INTRODUCTION
The border which faces all the onslaughts and still marches further forward is the frontier. We are referring here to the frontier of knowledge which makes excursions into the domain of the unknown and wins it over step by step through persistence and perseveration. This is what we call “advancement.” The realm of the unknown is presumably much larger and undefined compared to what is known to us. The unknown contains within itself the precious “secrets” of all-powerful Nature in a variably encrypted and selectively accessible format which is revealed to us in unpredictably incremental fashion through the valor of committed and dedicated pursuit. It is the tenacious human curiosity, combined with creativity that leads to discovery of unknown treasures in the form of revelations of secrets and new laws of the Nature. Within our own lifetime, we have seen the march of science in several areas of life. Mass media has moved from big box-like radios to televisions to palm-sized smartphones which have evolved to become an obligate all-in-one constant companion; it has made redundant many technological marvels of the yesteryears in one stroke. It has become an indispensable, ever-ready, ever accessible supplement to our mental faculties. If we were to stretch the imagination a little farther on the same timescale, may be a time will come when we will have gadgets for revisiting the past or foreseeing the future. It might appear a bit quixotic today but given the fact that the rate of change currently, in the area of science, is multiplying in geometric proportions, it may not be surprising to find that a wild imagination of today becomes a reality of tomorrow. Who would have imagined about a century ago that nearly 4.6 billion passengers would have flown across the skies of the world in 2019 alone in a flawless and increasingly more comfortable manner. We have now entered into the 21st Century, also known as the information age. In this information age, the models and paradigms of intervention for mental maladies have also been multiplying very fast. But unfortunately, the mainstream psychiatry keeps confined itself to only a few easily accessible and easily dispensable modes of intervention, ruled predominantly by prescription of pills. Prescribing a pill is the easiest intervention to deliver; therefore, if prescribed judiciously it can be cater to a larger population in a cost-effective manner. From this point 2of view, the overshadowing of other modes of therapeutic interventions by greater reliance on drugs may appear justified. But drugs alone have great limitations. They are highly inadequate when compared to the complexity and multiplicity of multi-level factors involved in causation and correction of mental derangements, deviations, and disorders that we come across in real life. We have to think and explore “out of the box” to devise innovative strategies to match the enormousness of this difficult task. We as mental health professionals must inculcate an eclectic approach and bring to the doorsteps of each suffering individual all possible ways of healing methods in a convergent manner. With this goal in mind, it was decided to pool together the talent of Indian Psychiatric Fraternity to overview most of the possible therapeutic strategies which are currently being given shape at the cutting edge of advancing frontiers of psychiatric therapeutics. The advancements are always made at the frontiers which are multifaceted, multidimensional, and generally interconnected.
Healing the hurt, at all levels of life, be it personal or social, somatic or psychic, spiritual or mundane, is the first duty of all practitioners of science of health. Health delivery is the executive arm of all Health Sciences. The art of practice of health delivery is to deploy the power of knowledge, be it scientific or experiential, in a most befitting manner to cater to the uniqueness of the individual, his milieu, and the disorder he is suffering from. It has to be used in a most effective and innovative manner so as to minimize any harm while at the same time ensuring maximal recovery from the disorderliness to reduce distress and dysfunction. Healing professionals work at the interface of Science and Society. They have the never ending duty to heal. It is from this social endpoint that all academics and therapeutic research derive their meaningfulness. From this viewpoint, it is imperative that all health practitioners keep themselves updated about all the latest and cutting edge principles, concepts, and technologies so that they are maximally enabled and empowered to function as an effective healer. In fact, the healing hand may be viewed as the adaptive loop of human race to maximize its survival potential. This therapeutic loop, which is the corrective loop for constantly unleashing disorderliness, will determine not only the survival but also the quality of life of individual human beings.
It was with this outlook that the theme of this issue of “Different Strokes” was chosen as “Advancing Frontiers of Psychiatric Therapeutics.” There are 20 additional chapters in this booklet, which cover a very wide range of intervention strategies. It ranges from Spirituality to Psychosurgery, from the most esoteric to the most mundane of all therapeutic strategies.
THE ANCIENT TIMES
Historically, there always has been need and also attempts at modifying the behavior of people who exhibit altered, abnormal, and/or dangerous 3behavior through various means called therapy. The nature of intervention depended on the understanding and convictions of that period about the cause of such alterations. Such convictions have gradually changed and/or evolved over period of time. The earliest has been the belief that mental disorders are caused by supernatural forces in the form of being possessed by devils or demons. The belief in demoniac possession as a cause of mental illness led to two different kinds of reactions with the aim to either protect the individual from being possessed or getting the individual freed from possession. The corrective measures ranged from exorcism or trephining of skull to relieve the person from possession by spirit in some societies, to the other extreme of maintaining such piety so that these devils cannot take hold of the individual. Maintenance of personal purity was done by the ancient Persians, who took to precautionary measures in the form of ensuring purity of mind and body to pre-empt and reduce the chances of being possessed and thus keep oneself protected from mental illness.
The evidences obtained from the remnants of trephined skulls from a period dating back to 5000 bc, point toward the antiquity of this practice. It appears very barbaric from the perspectives of modern times. But paradoxically and most surprisingly, even today we drill holes in human skull to put in place slender wires of metal for a modern intervention, called brain stimulation therapy, albeit in a very sophisticated manner, vindicating though the aphorism that life moves in a circle. We also have a chapter on “Brain Stimulation Therapies” in this book.
Bleeding, purging, and vomiting to undo the bodily humoral imbalance, malaria therapy, metrazol therapy, hydrotherapy, insulin coma therapy, and frontal lobotomies have had their own hey days of being on the high, to the extent that some of them also having been recognized with the award of prestigious and coveted Nobel prize. Some of the other irrational therapies of yesteryears include blistering, dousing patients with boiling or ice-cold water, using physical restraints such as straitjackets or simply using sedatives to keep the patients sedated for long periods of time. Use of religious rituals and use of amulets and talisman are still quite prevalent. In many of the private madhouses run by clergymen in the west of those days, certain religious practices that were used for such patients included attending Churches, going on pilgrimages, engaging in confessions of sins, and undertaking repentance.
Only electroconvulsive therapy of that period, used to induce controlled seizure for therapeutic purposes, has survived because of its proven and rapid efficacy in certain severe mental conditions with high margin of safety. Even though this method has also undergone substantial modification and further technological sophistication, in keeping with the times, it has increasingly been brought under societal and legislative controls in different parts of the world. This is only reflective of the highly enigmatic, multifactorial and multifaceted nature of the mental disorders and the different aspects of life it interfaces with.4
Egyptians have been recorded to advise recreational activities to help recovery from symptoms of mental illness. This is indicative of a very enlightened view that they held at that time, even though it must have been quite inadequate for inducing recovery from the different states of mental disorders.
Hippocrates probably was the first to suggest in 3rd–5th century bc that mental illnesses are because of natural occurrences in the body and not because of supernatural forces, wrath or curse of divine bodies, or possession by evil spirits. He suggested that it was because of the imbalances between four humors of the body. The methods of correction of these imbalances, such as bloodletting, purging, and vomiting, suggested in those days would not be acceptable today. However, Hippocrates had also suggested change of occupation and/or environment as a method of remedy for mental patients, which is quite consistent with current views and understanding of mental illnesses.
Mental illnesses were also thought to be a consequence of immoral behavior or sin having been committed by the individual or their family members. Mentally sick people were treated as less than human entities, at times like animal. In fact, at different times, they were subjected to sterilization and other forms of genital restrictions. The conditions of asylums and madhouses have been described as pathetic throughout history. A major turning point in the history of care of mentally ill has been the refreshingly reformist “Humanitarian Movement” ushered in by Philippe Pinel and William Tuke in France. They thought and practiced that mentally ill patients would improve if they were treated with “kindness and care” and “respect and compassion.” This was to take them out of the neglectful, abusive, demeaning, and filthy environment of the yesteryears. It did have a positive impact in the lives of the mentally ill inmates; it also had a positive impact in the functioning of the asylums throughout the world and also on the coming generations.
After this, came the hospital movement in the 18th century with the stated objective of “protecting society and individual from harm, to cure those amenable to treatment, to improve the lives of the incurable, and to fulfill the humanitarian duty of caring for the insane.”
THE MODERN TIMES
At the turn of the century came Dr Sigmund Freud, the Father of Psychoanalysis. With his lucid and coherent formulations of the structure of mind and psychodynamic causes of psychopathologies, he changed the mindset of professionals of the whole world that led to the wide acceptance of a completely new paradigm of intervention. It also had a deep impact on the literature as well as the general mindset of people of that time. Psychodynamic psychotherapy spread far and wide as one of the mainstream modes of 5intervention for mental illnesses, especially for the nonpsychotic ones. However, because of its highly subjective, conjectural, and nonverifiable nature of theories along with a very prolonged format of patient–therapist interaction requiring a highly skilled and trained therapist who are now not only very few but are also dwindling in number. The psychoanalysis later found itself on a weaker footing in face of strongly emerging bold and confident psychopharmacology. However, cognitive behavior therapy, more popularly known as CBT, has emerged to acquire the center stage of psychotherapeutic interventions. It focuses on the relationship between thoughts and emotions at the conscious level, analyzes their distortions, and suggests methods of correction.
With the introduction of chlorpromazine in early 50s and antidepressants in late 50s, the fate of mentally sick people took a quantum leap for the better. The speed and magnitude of predictable symptomatic improvement in psychotic and depressed patients was phenomenal. These drugs brought a sea change in their lives. Never before had such a thing happened that mentally ill patients could return back to their previous level of life in a predictable manner, very much like patients suffering from other medical illnesses. Based on these observations of clinical improvements with certain psychotropic drugs, many possible theories about their etiology, especially at the neurobiological levels, emerged in a retrograde fashion based on the putative mechanisms of actions of these drugs. Such theories are still being explored further. This definitely was a step forward but it seems to have very quickly led to a plateau. It is not showing up or leading to any newer doorsteps to either recovery or newer theories. Apart from the issues of short-term and long-term side effects, the efficacy rate and profile of effectiveness of even newer psychotropics are not showing any advancement. Their advancing edge needs to be emboldened further.
Stuck with a block on the traditional path, newer options for therapy are being explored at all possible levels, the physical, the psychic, and the spiritual levels. We have tried to include representative areas from each of them in this book. With the advancement in technologies, many hitherto unimagined and unthought of options for interventions have emerged and are being explored and experimented upon.
Mankind has now been able to fully analyze its own genome. Armed with the power of this knowledge, its applied potentials are also being examined with reference to mental health needs. One possible application of this knowledge is in the domain of developing personalized medicine as applicable to psychiatry in the form of pharmacogenomics which will allow pharmacotherapy to be tailored to the needs, uniqueness, and idiosyncracies of the individual. Further advancements in genetic technologies have made possible the power to edit the genes. With increasing understanding of the relationship between genes, endophenotypes, and the phenotype–behavior, 6it is possible that in near future we may have gene therapy as one of the established modes of psychiatric therapeutics. Another area full of potentials is the use of pluripotent cells in refreshing and replenishing the old and the crooked cells and tissues by way of stem cell therapy. Gut has been described as the second brain and increasingly the communications between the two for maintenance of mental health and execution of mental operations are being deciphered. This knowledge is being used as Psychobiotic Therapy for mental health.
Human intelligence is proving to be inadequate to meet mankind's own dreamy and imaginative aspirations. Human intelligence is being assisted in all walks of life by the artificial intelligence, at times threatening to overtake it. It is getting supplemented, assisted, and augmented by gadgets of artificial intelligence which of course is man's own creation. Artificial intelligence has spread its wings in many areas of life, predominantly in hospitality, in commerce, transport, defense and also very substantially in the area of medical investigation and intervention. Its use in mental health cannot be left behind. Already we have online psychotherapies and Avatar therapy. The full potential and role of this augmented power in psychiatric therapeutics will continue to remain an active area of professional and scientific explorations.
Further advancements of scientific technologies have empowered and also emboldened scientific researchers and practicing professionals to foray into hitherto unchartered caves, crevices, land and islands of mental health therapeutics. Lately, the technology of functional brain scans has opened a completely new window to the understanding of the functions of brain. The functional magnetic resonance imaging (fMRI) of brain taken after activating it with specific mental tasks or with experience of specific emotional states, are presenting very interesting pictures. In fact, there are scientists who claim that they can decipher from the brain scans as to what emotional state the individual is experiencing or what number he is holding in his mind. These claims are very interesting and are at the verge of immeasurable possibilities of futuristic nature. But how far this tech-toy will take us in our quest of trying to understand the true nature of mind and mental disorders, remains an unanswered question. One is reminded here of the hope and hype that was generated at the time of discovery of X-rays or invention of electroencephalography (EEG). In their euphoria at the time of their discovery, people thought that it will now lead to uncovering of all the mysteries of medical science. With the passage of time, we have now fully realized the stark limitations of both these technologies as regards their potential in providing answers to the perpetual questions relating to the mental dimension.
The preferred place and physical setting for treatment of mental disorders as well as goals of such treatments, have also undergone fundamental changes. It has moved from lunatic asylums to mental hospitals to institutes 7of mental health to the community; similarly the goals of treatment have also evolved from the initial position of providing protection to the society from the mentally insane to providing cure with recovery and rehabilitation back in the community, to realizing one's own full potential. The mental health scenario of today is completely different from that of yesteryears and is likely to get transformed for the better in future.
CONCLUSION
The area of mental health is going to increasingly acquire more and more importance and significance. In the information age, the psychological sophistication of people is bound to increase. People are likely to focus and seek more and more help for promotion and maintenance of their mental health. Even otherwise mental health is a very important determinant of all other dimensions of health. It is quite natural that all different, multilateral, and innovative approaches be brought together in a convergent manner for the rescue, restoration, and rejuvenation of mental health of the masses. Given the current level of ignorance about the nature, affiliations and dimensions of mind, we will have to try all possible weapons and strategies in our store to eventually win the race to provide foolproof shield and immunity to everyone's mental health.
SUGGESTED READING
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- Jutras M. Historical perspectives on the theories, diagnosis, and treatment of mental illness. BCMJ 2017;59(2):86–8.
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