1 I would like to thank La Société de L’Information Psychiatrique for the opportunity to address you here today.

2 Recently, I have been reading the Ron Chernow biography of Alexander Hamilton from which the Broadway musical theatre production was adapted. Hamilton was among the most gifted – along with Jefferson who served as the first US Ambassador to France – of the founding fathers, and was the first Secretary of the Treasury. No gold – no country. What you may be less aware of, is that he was fluent in French. His mother, who was of French ancestry, schooled him from an early age in French language and culture. So, it was inevitable I suppose, that when he served as General Washington's aide de camp during the revolution, he was among the key liaisons with the Marquis de Lafayette and the French forces, which helped Les Étas-Unis achieve its independence from British rule [1].

3 Now it may not be apparent to you the special place that France plays in the American psyche, but it does – and it is much more and much deeper than Humphrey Bogart singing La Marseillaise in the movie Casablanca – as powerful as that was. When the events which have so shaken France and of course our host country Belgium occurred, they had a profound impact on American feelings and sensibility. In particular, the attacks in Paris roused deep feelings of camaraderie and connection. The number of people changing their photos on Facebook to include the Tricolore was extraordinary and I believe this depth of reaction is due to the special place that France holds for us for many reasons, but of course your presence with us when our future as a free and egalitarian state was very very uncertain. And it is the very idea of France and its core principles of Liberté, Fraternité and Égalité, which being so close to core American values that affect us deeply.

Transformative forces

4I want to sketch out for you today some of what I believe are the overarching forces affecting psychiatry and the impact that at least some of these may have on our field both in the US, perhaps here, and potentially globally. And I then want to focus on two areas for more intensive discussion.

5 The first of the transformative forces is science and in particular neuroscience and genetics research. We know that our understanding of the brain and especially its circuitry, neurochemistry, and our ability to visualize these in vivo and in real time, has been, until recently, quite limited. While structural and destructive lesions have both taught us something about the assumed localization of mental functions, these are limited tools affecting only some disorders. The development of new technology and methods has – as it always has in the history of science – opened new perceptions and understanding. These techniques are as varied as using stem cell technology to create human neuronal circuits in vitro[2], optogenetics which allows more precise targeting of animal circuits, and neuroimaging techniques which when bound with cognitive neuroscience tests, may open more real time views of both how our brains operate in certain laboratory conditions. Finally, the development of genome-wide association studies has recently led to a set of hypotheses about schizophrenia which brings together important observations regarding age of onset, pruning, immune system, and complement function [3]. There are many others. None of these findings change, per se, the personal experience of these disorders, nor have they yet translated into new treatments. But these are important steps which will, because of these techniques, increase in their power over time. Many of these studies can only be performed by relying upon models in cognitive neuroscience. Ultimately a more complete understanding of these conditions should answer questions regarding their onset and relationship to discrete life and biological events, and will require a more comprehensive model of mental functioning and its relationship to presumed mechanisms of central nervous system functioning, whether circuitry, structurally, or pharmacologically based.

6 As much as we may learn about the causes and mechanisms of psychiatric illness, these are and will remain among the most personal and intimate of human conditions. The subjective experience of these conditions, the self judgments or criticisms we may have because of them, will likely always make the boundary between internal experience and externally derived models of illness one of importance and some tension for us and our patients.

7 A related area is the growth of technology in a more computational and internet based forms. Digital communication and sensors may yet generate new means to assess, deliver, and monitor care in many areas of clinical medicine. In particular, some of these if truly tested against existing definitions of illness and found to be reliable or useful, may be of benefit in how we monitor illness and where there is a substantial shortage of trained caregivers, provide some digitally based care, support, or treatment. These, and related efforts in artificial intelligence, machine learning, and so-called big data, also raise substantial privacy and other concerns, especially in an area of clinical medicine where prejudice is so common. And they may yet prove to be of benefit in other ways. It is simply far too early to know, but again we know that as technology changes, it has an impact on many ways we organize activity in many areas of daily life.

Social justice, equity and investment

8Another area for consideration is that of justice and equity for those who suffer from various mental illnesses. While the level of investment in mental health care varies greatly across more and less developed countries, as a general rule those with mental health disorders, and especially the most severe of these illnesses, are particularly short changed. In my own country, where we have record levels of incarceration, a great many of these individuals are in jail rather than in care. Decisions to close hospitals – particularly public hospitals – while motivated in part by concern for liberty, freedom, and community-based care, have also been cynically used to cut budgets for the care of a not popular group of individuals – a group who has few marching for them and perhaps even fewer voting. In many places increased insurance funding for mental health, a social justice and equity issue, has been promised as have parity with general health care, yet results are currently far short of what is required.

9 As I will discuss in greater details below, it is essential that policy makers at the international level as well, support the need for investment and performance guideposts in developing as well as developed countries. As such, the successful inclusion of mental health goals within the context of the UN sustainable development goals was of potentially significant importance and required collective effort on the part of the global psychiatric community among others [4].

10 As a corollary to the efforts in regard to justice and equity, are ones which fall under the term stigma. A more social, public – and I think this is critical for our thinking about this – a more internal view of mental disorders is essential. In the experience of stigma those with these conditions are set aside, marked, and placed outside of a certain boundary. Indeed, the term stigma itself derives from the Greek and Latin for mark and in English is defined as a mark of disgrace and en français is stigmate or marque d’infamie. The struggle over this more pervasive and pernicious form of social discrimination is also ongoing, and reflects for many patients as well as their doctors an internal form of self-criticism as well. Efforts to deal with this have included public campaigns, social media efforts and self-disclosure by those who are or have been ill, and attempts to develop more precise language for mental disorders among other measures. We also need, I think, to be careful to not be over expansive in our definitions of what constitutes a mental illness. While the boundaries of many illnesses are uncertain, there are many forms of real suffering which can also be understood as due to social, political, or existential causes. So caution and humility are also called for.

11From a different perspective, those with severe mental disorders are at times significantly, if temporarily, behaviorally disturbed by their illnesses. In all countries of which I am aware, persons with severe illness may have to be deprived of their general liberty to safeguard their lives or the lives of others. For psychiatrists, these unique roles as gatekeepers and potential guardians of those so affected, affects many of us who deal with these conditions or who have to assume these roles at the interface with the legal system. Because of this, psychiatrists may become targets of those we attempt to help, and may at times be at risk for losing our medical roles. These quasi-legal and police roles may be part of what stimulates, along with internal stigma, that is sometimes referred to as anti-psychiatry movements.

Medical-psychiatric co-morbidity and global mental health

12As I mentioned in the beginning there are two other issues which I would like to highlight in some greater detail. The first is the impact of psychiatric illness on illness burden and mortality – burden associated with medical psychiatric co-morbidity and shortened life expectancy. The second is the foreseeable consequences for global health and mental health, including the challenge of health care costs and investment in mental health care.

13 It is now widely established that medical-psychiatric co-morbidity is a significant problem for patients with psychiatric illness (including substance use). This includes high levels of medical illness in those with primary psychiatric illness and vice versa[5], and a recognition that years of life, lost to disability are significantly impacted by psychiatric disorders. Indeed, it is fair to say that psychiatric disorders are the preeminent illnesses of adolescence and early adulthood [6, 7]. This pattern is seen in developed countries such as the US and France, where the burden of infectious and water-borne diseases are a smaller percentage of the overall illness burden. In addition, there is widespread evidence of early mortality associated with psychiatric illness with two thirds of the premature loss of life due to general medical illnesses [8, 9], as well as an increased rate of general medical hospitalization for those with psychiatric illness [10, 11]. This increase in medically related hospital-based care is associated with substantially increased costs for total medical care for those with mental illnesses [9, 12, 13]. This suggests that an integrated whole health approach is essential for these patients, and also because much of their psychiatric care occurs in the general medical sector [14, 15].

14 When we turn to the issues of global mental health these challenges increase. While the burden of non-communicable diseases is not as high in the developing world, as countries develop, infectious diseases begin to decline and the relative burden of non-communicable disease and especially mental health conditions increases [7, 16]. These non-communicable disease costs led by mental health and cardiovascular diseases will increase significantly globally over the next 20 years. When combined with the limited physician and especially psychiatric workforce in these countries, the need for an integrated care approach to mental health including use of community health workers in the general health care environment becomes essential.

Conclusion

15In conclusion, let me thank you again for your time and attention. We are in what certainly may seem to us an extraordinary period in the history of psychiatry as techniques and technology allow for a more direct and complex evaluation of the brain in disease and health. Journeys like this one which involve so many different aspects of science, psychology, justice, and public policy rarely play out quickly, but I remain convinced that we have the opportunity to bequeath a better and healthier world, one which reduces the suffering of so many. We would also, as we undergo this change, be wise to heed the guidance of the great French neurologist Jean-Martin Charcot. Charcot as you know was Freud's teacher when he studied early in his career at the Salpêtrière.

16 Freud was fond of citing an aphorism of Charcot's which may also allow us to maintain some perspective and avoid being caught up in the enthusiasm of our times. “La theorie c’est bon, mais ca n’empeche pas d’exister” - Theory is good but it doesn’t prevent the existence of reality. Thank you very much.

Conflict of interest

17The author receive personal fees from CME Outfitters, Pharmasquire, and universities and associations for non-promotional speaking; royalties from Harvard University Press, Springer, and American Psychiatric Press; and consulting fees from Owl, Inc. and Quartet Health, Inc.: all outside the submitted work.