Psychiatry in the future

European nations - including Britain - have a common pattern in their history of mental health care. Most western and central European countries established large asylums in the 19th century and engaged in some form of de-institutionalisation during the second half of the 20th century. Since the 1950s, major mental health reforms have significantly improved the quality of care. Although time of onset, pace, fashion and outcomes of reforms varied greatly between countries, throughout western Europe community-based services have been established and become part of routine service provision (Becker & Vázquez-Barquero, 2001). Compared with the heyday of the reform spirit in the 1970s, we now appear to be experiencing a relatively calm period. Developments currently seem to be dominated by fragmented pragmatism rather than by dreamy visions. This may reflect a wider trend in politics: throughout Europe, ambitious long-term visions appear less relevant as drivers for political change than was the case a few decades ago.

In most western European countries, statutory services have recently endured spending cuts and stepwise reduction, which can be a demoralising experience. Here, Britain is an exception. It still has much lower spending levels than comparable countries, but has been enjoying a substantial increase of investment in mental health care over the past few years, and more has been pledged for the future.

The funding and organisation of mental health care varies substantially across Europe and is embedded in different national and regional traditions and cultures. In a way these different approaches might be utilised as a naturalistic experiment, the results of which have not yet been sufficiently evaluated in research. Considering all the differences, is there a common denominator that indicates a general direction of travel? Perhaps. For instance, the following processes are likely to influence the midterm and possibly long-term future of mental health care throughout the developed world.

Trends in mental health care

In general, the amount of money that is spent on mental health care has risen, and there is no reason to assume that it will not continue rising. Even if new treatments eradicated one or two major disorders and new prevention programmes reduced the frequency of others, mental health professionals would not be out of their jobs. On the contrary, the definition of mental health disorders is increasingly inclusive, and more and more problems that could be seen as social issues will be treated as individual psychological disorders. The public, potential patients and actual patients will demand the provision of more specific treatment. However, this money will not necessarily go into conventional and statutory services as we know them. In line with consumerism, people might prefer to spend money on improving their ‘wellness’ through questionable methods outside established medical care than on evidence-based intervention techniques. More money will not automatically lead to ‘met needs’ and an overall high satisfaction with care. On the contrary, the history of health care has shown that supply creates demand, and more funding may raise expectations, leading to a spiralling of costs and demands.

We are already experiencing a split between mental health care for patients who can actively seek treatment and - directly or indirectly - pay for it, on the one hand, and a statutory service for patients who do not actively seek treatment and are of actual or potential annoyance to the public, on the other. An increasing range of services will be provided to the former group, and many of those services will be attractive enough to lure patients into using them. For patients with severe mental illness, there may be a second-class statutory service, probably as part of social care rather than health care. To some extent, this has already happened: for example, some services for people with severe mental illness in parts of Scandinavia and Germany are run by social services, and are outside the health care system for other patients. These services may focus on social control rather than therapeutic change, and become highly unattractive to both patients and staff.

The current trend towards re-institutionalisation may continue. In mental health care, this is characterised by a rising number of forensic beds, higher numbers of involuntary admissions, and an ever-larger number of places in residential care and supported housing (Priebe & Turner, 2003). This is happening against the background of enormous increases in the general prison population in most European countries over the past decade, indicating a more conservative attitude to deviant behaviour and risk containment.

Role of psychiatrists

The psychiatric profession appears to be restricting itself to a niche with an increasingly managerial role and arguably little expertise that is of direct therapeutic relevance - particularly in places where forms of pyschological treatment are left to other professions. Once the entitlement to prescribe medication has been shared with other professions, the dominating role of psychiatrists in mental health care will be further challenged. Other mental health professions will continue to develop their profile, which in the long run might lead to significant changes in the roles of all the different professional groups involved in mental health care.

Shaping the future

Predictions about the future of mental health care are not simply a speculative forecast. Professionals are not merely subject to future changes, they are also active players with influence in the wider societal context. There certainly is an opportunity to utilise their professional status and the (still) strong interest of large sections of the public in mental health issues to initiate a lively debate on the ethical principles and the function of mental health care in modern societies. More or less directly, such debate might help to influence values as well as to further visions and plans. User empowerment, in a wide sense of the word, should be seen as a welcome driver towards change, and professionals must be prepared to adopt new roles. The challenge is to take a proactive role in creating the shape of mental health care in the future.