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August 25, 2013

The future of psychiatry

Reuel S. Amdur

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"The future is not what it used to be." That is how Dr. Simon Hatcher began his recent presentation at the Royal Ottawa Hospital.

The future of psychiatry

Reuel S. Amdur

“The future is not what it used to be.”  That is how Dr. Simon Hatcher began his recent presentation at the Royal Ottawa Hospital. 

The future he envisions for psychiatry involves computerized therapy, virtual reality, and brain implants.  Much of this future is already playing out, especially in New Zealand, were he practiced for a number of years and where he played a role in the developments. 

He indicated that New Zealand is far ahead of Canada in this regard, a situation that he relates to the nature of our governmental structure, with the division between federal and provincial responsibilities.

He reviewed briefly some of the changes in the field of medicine in recent decades.  Psychiatry has for the most part been low-tech, while other parts of medicine have been more technologically involved, in promoting self-care in the case of blood pressure. 

Drivers in computerized psychotherapy include an increasing demand in the face of financial restraint, along with a growth of knowledge of information technology among the population and with increased ownership of computers.   Computerized therapies are proliferating, and there are increased efforts in experimental validation of efficacy.

At this point, computerized therapy is in large measure used in treatment of depression and anxiety.  It can be employed either in self-treatment or in conjunction with therapeutic visits.  There is no waiting list and no stigma.  It can be tailored to specific groups.  (He used the New Zealand example of the Maori.)  It can address workforce problems.

Computerized therapy is not without its problems. 

To begin, not everyone has a computer, and thus the problem of unequal access to treatment is reinforced.  And computer technology becomes rapidly obsolete.  Beyond that technological problem, there is limited evidence of effectiveness, though there is some.  As well, there are ethical issues that arise in terms of privacy. 

For example, computer technology could be used in control of diet by putting a computer chip on a refrigerator door, to monitor access to food.   Then there is the matter of risk.  What happens when a patient tells the computer program that he is going to kill himself?What happens when a patient tells the computer program that he is going to kill himself?

NICE (Britain’s National Institute for Health Care Excellence) found, in an evaluation of computerized cognitive behavioral therapy (CBT) with people not in a clinical setting having mild to moderate depression and anxiety, that results were positive but not strong.  (CBT is an action-oriented therapy geared to addressing specific problems, for instance, actively replacing negative thoughts with positive ones.) 

Besides on-line therapy, New Zealand has SPARX, a CD program for treating depressions in adolescents through virtual worlds.  SPARX received an award from UNESCO Netexpo (“a global observatory on digital society).  Results with SPARX were comparable with those in face-to-face therapy.

“Beacon” is an Australian computerized therapy enterprise.  It has been shown that rates of suicide and depression have gone down with use of “Beacon”.

Virtual reality is a way of treating some problems, especially anxiety.  For example, a person can be desensitized to spiders or snakes through presentation of these creatures on a computer.  Even robots can be used therapeutically.

Robots can be “pets” in homes for the aged, serving to decrease loneliness and aggression.  They can also be designed to monitor medications and blood pressure.  And in a more invasive technology, implants are used to stimulate the brain function in Parkinson’s disease. 

Hatcher did not mention the renewed use of modified electroshock with depression, especially severe depression.

Why is not more use being made of therapeutic technological treatment in Canada?  There are a number of factors.  There is no mechanism for rolling out technological elements.  For a new drug, one goes to a drug company.  Where do you go for a new therapeutic computer program?  As well, there is no line in the budget for such technology and no plan to integrate technology into a service.  We do not know who would manage and evaluate computer programs that are developed.  There will need to be planning for integrating technology and for dealing with obsolescence.  Workforce integration planning would be a challenge.  Then, as ever, there are factors of professional and provincial boundaries as well as issues of confidentiality and risk.  Perhaps most important is the question of who is to pay.

In the old days, Freudians objected to behavioral approaches, claiming that they did not deal with root causes and that the problem resolved would simply reappear in another guise.  However, it became clear that not everyone can safely be confronted with the contents of the unconscious.  And we don’t live just at a “root” level.  We live day-to-day.  Nor could society afford to spend its mental health dollars solely on long drawn-out psychoanalytic treatment modalities.

A major limitation of technological fixes at this point is that they largely address the less serious forms of mental distress. 

Members of the audience at the Royal suggested that the technology might also be useful in dealing with alcoholism and other addictions, as well possibly with fetal alcohol spectrum disorder and as an adjunct in treating bipolar disorder.  Who knows what’s next?

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