, IT technologies will help make the work of highly qualified psychiatrists more accessible. The introduction of telemedicine [52] will allow any patient anywhere in the world to contact a psychiatrist specializing in the necessary direction (for example, a geneticist or a psychiatrist specializing in eating behavior) from their room. In Russia and around the world, such technologies are already being actively implemented in practice.
Various methods of psychotherapy will continue to improve and strengthen their methodology, but, having occupied the niche of “healing the soul”, they are unlikely to help bring psychiatry to a new level. Psychotherapy will remain an integral part of psychiatric care, but the main events will take place far away from it — in well-ventilated laboratories with powerful computers that will analyze terabytes of information 24/7 in search of a therapeutic target for creating the latest drugs for some “schizophrenoform psychosis of the 7th type associated with the 22nd chromosome deletion syndrome (22q11DS)”.
Another critical area of future psychiatry that will require the full power of megacomputers to succeed is genetic risk analysis and genetic counseling. Even today, mental health risk counseling is gradually moving away from risk assessment based on family history (if your mother was ill, then you also have some chance of getting sick) to risk assessment based on the results of genetic tests. Such a risk assessment is still possible only in a minority of patients with mental disorders who have rare genetic variants (variations in the number of copies of genes, etc.). In the psychiatry of the future, thanks to the analysis of large amounts of genetic data and the most complex biostatistical calculations, it will be possible to calculate the genetic risk of any mental disorder.
In the course of further genetic counseling, new ethical problems may arise that modern psychiatry is not familiar with. These include: preimplantation selection of embryos based on the likelihood of developing a mental disorder or abortion after the results of genetic analysis; stigma provoked by genetic information, as well as the right of family members to know genetic information about blood relatives, and, as a result, conflicts over the “culprit” of a mental disorder; the role of genetic tests in finding a partner for marriage, etc.
Big Data analysis in psychiatry is just one of the areas of application of IT technologies. In the near future, we can expect a significant increase in the capabilities of artificial intelligence, which could operate not with the laid-down grid of dialogues of an ordinary chatbot, but with entire categories of meanings. Artificial intelligence, installed as a mobile application, can be assigned to a diagnostic interview-collecting information about the patient’s life and medical history — as well as first aid or short sessions of cognitive behavioral therapy for, for example, insomnia. Of course, we understand that medical fields such as psychiatry, which require special empathy and empathy, are not likely to be irrevocably swept into the dustbin of history by technological innovations. But breakthrough technologies with the use of artificial intelligence will definitely take their place in the field of medical services, and psychiatry will not be an exception.
The human brain has done a good job of creating a rational picture of the world, but now it’s time to recognize that no brain on earth can hold all this grandiose data set. Work with the facts should be completely entrusted to the computer.
Everything that is contained in textbooks and lectures is transferred to the computer repository of knowledge without any critical difficulties. Guidelines [53], algorithms, protocols, all these normative documents (by the way, not always actually present in some medical disciplines and very often ignored in practice) should not clutter up a person’s memory. Everything that claims to be systematic in medicine can and should be transferred to the space where artificial intelligence comes into play.
As for education — there can be no doubt that human knowledge is inferior to computer knowledge. The medical computer not only has the quantitative advantage of knowledge, its knowledge is not only better structured, but it is also constantly (daily) updated. The information system, which will unite all health care providers, will be constantly updated with new information about how a particular treatment regimen works in practice. This will be a self-learning system that corrects the idea of effective treatment online.
Before the dismissal of doctors who argue in this way becomes a massive and irreversible process, it makes sense to outline the concept of unmanned medicine, which humanity will come to in the coming decades. However, we will have to immediately make a reservation about the fate of psychiatry in the world of unmanned medical technologies. Psychiatry in the form in which it exists and develops now, in the realm of high technology, of course, will not fall. What exactly will prevent her from joining the triumph of robotic healing is described at the end of the article.
When faced with a particularly large-scale self-confidence, clouding the essence of any question with clubs of pathos and honor, it is useful to reduce the conversation to the level of mundane details. What exactly is there in the personal clinical experience of a doctor that cannot be systematized in a file format. xls, i.e. in a spreadsheet? What is such an unprecedented variety of factors encountered by him within a certain clinical case that it is not able to fit in a table with a maximum allowed number of rows of 1,048,576 and a maximum allowed number of columns of 16,384 (Technical characteristics and limitations of Microsoft Excel 2016, website support.office.com)?
The experience of a doctor consists of very different cases. But all of them can be mathematically analyzed, otherwise the experience that the doctor is talking about probably belongs to the field of “intuition”. If medicine is a science, not an art, where gifted people operate, then medicine should respect the principles of rational data analysis. The scientific method works where it is possible to collect data and typologize them without the remainder reserved for unexplained incidents.
Intuition? Praecox feeling? Flair? With all this, you will have to go to the same cultural niche where healers, psychics and nuggets in the fifth generation are found.
Self-driving medicine will scare you in the same way that self-driving cars scare you. What is frightening is not the novelty of technology, but the fact that a person is excluded from the usual process, a being we understand, on whom we can hope and whom we trust as our own kind. More reliable devices, whose trust is statistically more justified than trusting a person, are seen as dangerous only because they are not human. Self-driving cars are safer, and with their introduction, everything that a person needs from transport will improve, except for one nuance — the human aspect will disappear.
It is strange that a modern person has to make such an effort to get used to this picture. A modern airliner is controlled by autopilot almost all the time in flight, and only at the moment of takeoff and landing, control of the aircraft passes to a person.
Garry Kasparov in the book “Man and the Computer” gives an example of how strongly the psychological factor affects the history of the development of new technologies. It turns out that the elevators that were installed in American skyscrapers at the beginning of the XX century could function without an elevator operator. There was nothing in their design that made the presence of an elevator operator mandatory. For passengers, using this unusual device was such an exciting experience that the mere presence of an elevator operator, i.e. a specialist in elevator management, eased the stress. The elevator operator symbolized human control over the mechanism. When the New York elevator workers ‘ union went on strike and people were forced to use the elevators on their own, the true state of affairs was instantly clarified — the elevator operator’s profession is not needed.
When the doctor is replaced by a robot, there will be the same problem. People will miss human involvement, while the safety and superior effectiveness of unmanned medicine will become apparent to everyone.
Human participation in unmanned medicine will end at the stage of ranking data from clinical trials. Probably, at the initial stage, a person will decide which research findings should be considered more valuable when prescribing treatment. Providing the computer with information raw materials, the person will not participate in decision-making. At more advanced stages, robot doctors will process the research data independently, focusing on their own ideas about the usefulness. The actual process of initiating and organizing clinical trials will at some point pass into the jurisdiction of artificial intelligence.
For many patients, the crucial obstacle will be the lack of human contact with the doctor. In this connection, it is useful to remember that a doctor in scientific medicine does not have to be a source of “human warmth”. This is rather the goal of junior medical staff, nurses, i.e. sisters of mercy-nuns, novices, or volunteers whose duty is not to treat, but to comfort. In the era of robotic medicine, they will not go anywhere, on the contrary, human resources will be redistributed in this direction, to where people provide care, comfort, compassion, prepare for the last journey.
Psychiatry will come to the unmanned model later than other medical disciplines. The main problem is the lack of uniformity in the collection of data on the disease, the vagueness of diagnostic definitions and the unfinished concept of a mental disorder. It is no more difficult to digitalize therapeutic decision-making in psychiatry than in other areas of medicine. Difficulties will arise before the start of treatment. The problem is how psychiatry presents its field of activity.
Imagine a global hypertension treatment system in which the input data is blood pressure readings received in the medical office or by the patient at home, or transmitted from a wearable device to a medical computer. The treatment guideline that the robot prescribes will be linked to these indicators.
In psychiatry, there is no such clarity that laboratory or hardware diagnostics provide. The main method of diagnosis is still the collection of information about the phenomenal experience of the patient. There is no uniformity in the interpretation of the narratives that patients supply doctors with. This means that it is not possible to create a single information system that will unite all doctors in the world, or rather, all electronic devices connected to a global database of diseases and treatment routes.
Psychiatry based solely on clinical symptoms has no place in the new reality of unmanned medicine, just as there is no place for nosologies that are more like philological articles than descriptions of biological reality. New technologies will make psychiatrists, as has happened in the history of medicine, feel behind the progress. Sometimes it seems that a certain delay in development is inherent in psychiatry as a scientific discipline. But this does not mean that psychiatry is doomed to stand still, watching as other medical specialties go to a qualitatively different level.
Moving forward is possible now. While the conceptual foundations of diagnostics remain in a rather archaic state, it is possible, without waiting for a new revolution in science, to start implementing new technologies in psychiatry right now. From a brightly blooming and rather chaotic and neglected garden of different opinions (“how many doctors, so many opinions”), psychiatry can be transferred to a clean, tidy room.
A clear order of algorithms based on the principles of evidence-based medicine is not just desirable, but necessary for modern psychiatry. And if earlier it was only possible to dream of a scientifically justified unity of methods, today information technologies make the dream a reality.
It is already possible to collect all the relevant data on the use of certain drugs and organize them in a convenient database for practical use. The information about medicines that is required to make clinically important decisions, a modern doctor is not required to keep in mind. Everything you need can be organized in the form of a software tool that compares patient data with the accumulated experience of scientific medicine (rather than an individual specialist) and offers the doctor the most reasonable therapeutic route, including the choice of medication, dose, means to alleviate side effects, treatment regimen, etc.
Such a tool will bring psychiatry closer to the ideal of unmanned medicine, based solely on scientific reliability, devoid of the “human factor” and continuously improving its own quality standards.