As research and volumetric imaging reveal a more detailed account of the causes of mental conditions, and digital diagnostic tools and interventions take over from pharmaceuticals, psychiatry will move back into the hospital.
Bioelectronics companies will replace pharmaceutical companies, as sensors, chips and telemetry data become essential to diagnosis, treatment and tracking patient data.
Rapid urbanization will spark a significant rise in a wide range of neuropsychiatric illnesses, including depression, anorexia, anxiety, post-traumatic stress disorder, psychosis and schizophrenia. All of these disorders have been linked to the stresses of living in megacities.
Children growing up in cities, for example, have twice the odds of developing schizophrenia in adulthood than children living in rural settings. By 2025 more than 60% of the world’s population will live in large, sprawling cities.
The biological and psychosocial triggers for this impact on mental health have yet to be fully identified.
Poverty, higher crime rates and lower social cohesion are likely factors. Urbanization and migration lead to the breakdown of families, kin networks and communities. That loss of social capital increases stress on individuals.
Although the rise in mental illnesses in urban environments likely has social causes, drug companies have been actively trying to convince foreign populations to adopt a Western “brain disease” narrative. To date, Western drug treatments, including antipsychotics and antidepressants, have become popular in cultures across industrialized Asia and Africa. The diagnosis of “depression” was rarely used in Japan, for instance, until drug companies effectively marketed antidepressants there in the early 1990s. Now the condition is commonplace.
The care provided for the mentally ill in the US is a disaster that shames our country.
—Dr. Allen Frances
Chair of the DSM-IV Task Force
The borders of mental illness categories are dynamic, culturally influenced and focus almost exclusively on groupings of symptoms.
In recent years, “not otherwise specified” has been used as often as any of the specific diagnostic categories of the Diagnostic and Statistical Manual for Mental Disorders (DSM).
Diagnostic categories are created by consensus but show high levels of comorbidities and common symptoms. For example, mood and anxiety disorders are themselves comorbid with substance abuse and personality and eating disorders.
This conceptual muddle argues strongly for a reclassification of mental illnesses based on causes, not symptoms.
Some research institutions have already abandoned the DSM—the “bible” of the mental health field—and have pioneered diagnostic systems based on measurable scientific indicators.
Machine learning algorithms will sift through mountains of data—from smartphones, metabolic biosensors, in-home sleep trackers, speech processors and body language monitors—to identify mental health “signatures”.
Within the next decade, mental diseases will be defined, diagnosed and treated by AI.
REINTEGRATION OF PSYCHIATRY INTO THE HOSPITAL
Successes in off-label use of implantable brain devices for sleep, arousal and attention will spur an elective brain enhancement industry. Robot-guided anesthesia, biological computer chips and AI-guided surgery will increase safety and cut surgical time drastically. Inevitably, these devices will be installed endoscopically, greatly enhancing their general adoption and elective appeal.
Advanced neuroimaging will become de facto in the diagnosis and treatment of many mental diseases, bringing psychiatric patients back into the hospital. Of course, someone will have to pay, given that NIMH data indicate that one in five Americans experiences a mental illness in a given year.
A dry central nervous system (CNS) drug pipeline and the hit-or-miss effectiveness of current CNS drugs will accelerate imaging-based drug efficacy studies. In combination with genomic data and stem cell–based in vitro drug screenings, these technologies will precede a revolution in personalized, patient-directed drug treatment. No longer will psychiatrists pull their first medications for a patient out of a hat. It might not even be psychiatrists doing the prescribing—psychiatry could become a radiological science.
A form of reinstitutionalization will become increasingly popular, modeled after addiction clinics. Private addiction centers available today will be bought up or expand into psychotic and depressive treatment centers, all of which offer short-term treatment and care. The balance between reinstitutionalization and personal autonomy will reemerge as a major social and political debate.
Psychiatrists remain the only medical specialists that rarely look at the organ they treat.
—Dr. Daniel Amen
Brain disorder specialist and director of the Amen Clinics
MENTAL HEALTH IS THE NEW DIABETES
Major neurodegenerative diseases and those often associated with aging will become “diabetes-like,” requiring a lifetime of early detection, care and intervention. At a point when options to intervene match disease detection (via genomics, behavior tracking, imaging and/or biopsy), those neurodegenerative diseases found to be largely preventable will create a new class of “previvor” patients—up to 25% of the US—that need chronic treatment on a recurring basis. Today’s companies focusing on “brain training” will pivot to absorb this massive source of revenue, and private clinics will pop up everywhere offering regular treatments.
Bioelectronic implants in the blood or CNS will monitor and one day intervene. As implanted, home and interventional sensors begin to allow homeostatic or metabolic feedback models for maintenance of many illnesses, “pacemakers” will find their way into the CNS.
Depending on the adoption rates of embryonic prescreening, genetic intervention or assisted reproduction, genomic risk factors and accelerants for many age-related diseases will be removed from the general population in only a few generations. Such genomic vaccinations will outpace research into a cure for such diseases. Alzheimer’s may never be cured, but simply removed from Western populations.
THE PSYCHOACTIVE COMEBACK
Today, drugs for mental disease are by and large variations of those deemed effective decades ago. These have failed to stem the rising tide of mental illness in the US. Succumbing to mounting social pressures, the FDA will reschedule the psychoactive components of many recreational drugs—MDMA, psilocybin, ketamine, ibogaine—and their derivatives.
Patentable derivatives will reawaken the dry CNS clinical pipeline and outmaneuver the social and legal complexities of adoption.
Recent data suggest that ketamine, given intravenously, might be the most important breakthrough in antidepressant treatment in decades.
—Dr. Tom Insel
Former head of the NIMH
One in three adults does not get enough sleep, despite its prominence in basic health. Apnea affects 18 million in the US, with a market of $4 billion per year in medical devices.
4% of US adults over age 20 use a prescription sleep aid.
It is thought that sleep disturbance is a core component in many psychotic and mood disorders, often exacerbating or causing some symptoms. As non-pharmacological sleep aid treatments become effective, diagnoses of sleep disorders will increase drastically. The major driver of bio-electronic, elective brain implants will be maintenance of sleep and wakefulness. The NIH will declare the 2020s the “Decade of Sleep.”
Smart mattresses will record sleep patterns, light, temperature and pressure to personalize sleep. A combination of AI and wearable sensors will allow for precisely timed waking during the optimal sleep phase.
Active brainwave monitoring in combination with basic brain implants will be able to prevent or interrupt the memory and subjective experience of nightmares, relieving sufferers of trauma-related mental disease.
On-demand therapy and cognitive training via smartphones, VR or tele- presence will replace all but acute crises in psychiatry.
“Nudging” apps will subtly prompt beneficial behavior, and stress-reduction algorithms in navigation systems will route drivers with hypertension or anxiety around high-traffic areas.