Psychiatry is the medical specialty devoted to the study and treatment of mental disorders. These mental disorders include various affective, behavioural, cognitive and perceptualabnormalities. A medical doctor specializing in psychiatry is a psychiatrist.
Psychiatric assessment typically starts with a mental status examination and the compilation of a case history. Psychological tests and physical examinations may be conducted, including on occasion the use of neuroimaging or other neurophysiological techniques. Mental disorders are diagnosed in accordance with criteria listed in diagnostic manuals such as the widely used Diagnostic and Statistical Manual of Mental Disorders (DSM), published by theAmerican Psychiatric Association, and the International Classification of Diseases (ICD), edited and used by theWorld Health Organization. The fifth edition of the DSM (DSM-5) is scheduled to be published in 2013, and its development is suspected to be of significant interest to many medical fields.
Psychiatric treatment applies a variety of modalities, including psychoactivemedication, psychotherapy and a wide range of other techniques such as transcranial magnetic stimulation. Treatment may be delivered on an inpatient oroutpatient basis, depending on the severity of functional impairment or on other aspects of the disorder in question. Research and treatment within psychiatry as a whole are conducted on an interdisciplinary basis, sourcing an array of sub-specialties and theoretical approaches.).
Anti-psychiatry and deinstitutionalization
The introduction of psychiatric medications and the use of laboratory tests altered the doctor-patient relationshipbetween psychiatrists and their patients. Psychiatry’s shift to the hard sciences had been interpreted as a lack of concern for patients. Anti-psychiatry had become more prevalent in the late twentieth century due to this and publications in the media which conceptualized mental disorders as myths. Others in the movement argued that psychiatry was a form of social control and demanded that institutionalized psychiatric care, stemming from Pinel’s thereapeutic asylum, be abolished.
Electroconvulsive therapy (ECT) was one treatment that the anti-psychiatry movement wanted eliminated. They alleged that ECT damaged the brain and was used as a tool for discipline. While some believe there is no evidence that ECT damages the brain, there are some citations that ECT does cause damage. Sometimes ECT is used as punishment or as a threat and there have been isolated incidents where the use of ECT was threatened to keep the patients “in line”.The prevalence of psychiatric medication helped initiate deinstitutionalization, the process of discharging patients from psychiatric hospitals to the community. The pressure from the anti-psychiatry movements and the ideology of community treatment from the medical arena helped sustain deinstitutionalization. Thirty-three years after deinstitutionalization started in the United States, only 19% of the patients in state hospitals remained.
Mental health professionals envisioned a process wherein patients would be discharged into communities where they could participate in a normal life while living in a therapeutic atmosphere. Psychiatrists were criticized, however, for failing to develop community-based support and treatment. Community-based facilities were not available because of the political infighting between in-patient and community-based social services, and an unwillingness by social services to dispense funding to provide adequately for patients to be discharged into community-based facilities.
Theory and focus
“Psychiatry, more than any other branch of medicine, forces its practitioners to wrestle with the nature of evidence, the validity of introspection, problems in communication, and other long-standing philosophical issues”
The term psychiatry (Greek “ψυχιατρική”, psychiatrikē), coined by Johann Christian Reil in 1808, comes from theGreek “ψυχή” (psychē: “soul or mind”) and “ιατρός” (iatros: “healer”).It refers to a field of medicine focused specifically on the mind, aiming to study, prevent, and treatmental disorders in humans. It has been described as an intermediary between the world from a social context and the world from the perspective of those who are mentally ill.
Those who specialize in psychiatry are different than most other mental health professionals and physicians in that they must be familiar with both the social and biological sciences. The discipline is interested in the operations of different organs and body systems as classified by the patient’s subjective experiences and the objective physiology of the patient. Psychiatry exists to treat mental disorders which are conventionally divided into three very general categories: mental illness, severe learning disability, and personality disorder. While the focus of psychiatry has changed little throughout time, the diagnostic and treatment processes have evolved dramatically and continue to do so. Since the late 20th century, the field of psychiatry has continued to become more biological and less conceptually isolated from the field of medicine.
Scope of practice
While the medical specialty of psychiatry utilizes research in the field of neuroscience, psychology, medicine,biology, biochemistry, and pharmacology, it has generally been considered a middle ground between neurology and psychology. Unlike other physicians and neurologists, psychiatrists specialize in the doctor-patient relationship and are trained to varying extents in the use of psychotherapy and other therapeutic communication techniques. Psychiatrists also differ from psychologists in that they are physicians and the entirety of their post-graduate trainingis revolved around the field of medicine. Psychiatrists can therefore counsel patients, prescribe medication, orderlaboratory tests, order neuroimaging, and conduct physical examinations.
Like other purveyors of professional ethics, the World Psychiatric Association issues an ethical code to govern the conduct of psychiatrists. The psychiatric code of ethics, first set forth through the Declaration of Hawaii in 1977, has been expanded through a 1983 Vienna update and, in 1996, the broader Madrid Declaration. The code was further revised in Hamburg, 1999. The World Psychiatric Association code covers such matters as patient assessment, up-to-date knowledge, the human dignity of incapacitated patients, confidentiality, research ethics, sex selection,euthanasia, organ transplantation, torture, the death penalty, media relations, genetics, and ethnic or cultural discrimination. In establishing such ethical codes, the profession has responded to a number of controversies about the practice of psychiatry.
Various subspecialties and/or theoretical approaches exist which are related to the field of psychiatry. They include the following:
Psychiatric illnesses can be conceptualised in a number of different ways. The biomedical approach examines signs and symptoms and compares them with diagnostic criteria. Mental illness can be assessed, conversely, through a narrative which tries to incorporate symptoms into a meaningful life history and to frame them as responses to external conditions. Both approaches are important in the field of psychiatry, but have not sufficiently reconciled to settle controversy over either the selection of a psychiatric paradigm or the specification of psychopathology. The notion of a “biopsychosocial model” is often used to underline the multifactorial nature of clinical impairment. Alternatively, a “biocognitive model” acknowledges the physiological basis for the mind’s existence, but identifies cognition as an irreducible and independent realm in which disorder may occur. The biocognitive approach includes a mentalistetiology and provides a dualist revision of the biopsychosocial view, reflecting the efforts of psychiatrist Niall McLaren to bring the discipline into scientific maturity in accordance with the paradigmatic standards of philosopherThomas Kuhn.
Industry and academia
All physicians can diagnose mental disorders and prescribe treatments utilizing principles of psychiatry. Psychiatristsare either: 1) clinicians who specialize in psychiatry and are certified in treating mental illness; or (2) scientists in the academic field of psychiatry who are qualified as research doctors in this field. Psychiatrists may also go through significant training to conduct psychotherapy, psychoanalysis and cognitive behavioral therapy, but it is their training as physicians that differentiates them from other mental health professionals.
Psychiatric research is, by its very nature, interdisciplinary. It combines social, biological and psychological perspectives to understand the nature and treatment of mental disorders. Clinical and research psychiatrists study basic and clinical psychiatric topics at research institutions and publish articles in journals. Under the supervision ofinstitutional review boards, psychiatric clinical researchers look at topics such as neuroimaging, genetics, and psychopharmacology in order to enhance diagnostic validity and reliability, to discover new treatment methods, and to classify new mental disorders.
Psychiatric diagnoses take place in a wide variety of settings and are performed by many different health professionals. Therefore, the diagnostic procedure may vary greatly based upon these factors. Typically, though, a psychiatric diagnosis utilizes a differential diagnosis procedure where a mental status examination and physical examination is conducted, pathological, psychopathological or psychosocial histories obtained, and sometimesneuroimages or other neurophysiological measurements are taken, or personality tests or cognitive tests administered. In some cases, a brain scan might be used to rule out other medical illnesses, but at this time relying on brain scans alone cannot accurately diagnose a mental illness or tell the risk of getting a mental illness in the future. A few psychiatrists are beginning to utilize genetics during the diagnostic process but on the whole this remains a research topic.
Three main diagnostic manuals used to classify mental health conditions are in use today. The ICD-10 is produced and published by the World Health Organisation, includes a section on psychiatric conditions, and is used worldwide. The Diagnostic and Statistical Manual of Mental Disorders, produced and published by the American Psychiatric Association, is primarily focused on mental health conditions and is the main classification tool in the United States. It is currently in its fourth revised edition and is also used worldwide. The Chinese Society of Psychiatry has also produced a diagnostic manual, the Chinese Classification of Mental Disorders.
The stated intention of diagnostic manuals is typically to develop replicable and clinically useful categories and criteria, to facilitate consensus and agreed upon standards, whilst being atheoretical as regards etiology. However, the categories are nevertheless based on particular psychiatric theories and data; they are broad and often specified by numerous possible combinations of symptoms, and many of the categories overlap in symptomology or typically occur together. While originally intended only as a guide for experienced clinicians trained in its use, the nomenclature is now widely used by clinicians, administrators and insurance companies in many countries.
Individuals with mental health conditions are commonly referred to as patients but may also be called clients,consumers, or service recipients. They may come under the care of a psychiatric physician or other psychiatric practitioners by various paths, the two most common being self-referral or referral by a primary-care physician. Alternatively, a person may be referred by hospital medical staff, by court order, involuntary commitment, or, in the UK and Australia, by sectioning under a mental health law.
Whatever the circumstance of a person’s referral, a psychiatrist first assesses the person’s mental and physical condition. This usually involves interviewing the person and often obtaining information from other sources such as other health and social care professionals, relatives, associates, law enforcement and emergency medical personnel and psychiatric rating scales. A mental status examination is carried out, and a physical examination is usually performed to establish or exclude other illnesses, such as thyroid dysfunction or brain tumors, or identify any signs ofself-harm; this examination may be done by someone other than the psychiatrist, especially if blood tests and medical imaging are performed.
Like all medications, psychiatric medications can cause adverse effects in patients and hence often involve ongoing therapeutic drug monitoring, for instance full blood counts or, for patients taking lithium salts, serum levels of lithium, renal and thyroid function. Electroconvulsive therapy (ECT) is sometimes administered for serious and disabling conditions, especially those unresponsive to medication. The efficacy and adverse effects of psychiatric drugs have been challenged.
The close relationship between those prescribing psychiatric medication and pharmaceutical companies has become increasingly controversial along with the influence which pharmaceutical companies are exerting on mental health policies.
Also controversial are forced drugging and the “lack of insight” label. According to a report published by the US National Council on Disability,
Involuntary treatment is extremely rare outside the psychiatric system, allowable only in such cases as unconsciousness or the inability to communicate. People with psychiatric disabilities, on the other hand, even when they vigorously protest treatments they do not want, are routinely subjected to them anyway, on the justification that they “lack insight” or are unable to recognize their need for treatment because of their “mental illness”. In practice, “lack of insight” becomes disagreement with the treating professional, and people who disagree are labeled “noncompliant” or “uncooperative with treatment”.
Psychiatric treatments have changed over the past several decades. In the past, psychiatric patients were oftenhospitalized for six months or more, with some cases involving hospitalization for many years. Today, people receiving psychiatric treatment are more likely to be seen as outpatients. If hospitalization is required, the average hospital stay is around one to two weeks, with only a small number receiving long-term hospitalization.
Psychiatric inpatients are people admitted to a hospital or clinic to receive psychiatric care. Some are admitted involuntarily, perhaps committed to a secure hospital, or in some jurisdictions to a facility within the prison system. In many countries including the USA and Canada, the criteria for involuntary admission vary with local jurisdiction. They may be as broad as having a mental health condition, or as narrow as being an immediate danger to themselves and/or others. Bed availability is often the real determinant of admission decisions to hard pressed public facilities. European Human Rights legislation restricts detention to medically-certified cases of mental disorder, and adds a right to timely judicial review of detention.
Patients may be admitted voluntarily if the treating doctor considers that safety isn’t compromised by this less restrictive option. Inpatient psychiatric wards may be secure (for those thought to have a particular risk of violence or self-harm) or unlocked/open. Some wards are mixed-sex whilst same-sex wards are increasingly favored to protect women inpatients. Once in the care of a hospital, people are assessed, monitored, and often given medication and care from a multidisciplinary team, which may include physicians, psychiatric nurse practitioners, psychiatric nurses, clinical psychologists, psychotherapists, psychiatric social workers, occupational therapists and social workers. If a person receiving treatment in a psychiatric hospital is assessed as at particular risk of harming themselves or others, they may be put on constant or intermittent one-to-one supervision, and may be physically restrained or medicated. People on inpatient wards may be allowed leave for periods of time, either accompanied or on their own.
In many developed countries there has been a massive reduction in psychiatric beds since the mid 20th century, with the growth of community care. Standards of inpatient care remain a challenge in some public and private facilities, due to levels of funding, and facilities in developing countries are typically grossly inadequate for the same reason.
People may receive psychiatric care on an inpatient or outpatient basis. Outpatient treatment involves periodic visits to a clinician for consultation in his or her office, usually for an appointment lasting thirty to sixty minutes. These consultations normally involve the psychiatric practitioner interviewing the person to update their assessment of the person’s condition, and to provide psychotherapy or review medication. The frequency with which a psychiatric practitioner sees people in treatment varies widely, from days to months, depending on the type, severity and stability of each person’s condition, and depending on what the clinician and client decide would be best. Increasingly, psychiatrists are limiting their practices to psychopharmacology (prescribing medications) with little or no time devoted to psychotherapy or “talk” therapies, or behavior modification. Psychiatrists who serve the lower end of the market, which is dependent on insurance reimbursements, do not receive insurance payments for lengthy psychotherapy sessions which is competitive with that offered for the brief consultations needed for prescribing and monitoring medication. Psychotherapy in such situations is performed by a lower paid psychologist or social worker. The role of psychiatrists is changing in community psychiatry, with many assuming more leadership roles, coordinating and supervising teams of allied health professionals and junior doctors in delivery of health services.