Psychiatric diagnosis and treatment in the 21st century: paradigm shifts versus incremental integration

Abstract

Psychiatry has always been characterized by a range of different models of and approaches to mental disorder, which have sometimes brought progress in clinical practice, but have often also been accompanied by critique from within and without the field. Psychiatric nosology has been a particular focus of debate in recent decades; successive editions of the DSM and ICD have strongly influenced both psychiatric practice and research, but have also led to assertions that psychiatry is in crisis, and to advocacy for entirely new paradigms for diagnosis and assessment. When thinking about etiology, many researchers currently refer to a biopsychosocial model, but this approach has received significant critique, being considered by some observers overly eclectic and vague. Despite the development of a range of evidence-based pharmacotherapies and psychotherapies, current evidence points to both a treatment gap and a research-practice gap in mental health. In this paper, after considering current clinical practice, we discuss some proposed novel perspectives that have recently achieved particular prominence and may significantly impact psychiatric practice and research in the future: clinical neuroscience and personalized pharmacotherapy; novel statistical approaches to psychiatric nosology, assessment and research; deinstitutionalization and community mental health care; the scale-up of evidence-based psychotherapy; digital phenotyping and digital therapies; and global mental health and task-sharing approaches. We consider the extent to which proposed transitions from current practices to novel approaches reflect hype or hope. Our review indicates that each of the novel perspectives contributes important insights that allow hope for the future, but also that each provides only a partial view, and that any promise of a paradigm shift for the field is not well grounded. We conclude that there have been crucial advances in psychiatric diagnosis and treatment in recent decades; that, despite this important progress, there is considerable need for further improvements in assessment and intervention; and that such improvements will likely not be achieved by any specific paradigm shifts in psychiatric practice and research, but rather by incremental progress and iterative integration.

Psychiatry in the 21st century: the glass is half full

“…Challenges for global mental health include climate change, displacement of large populations due to war and poverty, income inequality, and inadequate health care services [1][2][3] . These challenges interact, as climate change can reduce food production and increase violent conflicts, which may displace large parts of the local population, who then face income inequalities and inadequate health care services in the host countries.…”

“…Culture-, language-, class-and gendersensitive treatment can be promoted using telemedicine and digital interventions 1 . Participatory and interdisciplinary approaches can integrate disciplinary diversity with stakeholder engagement to fight stigmatization, racist stereotyping, and social exclusion.…”

Incremental integration of nosological innovations is improving psychiatric diagnosis and treatment

“…Consider for example the assertion that “categorical and dimensional approaches are interchangeable: any dimension can be converted into a category, and any category can be converted into a dimension” 1 . This statement, although appealingly ecumenical, may be scientifically misleading.…”

The future of CBT and evidence‐based psychotherapies is promising

“…Stein et al 1 point out that, while evidence‐based psychotherapies and particularly cognitive behavioral therapy (CBT) represent a “remarkable step forward”, their implementation in mental health systems globally is “arguably best conceptualized as representing incremental progress”.…”

“…Modest implementation is tied to several factors, including incompatibility with other psychotherapeutic models, frequent departure from evidence‐based guidelines in routine care, and lack of trained clinicians. Further, even with embedded training in evidence‐based therapies, as exemplified by the UK Improving Access to Psychological Therapies (IAPT) program, the authors report that rates of clinically significant improvement are estimated at only 26% when assuming poor treatment response among dropouts 1 .…”