Una lunga sfida. Snodi nella psichiatria e nell’assistenza psichiatrica in Italia. A cura di L. Dell’Osso, Lorenzi P. Alpes, 2024.

“Una lunga sfida. Snodi nella psichiatria e nell’assistenza psichiatrica in Italia” is an excellent book that aims to describe the developments in psychiatric thought and institutions in the last fifty years (Part I), the updated models and major conceptual innovations of the last decade (Part II and III), and the challenges for the future (Part IV).

The book includes twenty-three chapters written by major experts in the different topics: psychiatrists who works in academic institutions or in National Mental Health Services have written single chapters according to their specific competences: among them Liliana Dell’Osso, Primo Lorenzi, Andrea Fiorillo, Antonio Vita, Stefano Pini, Maria Rosaria Muscatello, Liliana Lorettu, Maurizio Pompili, Daniele La Barbera e Barbara Carpita from different Universities; Emi Bondi, Massimo Rabboni, Giuliano Casu, Luigi Ferrannini, Giuseppe Cardamone, Federico Meucci, Donatella Marazziti, Daniela Toschi, Dario Muti, Stefano Pallanti, Giulia Amatori, Paolo Peloso, Riccardo Cioni and the writer of this review from different Italian Departments of Mental Health. The common approach is didactic but ever critical. 

Psychiatric institutions, organizations and models develop itself continuosly according to neuroscientific evidences but also sociocultural changes in the course of times. The evolutions of concepts, models and therapeutic praxis in the last decades has been rowdy, compelling the professional to a large revision of the schemas learned in their training.

Psychiatric practice has evolved and changed in the therapeutic organizations, the pharmacologic and psychotherapeutic treatments, and in general in the respect of the individual rights, the struggle to stigma, the aim to recovery and social inclusion. This working reality, that is supported by a complex and elaborated thought about what are and how can be taken into care all kind of serious mental disorders is accepted by younger professionals without adequate knowledge of the long course that has been needed to its achievement. Nowadays in Italy, psychiatric services refer to a multidisciplinary work model, which is much more effective than single professional interventions; it has replaced both reductive or speculative approaches than primitive coercive or exclusionary praxis still largely operative at the end of the 70s. This long path deserves to be disclosed to the large public that frequently ignore it.

Among the great number of salient clinical topics covered in the book, I would like to stress the importance of the crisis of categorial approaches in psychiatry, both concerning nosography and pharmacotherapy. Comorbidities, both in clinical pictures and in the long-term course of the disorder, has put the traditional nosography into an irreversible crisis; nowadays a widespread international literature supports a dynamic conceptualization of disturbances and their trajectories that start since the childbirth, and even intrauterine life, and culminate with involutional age. In this lifetime frame, all kind of biologic and psychologic (traumatic for example) events can interfere with a vulnerable brain. The different disorders present with different stages, even with single symptoms or subthreshold pictures, from pre-psychotic to post-psychotic and more chronic stages in the long term of the duration of the illness. The clinical pictures can change with time also depending on the appropriateness and timeliness of the therapeutic interventions. Liliana Dell’Osso has given a strong impulse to this perspective in Italy in the last decade.

Concerning psychopharmacology, the different treatments are no more classified for their presumed nosographical application (i.e., antidepressive, antipsychotic), but for their mechanism of action often very different depending on the dose and the pharmacologic association. The use of drug is tailorized to the single patient and is often correlated to the different stages of the illness, and associated to psychotherapy. These new dynamic ways of conceiving nosography and pharmacotherapy fit well with the so called “biopsychosocial” model of mental disorders that has been applied in the Italian Mental Health Services since the 90s. 

Some chapters concern the updated critical issues of mental services, due to mistakes in programming and in the ever more greater limitations of the resources. A crucial topic is the shortage of the number of young psychiatrists with the passion to work in such complex organizations as the Mental Health Services: it is a matter of lacking of the passion needed to do this extraordinary but hard work? or is it about economic unsatisfaction? The public providers of the services should question themselves.

In the Part IV, some chapters concern the digital transition and the role of artificial intelligence (AI). The introduction of digital applications of communication and treatment in Mental Health Services will be a near to come challenge because private agencies already largely offer these digital services (for example for psychotherapy, but also for psychiatric consultations). More questionable is the use of AI in the field. AI will surely be used to elaborate review and metanalysis or guidelines and to define better the standard trajectories of the different disorders; however, AI cannot replace the therapeutic relationship. Human mind is relational by definition and, called to answer to ever new adaptative challenges, cannot conform to a binary logic. This is even truer for the mental functioning influenced by mental disorders, that is not-rational because of the alteration of cognitive, emotional and impulsive functioning (that is contextually also the reason of its possible creativity). Psychiatry will be always different from general medicine and its technical specialisations. It requires empathic psychiatrists able to intuitively and abductively understand what the patient feels and expresses verbally or not-verbally in the different stages of its illness. 

An endless workload awaits the psychiatric services the future of which relies on a deep knowledge of the road travelled by generations of psychiatrists to arrive where we actually are.