Executive Summary BackgroundThis Commission addresses several priority areas for psychiatry over the next decade, and into the 21st century. These represent challenges and opportunities for the profession to sustain and develop itself to secure the best possible future for the millions of people worldwide who will face life with mental illness. Part 1: The patient and treatmentWho will psychiatrists help? The patient population of the future will reflect general demographic shifts towards older, more urban, and migrant populations. While technical advances such as the development of biomarkers will potentially alter diagnosis and treatment, and digital tech-nology will facilitate assessment of remote populations, the human elements of practice such as cultural sensitivity and the ability to form a strong therapeutic alliance with the patient will remain central. Part 2: Psychiatry and health-care systemsDelivering mental health services to those who need them will require reform of the traditional structure of services. Few existing models have evidence of clinical effectiveness and acceptability to service users. Services of the future should consider stepped care, increased use of multidisciplinary teamwork, more of a public health approach, and the integration of mental and physical health care. These services will need to fit into the cultural and economic framework of a diverse range of settings in high-income, low-income, and middle-income countries. Part 3: Psychiatry and societyIncreased emphasis on social interventions and engagement with societal expectations might be an important a ea fo ps hiat s de elop e t. This ould e o pass ad o a fo the ights of individuals living with mental illnesses, political involvement concerning the social risk factors for mental illness, and, on a smaller scale, work with families and local social networks and communities. Psychiatrists should therefore possess communication skills and knowledge of the social sciences as well as the basic biological sciences. Part 4: The future of mental health lawMental health law worldwide tends to be based on concerns about risk rather than the protection of the rights of individuals experiencing mental illness. The United Nations Convention on the Rights of Persons with Disabilities, which states that compulsion based in whole or in part on mental disability is discriminatory, is a landmark document that should inform the future formulation and reform of mental health laws. An evidence-based approach needs to be taken: mental health legislation should mandate mental health training for all health professionals; ensure access to good-quality care; and cover wider societal issues, particularly access to housing, resources, and employment. All governments should include a mental health impact assessment when drafting relevant legislation. Part 5: Digital psychiatry-enhancing the future of mental healthDigital technology might offer psychiatry the potential for radical change in terms of service delivery and the development of new treatm...

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Mentally disordered offenders may be sent to secure psychiatric hospitals. These settings can resemble carceral spaces, employing high levels of security restricting resident autonomy, expression and social interaction. However, research exploring the restrictiveness of forensic settings is sparse. A systematic review was therefore undertaken to conceptualize this restrictiveness. Eight databases were searched for papers that address restrictive elements of secure forensic care in a non-cursory way. Fifty sources (empirical articles and policy documents) were included and subject to thematic analysis to identify 1) antecedent conditions to, 2) characteristic attributes, 3) consequences and 4) 'deviant' cases of the developing concept. The restrictiveness of forensic care was experienced across three levels: individual, institutional and systemic. Restrictiveness was subjective and included such disparate elements as limited leave and grounds access, ownership of personal belongings and staff attitudes. The manner and extent to which these are experienced as restrictive was influenced by two antecedent conditions; whether the purpose of forensic care was to be more caring or custodial and the extent to which residents were perceived to be risky. We argue that there must be a reflexivity from stakeholders between the level of restrictiveness needed to safely provide care in a therapeutic milieu and enable the maximum amount of resident autonomy.

Assertive outreach services have been central to community mental health policy within the UK. These multidisciplinary teams were established to engage with service users who have severe and enduring mental health problems and have found traditional community services unable to meet their needs. Mental health nurses have a pivotal role in these multidisciplinary teams, yet the nature of these relationships from the perspective of those who work in and receive care is poorly understood. This study set out to explore the nature and meaning of engagement for practitioners and service users within assertive outreach services. A qualitative approach, informed by philosophical hermeneutics, underpinned the study. Participants were recruited from a single assertive outreach team in the UK. To be eligible for the study, mental health practitioners needed to be employed within the assertive outreach team. All service users residing in the community and receiving care from the team were also eligible for inclusion. In total 14 interviews were conducted with mental health practitioners and 13 with service users. Data analysis was informed by Turner's method. Four themes emerged from the data; contact, dialogue, transformation and shared understanding. Meaningful engagement was found to manifest itself through experiences such as providing and receiving practical assistance, having a genuine two-way conversation and valuing the experiences and personal attributes of the other person. The findings indicate that engagement is an active, dynamic and skilled process, which leads practitioners and service users to transform together to create a new relationship.

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