The history of Italian general psychiatry and forensic psychiatry over the last 50 years has been unique in the European and Western healthcare landscape. Western politicians often visit Italy to observe the successful community-based systems that have developed in that country.

This article represents a first step toward a necessary attempt, to explore how specific political decisions, such as the Italian one, have produced positive outcomes for patients with psychotic disorders, outcomes not observed in many Western countries, which are instead grappling with negative outcomes such as the complicated management of homelessness and the incarceration of people who would instead require psychiatric care.

In its historical context, the 1978 decision to abandon the asylum tradition in favor of socialization for patients living with severe mental disorders represented a difficult choice. This choice led to inevitable critical issues, which today are still not completely dormant.

This choice has also, undoubtedly, restored dignity to people living with serious mental illness, even when that person commits a crime.

To understand these changes, it is appropriate to mention the regulations that finally led to Law number 180 of 1978, which decreed the closure of psychiatric hospitals (Ospedale Psichiatrico) throughout Italy and continued after 2015 with the closure of high-security psychiatric hospitals (Ospedale Psichiatrico Giudiziario) as well.

Culturally, much has changed throughout this time in assistance to the mentally ill in Europe.

Ayahuasca is a botanical hallucinogen traditionally used for therapeutic and ritual purposes by indigenous groups from Northwestern Amazonian countries such as Brazil, Peru, Colombia, and Ecuador. Ayahuasca is made by the decoction of two plants, which are rich in the 5-HT1A/2A partial agonist dimethyltryptamine or DMT (from the leaves of the Psychotria viridis bush) and β-carbolines such as harmine, from the stalks of the Banisteriopsis caapi vine. There is an increasing interest in the possible therapeutic effects of ayahuasca, especially for psychiatric disorders (major depression, posttraumatic stress disorder, and substance use disorder). This review summarizes information on the pharmacology, safety, and therapeutic potentials of ayahuasca. Although human experimental and naturalist studies published until now suggest a good safety and tolerability profile, often associated with improvements in depressive and anxious symptoms, there are few controlled studies, with small sample sizes, using only single doses, and with short follow-ups. Potential benefits of ayahuasca should be evaluated in larger samples in both experimental and observational studies and using different doses in controlled trials.

Balancing autonomy and beneficence remains an ongoing challenge in the ethical treatment of patients with schizophrenia and other psychiatric disorders of thought. Psychiatric advance directives (PADs) offer one mechanism through which individuals can guide their own care, but unlike medical advance directives, they are not widely utilized in the United States. They are also highly limited by state law in the scope of their legal authority. This article explores the evidentiary basis for PADs as well as the legal and ethical issues that arise in the use of PADs in individuals with schizophrenia, arguing that providers’ fears of complete opt-out from care by patients are likely unfounded and that PADs offer a powerful tool through which individuals with schizophrenia can ensure meaningful consideration of their own values and goals.

This article presents a comprehensive neuroethical framework that seeks to deepen our understanding of human consciousness and free will, particularly in the context of psychiatric and neurological disorders. By integrating insights from neuroscience with philosophical reflections on freedom and personal identity, the paper examines how various states of consciousness from interoception to self-awareness influence an individual’s autonomy and decision-making capabilities. The discussion utilizes a multidimensional, bottom-up approach to explore how neurobiological processes underlie different levels of conscious experience and their corresponding types of freedom, such as “intero-freedom” related to internal bodily states and “self-freedom” associated with higher self-awareness. This stratification reveals the profound impact of neurological conditions on patients’ freedom of choice and the ethical implications therein. The insights gained from this analysis aim to inform more tailored and effective treatments for psychiatric patients, emphasizing the restoration of autonomy and respect for their inherent dignity. This work underscores the essential unity of the human person through the lens of neuroethics, advocating for healthcare policies that recognize and enhance the personal freedom of those with mental health challenges.

This article, titled “A Unified Understanding of the Human Mind - A Neuroethical Perspective,” examines the evolution of the concept of the human mind in Western thought and its integration with neuroscience, psychology, psychiatry, and relational dimensions. The author explores how the understanding of the mind has changed over time, influenced by shifts in philosophical paradigms, scientific advancements, and societal perspectives. The article traces the historical development of the mind’s concept, starting from ancient Greece, through influential thinkers like Plato and René Descartes, and progressing to contemporary perspectives. It highlights various philosophical and scientific approaches, including structuralism, functionalism, empiricism, and associationism, which have shaped our understanding of the mind. The article also delves into contemporary integration, where advancements in neuroimaging and the rise of holistic approaches offer a more nuanced understanding of the human mind. The author emphasizes the importance of the relational dimension and the interconnectedness of mental processes, the brain, and the external environment. This integrated perspective can benefit psychiatric treatment and psychological assessments by fostering a holistic approach to mental health. In conclusion, the article advocates for a multidimensional perspective that bridges subjective and objective aspects of human experience, offering promise for theoretical knowledge and practical applications in psychology, psychiatry, and neuroscience.

Antipsychotics effective for schizophrenia approved prior to 2024 shared the common mechanism of postsynaptic dopamine D2 receptor antagonism or partial agonism. Positive psychosis symptoms correlate with excessive presynaptic dopamine turnover and release, yet this postsynaptic mechanism improved positive symptoms only in some patients, and with concomitant risk for off-target motor and endocrine adverse effects; moreover, these agents showed no benefit for negative symptoms and cognitive dysfunction. The sole exception was data supporting cariprazine’s superiority to risperidone for negative symptoms. The muscarinic M1/M4 agonist xanomeline was approved in September 2024 and represents the first of a new antipsychotic class. This novel mechanism improves positive symptoms by reducing presynaptic dopamine release. Xanomeline also lacks any D2 receptor affinity and is not associated with motor or endocrine side effects. Of importance, xanomeline treated patients with higher baseline levels of cognitive dysfunction in clinical trials data saw cognitive improvement, a finding likely related to stimulation of muscarinic M1 receptors. Treatment resistance is seen in one-third of schizophrenia patients. These individuals do not have dopamine dysfunction underlying their positive symptoms, and therefore show limited response to antipsychotics that target dopamine neurotransmission. Clozapine remains the only medication with proven efficacy for resistant schizophrenia, and with unique benefits for persistent impulsive aggression and suicidality. New molecules are being studied to address the array of positive, negative and cognitive symptoms of schizophrenia; however, until their approval, clinicians must be familiar with currently available agents and be adept at prescribing clozapine.

This article reviews the development of mental health and psychiatric services in Australia for the international reader. The development of relevant legislation, health-care systems, and the effectiveness of treatment for people with schizophrenia is reviewed. Gaps in service delivery and future directions are considered.

My name is Bethany Yeiser, and I am an individual living with schizophrenia. My schizophrenia has been in full remission since 2008, thanks to treatment with clozapine, the vastly underutilized medication for refractory schizophrenia.

The link between creativity and serious mental illness (SMI) is widely discussed. Jackson Pollock is one example of a giant in the field of art who was both highly creative and experiencing an SMI. Pollock created a new genre of art known as abstract expressionism (“action painting”) defined as showing the frenetic actions of painting. The question arises whether his SMI played any role in the way he created his drip paintings, especially when he was overactive and manic. Furthermore, did visual hallucinations or enhanced visual perception associated with mania or psychosis facilitate Pollock in embedding and camouflaging images under layers of thrown paint? Seeing images in Pollocks drip paintings has been a controversy ever since these paintings were created. Some experts attribute this to pareidolia—perceiving specific images out of random or ambiguous visual patterns—a phenomenon known to be enhanced by fractal fuzzy edges such as seen in Rorschach ink blots as well as in Pollock drip paintings. So, are Pollock’s drip paintings merely giant Rorschach images, or did Pollock insert polloglyphs—images that are encrypted that tell a story about Pollock’s inner being—into his paintings and then disguise them with drippings? Here, we explore answers to these questions and discuss images that Pollock included in his earliest sketches and used repeatedly in his abstract paintings and later in his drip paintings to argue that these images are not accidental.

A description is provided of the current situation in Aotearoa New Zealand with regard to compulsory treatment of people with schizophrenia. This is placed within the context of homelessness in New Zealand and the provision of services to the incarcerated mentally ill. There are high rates of homelessness and incarceration and services are struggling to meet their needs. This is particularly a problem for the indigenous population. The current Mental Health Act allows for compulsory treatment of people who as a result of schizophrenia are seriously impaired in their capacity to care for themselves, and this will include people where there is a nexus between homelessness and their illness. The Mental Health Act is being reformed, with a new act likely to emphasize autonomy and capacity to a greater degree. Finally, the author considers the learnings from 5 years working within the Fixated Threat Assessment Centre, which provides a unique perspective on these issues.

The perspective article explores systemic issues in psychiatric care, particularly the barriers to timely treatment and the ethical dilemmas involved in involuntary interventions. It further examines the impact of anosognosia—lack of disease insight—on treatment, noting the difficulties in managing care for those unaware of their illness, and scrutinizes training materials from international organizations that might mislabel necessary psychiatric practices as human rights violations, thereby complicating the care landscape. The discussion extends to the legal and societal implications of psychiatric interventions, using Massachusetts’ Rogers Guardianship as a case study to highlight the consequences of legalistic approaches to mental health treatment.

The article calls for destigmatizing psychiatric treatment and integrating robust, evidence-based practices to improve patient outcomes and healthcare equity. The global mental health policy landscape is urged to recognize the critical role of psychiatric care in restoring health and dignity to individuals with serious mental illnesses, advocating for a more nuanced understanding and application of human rights in mental health.

Schizophrenia is a highly heterogenous disorder with substantial interindividual variation in how the illness is experienced and how it presents clinically. The disorder is composed of primary symptom clusters—positive symptoms, negative symptoms, disorganization, neurocognitive deficits, and social cognitive impairments. These, along with duration, severity, and excluding other possible etiologies, comprise the diagnostic criteria for the disorder outlined in the two commonly used diagnostic classification systems—the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition, Text Revision and the International Classification of Diseases, 11th Revision. These primary symptoms as well as accessory symptoms (mood disturbances, anxiety, violence) and comorbidities (substance use, suicidality) bear upon each other to varying degrees and impact functional outcomes. The following review presents two patient cases illustrating the clinical heterogeneity of schizophrenia, the natural history of the illness and diagnosis, followed by the current understanding of the primary symptom clusters, accessory symptoms, and comorbidities. In addition to noting symptom prevalence, onset, and change over time, attention is paid to the impact of symptoms on functional outcome.

Schizophrenia spectrum disorders are brain diseases that are developmental dementias (dementia praecox). Their pathology begins in utero with psychosis most commonly becoming evident in adolescence and early adulthood. It is estimated they afflict the U.S. population at a prevalence rate of approximately 0.8%. Genetic studies indicate that these brain diseases are about 80% determined by genes and about 20% determined by environmental risk factors. Inheritance is polygenic with some 270 gene loci having been identified as contributing to the risk for schizophrenia. Interestingly, many of the identified gene loci and gene polymorphisms are involved in brain formation and maturation. The identified genetic and epigenetic risks give rise to a brain in which neuroblasts migrate abnormally, assume abnormal locations and orientations, and are vulnerable to excessive neuronal and synaptic loss, resulting in overt psychotic illness. The illness trajectory of schizophrenia then is one of loss of brain mass related to the number of active psychotic exacerbations and the duration of untreated illness. In this context, molecules such as dopamine, glutamate, and serotonin play critical roles with respect to positive, negative, and cognitive domains of illness. Acutely, antipsychotics ameliorate active psychotic illness, especially positive signs and symptoms. The long-term effects of antipsychotic medications have been debated; however, the bulk of imaging data suggest that antipsychotics slow but do not reverse the illness trajectory of schizophrenia. Long-acting injectable antipsychotics (LAI) appear superior in this regard. Clozapine remains the “gold standard” in managing treatment-resistant schizophrenia.

Throughout its two and a half centuries in existence, US mental health policy has repeatedly failed people living with schizophrenia. The failures are cyclical—the inhumane conditions uncovered in the first 75 years of existence were addressed with the construction of state asylums to deliver moral treatment. One hundred years later, the asylums were themselves revealed to be inhumane. Deinstitutionalization, the response to the failure of asylums starting in the 1960s, now drives outcomes such as homelessness, incarceration, and early death for people living with psychotic illnesses. In all cases, well-intentioned policy reform has failed at the level of implementation, largely due to a lack of accountability. The result has been a consistent failure to adequately treat people living with schizophrenia, which is now understood to be a highly treatable condition. As the country passes into a quarter millennium in existence, reform is once again underway. Unlike other points in history, there is good news. Other countries, such as Italy, have successfully leveraged reform to achieve greatly improved outcomes. Understanding US history and the successful implementation of policy change in other countries is imperative and teaches us that accountability in implementation is necessary to break the cycle of policy failure.

This chapter explores the complex and controversial path of MDMA-assisted therapy (MDMA-AT) for treating post-traumatic stress disorder (PTSD) and other behavioral disorders. It covers MDMA’s history from research to recreation to medicine, the pivotal trials, and the challenges faced by researchers. Despite recent setbacks for the clinical application of MDMA, the chapter argues that it holds potential for transforming psychiatry and discusses the uncertain future amidst ongoing debates over ethics, methodology, and political influence.

Major depressive disorder (MDD) is a disabling condition affecting children, adolescents, and adults worldwide. A high proportion of patients do not respond to one or more pharmacological treatments and are said to have treatment-resistant or difficult-to-treat depression. Inadequate response to current treatments could be due to medication nonadherence, inter-individual variability in treatment response, misdiagnosis, diminished confidence in treatment after many trials, or lack of selectivity. Demonstrating an adequate response in the clinical trial setting is also challenging. Patients with depression may experience non-specific treatment effects when receiving placebo in clinical trials, which may contribute to inadequate response. Studies have attempted to reduce the placebo response rates using adaptive designs such as sequential parallel comparison design. Despite some of these innovations in study design, there remains an unmet need to develop more targeted therapeutics, possibly through precision psychiatry-based approaches to reduce the number of treatment failures and improve remission rates. Examples of precision psychiatry approaches include pharmacogenetic testing, neuroimaging, and machine learning. These approaches have identified neural circuit biotypes of MDD that may improve precision if they can be feasibly bridged to real-world clinical practice. Clinical biomarkers that can effectively predict response to treatment based on individual phenotypes are needed. This review examines why current treatment approaches for MDD often fail and discusses potential benefits and challenges of a more targeted approach, and suggested approaches for clinical studies, which may improve remission rates and reduce the risk of relapse, leading to better functioning in patients with depression.

Assisted Outpatient Treatment (AOT) is a controversial civil court program wherein a judge orders a person with severe mental illness to adhere to an outpatient treatment plan designed to improve treatment adherence, prevent relapse and dangerous deterioration. Several states, including California and New York, have recently promoted use of AOT to try to address high rates of homelessness among person with severe mental illness. Under AOT, clinicians treating these patients must balance the ethical principles of patient autonomy and beneficence, and employ AOT only when previous treatment failed as a result of treatment non-adherence. However, some critics of AOT argue that not only is it coercive and ineffective but that the court mandate to adhere to prescribed medications, usually antipsychotic medications, compels AOT recipients to take ineffective and even harmful medications. This article examines the assertion of these critics and reviews the evidence of antipsychotic effectiveness and potential harms in treating psychotic disorders under a civil court order.

The role of serotonin reuptake inhibitors (SSRIs) in treating psychiatric disorders has been a subject of heated debate since their introduction. Initially celebrated for their potential to address various mental health conditions during the late 1980s and 1990s, SSRIs have since faced significant scrutiny. Critics argue that their benefits may not be as substantial as initially believed. Over the past two decades, concerns have intensified with the emergence of boxed warnings about the risks associated with SSRIs, particularly regarding their link to increased suicidal thoughts in youth. This controversy is further complicated by questions about the integrity of early industry-sponsored trials and the reliability of subsequent National Institute of Mental Health (NIMH) trials. These issues have raised ongoing critical concerns about the effectiveness and safety of SSRIs, especially for treating a range of disorders in children and adolescents. This review seeks to critically appraise by presenting empirical evidence that addresses these controversies. It explores the validity of the monoamine theory, examines the fidelity of early and recent trials, and considers the broader implications for clinical practice. By answering specific, targeted questions, this article aims to clarify the ongoing debate and enhance the understanding of SSRIs’ role in mental health treatment. The goal is to support clinicians in making more informed decisions when prescribing these medications and to ensure consideration of the balance between potential benefits and risks for young patients with mental health disorders.

Epidemiological data indicates a rising prevalence of autism spectrum disorder (ASD) among eight-year-old children, with rates increasing from 1 in 44 to 1 in 36 between 2022 and 2023. This growing prevalence poses significant challenges in achieving accurate diagnoses, particularly due to comorbid conditions and diagnostic overshadowing. Certain subgroups—such as females with ASD, individuals with high cognitive abilities, and ethnic minorities—remain at heightened risk of underdiagnosis. Diagnostic tools like the Autism Diagnostic Observation Schedule (ADOS-2) have limitations, particularly in clinical settings where gender biases and cultural differences in symptom presentation can complicate accurate assessment. Moreover, rural areas face additional burdens due to limited access to care, further exacerbating diagnostic challenges. The review underscores the necessity for improved screening and diagnostic methods tailored to diverse populations, acknowledging the current limitations of existing tools. It also highlights significant barriers such as workforce shortages and lengthy wait times for evaluations. Emphasizing the importance of clinician education and targeted diagnostic approaches, the review calls for attention to cultural and gender differences in ASD evaluation.