Literature Collection

The current opioid epidemic in the United States has been characterized as having three waves: prescription opioid use, followed by heroin use, and then use of synthetic opioids (e.g., fentanyl), with early waves affecting a population that was younger, less predominantly male, and more likely to be Caucasian and rural than in past opioid epidemics. A variety of recent data suggest that we have entered a fourth wave which can be characterized as a stimulant/opioid epidemic, with mental illness co-morbidities being more evident than in the past. Stimulant use has introduced new complexities in terms of behavioral consequences (e.g., neurological deficits, suicidal ideation, psychosis, hostility, violence), available treatments, and engagement into services. These compound existing issues in addressing the opioid epidemic in rural areas, including the low density of populations and the scarcity of behavioral health resources (e.g., fewer credentialed behavioral health professionals, particularly those able to prescribe Buprenorphine). Considerations for addressing this new wave are discussed, along with the drawbacks of a wave perspective and persistent concerns in confronting drug abuse such as stigma.

The last quarter century has seen a clear move internationally towards greater integration between healthcare service types - including across mental and physical health - as well as with social care. The drivers include growing population complexity and clinical need, and a recognition that the broader evidence base supports better outcomes and cost effectiveness through tackling social determinants of health in a more joined-up and preventative manner. Challenges have included a lack of granularity about which approaches work best at a local level, which data might support learning from these, and how we might disseminate this between often very different systems and populations. The next 25 years will see renewed efforts towards greater integrated and preventative community approaches. However, we still lack a consensus about inpatient provision and need to optimise this through clinically led learning and care models. Technology is at a point where we can have digital infrastructure that pulls large-scale population-level clinical effectiveness data. The opportunity is to anchor this as our key tool to grow and refine better care models, augmenting more traditional process and governance data-sets, and therein also leverage research findings into measured novel implementation in practice.

Psychiatry in the UK stands at a cross-roads, and this has significant implications for training. On the one hand the profession may have reached a limit in terms of of what can be achieved in a National Health Service now increasingly modelled on quasi- industrial processes designed to achieve ever greater effciencies. On the other hand, any return to the traditional idea of the stand-alone physician working in isolation in the clinic is untenable as it would obviously be unable to accommodate wider population needs, namely, the rising demand for mental health services, and an increasingly diverse and complex set of patients. In this paper we look to the past as well as the present, in order sketch out the future for training in psychiatry. An assortment of potential new 'horizons' are identified including integrative service models, transdiagnostic approaches, digital technologies, and psychometrics. There will need also to be an increased emphasis on 'system' skills eg advocacy, leadership, team working, network and cross-cultural working. Paradoxically, there is at the same time a strong appetite to reprise of some of the 'old' ways of working and training: greater flexibility and support for learners, the primacy of the therapeutic relationship, the importance of embedding discovery and research within practice, and the strengthening of a professional identity based on both the 'art and science' of psychiatry, as a branch of medicine. Combined with the 'new', the 'old' ways' will require shifts in training too.

OBJECTIVE: The American Psychiatric Association (APA) issued a 2023 report on the future of psychiatry, focusing on how the organization should position itself in relation to coming developments over the next 10 years. Here, we follow up with a discussion of how the psychiatrist's role needs to evolve to adapt to the changes ahead. METHODS: We drew on senior experts and junior trainees within the APA's Council on Healthcare Systems and Financing, along with additional content experts, to choose areas of focus and discuss their interrelationships. Literature review focused on publications with implications of these areas for future training and practice. RESULTS: We are only ∼5% of the mental health work force, and we have unique strengths, including training providing us the ability to discern the varied factors contributing to distress, and direct and apply interventions across all available modalities. Psychiatrists make best use of our capabilities when we lead the process of comprehensively formulating patients' problems and generating a multi-faceted treatment approach. We have chosen six areas where we envision new developments impacting how psychiatrists will practice and residents should train: digital data and precision medicine, measurement-based care, artificial intelligence (AI), psychotherapy, integrated care, and care for the seriously mentally ill. We provide suggestions regarding next steps that will allow us to make the best use of our training and expand access to high quality diagnosis and care. CONCLUSIONS AND RELEVANCE TO CLINICAL PRACTICE: We will need to handle the most challenging cases: the most psychiatrically complex, medically complex, and treatment-resistant. We must preserve our skill, unique among physicians, in psychotherapeutic approaches, even as we manage psychiatric illness. We must also adapt and become more tech-savvy, as digital data, mobile and computer-based treatments, electronic medical records, and AI algorithms take on increasing prominence in our field.