Psychiatry is a medical specialty which exists to study, prevent, and treat
mental disorders in humans. Psychiatric assessment typically involves a mental status examinationand taking a case history, and psychological tests may be administered. Physical examinations may be conducted and occasionally neuroimages or other neurophysiological measurements taken. Diagnostic procedures vary but official criteria are listed in manuals, the most common being the ICDfrom the World Health Organization and the DSM from the American Psychiatric Association. Psychiatric medicationis a central treatment option, which is largely unique to psychiatry along with rarer procedures such as Electroconvulsive therapy. Psychotherapyis also a major treatment option in psychiatry, although it is also the speciality of other mental health professions. Psychiatric services may be provided on an inpatientor outpatientbasis. In certain authorized cases this may be done on an involuntary basis. Both the research and clinical application of psychiatry are considered interdisciplinary. Because of this, various subspecialties and theoretical approaches exist. Psychiatrists can be considered physicians who specialize in the doctor-patient relationship utilizing some of medicine's newest classification schemes, diagnostic tools and treatments.
Psychiatry can be said to have originated in the 5th century BC, while the first hospitals for the mentally ill were created in the
Middle Ages. The 18th century saw the development of psychiatry as a recognized field and mental health institutions came to utilize more elaborate, as well as some more humane, treatments. The 19th century saw a massive increase in patient populations. The 20th century saw a rebirth of a biological understanding of mental disorders as well the introduction of disease classifications and psychiatric medications. An anti-psychiatrymovement emerged in the 1960s and a shift led to the dismantling of state psychiatric hospitals in favor of community treatment. There have been changes in psychiatric diagnoses and treatments and in the balance between the biological and social sciences. Research has continued looking into the origins, classification, and treatment of mental disorders.
[http://www.insects.org/ced4/etymology.html] . The butterfly features on the coat of arms of the Royal College of Psychiatrists. [cite journal|last=James|first=F.E.|date=1991|title=Psyche|journal=Psychiatric Bulletin|volume=15|pages=429–431|url=http://pb.rcpsych.org/cgi/reprint/15/7/429.pdf|accessdate=2008-08-04|doi=10.1192/pb.15.7.429]
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" (Guze, 1992, p.4).
The term psychiatry (ψυχιατρική), coined by
Johann Christian Reilin 1808, comes from the Greek “ψυχή” (soul or mind) and “ιατρός" (healer or doctor). It refers to a field of medicine focused specifically on the mind, aiming to study, prevent, and treat mental disorders in humans.Guze, S.B. (1992). "Why Psychiatry Is a Branch of Medicine". New York: Oxford University Press, p. 4. ISBN 978-0-19-507420-8] Storrow, H.A. (1969). "Outline of Clinical Psychiatry". New York: Appleton-Century-Crofts, p. 1. ISBN 978-0-39-085075-1] Lyness, J.M. (1997). "Psychiatric Pearls". Philadelphia: F.A. Davis Company, p. 3. ISBN 978-0-80-360280-9] 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.Gask, L. (2004). "A Short Introduction to Psychiatry". London: SAGE Publications Ltd., p. 7 ISBN 978-0-7619-7138-2]
Those who practice psychiatry are different than most other
mental health professionals and physicians in that they must be familiar with both the social and biological sciences.Storrow, H.A. (1969). "Outline of Clinical Psychiatry". New York:Appleton-Century-Crofts, p 1. ISBN 978-0-39-085075-1] 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.Guze, S. B. (1992). "Why Psychiatry is a Branch of Medicine". New York: Oxford University Press, p 131. ISBN 978-0-19-507420-8.] Psychiatry exists to treat mental disorders which are conventionally divided into three very general categories; mental illness, severe learning disability, and personality disorder.Gask, L. (2004). "A Short Introduction to Psychiatry". London: SAGE Publications Ltd., p. 113 ISBN 978-0-7619-7138-2] 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.Gask, L. (2004). "A Short Introduction to Psychiatry". London: SAGE Publications Ltd., p. 128 ISBN 978-0-7619-7138-2]
Scope of practice
While the medical specialty of psychiatry utilizes research in the field of
neuroscience, psychology, medicine, biology, biochemistry, and pharmacology,Pietrini, P. (2003). Toward a Biochemistry of Mind? "American Journal of Psychiatry, 160", 1907-1908.] it has generally been considered a middle ground between neurologyand psychology.Shorter, E. (1997). A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. New York: John Wiley & Sons, Inc, p. 326. ISBN 978-0-47-124531-5] Unlike other physicians and neurologists, psychiatrists specialize in the doctor-patient relationshipand are trained to varying extents in the use of psychotherapy and other therepautic communication techniques. Psychiatrists also differ from psychologists in that they are physicians and the entirety of their post-graduate training is revolved around the field of medicine.Hauser, M.J. (Unknown last update). "Student Information". Retrieved September 21, 2007, from http://www.psychiatry.com/student.php] Psychiatrists can therefore prescribe medication, order laboratory tests, utilize neuroimagingin a clinical setting, and conduct physical examinations.National Institute of Mental Health. (2006, January 31). "Information about Mental Illness and the Brain". Retrieved April 19, 2007,from http://science-education.nih.gov/supplements/nih5/Mental/guide/info-mental-c.htm]
Like other professions, the
World Psychiatric Associationissues an ethical codeto govern the conduct of psychiatrists. The psychiatric code of ethics, first set forth through the Declaration of Hawaiiin 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,cite journal | doi = 10.1016/j.pnpbp.2006.12.007 | title = Progress in Neuro-Psychopharmacology and Biological Psychiatry : Psychiatry and political–institutional abuse from the historical perspective: The ethical lessons of the Nuremberg Trial on their 60th anniversary |date=2006-12-07 | author=López-Muñoza, Francisco | others= Cecilio Alamoa, Michael Dudleyb, Gabriel Rubioc, Pilar García-Garcíaa, Juan D. Molinad and Ahmed Okasha | publisher = Science Direct |quote=These practices, in which racial hygiene constituted one of the fundamental principles and euthanasia programmes were the most obvious consequence, violated the majority of known bioethical principles. Psychiatry played a central role in these programmes, and the mentally ill were the principal victims. | journal = Progress in Neuro-Psychopharmacology and Biological Psychiatry | volume = 31 | pages = 791] organ transplantation, torture,cite journal
author = Gluzman, S.F.
year = 1991
title = Abuse of psychiatry: analysis of the guilt of medical personnel
journal = J Med Ethics
volume = 17
pages = 19–20
url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11651120&dopt=Citation
accessdate = 2007-09-30
quote=Based on the generally accepted definition, we correctly term the utilisation of psychiatry for the punishment of political dissidents as torture.] cite book | url = http://books.nap.edu/openbook.php?record_id=9733&page=21 | author= Debreu, Gerard | editor= Corillon, Carol | title = Science and Human Rights | chapter = Part 1: Torture, Psychiatric Abuse, and the Ethics of Medicine| accessdate = 2007-10-04 | year=1988|publisher=National Academy of Sciences|quote=Over the past two decades the systematic use of torture and psychiatric abuse have been sanctioned or condoned by more than one-third of the nations in the United Nations, about half of mankind. ] the
death penalty, media relations, genetics, and ethnic or cultural discrimination. [ [http://www.wpanet.org/generalinfo/ethic1.html The WPA code of ethics.] ] 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:
Biological psychiatry; an approach to psychiatry that aims to understand mental disorder in terms of the biological function of the nervous system.
Child and adolescent psychiatry; a branch of psychiatry that specialises in work with children, teenagers, and their families.
Community psychiatry; an approach that reflects an inclusive public healthperspective and is practiced in community mental health services. [American Association of Community Psychiatrists [http://www.comm.psych.pitt.edu/mission.html About AACP] Retrieved on Aug-05-2008]
Cross-cultural psychiatry; a branch of psychiatry concerned with the cultural and ethnic context of mental disorder and psychiatric services.
Emergency psychiatry; the clinical application of psychiatry in emergency settings.
Forensic psychiatry; the interface between law and psychiatry.
Geriatric psychiatry; a branch of psychiatry dealing with the study, prevention, and treatment of mental disorders in humans with old age.
Liaison psychiatry; the branch of psychiatry that specializes in the interface between other medical specialties and psychiatry.
Military psychiatry; covers special aspects of psychiatry and mental disorders within the military context.
Neuropsychiatry; branch of medicine dealing with mental disorders attributable to diseases of the nervous system.
Social psychiatry; a branch of psychiatry that focuses on the interpersonal and cultural context of mental disorder and mental wellbeing.
In the United States, psychiatry is one of the specialties which qualifies for further education and board-certification in
Starting in the 5th century BC, mental disorders, especially those with psychotic traits, were considered
supernaturalin origin.Elkes, A. & Thorpe, J.G. (1967). "A Summary of Psychiatry". London: Faber & Faber, p. 13.] This view existed throughout ancient Greeceand Rome. Early manuals written about mental disorders were created by the Greeks.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 1. ISBN 978-0-47-124531-5] In 4th century BC, Hippocratestheorized that physiological abnormalities may be the root of mental disorders. However further explorations of this perspective ceased shortly thereafter following the fall of the Roman Empire. Religious leaders and others returned to using early versions of exorcisms to treat mental disorders which often utilized cruel, harsh, and other barbarous methods.
psychiatric hospitals were built in the medieval Islamic world from the 8th century. The first was built in Baghdadin 705, followed by Fesin the early 8th century, and Cairoin 800. Unlike medieval Christian physicians who relied on demonological explanations for mental illness, medieval Muslim physicians relied mostly on clinical observations. They made significant advances to psychiatry and were the first to provide psychotherapyand moral treatmentfor mentally ill patients, in addition to other forms of treatment such as baths, drug medication, music therapyand occupational therapy. In the 10th century, the Persian physician Muhammad ibn Zakarīya Rāzi(Rhazes) combined psychological methods and physiological explanations to provide treatment to mentally ill patients. His contemporary, the Arabphysician Najab ud-din Muhammad, first described a number of mental illnesses such as agitated depression, neurosis, priapismand sexual impotence ("Nafkhae Malikholia"), psychosis("Kutrib"), and mania("Dual-Kulb").Ibrahim B. Syed PhD, "Islamic Medicine: 1000 years ahead of its times", "Journal of the International Society for the History of Islamic Medicine", 2002 (2): 2-9 [7-8] .]
In the 11th century, another Persian physician
Avicennarecognized ' physiological psychology' in the treatment of illnesses involving emotions, and developed a system for associating changes in the pulserate with inner feelings, which is seen as a precursor to the word associationtest developed by Carl Jungin the 19th century. [Ibrahim B. Syed PhD, "Islamic Medicine: 1000 years ahead of its times", "Journal of the International Society for the History of Islamic Medicine", 2002 (2): 2-9  .] Avicennawas also an early pioneer of neuropsychiatry, and first described a number of neuropsychiatric conditions such as hallucination, insomnia, mania, nightmare, melancholia, dementia, epilepsy, paralysis, stroke, vertigo and tremor. [S Safavi-Abbasi, LBC Brasiliense, RK Workman (2007), "The fate of medical knowledge and the neurosciences during the time of Genghis Khan and the Mongolian Empire", "Neurosurgical Focus" 23 (1), E13, p. 3.]
Psychiatric hospitals were built in medieval Europe from the 13th century to treat mental disorders but were utilized only as custodial institutions and did not provide any type of treatment.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 4. ISBN 978-0-47-124531-5] Founded in the 13th century,
Bethlem Royal Hospitalin Londonis one of the oldest psychiatric hospitals. By 1547 the City of London acquired the hospital and continued its function until 1948.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 5. ISBN 978-0-47-124531-5]
Early modern period
Louis XIV of Francecreated a public system of hospitals for those suffering from mental disorders, but as in England, no real treatment was being applied. In 1758 English physician William Battiewrote the " Treatise on Madness" which called for treatments to be utilized in asylums.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 9. ISBN 978-0-47-124531-5] Thirty years later the new ruling monarch in England, George III, was known to be suffering from a mental disorder. Following the King's remission in 1789, mental illness was seen as something which could be treated and cured. By 1792 French physician Philippe Pinelintroduced humane treatment approaches to those suffering from mental disorders. William Tukeadopted the methods outlined by Pinel and that same year Tuke opened the York Retreat in England. That institution became known as a model throughout the world for humane and moral treatment of patients suffering from mental disorders.Borthwick, A.; Holman, C.; Kennard, D.; McFetridge, M.; Messruther, K.; Wilkes, J. (2001). The relevance of moral treatment to contemporary mental health care. "Journal of Mental Health, 10", 427-439.] It inspired similar institutions in the United States, most notably the Brattleboro Retreatand the Hartford Retreat (now the Institute of Living).
At the turn of the century, England and France combined only had a few hundred individuals in asylums.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 34. ISBN 978-0-47-124531-5] By the late 1890s and early 1900s, this number skyrocketed to the hundreds of thousands. The United States housed 150,000 patients in mental hospitals by 1904. German speaking countries housed more than 400 public and private sector asylums. These asylums were critical to the evolution of psychiatry as they provided a universal platform of practice throughout the world.
Universities often played a part in the administration of the asylums.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 35. ISBN 978-0-47-124531-5] Due to the relationship between the universities and asylums, scores of competitive psychiatrists were being molded in Germany. Germany became known as the world leader in psychiatry during the nineteenth century. The country possessed more than 20 separate universities all competing with each other for scientific advancement. However, because of Germany's individual states and the lack of national regulation of asylums, the country had no organized centralization of asylums or psychiatry. Britain, like Germany, also lacked a centralized organization for the administration of asylums.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 41. ISBN 978-0-47-124531-5] This deficit hindered the diffusion of new ideas in medicine and psychiatry.
In the United States in 1834,
Anna Marsh, a physician's widow, deeded the funds to build her country's first financially-stable private asylum. The Brattleboro Retreatmarked the beginning of America's private psychiatric hospitals challenging state institutions for patients, funding, and influence. Although based on England's York Retreat, it would be followed by speciality institutions of every treatment philosophy.
In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 40. ISBN 978-0-47-124531-5] By 1840, asylums as therapeutic institutions existed throughout Europe and the United States.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 46. ISBN 978-0-47-124531-5]
Emil Kraepelinstudied and promoted ideas of disease classification for mental disorders.]
However, the new and dominating ideas that mental illness could be "conquered" during the mid-nineteenth century all came crashing down. Psychiatrists and asylums were being pressured by an ever increasing patient population. The average number of patients in asylums in the United States jumped 927%. Numbers were similar in England and Germany. Overcrowding was rampant in France where asylums would commonly take in double their maximum capacity.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 47. ISBN 978-0-47-124531-5] Increases in asylum populations may have been a result of the transfer of care from families and
poorhouses, but the specific reasons as to why the increase occurred is still debated today.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 48. ISBN 978-0-47-124531-5] Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 49. ISBN 978-0-47-124531-5] No matter the cause, the pressure on asylums from the increase was taking its toll on the asylums and psychiatry as a specialty. Asylums were once again turning into custodial institutionsRothman, D.J. (1990). "The Discovery of the Asylum: Social Order and Disorder in the New Republic". Boston: Little Brown, p. 239. ISBN 978-0-316-75745-4] and the reputation of psychiatry in the medical world had hit an extreme low.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 65. ISBN 978-0-47-124531-5]
Disease classification and rebirth of biological psychiatry
The 20th century introduced a new psychiatry into the world. The different perspectives of looking at mental disorders began to be introduced. The career of
Emil Kraepelinsomewhat model this hiatus of psychiatry between the different disciplines.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 101. ISBN 978-0-47-124531-5] Kraepelin initially was very attracted to psychology and ignored the ideas of anatomical psychiatry. Following his acceptance for a professorship of psychiatry, and later his work in a university psychiatric clinic, Kraepelin's interest in pure psychology began to fade and he introduced a plan of a more comprehensive psychiatry.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 102. ISBN 978-0-47-124531-5] Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 103. ISBN 978-0-47-124531-5] Kraepelin also began to study and promote the ideas of disease classification for mental disorders, an idea introduced by Karl Ludwig Kahlbaum. The initial ideas behind biological psychiatry, stating that these different disorders were all biological in nature, evolved into a new idea of "nerves" and psychiatry became a sort of rough neurology or neuropsychiatry.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 1114. ISBN 978-0-47-124531-5] Following Sigmund Freud's death, ideas stemming from psychoanalytic theoryalso began to take root.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 145. ISBN 978-0-47-124531-5] The psychoanalytic theory became popular among psychiatrists because it allowed the patients to be treated in private practices instead of asylums. However the progress of psychiatry by the 1970s turned psychoanalytic theory into a marginal school of thought within the field.This period of time saw the reemergence of biological psychiatry. Psychopharmacologybecame an integral part of psychiatry starting with Otto Loewi's discovery of the first neurotransmitter, acetylcholine. Neuroimagingwas first utilized as a tool for psychiatry in the 1980s.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 270. ISBN 978-0-47-124531-5] The discovery of chlorpromazine's effectiveness in treating schizophreniain 1952 revolutionized treatment of the disease,cite journal | author=Turner T. | title=Unlocking psychosis | journal=Brit J Med | year=2007 | volume=334 | issue=suppl | pages=s7 | doi=10.1136/bmj.39034.609074.94 | pmid=17204765 ] as did lithium carbonate's ability to stabilize mood highs and lows in bipolar disorderin 1948. [Cade, JFJ; "Lithium salts in the treatment of psychotic excitement". Med J Aust 1949, 36, p349-352] While psychosocial issues were still seen as valid, psychotherapy was seen to be their "cure."Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 239. ISBN 978-0-47-124531-5] Genetics were once again thought to play a role in mental illness.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 246. ISBN 978-0-47-124531-5] Molecular biology opened the door for specific genes contributing mental disorders to be identified. By 1995 genes contributing to schizophreniahad been identified on chromosome 6 and genes contributing to bipolar disorderon chromosomes 18 and 21.
Anti-psychiatry and deinstitutionalization
The introduction of
psychiatric medications and the use of laboratory tests altered the doctor-patient relationshipbetween psychiatrists and their patients.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 273. ISBN 978-0-47-124531-5] Psychiatry's shift to the hard sciences had been interpreted as a lack of concern for patients. Anti-psychiatryhad become more prevalent in the late twentieth century due to this and publications in the media which conceptualized mental disorders as myths.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 274. ISBN 978-0-47-124531-5] 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.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 277. ISBN 978-0-47-124531-5] Incidents of physical abuse by psychiatrists took place during the reign of some totalitarian regimes as part of a system to enforce political control with some of the abuse even continuing to our present day. [Sunny Y. Lu & Viviana B. Galli, "The Journal of the American Academy of Psychiatry and the Law"] Historical examples of the abuse of psychiatry took place in Nazi Germany[ [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12817666&dopt=Abstract The killing of psychiatric patients in Nazi German... [Isr J Psychiatry Relat Sci. 2003 - PubMed Result ] ] , in the Soviet Unionunder Psikhushka, and in the apartheidsystem in South Africa. [ [http://www.info.gov.za/speeches/1997/06160x76497.htm Mental Health During Apartheid ] ] Electroconvulsive therapywas one treatment that the anti-psychiatry movement wanted eliminated.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 282. ISBN 978-0-47-124531-5] They alleged that electroconvulsive therapy damaged the brain and it was used as a tool for discipline. While there is no evidence that brain damage was a result of electronconvulsive therapyWeiner, R.D. (1984). Does ECT cause brain damage? "Behavioral and Brain Sciences, 7", 153.] Meldrum, B.S. (1986). Neuropathological consequences of chemically and electrically induced seizures. "Annals of the New York Academy of Sciences, 462", 18693.] Dwork, A.J.; Arango, V.; Underwood, M.; Ilievski, B.; Rosoklija, G.; Sackeim, H.A.; Lisanby, S.H. (2004). Absence of histological lesions in primate models of ECT and magnetic seizure therapy. "American Journal of Psychiatry, 161", 576-578.] , there have been isolated incidents where the use of electroconvulsive therapy 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.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley & Sons, Inc, p. 279. ISBN 978-0-47-124531-5] 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 released into communities where they could participate in a normal life while living in a therapeutic atmosphere.
Transinstitutionalization and the aftermath
In 1963, United States president
John F. Kennedyintroduced legislation delegating the National Institute of Mental Healthto administer Community Mental Health Centers for those being discharged from state psychiatric hospitals.Shorter, E. (1997). "A History of Psychiatry: From the Era of the Asylum to the Age of Prozac". New York: John Wiley &; Sons, Inc, p. 280. ISBN 978-0-47-124531-5] Later, though, the Community Mental Health Center's focus was diverted to provide psychotherapy sessions for those suffering from acute and/or mild mental disorders. Ultimately there were no arrangements made for actively ill patients who were being discharged from hospitals. Some of those suffering from mental disorders drifted into homelessness or ended up in prisons and jails.Slovenko, R. (2003). The transinstitutionalization of the mentally ill. "Ohio University Law Review, 29", 641.] Studies found that 33% of the homeless population and 14% of inmates in prisons and jails were already diagnosed with a mental illness.Torrey, E.F. (1988). "Nowhere to Go: The Tragic Odyssey of the Homeless Mentally Ill". New York: Harper and Row, pp.25-29, 126-128. ISBN 978-0-06-015993-1]
In 1972, psychologist
David Rosenhanpublished the Rosenhan experiment, a study analyzing the validity of psychiatric diagnoses.Rosenhan, D. (1973). [http://www.sciencemag.org/cgi/content/abstract/179/4070/250 On being sane in insane places] . "Science" 179, 250-258.] The study arranged for eight individuals with no history of psychopathology to attempt admission into psychiatric hospitals. The individuals included a graduate student, psychologists, an artist, a housewife, and two physicians, including one psychiatrist. All eight individuals were admitted with a diagnosis of schizophrenia or bipolar disorder. Psychiatrists then attempted to treat the individuals using psychiatric medication. All eight were discharged within 7 to 52 days. Rosenhan's study concluded that individuals with no presence of mental disorders could not be distinguished from those suffering from mental disorders. While critics such as Robert Spitzer placed doubt on the validity and credibility of the study, they also conceded that the consistency of psychiatric diagnoses needed improvement.Spitzer, R.L.; Lilienfeld, S.O.; Miller, M.B. (2005). Rosenhan revisited: The scientific credibility of Lauren Slater's pseudopatient diagnosis study. "Journal of Nervous and Mental Disease, 193", 734-739.]
Psychiatry, like many medical specialties, has a continuing, significant demand for research investigating its related diseases, classifications, origins, and treatments.Lyness, J.M. (1997). "Psychiatric Pearls". Philadelphia: F.A. Davis Company. ISBN 978-0-80-360280-9] Psychiatry falls into biology's fundamental belief that disease and health are different elements of an individual's adaptation to an environment.Guze, S. B. (1992). Why Psychiatry is a Branch of Medicine. New York: Oxford University Press, p 130. ISBN 978-0-19-507420-8.] But psychiatry also recognizes that the environment of the human species is complex and includes physical, cultural, and relational elements. In addition to external factors, the
human brainmust recognize or organize an individual's hopes, fears, desires, fantasies and feelings. Psychiatry's difficult task is the attempt to envelop the understanding of these factors so that they can be studied both clinically and physiologically.
Industry and academia
As with most medical specialties, all
physicians can diagnose mental disorders and prescribe treatments utilizing principles of psychiatry. Psychiatrists are physicians who specialize in psychiatry and are certified in treating mental illnessusing the biomedical approach to mental disorders.About:Psychology. (Unknown last update). "Difference Between Psychologists and Psychiatrists". Retrieved March 25, 2007, from http://psychology.about.com/od/psychotherapy/f/psychvspsych.htm] Psychiatrists may also go through significant training to conduct psychotherapy, psychoanalysis, and/or cognitive behavioral therapy, but it is their medical training, access to medical laboratories, and ability to prescribe medication that differentiates them from other mental health professionals.
Psychiatric research is, by its very nature, interdisciplinary. From a general perspective it studies and combines social, biological and psychological approaches and how those perspectives cause mental disorders.University of Manchester. (Unknown last update). "Research in Psychiatry". Retrieved October 13, 2007, from http://www.manchester.ac.uk/research/areas/subareas/?a=s&id=44694] While practicing psychiatrists and other psychiatric researchers study outcomes from such a wide variety of fields, research institutions and publications exist that are dedicated to the interdisciplinary study of mental disorders within the psychiatric context.New York State Psychiatric Institute. (2007, March 15). "Psychiatric Research Institute New York State". Retrieved October 13, 2007, from http://nyspi.org/] Canadian Psychiatric Research Foundation. (2007, July 27). "Canadian Psychiatric Research Foundation". Retrieved October 13, 2007, from http://www.cprf.ca/] Elsevier. (2007, October 08). "Journal of Psychiatric Research". Retrieved October 13, 2007, from http://www.elsevier.com/wps/find/journaldescription.cws_home/241/description] Under the supervision of
institutional review boards, psychiatric researchers look at a variety of topics such as neuroimaging, genetics, and psychopharmacology, which in turn help enhance diagnostic consistency, discover new treatment methods, and classify new mental disorders.Mitchell, J.E.; Crosby, R.D.; Wonderlich, S.A.; Adson, D.E. (2000). "Elements of Clinical Research in Psychiatry". Washington D.C.: American Psychiatric Press. ISBN 978-0-88-048802-0.] On the basis of Tinbergen's four questionsa framework of reference or "periodic table" of all fields of anthropological research and humanities can be established. It helps to structure interdisciplinarity in Psychiatry, e.g. how Neurology, Psychiatry and Psychotherapymight be connected with other fields of anthropological research.
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 diagnosisprocedure where a mental status examinationand physical examination is conducted, pathological, psychopathological and psychosocialhistories obtained, neuroimages or other neurophysiological measurements are taken, and personality tests or cognitive tests may be administered.Meyendorf, R. (1980). Diagnosis and differential diagnosis in psychiatry and the question of situation referred prognostic diagnosis. "Schweizer Archiv Neurol Neurochir Psychiatry für Neurologie, Neurochirurgie et de psychiatrie, 126", 121-134.] Leigh, H. (1983). "Psychiatry in the practice of medicine". Menlo Park: Addison-Wesley Publishing Company, p. 15. ISBN 978-0-20-105456-9] Leigh, H. (1983). "Psychiatry in the practice of medicine". Menlo Park: Addison-Wesley Publishing Company, p. 67. ISBN 978-0-20-105456-9] Leigh, H. (1983). "Psychiatry in the practice of medicine". Menlo Park: Addison-Wesley Publishing Company, p. 17. ISBN 978-0-20-105456-9] Lyness, J.M. (1997). "Psychiatric Pearls". Philadelphia: F.A. Davis Company, p. 10. ISBN 978-0-80-360280-9] Hampel, H.; Teipel, S.J.; Kotter, H.U.; et al. (1997). Structural magnetic resonance imaging in diagnosis and research of Alzheimer's disease. "Nervenarzt, 68", 365-378.] Townsend, B.A.; Petrella, J.R.; Doraiswamy, P.M. (2002). The role of neuroimaging in geriatric psychiatry. "Current Opinion in Psychiatry, 15", 427-432.] In addition psychiatrists are beginning to utilize geneticsduring the diagnostic process.Krebs, M.O. (2005). Future contributions on genetics. "World Journal of Biological Psychiatry, 6", 49-55] Some endophenotypes being researched may predispose certain individuals to certain conditions.Benes, F.M. (2007). An electrophysiological endophenotype of hypomanic and hyperthymic personality. "Journal of Affective Disorders, 101", 13-26.] Vonk, R.; van der Schot, A.C.; Kahn, R.S.; et al. (2007). Is autoimmune thyroiditis part of the genetic vulnerability (or an endophenotype) for bipolar disorder? "Biological Psychiatry, 62", 135-140.]
Three main diagnostic manuals used to classify mental health conditions are in use today. The
ICD-10is produced and published by the World Health Organisation, includes a section on psychiatric conditions, and is used worldwide.World Health Organisation. (1992). "The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines". Geneva: World Health Organisation. ISBN 978-9-24-154422-1] 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.American Psychiatric Association. (2000). "Diagnostic and Statistical Manual of Mental Disorders" (4th Edition). Washington D.C.: American Psychiatric Publishing, Inc. ISBN 978-0-89-042025-6] It is currently in its fourth revised edition and is also used worldwide. The Chinese Society of Psychiatryhas also produced a diagnostic manual, the Chinese Classification of Mental Disorders.Chen, Y.F. (2002) Chinese classification of mental disorders (CCMD-3): towards integration in international classification. "Psychopathology, 35", 171-175]
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.Essen-Moller, E. (1971). On classification of mental disorders. "
Acta Psychiatrica Scandinavica, 37", 119-126.] 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.Mezzich, J.E. (1979). Patterns and issues in multiaxial psychiatric diagnosis. "Psychological Medicine, 9", 125-137.] 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.Guze, S.B. (1970) The need for toughmindedness in psychiatric thinking. "Southern Medical Journal, 63", 662-671.]
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- referralor 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 sectioningunder 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 examinationis carried out, and a physical examinationis usually performed to establish or exclude other illnesses, such as thyroid dysfunction or brain tumors, or identify any signs of self-harm; this examination may be done by someone other than the psychiatrist, especially if blood tests and medical imagingare 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 efficacity [Moncrieff et al. (2003). [http://www.cochrane.org/reviews/en/ab003012.html Active placebos versus antidepressants for depression] . Cochrane databases.] [Hopper K, Wanderling J (2000). Revisiting the developed versus developing country distinction in course and outcome in schizophrenia: results from ISoS, the WHO collaborative followup project. International Study of Schizophrenia. "Schizophrenia Bulletin", 26 (4), 835–46. PMID 11087016] and adverse effects of psychiatric drugs have been challengedEds. Spiegel D, Lake J. (2006). " [http://books.google.com/books?id=tbJx_fYIfegC Complementary And Alternative Treatments in Mental Health Care] " American Psychiatric Pub, Inc. Quote from p. xxi]
The close relationship between those prescribing psychiatric medication and pharmaceutical companies has become increasingly controversial [Loren R. Mosher, Richard Gosden and Sharon Beder, 'Drug companies and Schizophrenia: Unbridled Capitalism meets Madness', in [http://homepage.mac.com/herinst/sbeder/drugcompanies.html Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia] edited by John Read, Loren Mosher and Richard Bentall, Brunner-Routledge, New York, 2004, pp. 115-130.] along with the influence which pharmaceutical companies are exerting on mental health policies. [Richard Gosden and Sharon Beder, [http://homepage.mac.com/herinst/sbeder/pharm-agenda.html 'Pharmaceutical Industry Agenda Setting in Mental Health Policies'] , Ethical Human Sciences and Services 3(3) Fall/Winter 2001, pp. 147-159 ] [Thomas Ginsberg. [http://mindfreedom.org/campaign/media/mf/inquirer-on-drug-firms/ "Donations tie drug firms and nonprofits"] .
The Philadelphia Inquirer28 May 2006.]
Also controversial are forced drugging and the "lack of insight" label. According to a report published by the U.S. 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." [Rae E. Unzicker, Kate P. Wolters, Debra Robinson et al. [http://www.ncd.gov/newsroom/publications/2000/privileges.htm From Privileges to Rights: People Labeled with Psychiatric Disabilities Speak for Themselves] .
National Council on Disability20 January 2000.]
Psychiatric treatments have changed over the past several decades. In the past, psychiatric patients were often hospitalized 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.Fact|date=August 2008
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.Fact|date=August 2008
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. [cite book|last=Treatment Protocol Project|title=Acute inpatient psychiatric care: A source book|publisher=World Health Organisation|location=Darlinghurst, Australia|date=2003|isbn=0-9578073-1-7|oclc=223935527]
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.Fact|date=August 2008
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 less time devoted to psychotherapy or "talk" therapies, or behavior modification. 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.Fact|date=October 2007
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* [http://www.wpanet.org/ World Psychiatric Association]
* [http://www.psych.org American Psychiatric Association]
* [http://www.rcpsych.ac.uk The Royal College of Psychiatrists]
* [http://www.ranzcp.org/ Royal Australian and New Zealand College of Psychiatrists]
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