Future modern psychiatry

Expectations and the Future of Psychiatric Treatment

In order to meaningfully discuss expectations related to psychiatric treatment, it is first necessary to briefly describe a patient’s current clinical condition. For clarity, we will focus on three major psychiatric disorders: depression, schizophrenia, and Alzheimer’s dementia.

Depression

The treatment of depression is most often long-term and chronic, typically extending over many years and frequently associated with adverse effects.

The most commonly used medications include:

SSRIs
SNRIs
tricyclic and tetracyclic antidepressants

In clinical practice, patients are often treated for several to more than ten years.

Schizophrenia

In schizophrenia, treatment traditionally involves:

first-generation antipsychotics, associated with significant side effects
second-generation antipsychotics, which are generally better tolerated
third-generation antipsychotics, which allow, in some patients, functional remission with minimal adverse effects

In reality, schizophrenia is usually treated lifelong.

Dementia and Alzheimer’s Disease

Another major group of disorders are dementias, most commonly Alzheimer’s disease.

In dementias caused by reversible factors — for example:

vitamin B12 deficiency
certain metabolic causes

— cognitive impairment may be reversible.

In selected neurodegenerative conditions such as prion-related dementias, targeted antibody therapies have demonstrated the ability to reverse pathological processes.

But what about Alzheimer’s disease?

Currently, treatment relies mainly on two groups of medications:

acetylcholinesterase inhibitors
memantine, a non-competitive NMDA receptor antagonist

The limitation of these therapies is that after one to two years their effectiveness often diminishes, while the disease continues to progress.

The Future of Psychopharmacology

What, then, are the prospects for future psychiatric treatment?

Imagine a patient with severe, long-standing, treatment-resistant depression, unresponsive to most available medications.

Novel investigational substances are currently being tested that, in many cases, are capable of terminating depressive symptoms within two hours. Patients experience:

rapid mood improvement
disappearance of suicidal thoughts
improved energy and concentration

Do such medications already exist?

Yes. The first such drug currently available is esketamine, which rapidly improves mood and reduces suicidal ideation. However, repeated administration is required.

Ongoing research focuses on substances capable of inducing long-lasting synaptic reconfiguration, making repeated dosing unnecessary by restoring patients to functional baseline.

In the future, the treatment of chronic depression may become faster than treating a common cold, lasting no more than two hours.

Schizophrenia – New Therapeutic Directions

Historically, schizophrenia treatment has focused primarily on postsynaptic receptor modulation, particularly dopamine and serotonin antagonism. This approach has often resulted in adverse effects leading to poor adherence.

Newer antipsychotics, including partial agonists, aim to minimize these side effects.

But what if dopamine release could be regulated precisely — releasing exactly the amount required at the synapse?

New investigational compounds target:

presynaptic systems
extracellular and intracellular receptors

These agents modulate dopamine availability within the synaptic cleft rather than simply blocking receptors.

Observed effects include:

resolution of hallucinations and delusions
improved social engagement
increased emotional openness
better integration with the environment

This treatment will likely remain long-term, but with minimal adverse effects and the possibility of full functional remission.

Alzheimer’s Disease – Emerging Hope

Alzheimer’s disease is characterized by the accumulation of amyloid plaques.

Early attempts to modify the genotype responsible for amyloid protein production were abandoned due to significant adverse effects.

Current research focuses on compounds that:

prevent amyloid aggregation into plaques
facilitate effective clearance of individual amyloid proteins by astrocytes
improve memory through muscarinic agonist mechanisms

Preliminary results from several investigational substances are promising.

A Broader Perspective

The results of ongoing clinical research provide hope that future psychiatric treatment will become:

significantly more effective
far less burdensome for patients

Psychopharmacology is evolving not only toward remission, but toward the possibility of complete recovery, something already observed in selected patients participating in clinical trials.

At the same time, increasing levels of:

chronic stress
aggression and hostility
poor diet
environmental pollution
digital and social overload

are likely to contribute to a rising prevalence of mental disorders.

Fortunately, mental illness is gradually losing its status as a social taboo. Increasingly, it is treated like any other medical condition — one that can and should be treated.

The challenge now is to ensure that treatment can be delivered effectively and without unnecessary stigma.

Concepts of Schizophrenia Treatment

Everyone has heard the term schizophrenia. Around this disorder, numerous myths and misunderstandings have accumulated over the centuries. Since ancient times, people experiencing psychotic disorders were treated either as madmen—excluded from society—or as saints—also excluded from society, albeit for different reasons.

Attempts to treat schizophrenia date back to the Middle Ages, when various methods were employed in an effort to restore individuals to “normality.” A wide range of therapeutic approaches were used, among which physical punishment and torture were disturbingly popular—the more elaborate, the better.

Until relatively recently, treatment through forced labour was also common. Even toward the end of the twentieth century, agricultural hospital facilities were still being closed.

The Evolution of Schizophrenia Concepts

With the development of scientific research methods, new concepts of schizophrenia began to emerge.

These ranged from the theory of the “schizophrenogenic mother”—which unjustly blamed mothers for their children’s illness—through psychoanalytic interpretations, to environmental, stress-related, viral, genetic, and immunological theories.

There are dozens of conceptual models of schizophrenia.

Fortunately, it became evident that schizophrenia is a disorder that can be treated by means other than branding with hot iron or exorcisms.

What Is Schizophrenia?

The challenge of defining schizophrenia was aptly described by Professor Henry A. Nasrallah, who compared it to scientists describing an elephant while blindfolded.

One researcher touches the tail and concludes the elephant is a rope.
Another touches the trunk and believes it is a pipe.
A third touches the side and declares it a wall.

Similarly, schizophrenia is a complex phenomenon perceived differently depending on the angle of observation.

Schizophrenia is currently understood as a neurodevelopmental disorder, in which pathological symptoms emerge over time.

If left untreated, it may lead to early-onset dementia, as Emil Kraepelin accurately described when he coined the term dementia praecox.

Advances in Understanding

Today, we are increasingly closer to understanding schizophrenia as a biological and neurofunctional disorder.

We can identify:

structural and functional brain changes
alterations at the neuronal level
abnormalities in receptors and neurotransmitter systems

We now know that neurons in schizophrenia function differently:

they produce altered amounts of neurotransmitters
receptor activity is dysregulated

Traditional Treatment Approaches

Historically, treatment focused on:

blocking postsynaptic receptors
modulating presynaptic mechanisms

However, neurons are not passive. When postsynaptic receptors are blocked, neurons compensate by producing additional receptors, which leads to adverse effects such as:

akathisia
tremors
hyperprolactinaemia

As a result, many patients developed strong resistance to first-generation antipsychotics.

Classic drugs such as chlorpromazine, fluphenazine, and promazine were associated with significant side effects. One notable exception was clozapine, which demonstrated a unique ability to induce remission. Its effect was long attributed to its broad receptor-binding profile.

Today we know that this unique effect is largely due to its influence on intracellular TAAR1 receptors, enabling modulation of neurotransmitter release.

Second- and Third-Generation Antipsychotics

Second-generation antipsychotics—such as risperidone and olanzapine—offered improved tolerability and fewer side effects.

The third generation, including aripiprazole, brexpiprazole, and cariprazine, consists of partial receptor agonists, functioning fundamentally differently from earlier medications.

Emerging Therapeutic Strategies

Current research focuses on entirely new classes of compounds acting on:

peptide receptors
trace amine-associated receptors (TAAR 1–3)

These agents modulate the presynaptic neuron itself across multiple neurotransmitter systems. Their effects may be:

direct
indirect, via activation of other neurotransmitter pathways that subsequently regulate neuronal function associated with schizophrenic symptoms

Additionally, promising effects have been observed with agents acting on muscarinic M1 and M4 receptors, leading to significant symptom improvement.

Clinical Effects of Novel Treatments

Based on current observations, the use of investigational next-generation agents results in:

resolution of delusions and hallucinations (positive symptoms)
substantial improvement in negative symptoms

Patients exhibit:

reduced apathy and social withdrawal
renewed interest in social interaction
return to hobbies and personal interests
improved cognitive functions, including memory and concentration
reduction of dementia-like symptoms

Patients re-engage with external reality, symptoms resolve, and they begin functioning comparably to healthy individuals.

Future Outlook

Provided that no significant adverse effects emerge, we may soon be able to treat psychotic disorders effectively while focusing on the development of therapies capable of permanently curing schizophrenia.

The trajectory of modern psychopharmacology suggests a future in which remission is no longer the ultimate goal—complete recovery may become achievable.

ADHD – Is It Really a Disorder?

The issue of ADHD has been discussed increasingly often in recent years, yet there is still no clear and definitive answer regarding the true nature of this condition.

Individuals diagnosed with ADHD are typically characterised by:

increased activity levels
difficulties with sustained attention
rapid boredom
a strong need for change and novelty

The problem does not seem to lie in the presence of these traits themselves, but rather in their intensity and impact on daily functioning.

It is estimated that between 2.5% and up to 20% of the global population may exhibit features consistent with ADHD.

An Evolutionary Perspective

The transmission of ADHD-related traits is associated with genetic inheritance, particularly variations of the dopamine receptor gene DRD4-7R. This raises an important question:
how is it that such traits were passed down through thousands of years instead of being eliminated?

Imagine a human tribe struggling to survive on the savannah. Individuals carrying the DRD4-7R variant respond to stimuli much more rapidly, enabling:

faster capture of prey
quicker avoidance of danger

Only a few such individuals within a tribe would have been sufficient to increase the group’s chances of survival.

Hunters needed rapid reactions, unconventional thinking, high energy levels, and speed. For this reason, traits now associated with ADHD were once highly desirable.

These characteristics also contributed to the expansion of humans across the globe. Many explorers, innovators, and scientists—historically and today—display traits consistent with ADHD.

Attention Deficit or Attention Difference?

Does this not contradict the idea of “attention deficit”?

Not entirely. It is not accurate to say that individuals with ADHD are unable to concentrate. Instead, many experience a phenomenon known as hyperfocus. When something captures their interest, they can remain intensely focused for hours without interruption or fatigue.

Such individuals often generate numerous creative and unconventional ideas. The challenge lies not in creativity itself, but in selecting the most appropriate solution, as many ideas appear equally valuable. In this area, guidance and support are often beneficial.

Behavioural Characteristics

In school, children with ADHD may appear disengaged or disruptive due to:

hyperactivity
unconventional approaches to problem-solving

These behaviours are frequently misinterpreted as misconduct or defiance.

In adult life, individuals with ADHD often struggle with repetitive or monotonous tasks. Full engagement typically occurs only in activities they find genuinely interesting.

Unfortunately, rapid shifts in attention do not favour long-term retention of routine information.

Neurobiology of ADHD

At the neurobiological level, this pattern of functioning is closely linked to the brain’s reward system, particularly dopamine.

The dopamine receptor DRD4-7R requires stronger and more frequent stimulation, meaning that individuals with ADHD:

need higher levels of stimulation
actively seek novelty and new experiences
become bored quickly with low-stimulation tasks

It is therefore not difficult to understand why some individuals are drawn to psychoactive substances, which rapidly increase dopamine levels and temporarily alleviate ADHD symptoms.

Paradoxically, when treated with psychostimulants, individuals with ADHD often become calmer and more focused. Similar effects can be observed with video games, gambling, and other activities that rapidly elevate dopamine and provide immediate reward.

Discovering a true passion may allow such individuals to reach levels of expertise, mastery, or even exceptional achievement.

ADHD in the Modern World

A major challenge today is determining how to provide children with ADHD an appropriate educational environment and how to tailor learning methods to their needs.

Originally, ADHD-related traits supported success in hunting and defence—activities requiring high physical activity. Research and clinical observation suggest that physical activity early in the day can significantly help individuals with ADHD calm down and improve concentration during lessons or lectures.

Diagnosis, Spectrum, and Management

There are numerous diagnostic methods for ADHD. Increasingly, ADHD is viewed not as a binary condition, but as a spectrum of traits with varying intensity.

After all, every person occasionally displays:

restlessness
emotional reactivity
distractibility

What matters most is the degree of severity and the extent to which these traits interfere with daily life.

ADHD can be stabilised through:

appropriate educational strategies
psychological interventions
environmental adaptations
pharmacological treatment

This raises an important question:
Does symptom reduction come at the cost of creativity, entrepreneurship, rapid decision-making, and hyperfocus?

Or should we instead help individuals develop and channel these traits—traits that may not necessarily represent a disorder requiring strong pharmacological intervention?

Conclusion

We therefore return to the central question:

Is ADHD a disorder—or a constellation of traits that, when properly guided, can lead to innovation, creativity, and new discoveries?

Home

Drugs – Unwashed Souls?

For generations, people have turned to drugs. Yet few stop to ask a fundamental question: why?
Why use psychoactive substances that alter consciousness, induce euphoria, and may ultimately lead to dependence?

And more importantly—why does a person reach for drugs knowing that doing so may result in imprisonment or serious consequences?

Despite these risks, many people continue to use psychoactive substances. Is it merely curiosity?

A closer look at individuals who use drugs or abuse alcohol often reveals underlying psychological distress or personality-related difficulties. Every human being seeks well-being, emotional balance, and effective functioning—both socially and professionally.

For many, the first contact with drugs—often encouraged by peers—brings a rapid and seemingly “therapeutic” effect: increased self-confidence, improved mood, reduced anxiety, and a surge of energy.

The problem is that for most substances, this effect is short-lived. To maintain the desired state, another dose is required. And then another.

From Drugs to Medicine

In experimental psychiatry, the goal is to design treatments that preserve therapeutic effects while eliminating addictive potential.

Two examples illustrate this approach:

1. Dimethyltryptamine and phenethylamine derivatives

These compounds form the basis of substances such as amphetamines and methamphetamine. Through precise chemical modifications, it has become possible—in controlled clinical settings—to alleviate depressive symptoms within minutes. Research has focused primarily on severe, long-standing depression. In some cases, symptoms resolve within an hour: energy returns, anxiety diminishes, and mood stabilises.
A clinically available example from this group is esketamine (Spravato).

2. Psychedelics

Administration of substances such as psilocybin or LSD often results in rapid reduction of anxiety, fear, and panic, accompanied by significant mood improvement. However, their strong effects on dopaminergic systems may provoke hallucinations or delusions. This is why ongoing research is essential—to determine optimal dosing and develop molecular modifications that reduce the risk of addiction and psychotic symptoms.

Repairing, Not Escaping

At their core, psychoactive substances exert their effects through intense receptor activation, particularly within serotonergic systems, temporarily restoring dysfunctional pathways.

The long-term objective is different:
to repair receptors permanently, so that after a single therapeutic intervention, normal functioning can resume without the need for continued substance use.

Drugs – Washed Souls?

The title of this article—“Drugs – Unwashed Souls”—is used deliberately and somewhat ironically, referencing essays by Stanisław Ignacy Witkiewicz (Witkacy) written in 1932.

After many years working as a psychiatrist—leading detoxification units, addiction services, and psychiatric wards—I would propose an alternative title:

“Drugs – Washed Souls.”

Why?

Because clinical experience suggests that many individuals turn to psychoactive substances not to destroy themselves, but to restore inner balance—to “wash” the mind and regain a sense of normal functioning, even at the cost of freedom or other serious consequences.

Looking Forward

Research into psychoactive substances should continue. Properly studied and responsibly applied, these compounds may offer lasting improvements in brain function and the possibility of genuine recovery from depression and anxiety disorders.

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Shame as an Internal Regulator of Norms and Values – A Clinical Perspective

In recent years, increasing difficulties have been observed in maintaining social, professional, and ethical norms, both in the general population and within institutions bearing a high level of responsibility. Behavioral regulation is more and more frequently based exclusively on external control mechanisms such as procedures, legal sanctions, and institutional supervision. At the same time, a noticeable decline can be seen in the role of shame as an internal regulator of behavior.

From a clinical perspective, shame serves a key function. It is a normative affect that integrates social norms, moral values, and the individual’s self-concept. When functioning in a healthy manner, shame enables self-reflection, inhibits destructive behaviors, and acts preventively, long before external intervention becomes necessary.

In psychiatric practice—particularly when working with high-risk populations such as incarcerated individuals or patients with substance use disorders or personality pathology—it is evident that the absence of shame does not lead to freedom, but rather to an escalation of risky and antisocial behaviors. Punishment alone, devoid of internalized norms, results in either defiance or emotional disengagement. A system lacking internal regulators is therefore forced to rely increasingly on rigid external control.

It is crucial to distinguish healthy shame from toxic shame. Healthy shame is proportional, behavior-focused rather than identity-focused, and facilitates behavioral correction and personal responsibility. Toxic shame, by contrast, is global, overwhelming, and associated with withdrawal, aggression, or denial, failing to fulfill any regulatory function.

Contemporary social discourse often leads to a pathological elimination of shame by equating it solely with oppression or symbolic violence. The paradoxical outcome is the erosion of internal regulation and the subsequent necessity to strengthen external control mechanisms, which in turn increases tension, instability, and systemic rigidity.

From a medical standpoint, procedures and sanctions should not be viewed as substitutes for morality, but rather as prosthetic supports when internal regulators fail. The restoration of shame’s regulatory function does not occur through moralizing, but through normative coherence, consistency, clear boundaries, and authority grounded in responsibility rather than formal power alone.

For physicians—particularly those working in psychiatry, forensic medicine, and public health—understanding shame as an internal regulator is essential not only for effective therapeutic intervention, but also for the long-term stability and humanity of institutional systems.