Psychiatry in the future

The 1990s witnessed a strikingly accelerated rate of change in the structure and delivery of mental health care in the UK. The preceding 15 years had been marked, in my practice, by two inexorable processes which transformed the face of clinical psychiatry, but without the convulsive upheavals and discontinuities that we have come to live with since. The first was the running down and eventual closure of the large mental hospitals - a change so fundamental that it may be difficult for those trained recently to grasp just how different mental health care was then. The second was the internationalisation of research, and the growing influence of evidence and formal instruction as a determinant of practice, rather than simply relying on the consultants to whom one was apprenticed. For all the occasional criticisms of it, evidence-based medicine dominates modern psychiatry, and this is evident in the much greater consistency of practice than 30 years ago. The changes in the 1970s and early 1980s were essentially egosyntonic within the profession; the past 15 years have been more dramatic and less comfortable.

My task was to identify the major changes in these past 15 years and try to suggest the influences that led to them. The major drivers of change fall conveniently into three groups: developments in the general environment in which mental health care is delivered, new treatments and dramatic public events.

During this time, there has been a steady change in the social context of care. Families and society have become increasingly fragmented and diverse, and we have witnessed the rise of consumerism and managerialism in health care. The 1980s witnessed the first of several attempts to introduce a modified market economy into what had traditionally been a monolithic and professionally dominated service. Alongside this has been the exponential growth in mental health services research; what was once a trickle is now a flood - a recent review of home-based care (Catty et al, 2002) found over 90 high-quality published studies. With the rise in status of evidence-based medicine these studies have been used to support service changes, despite the difficulty of replicating some of the international results within the UK (Burns et al, 2002).

New treatments such as the use of selective serotonin reuptake inhibitors for depression, the impact of the new atypical antipsychotic drugs and the ‘ rediscovery’ of clozapine have changed the practice of psychiatrists. The impact of these innovations is not simply through improved efficacy; in addition the introduction of an element of choice of treating agent has broadened and softened the nature of the psychiatric consultation. Having more than one approach available has begun to make a reality, rather than just a politically correct aspiration, of collaboration. On the other hand, the range of psychosocial interventions in psychosis has not spread through routine practice, despite a powerful research literature (Pilling et al, 2002) and the heavy artillery of guidance from the National Institute for Clinical Excellence (2003).

Probably the most overwhelming change in practice in the UK has been the shift of power over clinical service development from the professions to the government. This is manifest in the highly structured approach to the documentation and review of community care of the severely ill encaspulated in the care programme approach (Department of Health, 1990) and in the highly-prescribed ‘modernisation teams’, which are a centrepiece of the National Health Service Plan (Department of Health, 2000). These ‘designer’ teams represent the most radical change in practice from the steady evolution of integrated, sector community mental health teams that had come to serve most of the country (Johnson & Thornicroft, 1993). Their introduction, and indeed the consolidation of the care programme approach (when so many other government initiatives withered on the vine), stem from the political fallout of the killing of Jonathan Zito. This tragedy, and the loss of public and political confidence in the mental health services following the subsequent report (Ritchie, 1994), resulted in a profound shift in power, which has coloured the development of care far more than any research evidence. The balance between treatment and social control (always a tension within psychiatry) has shifted markedly at present. Current practice is dominated by central prescription and risk assessment to a degree that would have been altogether impossible to imagine in 1990.

The changes in UK mental health practice witnessed in the 15 years preceding the period that is the rightful focus of this piece (the run-down of the large mental hospitals and the professionalisation of postgraduate training) are probably those that history will note. They were also driven entirely by the profession, and based on conviction rather than research evidence. The past 15 years has seen an acceleration in the pace of change and the responsibility for it away from the professions. Despite the fig-leaf of an ‘evidence base’, these changes are undoubtedly political and confirm the cultural specificity of mental health care. The shake-up is uncomfortable for the profession, and will result in a higher rate of blind alleys and mistakes in service developments. However, it is also likely to have stimulated creativity and shaken off some worthy, but stifling, conservatism.