International Review of Psychiatry, August 2014; 26(4): 530–534
The crisis in psychiatry: A public health perspective LUCA PINGANI1, MARIO LUCIANO2, GAIA SAMPOGNA2, CORRADO DE ROSA2, FEDERICA PINNA3, UMBERTO VOLPE2, VALERIA DEL VECCHIO2 & ANDREA FIORILLO2 1Human
Resource Development, Local Health Agency, Reggio Emilia Italy, 2Department of Psychiatry, University of Naples SUN, Naples, Italy, and 3Department of Public Health, Clinical and Molecular Medicine-Section of Psychiatry, University of Cagliari, Sardinia, Italy
Abstract The role and responsibilities of psychiatry and psychiatrists have changed significantly in recent decades as a consequence of changes in society. The target of psychiatrists has moved from the treatment of specific mental disorders to the management of a wide range of psychological conditions. Following these changes, a public health approach has been claimed as necessary for psychiatric practice and research, given the current ongoing crisis in mental health. If we want to promote a public health approach, the following actions should be responsibly taken by modern mental health professionals: (1) the identification of causes of mental disorders, (2) the refinement of diagnoses, (3) the social inclusion of patients, (4) the involvement of users and carers in mental health research and practice, and (5) the improvement of psychiatric treatments and services. This crisis should represent a stimulus for all psychiatrists and a reconceptualization of psychiatry as public health is not in question.
Background Recent decades have brought significant changes in society, in different aspects such as ethics, politics, economics and communication (Fiorillo et al., 2013a). Following these, psychiatry has had to redefine its role and target (Maj, 2012). Under social pressures the role and responsibilities of psychiatry and psychiatrists moved from the treatment of mental disorders, a wide range of well-defined and clear nosological entities, to the management of a range of psychological conditions named ‘mental health problems’, which are not proper mental illnesses, but rather psychological consequences caused by the rapid changes in society, such as those following natural disasters (Christodoulou & Christodoulou, 2013; Ekanayake et al., 2013), the economic crisis (De Rosa et al., 2013; Heinz et al., 2013; Whalbeck & McDaid, 2012), and changes in the organization of modern society (Swendsen & Salamon, 2012; Bhugra et al., 2014). As society changes, psychiatrists need to adapt their target, since mental health problems are the results of different biological, social and psychological factors (Lopez-Ibor & Lopez-Ibor, 2013). If the primary outcome of psychiatry 20 years ago was the reduction of symptoms and the management
of people with mental disorders, recently it has shifted to the promotion of mental health and prevention of mental disorders (Clarke et al., 2007). The public mental health approach has become an important and significant branch of psychiatry as a consequence of the affirmation of the bio-psycho-social model and of the need to reduce the burden of mental disorders in terms of disabilities and of public resources devoted to mental healthcare (Forsman et al., in press). Several editorials and papers have discussed whether psychiatrists will be able in the future to define their own identity and to properly address the needs and values of their patients (Fiorillo et al., 2014). On these grounds, it has been argued that psychiatry is facing a ‘conceptual crisis’ (Brüne et al., 2012; Fava, 2006), both on a clinical and a research level. In this paper we will focus on the research challenges from a public health perspective, whose ultimate aim should be the improvement of patients’ care.
The factors behind the current crisis Several factors can be taken into account to explain the ongoing crisis in research in psychiatry. Among
Correspondence: Luca Pingani, Dr, PhD, Human resource Development, Local Health Agency Via Amendola, 2 42122, Reggio Emilia Italy. Tel: 0039 0522522077. E-mail: [email protected] (Received 3 June 2014 ; accepted 3 June 2014 ) ISSN 0954–0261 print/ISSN 1369–1627 online © 2014 Institute of Psychiatry DOI: 10.3109/09540261.2014.931838
The crisis in psychiatry: A public health perspective these, the paucity of resources is the key factor which has limited the promotion of research into mental health and well-being (Haro et al., 2014). In fact, despite the efforts of the European Commission through the publication of several documents such as the Green Paper (EC, 2005), the European Pact for Mental Health and Well-Being (EC, 2009) and the European Parliament Resolution on Mental Health (EC, 2010), mental health is still not considered a priority by stakeholders within the health sector, resulting in poor resources devoted to psychiatry (Fiorillo et al., 2013b). More resources could have the effect of fostering research into new and ambitious studies and, as a consequence, to ameliorate the quality of mental healthcare. Politicians, and all relevant stakeholders who have the role of defining priorities for national and international health systems, should know that mental disorders are among the most common, disabling and burdening diseases with high rates of morbidity and mortality (Jenkins, 2013). They need to be convinced that interventions we have for treating mental disorders are among the most effective in medicine (Leucht et al., 2012). Another important factor affecting research in public mental health is the limited coordination among different centres and different approaches (Haro et al., 2014). Research into brain disorders is less well funded and more fragmented than in other areas, both in the EU and the USA. This fragmentation has limited research on mental health promotion, and on prevention and early intervention of mental disorders, at a time when in the rest of medicine prevention nowadays represents the lodestone. One more factor affecting psychiatric patients and mental health professionals is stigma, which has determined – on a research level – the lack of population-based informative campaigns on the effects of stress, street drugs, social changes and misconducts on mental health and well-being of the population (Evans-Lacko et al., 2012). To have a clear picture of the state of the art of mental health research in Europe, in 2012 the European Commission funded the ROAMER project, aiming ‘to develop a comprehensive and integrated mental health research roadmap, orientated to translational research, sensitive to potential shifts in future needs in light of demographic changes, aligned with the policies of the Horizon 2020 programme, and addressing a pragmatic and integrated approach to the development of a pan-European strategy to matching mental health services to needs’ (Haro et al., 2014). Within this ambitious project an initial survey was carried out in all the 27 European countries, with the involvement of national associations of psychiatrists, other mental health professionals, and users and carers aiming to identify the research priorities in mental health. This study can
531
be considered one of the first attempts to overcome the crisis of research in mental health by collecting the opinions of stakeholders in planning the research agenda and by creating a network of research teams active at the European level in order to turn the light on mental health research (Evans-Lacko et al., 2014; Fiorillo et al., 2013b; Forsman et al., in press). Summarizing, the current crisis of research in public mental health is probably the consequence of stereotypes, and reflects the different models and theories behind mental disorders. Some actions should be responsibly and urgently taken by modern psychiatrists.
What are the causes of mental disorders? The progress of neurosciences over the past two decades has often led to the belief that clinical problems in psychiatry were likely to be ultimately solved by this approach. However, the biological approach has failed in identifying the neurobiological bases of mental disorders and in explaining the relationship between brain functioning and the pathophysiology of mental illnesses (Kleinman, 2012). Clear and unequivocal markers for severe mental disorders are missing, and biological findings are not robust enough to become test-worthy, with the consequence that the progresses of neurosciences are very far from having a practical impact on psychiatric practice (Bracken et al., 2012). Of course, we are not saying that the neuroscientific approach should be abandoned, but it should be complemented with the social and the psychological approaches. In fact, psychiatry, as a modern medical discipline, needs to adopt the same scientific methods for research and clinical practice of the other branches of medicine, but it has to consider that causes (and risks) of mental disorders may operate at many levels, including biological (i.e. genetic and neural) and psychosocial (i.e. family environment, social context and individual level) factors (Bolton, 2013). Whether psychiatric illnesses are ‘disorders of the brain’ alone is still an unsolved and debated issue (Maj, 2013a), which deserves much more exploration.
Are our diagnoses correct? The ongoing discussion about the international diagnostic systems does not help to shed the light, and, despite efforts provided by the task forces who worked on the new DSM-5, psychiatric categories do not seem to catch the heterogeneity of psychiatric disorders that remain without clear boundaries (Frances, 2013; Regier et al., 2013). The core of psychiatric diagnosis is still undergoing constant evolution. With the publication of the new edition of
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the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), diagnostic systems have been significantly transformed including, among others, new disorders, new specifiers and new subtypes (APA, 2013; Maj, 2013a). If, on one hand, this could be considered an advance in psychiatric nosology, on the other hand we are still far from precisely distinguishing between normality and psychopathology (Bolton, 2008). Moreover, the heterogeneity of clinical presentations of a given psychiatric disorder in terms of psychopathology, treatment response, needs for care, environmental context and biological correlates make it impossible in clinical practice to use the labels included in the classification system (Van Os et al., 2013). Currently, the diagnostic process cannot be satisfactory if only the operational criteria of the DSM-5 and the ICD-10 are considered. Individual clinical judgements still need to be part of the armamentarium of modern psychiatrists, provided that they have solid psychopathological bases (Spitzer, 1983). This is well exemplified by a note from the DSM-5 for major depressive episodes, which poses the emphasis on the importance of the clinical approach to mental disorders, thus reflecting the assumption that some aspects of mental disorders are not easily nor explicitly specifiable (Lewis & Williams, 1989). The criticisms of the current classification systems in mental health, which came from inside and outside the profession, do not give a positive public image of psychiatry. Clearly the evidence is not strong enough to define whether the diagnostic process should be guided by clinical judgement or by operational criteria, but for sure this should represent a stimulus for new research, in order to refine the validity and reliability of psychiatric diagnoses (Maj, 2013b). What do others think of us? There is no doubt that psychiatry and psychiatrists have a very bad public image (Ditchman et al., 2013). Stigma reduces patients’ opportunities for appropriate treatments, prevents recovery, and results in reduced opportunities for patients with mental disorders (i.e. working, living independently, developing relationships) in society (Angermayer & Schomerus, 2012). Stigma does not refer only to patients, but also to relatives and mental health professionals. Psychiatry has recently been accused of being a ‘pseudoscience’ that can destroy patients’ lives, and that psychotropic drugs have toxic and irreparable effects on the brain (Maj, 2013c). The negative image of psychiatry has a major consequence: the reduction of young doctors choosing psychiatry as a career (Riese et al., 2013). Psychiatry is not perceived as a medical discipline
among medical students, and generally speaking, our specialism is not considered as prestigious as other medical specialisms (Bhugra, 2013; Casini et al., 2013). This could probably be due to the perceived lack of intellectual challenges, doubts about the effectiveness of psychiatric treatments, and a perceived lack of a coherent theoretical basis (Fiorillo et al., 2013a). Researchers need to be aware that stigma is related to all mental health professionals and to psychiatry itself, and they need to find practical and new strategies to efficiently fight it. The promotion of the public image of psychiatry is one of the most important challenges psychiatrists will have to deal with in the near future if we want to overcome the current crisis (Corrigan & Angermeyer, 2012). The specific skills needed to effectively interact with families, administrators and journalists should become an essential part of the professional curricula of psychiatrists and other mental health professionals (Fiorillo et al., 2013a; Nawka et al., 2012).
Shall we involve users and carers in research in public mental health? Discontent towards our profession is increasingly reported by patients with mental disorders and their relatives (Trivedi & Wykes, 2002). Criticisms by our ‘clients’ (Katschnig, 2010) are mainly related to the quality of mental healthcare, to poor information received about their treatments and to the existing divergences between the goals of clinicians and those of users and carers (Oliver et al., 2004). In fact, while clinicians typically afford pride of place to symptom reduction, the primary interest of family members is in receiving information, support and services. Patients with mental health problems are concerned with issues of choice and control, and the importance of decent lives (Perkins, 2001). Therefore, practitioners’, service commissioners’ and service users’ views are progressively being considered in the process of developing public health recommendations and in research protocols (Renfrew et al., 2008). In fact, the direct involvement of different categories of stakeholders can lead to a ‘better’ quality of health research in terms of (1) a methodological and an ethical viewpoint, (2) findings which are more relevant to consumers’ and carers’ practical needs, and (3) a higher impact on public health policies and routine care (Oliver et al., 2004). More recently it has been proposed that ‘research agendas should reflect the needs and values of people who use and pay for health services, and this is unlikely to be achieved without directly involving some of these people’ (Oliver et al., 2004). Although users and carers from passive subjects are now con-
The crisis in psychiatry: A public health perspective sidered equal partners (Trivedi & Wykes, 2002), their involvement in research has happened so far only in a limited number of studies. There is the need to rethink research goals in psychiatry by involving the different categories of stakeholders from the early stages of the research processes, since research priorities are still not compliant with users’ and carers’ priorities and are very far from having a clinical utility (Bracken et al., 2012). Conclusions The issues discussed in this paper document that, following the social, economic and political changes of modern society, psychiatry is facing a critical period. Some urgent issues, such as the promotion of psychiatry, the identification of clear boundaries for mental disorders, and the involvement of users and carers in research activities, are no longer postponeable. However, we do not share the underlying pessimism of many authors on the crisis in psychiatry. We are strongly convinced that this crisis should represent a stimulus for all psychiatrists, but especially for the early career ones, and that a reconceptualization of psychiatry as a public health and as a medical discipline is not in question. This can be easily achieved but only if researchers start working together, sharing ideas and building up networks to create a common and positive vision of mental health. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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The crisis in psychiatry: A public health perspective LUCA PINGANI1, MARIO LUCIANO2, GAIA SAMPOGNA2, CORRADO DE ROSA2, FEDERICA PINNA3, UMBERTO VOLPE2, VALERIA DEL VECCHIO2 & ANDREA FIORILLO2 1Human
Resource Development, Local Health Agency, Reggio Emilia Italy, 2Department of Psychiatry, University of Naples SUN, Naples, Italy, and 3Department of Public Health, Clinical and Molecular Medicine-Section of Psychiatry, University of Cagliari, Sardinia, Italy
Abstract The role and responsibilities of psychiatry and psychiatrists have changed significantly in recent decades as a consequence of changes in society. The target of psychiatrists has moved from the treatment of specific mental disorders to the management of a wide range of psychological conditions. Following these changes, a public health approach has been claimed as necessary for psychiatric practice and research, given the current ongoing crisis in mental health. If we want to promote a public health approach, the following actions should be responsibly taken by modern mental health professionals: (1) the identification of causes of mental disorders, (2) the refinement of diagnoses, (3) the social inclusion of patients, (4) the involvement of users and carers in mental health research and practice, and (5) the improvement of psychiatric treatments and services. This crisis should represent a stimulus for all psychiatrists and a reconceptualization of psychiatry as public health is not in question.
Background Recent decades have brought significant changes in society, in different aspects such as ethics, politics, economics and communication (Fiorillo et al., 2013a). Following these, psychiatry has had to redefine its role and target (Maj, 2012). Under social pressures the role and responsibilities of psychiatry and psychiatrists moved from the treatment of mental disorders, a wide range of well-defined and clear nosological entities, to the management of a range of psychological conditions named ‘mental health problems’, which are not proper mental illnesses, but rather psychological consequences caused by the rapid changes in society, such as those following natural disasters (Christodoulou & Christodoulou, 2013; Ekanayake et al., 2013), the economic crisis (De Rosa et al., 2013; Heinz et al., 2013; Whalbeck & McDaid, 2012), and changes in the organization of modern society (Swendsen & Salamon, 2012; Bhugra et al., 2014). As society changes, psychiatrists need to adapt their target, since mental health problems are the results of different biological, social and psychological factors (Lopez-Ibor & Lopez-Ibor, 2013). If the primary outcome of psychiatry 20 years ago was the reduction of symptoms and the management
of people with mental disorders, recently it has shifted to the promotion of mental health and prevention of mental disorders (Clarke et al., 2007). The public mental health approach has become an important and significant branch of psychiatry as a consequence of the affirmation of the bio-psycho-social model and of the need to reduce the burden of mental disorders in terms of disabilities and of public resources devoted to mental healthcare (Forsman et al., in press). Several editorials and papers have discussed whether psychiatrists will be able in the future to define their own identity and to properly address the needs and values of their patients (Fiorillo et al., 2014). On these grounds, it has been argued that psychiatry is facing a ‘conceptual crisis’ (Brüne et al., 2012; Fava, 2006), both on a clinical and a research level. In this paper we will focus on the research challenges from a public health perspective, whose ultimate aim should be the improvement of patients’ care.
The factors behind the current crisis Several factors can be taken into account to explain the ongoing crisis in research in psychiatry. Among
Correspondence: Luca Pingani, Dr, PhD, Human resource Development, Local Health Agency Via Amendola, 2 42122, Reggio Emilia Italy. Tel: 0039 0522522077. E-mail: [email protected] (Received 3 June 2014 ; accepted 3 June 2014 ) ISSN 0954–0261 print/ISSN 1369–1627 online © 2014 Institute of Psychiatry DOI: 10.3109/09540261.2014.931838
The crisis in psychiatry: A public health perspective these, the paucity of resources is the key factor which has limited the promotion of research into mental health and well-being (Haro et al., 2014). In fact, despite the efforts of the European Commission through the publication of several documents such as the Green Paper (EC, 2005), the European Pact for Mental Health and Well-Being (EC, 2009) and the European Parliament Resolution on Mental Health (EC, 2010), mental health is still not considered a priority by stakeholders within the health sector, resulting in poor resources devoted to psychiatry (Fiorillo et al., 2013b). More resources could have the effect of fostering research into new and ambitious studies and, as a consequence, to ameliorate the quality of mental healthcare. Politicians, and all relevant stakeholders who have the role of defining priorities for national and international health systems, should know that mental disorders are among the most common, disabling and burdening diseases with high rates of morbidity and mortality (Jenkins, 2013). They need to be convinced that interventions we have for treating mental disorders are among the most effective in medicine (Leucht et al., 2012). Another important factor affecting research in public mental health is the limited coordination among different centres and different approaches (Haro et al., 2014). Research into brain disorders is less well funded and more fragmented than in other areas, both in the EU and the USA. This fragmentation has limited research on mental health promotion, and on prevention and early intervention of mental disorders, at a time when in the rest of medicine prevention nowadays represents the lodestone. One more factor affecting psychiatric patients and mental health professionals is stigma, which has determined – on a research level – the lack of population-based informative campaigns on the effects of stress, street drugs, social changes and misconducts on mental health and well-being of the population (Evans-Lacko et al., 2012). To have a clear picture of the state of the art of mental health research in Europe, in 2012 the European Commission funded the ROAMER project, aiming ‘to develop a comprehensive and integrated mental health research roadmap, orientated to translational research, sensitive to potential shifts in future needs in light of demographic changes, aligned with the policies of the Horizon 2020 programme, and addressing a pragmatic and integrated approach to the development of a pan-European strategy to matching mental health services to needs’ (Haro et al., 2014). Within this ambitious project an initial survey was carried out in all the 27 European countries, with the involvement of national associations of psychiatrists, other mental health professionals, and users and carers aiming to identify the research priorities in mental health. This study can
531
be considered one of the first attempts to overcome the crisis of research in mental health by collecting the opinions of stakeholders in planning the research agenda and by creating a network of research teams active at the European level in order to turn the light on mental health research (Evans-Lacko et al., 2014; Fiorillo et al., 2013b; Forsman et al., in press). Summarizing, the current crisis of research in public mental health is probably the consequence of stereotypes, and reflects the different models and theories behind mental disorders. Some actions should be responsibly and urgently taken by modern psychiatrists.
What are the causes of mental disorders? The progress of neurosciences over the past two decades has often led to the belief that clinical problems in psychiatry were likely to be ultimately solved by this approach. However, the biological approach has failed in identifying the neurobiological bases of mental disorders and in explaining the relationship between brain functioning and the pathophysiology of mental illnesses (Kleinman, 2012). Clear and unequivocal markers for severe mental disorders are missing, and biological findings are not robust enough to become test-worthy, with the consequence that the progresses of neurosciences are very far from having a practical impact on psychiatric practice (Bracken et al., 2012). Of course, we are not saying that the neuroscientific approach should be abandoned, but it should be complemented with the social and the psychological approaches. In fact, psychiatry, as a modern medical discipline, needs to adopt the same scientific methods for research and clinical practice of the other branches of medicine, but it has to consider that causes (and risks) of mental disorders may operate at many levels, including biological (i.e. genetic and neural) and psychosocial (i.e. family environment, social context and individual level) factors (Bolton, 2013). Whether psychiatric illnesses are ‘disorders of the brain’ alone is still an unsolved and debated issue (Maj, 2013a), which deserves much more exploration.
Are our diagnoses correct? The ongoing discussion about the international diagnostic systems does not help to shed the light, and, despite efforts provided by the task forces who worked on the new DSM-5, psychiatric categories do not seem to catch the heterogeneity of psychiatric disorders that remain without clear boundaries (Frances, 2013; Regier et al., 2013). The core of psychiatric diagnosis is still undergoing constant evolution. With the publication of the new edition of
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the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), diagnostic systems have been significantly transformed including, among others, new disorders, new specifiers and new subtypes (APA, 2013; Maj, 2013a). If, on one hand, this could be considered an advance in psychiatric nosology, on the other hand we are still far from precisely distinguishing between normality and psychopathology (Bolton, 2008). Moreover, the heterogeneity of clinical presentations of a given psychiatric disorder in terms of psychopathology, treatment response, needs for care, environmental context and biological correlates make it impossible in clinical practice to use the labels included in the classification system (Van Os et al., 2013). Currently, the diagnostic process cannot be satisfactory if only the operational criteria of the DSM-5 and the ICD-10 are considered. Individual clinical judgements still need to be part of the armamentarium of modern psychiatrists, provided that they have solid psychopathological bases (Spitzer, 1983). This is well exemplified by a note from the DSM-5 for major depressive episodes, which poses the emphasis on the importance of the clinical approach to mental disorders, thus reflecting the assumption that some aspects of mental disorders are not easily nor explicitly specifiable (Lewis & Williams, 1989). The criticisms of the current classification systems in mental health, which came from inside and outside the profession, do not give a positive public image of psychiatry. Clearly the evidence is not strong enough to define whether the diagnostic process should be guided by clinical judgement or by operational criteria, but for sure this should represent a stimulus for new research, in order to refine the validity and reliability of psychiatric diagnoses (Maj, 2013b). What do others think of us? There is no doubt that psychiatry and psychiatrists have a very bad public image (Ditchman et al., 2013). Stigma reduces patients’ opportunities for appropriate treatments, prevents recovery, and results in reduced opportunities for patients with mental disorders (i.e. working, living independently, developing relationships) in society (Angermayer & Schomerus, 2012). Stigma does not refer only to patients, but also to relatives and mental health professionals. Psychiatry has recently been accused of being a ‘pseudoscience’ that can destroy patients’ lives, and that psychotropic drugs have toxic and irreparable effects on the brain (Maj, 2013c). The negative image of psychiatry has a major consequence: the reduction of young doctors choosing psychiatry as a career (Riese et al., 2013). Psychiatry is not perceived as a medical discipline
among medical students, and generally speaking, our specialism is not considered as prestigious as other medical specialisms (Bhugra, 2013; Casini et al., 2013). This could probably be due to the perceived lack of intellectual challenges, doubts about the effectiveness of psychiatric treatments, and a perceived lack of a coherent theoretical basis (Fiorillo et al., 2013a). Researchers need to be aware that stigma is related to all mental health professionals and to psychiatry itself, and they need to find practical and new strategies to efficiently fight it. The promotion of the public image of psychiatry is one of the most important challenges psychiatrists will have to deal with in the near future if we want to overcome the current crisis (Corrigan & Angermeyer, 2012). The specific skills needed to effectively interact with families, administrators and journalists should become an essential part of the professional curricula of psychiatrists and other mental health professionals (Fiorillo et al., 2013a; Nawka et al., 2012).
Shall we involve users and carers in research in public mental health? Discontent towards our profession is increasingly reported by patients with mental disorders and their relatives (Trivedi & Wykes, 2002). Criticisms by our ‘clients’ (Katschnig, 2010) are mainly related to the quality of mental healthcare, to poor information received about their treatments and to the existing divergences between the goals of clinicians and those of users and carers (Oliver et al., 2004). In fact, while clinicians typically afford pride of place to symptom reduction, the primary interest of family members is in receiving information, support and services. Patients with mental health problems are concerned with issues of choice and control, and the importance of decent lives (Perkins, 2001). Therefore, practitioners’, service commissioners’ and service users’ views are progressively being considered in the process of developing public health recommendations and in research protocols (Renfrew et al., 2008). In fact, the direct involvement of different categories of stakeholders can lead to a ‘better’ quality of health research in terms of (1) a methodological and an ethical viewpoint, (2) findings which are more relevant to consumers’ and carers’ practical needs, and (3) a higher impact on public health policies and routine care (Oliver et al., 2004). More recently it has been proposed that ‘research agendas should reflect the needs and values of people who use and pay for health services, and this is unlikely to be achieved without directly involving some of these people’ (Oliver et al., 2004). Although users and carers from passive subjects are now con-
The crisis in psychiatry: A public health perspective sidered equal partners (Trivedi & Wykes, 2002), their involvement in research has happened so far only in a limited number of studies. There is the need to rethink research goals in psychiatry by involving the different categories of stakeholders from the early stages of the research processes, since research priorities are still not compliant with users’ and carers’ priorities and are very far from having a clinical utility (Bracken et al., 2012). Conclusions The issues discussed in this paper document that, following the social, economic and political changes of modern society, psychiatry is facing a critical period. Some urgent issues, such as the promotion of psychiatry, the identification of clear boundaries for mental disorders, and the involvement of users and carers in research activities, are no longer postponeable. However, we do not share the underlying pessimism of many authors on the crisis in psychiatry. We are strongly convinced that this crisis should represent a stimulus for all psychiatrists, but especially for the early career ones, and that a reconceptualization of psychiatry as a public health and as a medical discipline is not in question. This can be easily achieved but only if researchers start working together, sharing ideas and building up networks to create a common and positive vision of mental health. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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