A psychiatry residency means working on some of the most open questions in medicine. Depression alone illustrates the scale of the challenge: by 2030, WHO projections place it as the leading cause of global disease burden. Yet the mechanisms behind it remain only partially understood. The brain is still, in many ways, an unsolved problem.
«Neurology covers the central and peripheral nervous system as a whole» explains Prof. Cristina Colombo, Head of the Department of Psychiatry at IRCCS San Raffaele Hospital (a designated clinical research institution). «It identifies defined conditions: Parkinson's disease, multiple sclerosis, cerebral ischaemia. It works on something visible, something that can be documented».
Psychiatry is a different matter. Its subject is the functional disruption of the brain: an organ that produces symptoms such as insomnia, loss of energy and motivation, and deeply negative thinking, without any underlying structural damage.
The old term neuropsychiatry, which grouped the two disciplines together, was formally abolished in Italy in the 1970s at the initiative of Professor Carlo Lorenzo Cazzullo, who separated them permanently. The one remaining exception is child neuropsychiatry: in paediatric medicine, differential diagnosis is more complex, and the overlap between neurological conditions and behavioural disorders such as autism still requires an integrated approach.
Prof. Colombo uses a precise image to describe depression: the brain shuts down. A total freeze, emotional, cognitive, behavioural. A person who the day before was running a department or teaching a class finds themselves unable to get dressed, unable to perform the basic tasks of daily life. This is something far more physical and deep-rooted than what is commonly called sadness, and it has little to do with grief over a specific event.
«When a patient starts to cry, I'm pleased» Prof. Colombo explains. «It means they're starting to feel emotions again». Treated correctly, depression can resolve completely, not just functionally, and patients sometimes describe feeling better than they did before. This reversibility, a brain that locks up and then restarts, is what drew Prof. Colombo to psychiatry during her years as a medical student.
Schizophrenia follows an entirely different trajectory: a patient who may initially be highly intelligent and socially integrated can, over time, lose progressively more of their capacities if left without support. Two opposing clinical pictures, both involving the brain, both still only partially understood.
In psychiatry, the distance between a research finding and its clinical application is often shorter than in other specialties. «We're more adaptable» Prof. Colombo observes. «Perhaps because we're used to the difficulty of working on something invisible. That may be why we try to bring what we've observed in the lab into the ward as quickly as possible».
Chronotherapy is one example. The Department of Psychiatry at IRCCS San Raffaele Hospital has published on the subject for years, producing concrete results on the relationship between the biological clock, circadian rhythms, and depression. Early findings were met with scepticism; today chronotherapy is recognised in international treatment guidelines for bipolar depression.
The same drive characterises research into inflammation: studies are currently under way examining peripheral inflammatory markers in psychiatric patients, with preliminary data showing variation across the seasons with the highest rates of depression. The conclusions are still distant. «We can't say anything definitive yet» Prof. Colombo notes, «but the direction is worth pursuing».
Supporting this line of inquiry is functional MRI, a tool that allows researchers to compare brain activity in a depressed patient before and after treatment, making visible, at a population level rather than an individual one, the functional disruption that standard structural imaging cannot detect.
The Department of Psychiatry at IRCCS San Raffaele Hospital has a feature that sets it apart: following the acquisition of Villa Turro, it now has over one hundred inpatient beds, organised by diagnosis. That structure has had a significant effect on both clinical practice and the training of residents.
«Placing a person with depression on a ward alongside patients with very different psychiatric conditions can be deeply frightening», Prof. Colombo explains. «Separating by diagnosis has produced a great deal: specialist teams for each condition, better-protected patients, environments that allow extended observation». The separation has also shaped research: the ability to follow patients over time and isolate variables has enabled the department to build scientific programmes with direct clinical relevance.
For residents, this translates into time with patients: careful observation, working alongside active researchers, and frequent contributions to publications. Most will not go on to make research the centre of their career. But the method stays. «You become a doctor who understands that it matters to keep studying» Prof. Colombo notes. «A disposition that creates the conditions for professional growth».
To students who ask why psychiatry, Prof. Colombo gives the same answer: medicine's last frontier, with more left to discover than almost anywhere else. Progress in oncology and cardiovascular medicine, along with routine monitoring of cholesterol and blood pressure, has reduced the relative burden of many conditions. In psychiatry, the link between cause, mechanism, and disease remains largely uncharted. The human and social cost stays high: patients with psychiatric conditions often live long lives but struggle to work, to build, to function in the world.
There is a further dimension to the daily work, one that tends to go unnoticed: the psychiatrist is often the only doctor who sees the patient as a whole person. When a physical problem arises, a tumour, a chronic condition, it is frequently the psychiatrist who accompanies the patient through it, who persuades colleagues to act, who bridges the gap. «We have to consider everything,» Prof. Colombo observes, «because if we treat the depression but another clinical condition is present, the person will keep suffering psychologically too.»
Prof. Colombo holds a second specialisation in clinical criminology, a choice driven by curiosity about a specific boundary: the difference between a crime committed because of mental illness and a crime committed in the presence of mental illness. «Working through that distinction is genuinely fascinating» she explains. «And then there is a particular category of individuals, those without empathy, who experience no emotions, which is rare, and the research on the subject is compelling».
Forensic psychiatry is in a period of significant development. Where a diagnosis of schizophrenia was once sufficient to close an evaluation, today the process is considerably more complex. The aim is to establish whether the person retained the capacity not to commit the act, even while affected by a psychiatric condition. A psychiatry residency is the required starting point for this field.
Career paths are broad: acute inpatient wards, community mental health centres, academic research, private practice, and the forensic and custodial settings described above. Different contexts with a single thread running through them: working on an organ that has not yet finished revealing itself.