Paul Summergrad, MD, on the state of psychiatry

Under the National Health Service the status of British psychiatry has improved in relation to that of general medicine. One of the most important factors has been the ending of the comparatively isolated position of psychiatry. Another has been increased financial provision, and a third the rapid expansion of undergraduate teaching. As a result, psychiatry has emerged from the status of an isolated specialty to that of a major branch of the medical profession.

The defi nition of Europe raises some interesting questions both in geographical and political terms (see Muijen in this issue). The World Health Organization (WHO) European Region, for example, consists of 53 member states with a total population of around 900 million, with a large number of languages, religions, cultures and dialects, with signifi cant variations in social, economic and political structures and systems. Not only is there a massive variation in the gross domestic product across countries, but within counties as well. These variations cause an increase in mental illness across countries and even within the same country. Needless to say, social variations affect longevity and physical illnesses as well. It is well known that the burden of disease is highest due to non-communicable diseases such as cancer, cardiovascular disease and mental illness. Changing social structures as a result of migration and globalization, along with changing demographic factors as more people living longer, will all affect the prevalence of mental illness and increase the burden on services. Mental illnesses are well known to have a public mental health facet, which is crucial in developing and delivering services. Between a quarter and a third of the population will experience a mental disorder and will require intervention. Even within the same country, the treatment gap is notable. Stigma and fear of prejudice stop people from seeking help. Countries within the WHO European Region have often developed local strategies and examples of good practice, but often these are not available to others. In the past, the International Review of Psychiatry has looked at the state of psychiatry in Asia and in Latin America. Hence, we decided to commission this volume to share knowledge and examples of good clinical practice in Europe. We would like to thank all the contributors who, in spite of their busy schedules, have delivered their papers on time. There are many lessons here to be shared across the WHO European Region.

Maria A. Oquendo, MD, PhD, on the state of psychiatry

Attitudes toward psychiatry affect personnel working in the field and treatment of mentally ill patients (1). Attitudes toward psychiatry as a vocation might primarily affect recruitment, whereas attitudes toward psychiatry patients may affect clinical practice; these issues have not been investigated (2). Doctors’ attitudes likely mirror those of the general population, although, unlike the general population, physicians come into contact with psychiatrists and psychiatry patients during their formal training or practice. Thus, a physician may develop a more objective perception of psychiatry than society as a whole. Physicians’ opinions are composed of several elements: impressions of psychiatrists themselves, psychiatry patients, and psychiatry as a discipline. Each of these is independent to a degree; one can have a low perception of psychiatry patients but high regard for psychiatrists (2). There is little research on residents’ or specialists’ perceptions of psychiatry (2–7). Within the medical community, there is controversy over the role and status of psychiatry, not only among other specialists, but among psychiatrists too (7). A number of published studies tried to assess medical students’ perceptions of psychiatry, aiming to counteract the decline of recruitment into psychiatry, although students’ preferences were found to be poor predictors of career choice (8). On one hand, some authors state that general opinions of psychiatry are considerably improving, together with its social image (9–13). On the other hand, according to some U.S., U.K., and Australian studies, the number of students choosing psychiatry as their future specialty has decreased considerably in the last four decades (3, 8, 9, 14–20). Among the possible explanations are psychiatry’s low status, low treatment efficacy, lack of scientific support, and frequent criticism by other physicians (9, 18, 21). While medical students’ attitudes toward psychiatry may influence recruitment, attitudes in trainees and physicians may also influence the ability of doctors to identify, treat, and refer patients with mental disorders. The aim of this study was to evaluate the attitudes of medical residents toward psychiatry and to compare the opinions of residents in psychiatry with those of residents in other specialties. We hypothesized that psychiatric residents would have more favorable attitudes toward their specialty than would residents in other specialties.

All European countries are facing the challenge to address the very high prevalence of mental disorders with limited mental health resources, resulting in a treatment gap. Countries have drafted mental health strategies, replacing institutions with community based models of care with the aim to offer good and decent care. Psychiatry across Europe is very diverse, whether one considers models of care, resources, ways of working or training. Variation within countries, due to regionalization, can be as large as across frontiers. Valid comparisons of service delivery and their outcomes is essential for identification and dissemination of effective and efficient practice, but hampered by widely used but poorly defined terminology such as ‘primary care’ and ‘community services’, or assumptions about common ways of working. There is also still a lack of standardisation of outcome indicators. The combination of high morbidity and low supply in the presence of effective interventions is a strong argument in favour of investment, especially at times of growing need. It is necessary to support this argument with consistent evidence of improved outcome. It is essential that international groups now accept the challenge to reach consensus in order to advocate for more mental health resources.

Hungary has a tradition both in biological psychiatry and psychotherapy, and for decades developed together with neurology. From the mid 1980s the speed of development of psychiatry started lagging behind expected standards. Psychiatric care, research and teaching were hit hard in 2007 by unprecedented closures of facilities and budget reductions. Although suicide rates have decreased since the mid 1980s, the country has still the second highest rate in the European Union. The high prevalence of alcohol use and the rapidly increasing prevalence of illicit drug use contribute to comorbidity and related behavioural issues, including the increased frequency of severe violent events committed by people with psychiatric disorders, which have not been properly addressed. The country expects the first major restructuring of its healthcare starting in 2012 since the major political changes of 1989/1990. The profession, patients and their caregivers should use this opportunity to modernize psychiatry in Hungary.

Book Review: The State of Psychiatry, Inquiries in Psychiatry

Book Review: The State of Psychiatry

The State of Psychiatry: Essays and Addresses by Sir Aubrey Lewis.Inquiries in Psychiatry: Clinical and Social investigations by Sir Aubrey Lewis.Psychotherapie‐Fibel, 3rd edition. By G. Clauser.Brain Function, vol. III: Speech, Language and Communication. U.C.L.A. Forum of Medical Science, no. 4. Edited by E. C. Carterette.Psychodiagnosis in Schizophrenia. By Irving B. Weiner.The Theory and Practice of Psychiatry. By Frederick C. Redlich and Daniel X. Friedman.Research Design in Clinical Psychology and Psychiatry. By J. B. Chassan.Childbearing—Its Social and Psychological Aspects. Edited by Stephen Richardson and Alan Guttmacher.Toward a Unified Theory of Human Behavior: An Introduction to General Systems Theory, 2nd edition. Edited by Roy R. Grinker, Sr.Praxis der Selbsthypnose des autogenen Trainings. [Practice of autohypnosis in autogenic training.] By Klaus Thomas. Prefaced by I. H. Schultz.Motives and Thought: Psychoanalytic Essays in Honor of David Rapaport. Edited by Robert R. Holt.Personality and Arousal. A Psychophysiological Study of Psychiatric Disorder. By G. S. Claridge.The Neuroses. By Henry P. Laughlin.Anorexia Nervosa. By Helmut Thomä. Translated by Gillian Brydone.

The number of practising psychiatrists in Sweden has increased by nearly 30% between the years 1995–2009; however, the profession has suffered serious recruitment difficulties. The Swedish National Board of Health and Welfare estimated that about 5–10% of the population is in need of psychiatric treatment, but only 3–4% seek psychiatric care. Among patients who receive psychiatric care, approximately 47% are treated with psychopharmacology, 13% are treated with psychotherapy and 40% receive both treatments. There are still challenges facing Swedish psychiatry: reduction in waiting times for psychiatric care, broader accessibility of evidence-based treatment methods for all groups of psychiatric patients both in rural and urban areas, and targeting the needs of immigrants and refugees. The allocation of resources to psychiatric research, and development of novel treatment methods are crucially needed. The Swedish government is strongly committed to decreasing the number of suicides, as there are approximately 1,400 individuals lost to suicide every year in a country with a population of around 10 million. Given that nearly 20% of all suicides are amongst psychiatric inpatients, a regulation has been passed regarding the analysis of all completed suicides in the healthcare system. Results from these analyses can be used for increasing quality of treatment.

There is practically no knowledge in the west regarding the status of psychiatry in the People's Republic since the time of the Cultural Revolution. The three publications on Chinese psychiatry that I was able to find, all of which are based largely upon the primary literature, terminate abruptly at the Cultural Revolution. At that time the Chinese Journal of Neurology and Psychiatrystopped publication and has not been reinstituted. The only medical journal which has begun publication, the China Medical Journal, carries occasional papers in neurology but thus far there have been none in psychiatry. A group of American psychiatrists who had been hoping to participate in an exchange visit to China under the auspices of the National Institute of Mental Health and the American Psychiatric Association had not succeeded in making the necessary contacts, and were in fact unable to give me the names of any Chinese psychiatrists in responsible positions.

Inquiries in Psychiatry. Clinical and Social Investigations. By Sir Aubrey Lewis. London: Routledge and Kegan Paul. Pp. 325+vii. 1967. Price 63s. - The State of Psychiatry. Essays and Addresses. By Sir Lewis Aubrey. London: Routledge and Kegan Paul. Pp. 310 + ix. 1967. Price 63s. - Volume 114 Issue 506

Book reviewed in this article:Problems of an Industrial Society. By. W. A. Faunce.The Young Handicapped Child. By Agatha Bowley and Leslie Gardner.Psychodynamics of Externalization: Life from Without. By Carl Frankenstein.Aspects of Social Control in Welfare States. Edited by Nils Christie.Themes in Speculative Psychology. By N. Jordan.Learning Theory and Social Work. By Derek Jehu.Minnesota Symposium on Child Psychology, vol. 1. Edited by John P. Hill.The Psychology of Anxiety. By Eugene E. Levitt.Inquiries into Psychiatry: Clinical and Social Investigations. By Sir Aubrey Lewis.The State of Psychiatry: Essays and Addresses. By Sir Aubrey Lewis.Age and Function. By Alastair Heron and Sheila M. Chown.Cognitive Processes in Maturity and Old Age. By Jack Botwinick.Modern Trends in Mental Health and Subnormality, 1. Edited by G. O'Gorman.

Psychiatry in Medicine Retrospect and Prospect. By Denis Hill. (The Rock Carling Fellowship 1969.) Pp. xii+182. (The Nuffield Provincial Hospitals Trust: London, December 1969.) 12s 6d.

Thirty-four years have elapsed since the passing of the Italian Law 180, the reform law that marked the transition from a hospital-based system of care to a model of community psychiatry that was designed to be an alternative to, rather than to complement, the old hospital-centred services. The main principle of Law 180 is that psychiatric patients have the right to be treated the same way as patients with other diseases and only voluntary treatments are allowed, with a few exceptions that are strictly regulated. The main features and consequences of the Italian reform are initially reviewed; national and local level experiences and epidemiological data are then analysed in order to highlight and disentangle the ‘active ingredients’ of the Italian experience. A public health attitude with the capacity to network good practice in service organization by giving voice to successful experiences and promoting health service research, apart from some local services, is still generally lacking. Furthermore, it is still difficult to provide an evidence-based reply to the question: can à l’Italienne community-care be exported elsewhere?