Psychiatry is the branch of medicine that studies, diagnoses and treats mental illness and behavioral disorders. While all physicians will encounter patients with mental illnesses and any of them may treat it, psychiatrists specialize in these areas. They are more extensively trained in the differential diagnosis (the distinguishing of various forms) and treatment of mental illness and are required to keep up to date on the newest developments in the field. Many other professionals also provide mental health care, such as psychologists, nurse practitioners, counsellors, physician assistants and social workers. In general only doctors, nurse practitioners, or physician assistants may prescribe mental health medication in the United States[1]. In some countries, mental health medication may only be prescribed by medical doctors.
Practice of psychiatry
Psychiatry is one of the clinical medical disciplines which involve the diagnosis, treatment and prevention of mental and behavioral disorders such as clinical depression, bipolar disorder, schizophrenia and anxiety disorders.
The field of psychiatry itself can be divided into various subspecialties. These include:
Practicing psychiatrists may specialize in certain areas of interest such as psychopharmacology, mood disorders, neuropsychiatry, eating disorders, psychiatric rehabilitation, crisis assessment and treatment, early psychosis intervention, community psychiatry (home treatment and outreach) and various forms of psychotherapy such as psychodynamic therapy and cognitive behavioral therapy.
Individuals with mental illness are commonly referred to as patients (particularly in the UK) but may also be called clients, especially when treated privately. They may come under the care of a psychiatrist or other psychiatric practitioners by various paths, the two most common being self-referral or referral by a primary-care physician. Alternatively, a patient 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 their patient's referral, a psychiatrist first assesses their patient's mental and somatic (i.e. general medical) condition. This usually involves interviewing the patient and often obtaining information collated from other sources such as other health and social care professionals, relatives, associates, law enforcement personnel and psychiatric rating scales. Physical examination is usually performed to establish or exclude other illnesses (e.g. thyroid dysfunction or brain tumors) or identify any signs of self-harm. Blood tests and medical imaging may be also performed and their associated medical specialists consulted.
Various forms of medication, therapy and counseling deal with mental and behavioral conditions. Psychotherapy may be used for many conditions, either exclusively or in combination with medication. Commencing treatment with medication requires the patient to agree to this treatment (although in many countries the law provides overriding circumstances) and that they will follow the dosage prescribed. Many psychiatric medications can produce side-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. Electroconvulsive therapy (ECT) is sometimes administered for serious and disabling conditions, especially those unresponsive to medication. ECT has drawn criticism from anti-psychiatry groups despite evidence for its efficacy. Finally, ethnopsychopharmacology (environmental and genetic variables that dynamically affect patient receptivity to therapy) is considered. The SAMHSA (Substance Abuse and Mental Health Services Administration) initiative to improve service to ethnic minority groups illustrates that methodological efficacy is judged according to each particular case and not by the advocates of any one therapy. Use of SCID-DSMIV or formal criteria is encouraged due to evidence of diagnoses at odds with genetic makeup (Wells, 1998).
Psychiatric patients may be either inpatients or outpatients. Psychiatric outpatients periodically visit their psychiatrist for consultation in his or her office, usually for an appointment lasting thirty to sixty minutes. These consultations normally involve the psychiatrist interviewing the patient to update their assessment of the patient's condition and management of any medication. The psychiatrist may also provide psychotherapy. The frequency with which a psychiatrist sees patients varies widely, from days to months, depending on the type, severity and stability of each patient's condition.
Psychiatric inpatients are patients admitted to a hospital to receive psychiatric care, sometimes involuntarily. In North America, the criteria for involuntary admission vary with jurisdiction. It may be as broad as having a mental disorder and being capable of mental or physical deterioration or as narrow as a patient being considered to be an immediate danger to themselves or others. In the UK, involuntary admission is limited to this narrow criterion. In North America, some jurisdictions give psychiatrists the sole authority to admit patients forcibly, while others require a trial.
Once in the care of a hospital, patients are monitored, given medication and psychologically tested. If necessary, they are prevented from harming themselves or others. Hospitalized patients are increasingly being managed in a multidisciplinary fashion, meaning patients may encounter a variety of nursing staff, occupational therapists, psychotherapists, social workers and other healthcare professionals.
Historically, particularly before the advent of psychiatric medication, hospital stays averaged six months or more, with a significant number of cases involving hospitalization for many years. Today the average hospital stay is around two to three weeks, with only a small number of cases involving long-term hospitalization. When discharged from the hospital, inpatients often become outpatients.
The DSM system
In the United States, the standard system of psychiatric diagnoses is given in the Diagnostic and Statistical Manual of Mental Disorders (known as the DSM), overseen and revised by the American Psychiatric Association. It is currently in its fourth revised edition (IV-TR, published 2000) and is based on five axes:
Common axis I disorders include substance dependence and abuse (e.g. alcohol dependence); mood disorders (e.g. depression, bipolar disorder); psychotic disorders (e.g. schizophrenia, schizoaffective disorder); and anxiety disorders (e.g. post-traumatic stress disorder, obsessive-compulsive disorder). Axis II disorders include borderline personality disorder, schizotypal personality disorder, avoidant personality disorder and antisocial personality disorder.
The intention is to create a set of diagnoses that are replicable and meaningful, although the categories are broad and many of the symptoms overlap. While the system was originally intended to enhance research into both diagnosis and treatment, the nomenclature is now one of two standards widely used by clinicians, administrators and insurance companies in many countries. However, it has been critiqued for being vague, poorly defined and lacking proper scientific foundation [1].
ICD-10 (International Classification of Diseases-10), the main alternative to the DSM, is less specific in its criteria for each illess. It is used primarily in Europe.
Contrast with psychology
Psychiatry is practiced by psychiatrists, who are medical doctors specializing in mental illness. They are trained in the medical approach to disorders and in the use of medications. Many (but not all) psychiatrists are also trained to conduct psychotherapy. Psychiatrists ideally evaluate patients from a biopsychosocial perspective before prescribing treatment.
Psychology is the larger study of human behavior and thought processes. Psychology is as much an academic field of study (like biology or sociology) as a profession, and as a whole, is concerned with the study of normal everyday human behavior as much as it is the study of mental illness. Psychologists may study how drugs or other chemical agents affect the brain, but generally are not trained to prescribe or administer drugs.
Clinical psychology is the branch of psychology that specializes in understanding and helping those experiencing mental distress or behavioral problems. Clinical psychologists have extensive postgraduate training in mental health, psychological assessment, psychotherapy, and psychosocial interventions, and are often found working in similar settings and with the same kinds of patients or clients as psychiatrists. Unlike psychiatrists, they start with a general psychological training rather than a general medical training, before going onto postgraduate courses. They do not always assume a medical model or so-called 'neo-Kraepelinian' categories (named after the psychiatrist Emil Kraepelin, the father of descriptive psychiatry). While psychiatrists may claim exclusive expertise in medication-based interventions and the general medical context, clinical psychologists may claim particular exertise in psychosocial interventions and the general psychosocial context, although the two are not always separated in this way.
Clinical psychologists are generally not authorised to prescribe medications in the United States (exceptions have been made in the Department of Defense, Guam, New Mexico, and Louisiana, but the psychologist must complete a postdoctoral training program in clinical psychopharmacology and practicum, and pass a licensing examination prior to doing so). The turf battle over prescribing privileges is ongoing in the U.S. A significant subset of psychologists argue that there is an inadequate number of psychiatrists for the number of people with mental health problems, and that focused education in psychopharmacology is adequate to provide medication management. The American Psychiatric Association has long argued that a full medical training is necessary to make the diagnostic, therapeutic and potentially life-threatening decisions that accompany the pharmacologic treatment of those with serious mental health problems.
Professional requirements
In the United States, psychiatrists can be board certified as specialists in their field. After completing four years of medical school, physicians practice as psychiatry residents for four years. Psychiatry residents are required to complete at least four months of medicine (internal medicine or pediatrics) and two months of neurology during these four years. After completing their training, psychiatrists take written and then oral board examinations, each of which has a failure rate that approaches 50%, before becoming board certified. In the United Kingdom, people work as a senior house officer (SHO) in psychiatry for 2-3 years while sitting postgraduate exams, after which they may apply for a specialist registrar post, which may be in any one of several areas of specialization within psychiatry. In other countries, similar rules usually apply.
Some psychiatrists specialize in helping certain age groups; child and adolescent psychiatrists work with children and teenagers in addressing psychological problems. Those who work with the elderly are called geriatric psychiatrists, or in the UK, psychogeriatricians. Those who practice psychiatry in the workplace are called industrial psychiatrists (this is a term used in the US but not the UK); those working in the courtroom and reporting to the judge and jury (in both criminal and civil court cases) are forensic psychiatrists. Forensic psychiatrists also treat mentally disordered offenders and other patients whose condition is such that they have to be treated in secure units.
In the United Kingdom there are several different areas of specialization in which one may train as a specialist registrar (the 3-4 final years of training required before becoming a senior doctor or consultant). They are general adult psychiatry, child and adolescent psychiatry, psychogeriatrics, forensic psychiatry, psychotherapy, and drugs and alcohol. After this period as a specialist registrar, one has to be approved by the Royal College of Psychiatrists as an approved specialist in the chosen field before going on to apply for a consultant post in that field.
History
Psychiatric illnesses are sometimes characterized as disorders of the mind rather than the brain, although the distinction is not always obvious and has changed in the last few decades as understanding of the treated illnesses grew. Many conditions have been linked to biological or chemical abnormalities in the brain's psychology, but for some conditions the etiology and pathogenesis are still the subject of intense research.
For a long period of history, neurology and psychiatry were a single discipline, and following their division the tremendous advances in neurosciences (especially in genetics and neuroimaging) recently are bringing areas of the two disciplines back together. Indeed, in a 2002 review article in the American Journal of Psychiatry, Professor Joseph B. Martin, Dean of Harvard Medical School and a neurologist by training, wrote that "the separation of the (neurological versus psychiatric disorders) is arbitrary, often influenced by beliefs rather than proven scientific observations. And the fact that the brain and mind are one makes the separation artificial anyway" (Martin 2002). One example of this is the overlap between the two fields in the treatment of illnesses such as Alzheimer's disease.
Psychiatry was at first a pragmatic discipline that was part of general medicine, combining medicine and practical psychology. The work of Emil Kraepelin laid the foundations of scientific psychiatry. A neurologist, Sigmund Freud, used these same powers of medically based observation to develop the field of psychoanalysis. For many years, Freudian theories dominated psychiatric thinking.
The discovery of lithium carbonate as a treatment for bipolar disorder (and shortly thereafter after by the development of typical antipsychotics for treatment of schizophrenia), followed by the development of fields such as molecular biology and tools such as neuroimaging has led to psychiatry re-discovering its origins in physical and observational medicine without losing sight of its humane dimension.
Further considerations
Anti-psychiatry
- Main article: anti-psychiatry
Some professionals in the mental health field claim that in psychiatry there are no known biological markers for the purported DSM disorders [2].
Unlike most other areas of medicine, there is an anti-psychiatric movement opposed to the practices of, and in some cases the existence of, psychiatry. This phenomenon mainly originated in the 1960s and 1970s under the leadership of David Cooper, Thomas Szasz and R. D. Laing. Presently there is a scholarly journal, originally founded in 1999 by psychiatrist Peter Breggin, devoted exclusively to debunking bio-psychiatry [3]. And though the “medical model” of mental disorders is generally accepted in the field, some professionals and patients are advocating a “trauma model” of mental disorders, including schizophrenia [4] [5][6].
The Church of Scientology opposes psychiatry for various reasons, mainly through its Citizens Commission on Human Rights. Christian Science also forbids the use of psychiatric drugs.
Improvements and criticisms
Criticism has been made regarding the need for improvement in psychiatric medications, as illustrated by studies of [Pharmacogenetic_polymorphisms pharmacogenetic polymorphism] showing that people of various ethnicities, for example one third of African American and Asian groups have an increased risk of side effects and toxicity (Wells, 1998). Cultural and environmental factors including diet, medication, herb and alcohol use can affect enzyme activity.
Training and techniques of psychiatrists vary. There also appear to be problems in terms of diagnostic reliability (including misdiagnosis) in regard to ideal circumstances {Williams et al. 1992} and more so in routine clinical practice (McGorry et al. 1995), especially when comparing the criteria of the different psychiatric manuals (van Os et al. 1999). Also, as in any medical specialty, different individuals respond differently to a given drug. This can lead to some patients experiencing a prolonged trial-and-error process involving numerous serious adverse effects. There are also questions about whether psychiatric drugs are disorder- or problem- specific in the way that is claimed (Moncrieff & Cohen, 2004).
The number of psychiatric drug prescriptions in the United States and other developed countries has been rising dramatically for a number of years. For example, the high rate of methylphenidate (Ritalin) use among school children in the U.S. has come under greater scrutiny. In a 1984-2000 study, Australia and New Zealand ranked third in total psycho-stimulant use after the United States and Canada [7]. Australian physicians prescribe far fewer psychiatric drugs, in part out of concern for reducing the number of falls in their elderly medical patients, as described by Stephen Lord of the University of New South Wales.
Another concern regarding the practice of psychiatry centers on the issue of involuntary treatment. Such concerns center on issues of civil liberties and personal freedoms. In the U.S. there are many restrictions in place to attempt to maximize the desires of the patient with the need for treatment. Most states allow involuntary treatment only in the most severe cases where a person poses an immediate threat to themselves or others or if they are unable to provide for their own basic needs such as food, clothing, or shelter (see Laura's Law). Furthermore, children are allowed to be placed into an institution at the will of their parents or legal guardians [8].
Footnotes
Related terms
- "Alienist" was a somewhat derogatory and now obsolete term for a psychiatrist or psychologist.
- "Shrink", taken from "head shrinker", is a slang term for a psychiatrist or psychotherapist, sometimes treated as derogatory or offensive.
See also
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External links
References
- Martin J. B. "The integration of neurology, psychiatry and neuroscience in the 21st century". Am. J. of Psychiatry 2002; 159:695-704. Fulltext. PMID 11986119.
- Wells, S. M. "Research shows ethnicity a factor in medication response," in Psychopharmacology across cultures: The science and practice of ethnopsychopharmacology. the Evaluation Center@HSRI 23 Oct. 1998; 1(3). HSRI.
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