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The outlook for psychiatry in the age of informatization

International journal of culture and mental health, 2018

VOL. 11, NO. 1, 17–26

The outlook for psychiatry in the age of informatization

Alexey E. Bobrov

Consultative and distance psychiatry, Serbsky Federal Medical Research Centre for Psychiatry and Narcology, Moscow, Russia

Abstract

Psychiatry is evolving rapidly. Psychopathology needs a fundamentally new understanding of the accumulated facts. Information technologies are an extremely promising tool in this respect. Their implementation in the near future will not only radically change the organizational foundations of psychiatric care, but also enable the creation of new tools for diagnosing and correcting mental disorders. Analysis of existing theoretical controversies in the field of diagnostics, therapy and prevention of mental disorders provides evidence that the key scientific paradigms of psychiatry are changing. Development of scientific methodology is moving from the classical phenomenology of Jaspers to evidence-based medicine and criteria-based diagnostics, implemented in DSM-III and ICD-10. Further progress will, in all likelihood, be associated with the development of new methods based on information science which will be supplemented by the principles of system-based and functional analysis. This will make it possible to implement integrated bio-psycho-social programmes in the prevention and treatment of mental disorders.

Contact: Alexey E. Bobrov - Professor, Doctor of Medical Sciences, Head of Consultative and Remote Psychiatry Division, Serbsky Federal Medical Research Centre for Psychiatry and Narcology, Ul. Poteshnaya, Building 10, Moscow, Russia, 107076 © 2017 Informa UK Limited, trading as Taylor & Francis Group

The age of informatization is characterized by accelerated socio-economic development driven by the growing use of computer-based and telecommunications technologies. This process is transforming a wide variety of spheres in our society, including medicine. Informatization is having a substantial impact not only on scientific research and clinical practice but also on the mentality of many medical specialists (Aboujaoude, Salame, & Naim, 2015; Kraus, Stricker, & Speyer, 2010; Mitchell & Sullivan, 2001; Tang & Helmeste, 2000). Psychiatry, as the most information-loaded medical field, cannot escape this process. This is why the time has come to discuss the changes occurring in psychiatry due to the influence of informatization, and also to look at several promising areas for this development and its consequences.

The impact of informatization on the organization of psychiatric services

Informatization in psychiatry began with the introduction of electronic databases and electronic documentation (Luo, 2004), but this had relatively little impact on the everyday clinical practice of psychiatrists. A significantly larger organizational effect should be expected from the introduction of telepsychiatry, i.e. the methodology of remote psychiatric care using telecommunication systems (Deslich, Stec, Tomblin, & Coustasse, 2013; Tang & Helmeste, 2000). Indeed, telepsychiatry is already affecting the work of psychiatrists (Hubley, Lynch, Schneck, Tho- mas, & Shore, 2016). The possibilities offered by psychiatrists’ consultative and diagnostic tools are being enhanced substantially with the aid of telecommunication systems (Dill & Digiovanna, 2003; Hilty et al., 2013). Remote psychiatry is dramatically expanding the availability of mental health care. Consultative work using telepsychiatry is significantly increasing the possibility of early identification of mental disorders and providing the possibility of continuous medical support for psychiatric patients (Aboujaoude et al., 2015; Hubley et al., 2016). Telepsychiatry essentially also facilitates the practical implementation of the principles of psychiatric follow-up, whether for drug therapy monitoring and correction, for personalized psycho- logical help or psychosocial rehabilitation (Burns et al., 2001; Larsen, Nicholas, & Christensen, 2016). The use of telepsychiatry contributes to a marked reduction in hospitalizations in psychiatric hospitals, improves compliance of patients and increases attendance at mental health care facilities. Approaching the families of patients markedly increases the preventative potential of psychiatry, and the range of psychosocial and rehabilitation work is expanded. The Internet provides additional resources for self-help and remote interventions concerning the surrounding psychosocial environment (Demiris, 2006; Moock, 2014; Peek et al., 2015; Rosa, Campbell, Miele, Brunner, & Winstanley, 2015). Additionally, remote methods make it possible to significantly increase the volume and speed of information exchange between different specialists, which creates conditions for cooperation and teamwork. Multidisciplinary data integration, multidimensional analysis of the dynamics of the patient’s condition, and also the exchange of opinions between representatives of various faculties provide the opportunity of customizing the diagnosis and management of patients based on the principles of integrative medicine. Telecommunication technologies are bringing about the modification of professional education systems and the extension of inter-professional training, facilitating more rapid acquisition by doctors of essential expertise and knowledge and also development of the corresponding professional skills (Boatin, Ngonzi, Bradford, Wylie, & Goodman, 2015; Luo & Ton, 2006; Pantziaras, Fors, & Ekblad, 2015). All of this is paving the way for the emergence of new networked forms of organization of psychiatric care in which the dynamic ‘horizontal’ links not only complement the existing, vertically organized system of mental health services, but also create the conditions for overcoming the negative consequences of such a hierarchical organization. However, we cannot ignore the fact that the spread of telemedicine in psychiatry presents a number of serious problems, the most significant of these being privacy and security (Deslich et al., 2013; Stip, Thibault, Beauchamp-Chatel, & Kisely, 2016). The protection of personal information and medical confidentiality in the telecommunications sphere are relative. With each new step in the development of computer technology and means of communication, many previous systems that once provided security are becoming obsolete, jeopardizing the security of correspondence, medical data, as well of false, undesirable or compromising information (Mitchell & Sullivan, 2001; Sabin & Skimming, 2015; Stip et al., 2016). Here it is important to keep in mind the changed organizational principles regarding the work of psychiatrists and the control and recording of their professional activity. The format of psychiatric examinations and treatment could be massively transformed. Electronic manuals and medical histories, creation and management of electronic diaries, issue of prescriptions, virtual professional communities and groups, the use of informational methods for the treatment and rehabilitation of patients – these are just a few of the organizational changes which are increasingly being used in psychiatry in various countries (Carroll & Rounsaville, 2010; Clarke & Yarborough, 2013; Kraus et al., 2010; Larsen et al., 2016; Wright & Wright, 1997). As a result, one must pay attention to one important detail. Due to the rise in psychological, social and economic responses within the global information space, both antipsychiatric tendencies and the unethical use of psychiatric knowledge may substantially increase (Bracken & Thomas, 2001).

Informatization and mental health paradigms

These organizational developments are no doubt influencing the methodology of psychiatry, so that in the near future we may witness profound changes both in psychiatric diagnostics and in the preventative and therapeutic activities of psychiatrists (Carroll & Rounsaville, 2010; Deslich et al., 2013; Hughes, 2003). To understand the meaning of the forthcoming changes, it is helpful to consider the underlying shifts which have taken place in the history of psychiatry – particularly over the last few decades. These shifts are connected to the transformation of fundamental theoretical paradigms shaping the development of psychopathology. A historical analysis reveals that psychiatry has passed through several stages of development. Its emergence as a medical speciality at the turn of the eighteenth and nineteenth centuries was closely linked to the development of the concept of public health and the spread of principles of medical ethics (de Leon, 2013; Fàbrega, 2001; Фуко, 1991). However, since the treatment and prevention of mental disorders were imperfect at that time, in the initial period of development in psychiatry a quarantine approach prevailed which aimed at pre- venting socially dangerous actions by the mentally ill; there was also symptomatic treatment and measures linked to the development of methods of diagnosis and management of patients. At the same time, the theoretical foundations of psychiatry as a medical speciality were greatly strengthening. This process was reflected in the adoption of a biological understanding of the nature of mental disorders, their classification and the highlighting of different aetiological factors (Каннабих, 1994). In the early and mid-twentieth century, the primary tasks of psychiatry, as of medicine in general, were those of restoring working capacity and preventing disability. To a large extent these goals were attributable to accelerated industrial development in the leading countries. In accordance with this, determining the course, outcomes and in particular the social prognosis of a disease became crucial in psychiatry. Pathogenetic methods of therapy began to appear along with approaches for preventing mental disorders and psychosocial rehabilitation methods. During this period, one can trace the appearance and rise of two main tendencies: on the one hand there was a marked trend towards continued rapprochement of psychiatry with general medicine on the basis of the biomedical paradigm. On the other hand, there was an emergence and expansion of the socio-psychological approach to mental disorders (Fàbrega, 2001). Accordingly, for a long time the contradiction between these paradigms and the associated ethical values determined the overall development of psychopathology. The third stage of development of medicine gradually prioritized the tasks of preserving and improving the quality of life of patients, corresponding to the ethical values of a post-industrial society. This change was accompanied by a trend towards increased prevention and destigmatization of mental disorders, as well as the development of a concept of psychological growth. According to this concept, mental disorder started to be understood as one of the stages of the progressive development of personality, overcoming a psychological crisis and biological limitations caused by disturbances in brain activity (Pies, 2015). Finally, if one tries to look into the future, one could assume that as medicine turns into an evolutionary development tool of mankind, psychiatry looks set to be transformed into an area of implementation of humanistic cognitive technologies. The emergence of a new – informational – paradigm may play a key role in the integration of biomedical and socio-psychological views on the nature of mental illnesses and the subject and methods of mental health sciences. The most important requirement for this integration is the emergence and propagation of new medical ethics.

Informatization and the problem of method in psychiatry

In addition to organizational changes, informatization is giving rise to deep methodological shifts in the understanding of psychiatric nosography. As we know, psychiatry in Russia in the 1990s was marked by the introduction of new principles of diagnostics embedded in the International Classification of Diseases (10-th revision) (ICD-10) (ВО З, 2004). The process has proved complex and ambiguous (Абрамов, 1999). Psychiatrists have had to deal with new and unfamiliar terminology, with many of the key psychopathological categories being renamed. For a long time these innovations were not fully accepted in Russia by specialists because of their ‘artificiality’, ‘formality’ and ‘strangeness’. However, as time passed the understanding came that behind the new terminology, in disguised, implicit form, were clinical and theoretical concepts, unknown to Russian psychiatrists. This was reflected in the discussions about appreciation of the validity of typology and boundaries of schizophrenia and also of affective disorders. Concepts describing non-psychotic forms of mental illnesses, including neurosis, reactive states and psychopathy were also a field that was subjected to a deep re-evaluation (Бобров, 2006; Вельтищев, 2006). This discourse on the ‘formality’ and ‘schematism’ of ICD-10 often overlooked the fact that one of the subtle but powerful ‘drivers’ behind the introduction of ICD-10 was the need to use diagnostic tools suitable for translating psychopathology terms into ‘machine languages’ and an information- driven, categorial system. In this connection, psychiatrists were faced with the necessity of analysing the existing methods in our clinical toolkit. It turned out that the psychopathological method, which the majority of psychiatrists viewed as unique and dominant in clinical practice, was in fact not uniform, and psychopathology is not the same as a phenomenological approach. In particular, clinical implementation of the phenomenological method involves the definition of major and additional syndromes, and also a dynamic analysis of the structure of psychopathological disorders. Clinical data collection is based on an integrative assessment of the patient during the course of an interview with him, his self-report, information from his relatives, and also monitoring and systematic registration of his behavioural features. However, the essential characteristics of this method should not be reduced to a mode of information collection. On the contrary, they are determined by the mode of data systematization. The specific character of the phenomenological method is due to the fact that it comes from a tradition of introspection. The perception of psychopathological phenomena and the relationships between them is mediated by the subjective empathic and intuitive experience of the psychiatrist, who repeatedly reproduces them in his clinical observations and shares them with his colleagues (Häfner, 2015; Ясперс, 1996; Parnas, Sass, & Zahavi, 2013; Савенко, 2013). Such reproduction and reciprocal exchange form the basis for objectivization and the clinical classification of psychopathological phenomena, but also contribute to the formation of an understanding of symptoms, syndromes and diseases. The phenomenological method, by virtue of its empathic nature, is focused on the detection of mental disorders which come to the fore in the patient’s condition. Therefore, in cases where psychopathological manifestations become more complex, the reproducibility of this method decreases. The phenomenological approach was historically associated with philosophy. However, an unbalanced union of philosophical principles and empirical research does not always facilitate progress, and, conversely, can create the conditions for the emergence of scholastic or ideologically rooted concepts. The practical use of these concepts generally leads to oversimplification, ignoring the critical ‘details’, and is ultimately fraught with serious negative consequences. This was particularly evident at the ‘quarantine’ stage of development of psychiatry and occurred in all countries where psychiatry was included in the structure of public health. Well-known examples of these kinds of consequences are the implementation of theoretical ideas about ‘a single’ schizophrenic psychosis, the linear progression of alcoholism and drug addiction, as well as about mental disorders being caused by early psychological trauma. Modern operational diagnostic systems introduced into clinical practice another type of clinico-psychopathological method, which can be described as a criteria-based approach (Краснов, 2010). Unlike the traditional phenomenological approach, it is based on the necessity of taking into account only objective (that is, independent of the observer) criteria of abnormal behaviour and social functioning, as well as on the evaluation of various combinations of these criteria. Criteria-based diagnostics is based on the operational principle. This approach enhances the reliability of classification of psychopathological states and aids the realistic identification of types of mental disorder. The criteria-based approach, however, has a number of limitations. Its use essentially makes the diagnostic procedure more complicated, and a formalized system for recording signs replaces clinical intuition. This is a complex process which by no means always fits into the description of the ‘psychopathological picture’ understood by clinicians and can only be fully implemented with the aid of computer technology. An important improvement to the criteria-based method is the psychometric approach. This pro- vides an opportunity for supplementing the categorial classification of patients’ mental states with a quantitative assessment of the symptoms present. This approach also allows a balanced description of what are known as the psychopathological ‘radicals’ and ‘spectra’ of mental disorders. As a result, different diagnostic categories are seen not as independent, discrete entities, but as elements of a continuum of clinically and socially significant properties and parameters (e.g. schizophrenia spectrum disorders, anxiety disorders, addiction, deviant behaviour spectra, etc.). This makes it feasible to switch to a dimensional diagnostic principle, which is more in line with the requirements of informatization. There is one more diagnostic approach based on the psychometric principle. This approach could very much be classed as an independent type of clinico-psychopathological method and termed a descriptive analysis of behaviour. The main difference between this approach and the conventional clinical method is the focus on the objective registration of behaviour and the de facto exclusion of all introspective psychopathological phenomena from scientific consideration. The essence of this approach is the objective registration of a patient’s psychological reactions to standard stimuli. This principle is implemented in several psychodiagnostic as well as neurocognitive tests. Methods for the systematic observation of behaviour and remote monitoring of the psychophysiological state of a patient could be assigned to the same methodological category. The main limitation of the psychometric principle is that the dominance of measurement-based approaches results in the loss of the qualitative specifics of the mental disorder assessment (Давтян, 2012). Psychopathological analysis starts to be reduced to the consideration of different combi- nations of symptoms of disorders and degrees of their severity. The diagnostic process has been likened to a simple search of a previously restricted number of parameters and the automatic com- parison of these against the templates (Andreasen, 2007). Thus, in recent years descriptive psychopathology has shown a trend towards combining the categorial and psychometric approaches (Broome, Stanghenellini, & Thornton, 2005). This is illustrated in particular by DSM-5, where the psychometric component has virtually become an essential part of clinical diagnosis (APA, 2013). However, such a ‘multiaxial’ approach also has serious shortcomings. These include: increasing complexity of diagnostic procedures, the formalization of diagnosis and a reduction in its internal validity due to the increase in potentially irrelevant criteria (Rief, Wittchen, & Frances, 2013). It is possible to overcome the limitations imposed by the formalization of data using an interpretative approach. Methodologically, this goes back to the hermeneutical interpretation of texts and meaning and the multi-sided evaluation of their content with reference to various semantic and categorial systems. A classic example in this regard is the psychodynamic approach that focuses on identifying ‘deep-seated’ motives, feelings and personality. However, a trend towards a qualitative interpretation of psychological and psychophysiological phenomena, based on a structural and system-based understanding of the psyche, is also present in other areas of psychiatry. An example of the implementation of such an approach is the concept of early cognitive patterns. The interpretative approach is a methodological tool for describing, understanding and explaining in conceptual terms the significance of various psychopathological phenomena on the basis of preliminary assumptions concerning their system-related organization, dynamic interrelations and hierarchical structure. The tools of such an understanding are active psychological interaction, analysis, interpretation and a ‘working-through’ of the patient’s experiences with the help of psychotherapist. This trend in psychopathology has generated a variety of diagnostic and therapeutic methods based on a causal understanding of the structure and dynamics of psychopathological phenomena. What is more, these phenomena themselves are frequently in combination and equate to ideas about the nature of mental suffering. In line with the interpretative approach, clinical phenomena are considered not per se but as a reflection of intrapsychic or even psychophysiological processes such as motivations, feelings, styles and forms of communication, or the structural and dynamic changes between systems of internal representation of real objects. The most important feature of this approach is the denial of fundamental differences between a ‘normal’ and ‘abnormal’ psyche. In other words, pathology is no more than a specific refraction of the normal psychological processes. The main task of psychiatric examination is to identify the process hindering adaptation by the individual. External clinical manifestations of a disease are secondary and not fundamentally significant (Malan, 1979). The main clinical task is that of creating an individualized concept of mental disorder, which makes it possible to understand and explain a patient’s condition and provide him with adequately tailored psychiatric care. The limitations of the interpretative method are usually linked to its ‘arbitrariness’, ‘speculative nature’ and insufficient scientific character. And indeed, this method, disregarding the study of the multitude of clinical phenomena and the analysis of empirical data, easily degenerates into unfounded fantasy about the patient and construction of unverified hypotheses about possible therapeutic interventions. Nevertheless, causal interpretation and the construction of theoretical concepts are essential elements of clinical thinking. Diagnostic characterization of the patient’s condition, the establishing of an individual prognosis, and also the selection of therapeutic approaches and strategies are largely determined by the interpretation of a clinical case by the doctor and the set of clinical disease concepts available to him. That said, the most important reference point allowing the use of interpretive methodology in psychiatry is diagnostics based upon system and functional assumptions, which allows the consistent integration of different terms and methodologies in order to support individualized classification of specific clinical observations.

Informatization, treatment and prevention in psychiatry

Informatization and statistical methods have played a decisive role in the incorporation of methods of evidence-based medicine into psychiatry (Freedman, 2003). The main idea behind this method- ology is that of ensuring the reliability of data on the efficacy and safety of different methods for treating and preventing mental disorders. This is achieved thanks to the representative quality of the data and the implementation of standard procedures for the statistical control and analysis of the results, including meta-analyses. It is clear that without substantial changes to the diagnostic process and the organizational principles of psychiatric services, application of the methodology of evidence-based medicine in psychiatric practice is impossible. It should also be emphasized that evidence-based medicine in psychiatry relies mainly on the criteria-based approach to diagnostics, while phenomenological diagnosis is rejected owing to high subjectivity and the interpretative approach is rejected because of its speculative nature. The emergence of this trend reflected the need to protect patients and the general population from the negative impacts of market mechanisms, which are playing an increasingly important role in health care. At the same time, one should bear in mind that evidence-based medicine does not, per se, create new systems of treatment and prevention. This methodology only serves as a tool for streamlining them and matching them to existing economic and managerial capabilities. It is important to note that this methodology has a number of significant limitations. The most important of these is utilitarianism, and the narrow range of application of research results caused by the rigour with which the group of patients – for which the particular results were obtained – was selected. Furthermore, the methodology of evidence-based medicine is difficult to use in integrated research and also in the assessment of the role of psychosocial and organizational factors owing to their insufficient stability. Informatization also has great potential in other fields of psychiatric treatment and prevention. The cognitive approach in psychiatry, which to a large extent is the clinical expression of information paradigm, serves as a good example (Barack & Platt, 2016). The essence of this approach can be reduced to the interpretation of mental disorders as diseases linked to impaired information processing both in the brain and in superindividual social communities. Accordingly, the assessment of the effectiveness of therapeutic and preventive measures according to this approach should be made in the context of their influence on cognitive processes. The cognitive approach has little in common with traditional methods for assessing the efficacy of psychopharmacological effects. In fact, assessment of the effect of psychopharmacological preparations has until now used the principle of targets (Freyhan, 1959). In accordance with ideas about ‘target symptoms’, different classes of psychopharmaceutical agents act differently on different symptoms of mental disorder. For example, targets for antipsychotics can be delusions and halluci- nations, catatonic and hebephrenic disorders, and for antidepressants such targets are depression, feelings of guilt, apathy, sleep and appetite disturbances. This principle forms the basis for all existing classification of psychopharmacological drugs, which takes into account what are known as the ‘effects of symptoms elimination’ or ‘spectra of psychotropic activity’ (Авруцкий & Недува, 1988, p. 18; Hippius, 1970, p. 130). In recent years the validity of this classification has been increasingly challenged, and other principles have been proposed instead. In particular, the classification of psychotropic drugs based on their suggested mechanisms of action is gaining in popularity. This is based on assumptions that different psychotropic agents act on neurone receptors in a variety of ways and this leads to their inherent specific pharmacological effect. Another concept arises from proposals that the specificity of pharmacological effects is determined by the activation of different neural networks. A third theory comes down to the fact that psychotropic drugs may, in acting on the RNA and DNA of neurons, influence multiple intracellular metabolic cascades, resulting in changes to protein synthesis. Nevertheless, the concept of spectra of psychotropic activity remains the dominant concept in clinical practice. It is dependent not so much on the established professional ‘stereotypes’ of doctors as on methodological difficulties arising during attempts to use purely biological classification of psychotropic effects in a clinical context, particularly taking into account the psychosocial representation of mental disorders. Furthermore, a biological interpretation is clearly insufficient. In practice the effects of psychotropic drugs vary considerably in their times of onset. They may change qualitatively depending on the dose and regimen. Moreover, at different stages of treatment in the same patient the drugs may cause qualitatively different effects. Along with ‘effects of symptoms elimination’ (Авруцкий & Недува, 1988, p. 18; Hippius, 1970, p. 130), pharmacological therapy is capable of producing ‘effects of restoration (of functions)’. The above contrasts substantially with the selection of methods of psychotherapy. Indications for psychotherapy are not based on symptoms or combinations thereof which are regarded as targets. The psychotherapeutic approach takes into account certain forms of non-adaptive relationships, behaviour, thinking or styles of response. This is true for psychodynamic, for cognitive–behavioural, and for interpersonal psychotherapy. In other words, a psychosocial intervention stems not so much from a criteria-based diagnosis as from the interpretative characterization of a patient’s condition. Here it is not static symptoms of a disease which are used as a basis but dynamic processes, through which are expressed the system-level mechanisms of the organization of consciousness and behaviour, constructed according to feedback principles. Thus, psychotherapy in accordance with the informational paradigm essentially directs the doctor towards the correction of functional systems, ensuring the restoration of the organism’s impaired functions and interactions.

The understanding of the human being as an immensely complex information system opens up fundamentally new avenues for the treatment of mental illnesses. An example of this is the idea, which currently appears fanciful, of ‘information prosthetics’. According to this idea, compensation of information processes in humans that have been impaired by illness can be achieved using artificial information systems. By way of illustration, we can cite methods for enhancing attention, improving perception and expanding capacities of associative memory, and also cognitive approaches based on the principles of informational support of decision-making (Бобров, 2008; Бобров, Довженко, & Кулыгина, 2014). Information systems are already now being used in bio- feedback devices to improve self-regulation and differentiation of behaviour. However, we cannot overlook the fact that there are fundamental differences between artificial information systems and human methods for processing information. Consequently, such methods can, for the moment, only be used as a means of correcting impairments of certain involuntary forms of behaviour. In the same context, one should actively explore the familiar range of application of information technologies for modelling the socio-psychological conditions of everyday life. Virtual reality and computer simulators and games with a psychological basis can be used to enhance patients’ psycho- logical competence, develop social skills, and overcome pathological anxiety and phobias as well as deepen a critical and balanced attitude to their condition.

Conclusion

Psychiatry is evolving rapidly, in spite of an apparent decline of interest in the field against the back- ground of technological breakthroughs in other areas of medicine. Psychopathology needs a fundamentally new understanding of the accumulated facts. Information technologies are an extremely promising tool in this respect. Their implementation in the near future will not only radically change the organizational foundations of psychiatric care but also enable the creation of new tools for diagnosing and correcting mental disorders. Analysis of existing theoretical controversies in the field of diagnostics, therapy and prevention of mental disorders provides evidence that the key scientific paradigms of psychiatry are changing. In particular, one can currently observe a shift from a biomedical understanding of the nature of mental illness towards socio-psychological concepts and, further, to the cognitive paradigm. Coinciding with this is the development of scientific psychiatric methodology, which is effecting a transition from the classical phenomenology of Jaspers to evidence-based medicine and criteria-based diagnostics, implemented in DSM-III and ICD-10. Further progress will, in all likelihood, be associated with the development of an interpretative method which is supplemented by the principles of system-based and functional analysis. It is this which will make it possible to implement integrated bio-psycho-social programmes in the prevention and treatment of mental disorders.

Disclosure statement

No potential conflict of interest was reported by the author.

Notes on contributor

Alexey E. Bobrov, Professor, Doctor of Medical Sciences, Head of Consultative and Remote Psychiatry Division, Serbsky Federal Medical Research Centre for Psychiatry and Narcology.

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