Demystifying Psychiatry: What's Changed in the Past 15 Years

Co-authored by Eugene Rubin, M.D., Ph.D., and Charles Zorumski, M.D.

We published the book Demystifying Psychiatry: A Resource for Patients and Families 15 years ago. Since then, we have published 206 articles on Psychology Today in which we have extended discussions in the book regarding advances in clinical and preclinical science.

The principles of treatment we outlined in the book remain timely. However, substantial progress in available treatments has occurred over the last 15 years. We mention some of these developments below.

Basic Principles of Psychiatric Treatment

We initially outlined seven basic principles of psychiatric care in Demystifying Psychiatry. These remain relevant today and bear repeating:

1. Accurate diagnosis is important in determining appropriate treatment.
2. Close communication between the treatment team and the patient is essential.
3. Some symptoms require aggressive action, including emergency care.
4. Things take time.
5. The effective use of medications requires expertise on the part of the practitioner.
6. Types of treatment should be tailored to a patient’s individual circumstances.
7. As much as possible, patients should be involved in their own care.

Examples of Major Treatment Advances

Since we published Demystifying Psychiatry, basic and clinical neuroscience research has led to new treatments with novel mechanisms of action that differ from older treatments. Prior to these more recent advances, new treatments involved tweaking approaches that had been available since the 1960s.

Below, we list several new treatments that have become available for post-partum depression, treatment-resistant depression, and schizophrenia. Other novel treatments are on the horizon.

1. Postpartum depression

Neuroactive steroids, a new category of medications with rapid onset of action, have been shown to be very effective in treating this painful and potentially devastating disorder. Both intravenous (brexanolone) and oral (zuranolone) treatments were approved for clinical use. Because of the success and easier use of the orally active agent, the intravenous treatment was recently discontinued.

2. Severe treatment-resistant depression

Medications that work by influencing the glutamate neurotransmitter system are currently available. Such drugs include esketamine, an FDA-approved nasal spray; intravenous ketamine (off-label use); and an oral drug that combines dextromethorphan and bupropion. Ketamine-based drugs work much more rapidly than traditional antidepressants.

Advances in methods using repetitive transcranial magnetic stimulation (rTMS) have made this form of neuromodulation treatment more effective and more broadly available. One example is the Stanford Neuromodulation Therapy (SNT) that combines an aggressive form of rTMS with brain system mapping. SNT has shown promise in treating severe, treatment-resistant depression.

The availability of this treatment is limited, but it may offer life-saving care for those who haven’t responded to other treatments. Other forms of rTMS are also more routinely available for clinical use.

3. Schizophrenia

A recently approved medication, xanomeline-trospium, is effective in decreasing positive, negative, and cognitive symptoms of schizophrenia. This drug’s mechanism of action differs significantly from prior antipsychotic medications in that it directly influences the acetylcholinergic (muscarinic) neurotransmitter system.

Advances in Treatment Delivery

Because of the limited number of psychiatrists, many patients are still not able to be evaluated or treated by psychiatrists. Yet there has been progress in treatment delivery. Examples include:

• The more routine use of telepsychiatry (including Zoom and other computer-based technologies) to reach patients at distant locations.
• The increasing use of treatment teams that include psychiatrists, psychiatric nurse practitioners, physician assistants, psychologists, and social workers.
• Collaborative care models that involve the integration of mental health professionals into the offices of primary care providers.

Psychiatry Essential Reads

Is Rural Living Better for Mental Health?

The Origin of Community-Based Mental Health Treatment

Reflections on the Past 15 Years of Psychiatry

Over the past 15 years, much progress has been made in clinically relevant basic neuroscience research, especially involving neuroimaging and genetics, and in the development of new treatments and treatment delivery systems. Psychiatry has advanced from a specialty that was a distant cousin to other branches of medicine in the 1980s to a highly respected and critical branch of medicine. The field is now attracting some of the brightest clinically-oriented and research-oriented medical students, including those in combined M.D.-Ph.D. programs.

It is likely that we will continue to see major scientific and clinical advances addressing psychiatric disorders over the coming years, including new medications with unique mechanisms of action and computer- and internet-based forms of psychotherapy. While it is early in development, the advent of approaches based on artificial intelligence (AI) shows promise as well. These future advances can’t come soon enough for the substantial numbers of patients suffering from these serious and disabling disorders.