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Psychiatry

February 16, 2024

Not to be confused with Clinical psychology.

Psychiatry is the medical specialty devoted to the diagnosis, prevention, and treatment of deleterious mental conditions.[1][2] These include various matters related to mood, behaviour, cognition, and perceptions.

Initial psychiatric assessment of a person begins with a case history and mental status examination. Physical examinations, psychological tests, and laboratory tests may be conducted. On occasion, neuroimaging or other neurophysiological studies are performed.[3] Mental disorders are diagnosed in accordance with diagnostic manuals such as the International Classification of Diseases (ICD),[4] edited by the World Health Organization (WHO), and the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA). The fifth edition of the DSM (DSM-5), published in May 2013, reorganized the categories of disorders and added newer information and insights consistent with current research.[5]

Treatment may include psychotropics (psychiatric medicines) and psychotherapy,[6][7] and also other modalities such as assertive community treatment, community reinforcement, substance-abuse treatment, and supported employment. Treatment may be delivered on an inpatient or outpatient basis, depending on the severity of functional impairment or risk to the individual or community. Research within psychiatry is conducted on an interdisciplinary basis with other professionals, such as epidemiologists, nurses, social workers, occupational therapists, and clinical psychologists.

Etymology edit

 
The word psyche comes from the ancient Greek for 'soul' or 'butterfly'.[8] The fluttering insect appears in the coat of arms of Britain's Royal College of Psychiatrists.[9]

The term psychiatry was first coined by the German physician Johann Christian Reil in 1808 and literally means the 'medical treatment of the soul' (psych- 'soul' from Ancient Greek psykhē 'soul'; -iatry 'medical treatment' from Gk. iātrikos 'medical' from iāsthai 'to heal'). A medical doctor specializing in psychiatry is a psychiatrist (for a historical overview, see: Timeline of psychiatry).

Theory and focus edit

"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).

Psychiatry refers to a field of medicine focused specifically on the mind, aiming to study, prevent, and treat mental disorders in humans.[10][11][12] 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.[13]

People who specialize in psychiatry often differ from most other mental health professionals and physicians in that they must be familiar with both the social and biological sciences.[11] The discipline studies the operations of different organs and body systems as classified by the patient's subjective experiences and the objective physiology of the patient. [14] Psychiatry treats mental disorders, which are conventionally divided into three general categories: mental illnesses, severe learning disabilities, and personality disorders.[15] Although the focus of psychiatry has changed little over 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 other medical fields.[16]

Scope of practice edit

Further information: Neurology § Overlap with psychiatry
 
Disability-adjusted life year for neuropsychiatric conditions per 100,000 inhabitants in 2002
  no data
  less than 10
  10–20
  20–30
  30–40
  40–50
  50–60
  60–80
  80–100
  100–120
  120–140
  140–150
  more than 150

Though the medical specialty of psychiatry uses research in the field of neuroscience, psychology, medicine, biology, biochemistry, and pharmacology,[17] it has generally been considered a middle ground between neurology and psychology.[18] Because psychiatry and neurology are deeply intertwined medical specialties, all certification for both specialties and for their subspecialties is offered by a single board, the American Board of Psychiatry and Neurology, one of the member boards of the American Board of Medical Specialties.[19] 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.[18] Psychiatrists also differ from psychologists in that they are physicians and have post-graduate training called residency (usually four to five years) in psychiatry; the quality and thoroughness of their graduate medical training is identical to that of all other physicians.[20] Psychiatrists can therefore counsel patients, prescribe medication, order laboratory tests, order neuroimaging, and conduct physical examinations.[3]

Ethics edit

See also: Ethical issues in psychiatry (disambiguation)

The World Psychiatric Association issues an ethical code to govern the conduct of psychiatrists (like other purveyors of professional ethics). 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 the broader Madrid Declaration in 1996. The code was further revised during the organization's general assemblies in 1999, 2002, 2005, and 2011.[21]

The World Psychiatric Association code covers such matters as confidentiality, the death penalty, ethnic or cultural discrimination,[21] euthanasia, genetics, the human dignity of incapacitated patients, media relations, organ transplantation, patient assessment, research ethics, sex selection,[22] torture,[23][24] and up-to-date knowledge.

In establishing such ethical codes, the profession has responded to a number of controversies about the practice of psychiatry, for example, surrounding the use of lobotomy and electroconvulsive therapy.

Discredited psychiatrists who operated outside the norms of medical ethics include Harry Bailey, Donald Ewen Cameron, Samuel A. Cartwright, Henry Cotton, and Andrei Snezhnevsky.[25][page needed]

Approaches edit

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[26] 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.[27][28][29] In this notion the word model is not used in a strictly scientific way though.[27] Alternatively, a Niall McLaren acknowledges the physiological basis for the mind's existence but identifies cognition as an irreducible and independent realm in which disorder may occur.[27][28][29] The biocognitive approach includes a mentalist etiology and provides a natural dualist (i.e., non-spiritual) revision of the biopsychosocial view, reflecting the efforts of Australian psychiatrist Niall McLaren to bring the discipline into scientific maturity in accordance with the paradigmatic standards of philosopher Thomas Kuhn.[27][28][29]

Once a medical professional diagnoses a patient there are numerous ways that they could choose to treat the patient. Often psychiatrists will develop a treatment strategy that incorporates different facets of different approaches into one. Drug prescriptions are very commonly written to be regimented to patients along with any therapy they receive. There are three major pillars of psychotherapy that treatment strategies are most regularly drawn from. Humanistic psychology attempts to put the "whole" of the patient in perspective; it also focuses on self exploration.[30] Behaviorism is a therapeutic school of thought that elects to focus solely on real and observable events, rather than mining the unconscious or subconscious. Psychoanalysis, on the other hand, concentrates its dealings on early childhood, irrational drives, the unconscious, and conflict between conscious and unconscious streams.[31]

Practitioners edit

Main article: Psychiatrist

All physicians can diagnose mental disorders and prescribe treatments utilizing principles of psychiatry. Psychiatrists are trained physicians who specialize in psychiatry and are certified to treat mental illness. They may treat outpatients, inpatients, or both; they may practice as solo practitioners or as members of groups; they may be self-employed, be members of partnerships, or be employees of governmental, academic, nonprofit, or for-profit entities; employees of hospitals; they may treat military personnel as civilians or as members of the military; and in any of these settings they may function as clinicians, researchers, teachers, or some combination of these. Although psychiatrists may also go through significant training to conduct psychotherapy, psychoanalysis or cognitive behavioral therapy, it is their training as physicians that differentiates them from other mental health professionals.

As a career choice in the US edit

Psychiatry was not a popular career choice among medical students, even though medical school placements are rated favorably.[32] This has resulted in a significant shortage of psychiatrists in the United States and elsewhere.[33] Strategies to address this shortfall have included the use of short 'taster' placements early in the medical school curriculum[32] and attempts to extend psychiatry services further using telemedicine technologies and other methods.[34] Recently, however, there has been an increase in the number of medical students entering into a psychiatry residency. There are several reasons for this surge, including the intriguing nature of the field, growing interest in genetic biomarkers involved in psychiatric diagnoses, and newer pharmaceuticals on the drug market to treat psychiatric illnesses.[35]

Subspecialties edit

The field of psychiatry has many subspecialties that require additional training and certification by the American Board of Psychiatry and Neurology (ABPN). Such subspecialties include:[36]

 
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Additional psychiatry subspecialties, for which the ABPN does not provide formal certification, include:[41]

Addiction psychiatry focuses on evaluation and treatment of individuals with alcohol, drug, or other substance-related disorders, and of individuals with dual diagnosis of substance-related and other psychiatric disorders. Biological psychiatry is an approach to psychiatry that aims to understand mental disorders in terms of the biological function of the nervous system. Child and adolescent psychiatry is the branch of psychiatry that specializes in work with children, teenagers, and their families. Community psychiatry is an approach that reflects an inclusive public health perspective and is practiced in community mental health services.[42] Cross-cultural psychiatry is a branch of psychiatry concerned with the cultural and ethnic context of mental disorder and psychiatric services. Emergency psychiatry is the clinical application of psychiatry in emergency settings. Forensic psychiatry utilizes medical science generally, and psychiatric knowledge and assessment methods in particular, to help answer legal questions. Geriatric psychiatry is a branch of psychiatry dealing with the study, prevention, and treatment of mental disorders in the elderly. Global mental health is an area of study, research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide,[43] although some scholars consider it to be a neo-colonial, culturally insensitive project.[44][45][46][47] Liaison psychiatry is 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 is a branch of medicine dealing with mental disorders attributable to diseases of the nervous system. Social psychiatry is a branch of psychiatry that focuses on the interpersonal and cultural context of mental disorder and mental well-being.

In larger healthcare organizations, psychiatrists often serve in senior management roles, where they are responsible for the efficient and effective delivery of mental health services for the organization's constituents. For example, the Chief of Mental Health Services at most VA medical centers is usually a psychiatrist, although psychologists occasionally are selected for the position as well.[citation needed]

In the United States, psychiatry is one of the few specialties which qualify for further education and board-certification in pain medicine, palliative medicine, and sleep medicine.

Research edit

Psychiatric research is, by its very nature, interdisciplinary; combining social, biological and psychological perspectives in attempt to understand the nature and treatment of mental disorders.[48] Clinical and research psychiatrists study basic and clinical psychiatric topics at research institutions and publish articles in journals.[17][49][50][51] Under the supervision of institutional 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.[52][page needed]

Clinical application edit

Diagnostic systems edit

See also: Diagnostic classification and rating scales used in psychiatry

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, with pathological, psychopathological or psychosocial histories obtained, and sometimes neuroimages or other neurophysiological measurements are taken, or personality tests or cognitive tests administered.[53][54][55][56][57] 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.[58] Some clinicians are beginning to utilize genetics[59][60][61] and automated speech assessment[62] during the diagnostic process but on the whole these remain research topics.

Potential use of MRI/fMRI in diagnosis edit

In 2018, the American Psychological Association commissioned a review to reach a consensus on whether modern clinical MRI/fMRI will be able to be used in the diagnosis of mental health disorders. The criteria presented by the APA stated that the biomarkers used in diagnosis should:

  1. "have a sensitivity of at least 80% for detecting a particular psychiatric disorder"
  2. "should have a specificity of at least 80% for distinguishing this disorder from other psychiatric or medical disorders"
  3. "should be reliable, reproducible, and ideally be noninvasive, simple to perform, and inexpensive"
  4. "proposed biomarkers should be verified by 2 independent studies each by a different investigator and different population samples and published in a peer-reviewed journal"

The review concluded that although neuroimaging diagnosis may technically be feasible, very large studies are needed to evaluate specific biomarkers which were not available.[63]

Diagnostic manuals edit

See also: Diagnostic and Statistical Manual of Mental Disorders

Three main diagnostic manuals used to classify mental health conditions are in use today. The ICD-11 is produced and published by the World Health Organization, includes a section on psychiatric conditions, and is used worldwide.[64] The Diagnostic and Statistical Manual of Mental Disorders, produced and published by the American Psychiatric Association (APA), is primarily focused on mental health conditions and is the main classification tool in the United States.[65] It is currently in its fifth revised edition and is also used worldwide.[65] The Chinese Society of Psychiatry has also produced a diagnostic manual, the Chinese Classification of Mental Disorders.[66]

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.[65][67] 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.[68] 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.[69]

The DSM has attracted praise for standardizing psychiatric diagnostic categories and criteria. It has also attracted controversy and criticism. Some critics argue that the DSM represents an unscientific system that enshrines the opinions of a few powerful psychiatrists. There are ongoing issues concerning the validity and reliability of the diagnostic categories; the reliance on superficial symptoms; the use of artificial dividing lines between categories and from 'normality'; possible cultural bias; medicalization of human distress and financial conflicts of interest, including with the practice of psychiatrists and with the pharmaceutical industry; political controversies about the inclusion or exclusion of diagnoses from the manual, in general or in regard to specific issues; and the experience of those who are most directly affected by the manual by being diagnosed, including the consumer/survivor movement.[70][71][72][73]

Treatment edit

General considerations edit

 
NIMH federal agency patient room for Psychiatric research, Maryland, US

Individuals receiving psychiatric treatment 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 countries such as the UK and Australia, by sectioning under a mental health law.

A psychiatrist or medical provider evaluates people through a psychiatric assessment for their 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 personnel, 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 that may be contributing to the alleged psychiatric problems. A physical examination may also serve to identify any signs of self-harm; this examination is often performed by someone other than the psychiatrist, especially if blood tests and medical imaging are performed.

Like most medications, psychiatric medications can cause adverse effects in patients, and some require ongoing therapeutic drug monitoring, for instance full blood counts, serum drug levels, renal function, liver function or thyroid function. Electroconvulsive therapy (ECT) is sometimes administered for serious conditions, such as those unresponsive to medication. The efficacy[74][75] and adverse effects of psychiatric drugs may vary from patient to patient.

Inpatient treatment edit

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.

Average inpatient psychiatric treatment stay has decreased significantly since the 1960s, a trend known as deinstitutionalization.[76][77][78][79] Today in most countries, 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.[80] However, in Japan psychiatric hospitals continue to keep patients for long periods, sometimes even keeping them in physical restraints, strapped to their beds for periods of weeks or months.[81][82]

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 United States 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 or others. Bed availability is often the real determinant of admission decisions to hard pressed public facilities.

People may be admitted voluntarily if the treating doctor considers that safety is not compromised by this less restrictive option. For many years, controversy has surrounded the use of involuntary treatment and use of the term "lack of insight" in describing patients. Internationally, mental health laws vary significantly but in many cases, involuntary psychiatric treatment is permitted when there is deemed to be a significant risk to the patient or others due to the patient's illness. Involuntary treatment refers to treatment that occurs based on a treating physician's recommendations, without requiring consent from the patient.[83]

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, pharmacists, 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 put in physical restraints or medicated. People on inpatient wards may be allowed leave for periods of time, either accompanied or on their own.[84]

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. Even in developed countries, programs in public hospitals vary widely. Some may offer structured activities and therapies offered from many perspectives while others may only have the funding for medicating and monitoring patients. This may be problematic in that the maximum amount of therapeutic work might not actually take place in the hospital setting. This is why hospitals are increasingly used in limited situations and moments of crisis where patients are a direct threat to themselves or others. Alternatives to psychiatric hospitals that may actively offer more therapeutic approaches include rehabilitation centers or "rehab" as popularly termed.[citation needed]

Outpatient treatment edit

Outpatient treatment involves periodic visits to a psychiatrist for consultation in his or her office, or at a community-based outpatient clinic. During initial appointments, a psychiatrist generally conducts a psychiatric assessment or evaluation of the patient. Follow-up appointments then focus on making medication adjustments, reviewing potential medication interactions, considering the impact of other medical disorders on the patient's mental and emotional functioning, and counseling patients regarding changes they might make to facilitate healing and remission of symptoms. The frequency with which a psychiatrist sees people in treatment varies widely, from once a week to twice a year, depending on the type, severity and stability of each person's condition, and depending on what the clinician and patient decide would be best.

Increasingly, psychiatrists are limiting their practices to psychopharmacology (prescribing medications), as opposed to previous practice in which a psychiatrist would provide traditional 50-minute psychotherapy sessions, of which psychopharmacology would be a part, but most of the consultation sessions consisted of "talk therapy". This shift began in the early 1980s and accelerated in the 1990s and 2000s.[85] A major reason for this change was the advent of managed care insurance plans,[clarification needed] which began to limit reimbursement for psychotherapy sessions provided by psychiatrists. The underlying assumption was that psychopharmacology was at least as effective as psychotherapy, and it could be delivered more efficiently because less time is required for the appointment.[86][87][88][89][90][91][a][excessive citations] Because of this shift in practice patterns, psychiatrists often refer patients whom they think would benefit from psychotherapy to other mental health professionals, e.g., clinical social workers and psychologists.[92]

Telepsychiatry edit

This section is an excerpt from Telepsychiatry.[edit]
 
Telemental health session

Telepsychiatry or telemental health refers to the use of telecommunications technology (mostly videoconferencing and phone calls) to deliver psychiatric care remotely for people with mental health conditions. It is a branch of telemedicine.[93][94]

Telepsychiatry can be effective in treating people with mental health conditions. In the short-term it can be as acceptable and effective as face-to-face care.[95]

It can improve access to mental health services for some but might also represent a barrier for those lacking access to a suitable device, the internet or the necessary digital skills. Factors such as poverty that are associated with lack of internet access are also associated with greater risk of mental health problems, making digital exclusion an important problem of telemental health services.[95]

During the COVID-19 pandemic mental health services were adapted to telemental health in high-income countries. It proved effective and acceptable for use in an emergency situation but there were concerns regarding its long-term implementation.[96]

History edit

Main article: History of psychiatry

Earliest knowledge edit

The earliest known texts on mental disorders are from ancient India and include the Ayurvedic text, Charaka Samhita.[97][98] The first hospitals for curing mental illness were established in India during the 3rd century BCE.[99]

Greek philosophers, including Thales, Plato, and Aristotle (especially in his De Anima treatise), also addressed the workings of the mind. As early as the 4th century BC, the Greek physician Hippocrates theorized that mental disorders had physical rather than supernatural causes. In 387 BCE, Plato suggested that the brain is where mental processes take place.In 4th to 5th century B.C. Greece, Hippocrates wrote that he visited Democritus and found him in his garden cutting open animals. Democritus explained that he was attempting to discover the cause of madness and melancholy. Hippocrates praised his work. Democritus had with him a book on madness and melancholy.[100] During the 5th century BCE, mental disorders, especially those with psychotic traits, were considered supernatural in origin,[101] a view which existed throughout ancient Greece and Rome,[101] as well as Egyptian regions.[102][page needed] Alcmaeon, believed the brain, not the heart, was the "organ of thought". He tracked the ascending sensory nerves from the body to the brain, theorizing that mental activity originated in the CNS and that the cause of mental illness resided within the brain. He applied this understanding to classify mental diseases and treatments.[17][103] Religious leaders often turned to versions of exorcism to treat mental disorders often utilizing methods that many consider to be cruel or barbaric methods. Trepanning was one of these methods used throughout history.[101]

In the 6th century AD, Lin Xie carried out an early psychological experiment, in which he asked people to draw a square with one hand and at the same time draw a circle with the other (ostensibly to test people's vulnerability to distraction). It has been cited that this was an early psychatric experiment.[104]

The Islamic Golden Age fostered early studies in Islamic psychology and psychiatry, with many scholars writing about mental disorders. The Persian physician Muhammad ibn Zakariya al-Razi, also known as "Rhazes", wrote texts about psychiatric conditions in the 9th century.[105] As chief physician of a hospital in Baghdad, he was also the director of one of the first bimaristans in the world.[105]

The first bimaristan was founded in Baghdad in the 9th century, and several others of increasing complexity were created throughout the Arab world in the following centuries. Some of the bimaristans contained wards dedicated to the care of mentally ill patients.[106] During the Middle Ages, Psychiatric hospitals and lunatic asylums were built and expanded throughout Europe. Specialist hospitals such as Bethlem Royal Hospital in London were built in medieval Europe from the 13th century to treat mental disorders, but were used only as custodial institutions and did not provide any type of treatment. It is the oldest extant psychiatric hospital in the world.[107]

An ancient text known as The Yellow Emperor's Classic of Internal Medicine identifies the brain as the nexus of wisdom and sensation, includes theories of personality based on yin–yang balance, and analyzes mental disorder in terms of physiological and social disequilibria. Chinese scholarship that focused on the brain advanced during the Qing Dynasty with the work of Western-educated Fang Yizhi (1611–1671), Liu Zhi (1660–1730), and Wang Qingren (1768–1831). Wang Qingren emphasized the importance of the brain as the center of the nervous system, linked mental disorder with brain diseases, investigated the causes of dreams, insomnia, psychosis, depression and epilepsy.[104]

Medical specialty edit

The beginning of psychiatry as a medical specialty is dated to the middle of the nineteenth century,[108] although its germination can be traced to the late eighteenth century. In the late 17th century, privately run asylums for the insane began to proliferate and expand in size. In 1713, the Bethel Hospital Norwich was opened, the first purpose-built asylum in England.[109] In 1656, Louis XIV of France created a public system of hospitals for those with mental disorders, but as in England, no real treatment was applied.[110]

During the Enlightenment, attitudes towards the mentally ill began to change. It came to be viewed as a disorder that required compassionate treatment. In 1758, English physician William Battie wrote his Treatise on Madness on the management of mental disorder. It was a critique aimed particularly at the Bethlem Royal Hospital, where a conservative regime continued to use barbaric custodial treatment. Battie argued for a tailored management of patients entailing cleanliness, good food, fresh air, and distraction from friends and family. He argued that mental disorder originated from dysfunction of the material brain and body rather than the internal workings of the mind.[111][112]

 
Dr. Philippe Pinel at the Salpêtrière, 1795 by Tony Robert-Fleury. Pinel ordering the removal of chains from patients at the Paris Asylum for insane women.

The introduction of moral treatment was initiated independently by the French doctor Philippe Pinel and the English Quaker William Tuke.[101] In 1792, Pinel became the chief physician at the Bicêtre Hospital. Patients were allowed to move freely about the hospital grounds, and eventually dark dungeons were replaced with sunny, well-ventilated rooms. Pinel's student and successor, Jean Esquirol (1772–1840), went on to help establish 10 new mental hospitals that operated on the same principles.[113]

Although Tuke, Pinel and others had tried to do away with physical restraint, it remained widespread into the 19th century. At the Lincoln Asylum in England, Robert Gardiner Hill, with the support of Edward Parker Charlesworth, pioneered a mode of treatment that suited "all types" of patients, so that mechanical restraints and coercion could be dispensed with—a situation he finally achieved in 1838. In 1839, Sergeant John Adams and Dr. John Conolly were impressed by the work of Hill, and introduced the method into their Hanwell Asylum, by then the largest in the country.[114][115][page needed]

The modern era of institutionalized provision for the care of the mentally ill, began in the early 19th century with a large state-led effort. In England, the Lunacy Act 1845 was an important landmark in the treatment of the mentally ill, as it explicitly changed the status of mentally ill people to patients who required treatment. All asylums were required to have written regulations and to have a resident qualified physician.[116][full citation needed] In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country. In the United States, the erection of state asylums began with the first law for the creation of one in New York, passed in 1842. The Utica State Hospital was opened around 1850. Many state hospitals in the United States were built in the 1850s and 1860s on the Kirkbride Plan, an architectural style meant to have curative effect.[117][page needed]

At the turn of the century, England and France combined had only a few hundred individuals in asylums.[118] By the late 1890s and early 1900s, this number had risen to the hundreds of thousands. However, the idea that mental illness could be ameliorated through institutionalization ran into difficulties.[119] Psychiatrists were pressured by an ever-increasing patient population,[119] and asylums again became almost indistinguishable from custodial institutions.[120]

In the early 1800s, psychiatry made advances in the diagnosis of mental illness by broadening the category of mental disease to include mood disorders, in addition to disease level delusion or irrationality.[121] The 20th century introduced a new psychiatry into the world, with different perspectives of looking at mental disorders. For Emil Kraepelin, the initial ideas behind biological psychiatry, stating that the different mental disorders are all biological in nature, evolved into a new concept of "nerves", and psychiatry became a rough approximation of neurology and neuropsychiatry.[122] Following Sigmund Freud's pioneering work, ideas stemming from psychoanalytic theory also began to take root in psychiatry.[123] The psychoanalytic theory became popular among psychiatrists because it allowed the patients to be treated in private practices instead of warehoused in asylums.[123]

 
Otto Loewi's work led to the identification of the first neurotransmitter, acetylcholine.

By the 1970s, however, the psychoanalytic school of thought became marginalized within the field.[123] Biological psychiatry reemerged during this time. Psychopharmacology and neurochemistry became the integral parts of psychiatry starting with Otto Loewi's discovery of the neuromodulatory properties of acetylcholine; thus identifying it as the first-known neurotransmitter. Subsequently, it has been shown that different neurotransmitters have different and multiple functions in regulation of behaviour. In a wide range of studies in neurochemistry using human and animal samples, individual differences in neurotransmitters' production, reuptake, receptors' density and locations were linked to differences in dispositions for specific psychiatric disorders. For example, the discovery of chlorpromazine's effectiveness in treating schizophrenia in 1952 revolutionized treatment of the disorder,[124] as did lithium carbonate's ability to stabilize mood highs and lows in bipolar disorder in 1948.[125] Psychotherapy was still utilized, but as a treatment for psychosocial issues.[126] This proved the idea of neurochemical nature of many psychiatric disorders.

Another approach to look for biomarkers of psychiatric disorders is [127] Neuroimaging that was first utilized as a tool for psychiatry in the 1980s.[128]

In 1963, US president John F. Kennedy introduced legislation delegating the National Institute of Mental Health to administer Community Mental Health Centers for those being discharged from state psychiatric hospitals.[129] Later, though, the Community Mental Health Centers focus shifted to providing psychotherapy for those with acute but less serious mental disorders.[129] Ultimately there were no arrangements made for actively following and treating severely mentally ill patients who were being discharged from hospitals, resulting in a large population of chronically homeless people with mental illness.[129]

Controversy and criticism edit

Main article: Controversy surrounding psychiatry

The institution of psychiatry has attracted controversy since its inception.[130]: 47  Scholars including those from social psychiatry, psychoanalysis, psychotherapy, and critical psychiatry have produced critiques.[130]: 47  It has been argued that psychiatry confuses disorders of the mind with disorders of the brain that can be treated with drugs;[130]: 53 : 47  that its use of drugs is in part due to lobbying by drug companies resulting in distortion of research;[130]: 51  and that the concept of "mental illness" is often used to label and control those with beliefs and behaviours that the majority of people disagree with;[130]: 50  and that it is too influenced by ideas from medicine causing it to misunderstand the nature of mental distress.[130] Critique of psychiatry from within the field comes from the critical psychiatry group in the UK.

Double argues that most critical psychiatry is anti-reductionist. Rashed argues new mental health science has moved beyond this reductionist critique by seeking integrative and biopsychosocial models for conditions and that much of critical psychiatry now exists with orthodox psychiatry but notes that many critiques remain unaddressed[131]: 237 

The term anti-psychiatry was coined by psychiatrist David Cooper in 1967 and was later made popular by Thomas Szasz. The word Antipsychiatrie was already used in Germany in 1904.[132] The basic premise of the anti-psychiatry movement is that psychiatrists attempt to classify "normal" people as "deviant"; psychiatric treatments are ultimately more damaging than helpful to patients; and psychiatry's history involves (what may now be seen as) dangerous treatments, such as psychosurgery an example of this being the frontal lobectomy (commonly called a lobotomy).[133] The use of lobotomies largely disappeared by the late 1970s.

See also edit

Notes edit

  1. ^ This article does not enter into that debate or seek to summarize the comparative efficacy literature. It simply explains why managed care insurance companies stopped routinely reimbursing psychiatrists for traditional psychotherapy, without commenting on the validity of that rationale.

References edit

Citations edit

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Cited texts edit

  • Gask L (2004). A Short Introduction to Psychiatry. London: SAGE Publications Ltd. ISBN 978-0-7619-7138-2. OCLC 56009828.
  • Guze SB (1992). Why Psychiatry Is a Branch of Medicine. New York: Oxford University Press. ISBN 978-0-19-507420-8. OCLC 25315637.
  • Lyness JM (1997). Psychiatric Pearls. Philadelphia: F.A. Davis Company. ISBN 978-0-8036-0280-9. OCLC 807453406.
  • Shorter E (1998) [1997]. A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. New York: John Wiley & Sons, Inc. ISBN 978-0-471-24531-5. OCLC 60169541.

Further reading edit

  • Berrios GE, Porter R, eds. (1995). The History of Clinical Psychiatry. London: Athlone Press. ISBN 978-0-485-24211-9. OCLC 1000559759.
  • Berrios GE (1996). History of Mental symptoms: The History of Descriptive Psychopathology since the 19th century. Cambridge: Cambridge University Press. ISBN 978-0-511-52672-5. OCLC 668203298.
  • Ford-Martin PA (2002). "Psychosis". In Longe JL, Blanchfield DS (eds.). Gale Encyclopedia of Medicine. Vol. 4 (2nd ed.). Detroit: Gale Group. OCLC 51166617.
  • Francis, Gavin, "Changing Psychiatry's Mind" (review of Anne Harrington, Mind Fixers: Psychiatry's Troubled Search for the Biology of Mental Illness, Norton, 366 pp.; and Nathan Filer, This Book Will Change Your Mind about Mental Health: A Journey into the Heartland of Psychiatry, London, Faber and Faber, 248 pp.), The New York Review of Books, vol. LXVIII, no. 1 (14 January 2021), pp. 26–29. "[M]ental disorders are different [from illnesses addressed by other medical specialties].... [T]o treat them as purely physical is to misunderstand their nature." "[C]are [needs to be] based on distress and [cognitive, emotional, and physical] need rather than [on psychiatric] diagnos[is]", which is often uncertain, erratic, and unreplicable. (p. 29.)
  • Halpern, Sue, "The Bull's-Eye on Your Thoughts" (review of Nita A. Farahany, The Battle for Your Brain: Defending the Right to Think Freely in the Age of Neurotechnology, St. Martin's, 2023, 277 pp.; and Daniel Barron, Reading Our Minds: The Rise of Big Data Psychiatry, Columbia Global Reports, 2023, 150 pp.), The New York Review of Books, vol. LXX, no. 17 (2 November 2023), pp. 60–62. Psychiatrist Daniel Barron deplores psychiatry's reliance largely on subjective impressions of a patient's condition – on behavioral-pattern recognition – whereas other medical specialties dispose of a more substantial armamentarium of objective diagnostic technologies. A psychiatric patient's diagnoses are arguably more in the eye of the physician: "An anti-psychotic 'works' if a [psychiatric] patient looks and feels less psychotic." Barron also posits that talking – an important aspect of psychiatric diagnostics and treatment – involves vague, subjective language and therefore cannot reveal the brain's objective workings. He trusts, though, that Big Data technologies will make psychiatric signs and symptoms more quantifiably objective. Sue Halpern cautions, however, that "When numbers have no agreed-upon, scientifically-derived, extrinsic meaning, quantification is unavailing." (p. 62.)
  • Hirschfeld RM, Lewis L, Vornik LA (February 2003). "Perceptions and impact of bipolar disorder: how far have we really come? Results of the national depressive and manic-depressive association 2000 survey of individuals with bipolar disorder". The Journal of Clinical Psychiatry. 64 (2): 161–74. doi:10.4088/JCP.v64n0209. PMID 12633125.
  • Krieke LV, Jeronimus BF, Blaauw FJ, Wanders RB, Emerencia AC, Schenk HM, Vos SD, Snippe E, Wichers M, Wigman JT, Bos EH, Wardenaar KJ, Jonge PD (June 2016). (PDF). International Journal of Methods in Psychiatric Research. 25 (2): 123–44. doi:10.1002/mpr.1495. hdl:11370/060326b0-0c6a-4df3-94cf-3468f2b2dbd6. PMC 6877205. PMID 26395198. Archived from the original (PDF) on 2019-08-02. Retrieved 2019-12-06.
  • McGorry PD, Mihalopoulos C, Henry L, Dakis J, Jackson HJ, Flaum M, Harrigan S, McKenzie D, Kulkarni J, Karoly R (February 1995). "Spurious precision: procedural validity of diagnostic assessment in psychotic disorders". The American Journal of Psychiatry. 152 (2): 220–3. CiteSeerX 10.1.1.469.3360. doi:10.1176/ajp.152.2.220. PMID 7840355.
  • Moncrieff J, Cohen D (2005). "Rethinking models of psychotropic drug action". Psychotherapy and Psychosomatics. 74 (3): 145–53. doi:10.1159/000083999. PMID 15832065. S2CID 6917144.
  • Burke C (February 2000). "Psychiatry: a "value-free" science?". Linacre Quarterly. 67/1: 59–88. doi:10.1080/20508549.2000.11877569. S2CID 77216987. from the original on 2021-11-29. Retrieved 2011-01-22.
  • "What is Cognitive-Behavioral Therapy?". National Association of Cognitive-Behavioral Therapists. from the original on 25 September 2006. Retrieved 20 September 2006.
  • Van Os J, Gilvarry C, Bale R, Van Horn E, Tattan T, White I, Murray R (May 1999). "A comparison of the utility of dimensional and categorical representations of psychosis. UK700 Group". Psychological Medicine. 29 (3): 595–606. doi:10.1017/s0033291798008162. PMID 10405080. S2CID 38854519.
  • Walker E, Young PD (1986). A Killing Cure (1st ed.). New York: H. Holt and Co. ISBN 978-0-03-069906-1. OCLC 12665467.
  • Williams JB, Gibbon M, First MB, Spitzer RL, Davies M, Borus J, Howes MJ, Kane J, Pope HG, Rounsaville B (August 1992). "The Structured Clinical Interview for DSM-III-R (SCID). II. Multisite test-retest reliability". Archives of General Psychiatry. 49 (8): 630–6. doi:10.1001/archpsyc.1992.01820080038006. PMID 1637253.
  • Hiruta G (June 2002). Beveridge A (ed.). "Japanese psychiatry in the Edo period (1600-1868)". History of Psychiatry. 13 (50): 131–51. doi:10.1177/0957154X0201305002. S2CID 143377079.

February 16, 2024
psychiatry, confused, with, clinical, psychology, medical, specialty, devoted, diagnosis, prevention, treatment, deleterious, mental, conditions, these, include, various, matters, related, mood, behaviour, cognition, perceptions, occupationnamesphysicianactivi. Not to be confused with Clinical psychology Psychiatry is the medical specialty devoted to the diagnosis prevention and treatment of deleterious mental conditions 1 2 These include various matters related to mood behaviour cognition and perceptions PsychiatryOccupationNamesPhysicianActivity sectorsMedicineDescriptionEducation requiredDoctor of Medicine MD Doctor of Osteopathic Medicine DO Bachelor of Medicine Bachelor of Surgery MBBS MBChB Bachelor of Science in Clinical Medicine Psychiatry Higher Diploma in Clinical Medicine and Surgery Psychiatry Diploma in Clinical Medicine and Surgery Diploma in Clinical PsychiatryRelated jobsMedical specialties Clinical psychologyInitial psychiatric assessment of a person begins with a case history and mental status examination Physical examinations psychological tests and laboratory tests may be conducted On occasion neuroimaging or other neurophysiological studies are performed 3 Mental disorders are diagnosed in accordance with diagnostic manuals such as the International Classification of Diseases ICD 4 edited by the World Health Organization WHO and the Diagnostic and Statistical Manual of Mental Disorders DSM published by the American Psychiatric Association APA The fifth edition of the DSM DSM 5 published in May 2013 reorganized the categories of disorders and added newer information and insights consistent with current research 5 Treatment may include psychotropics psychiatric medicines and psychotherapy 6 7 and also other modalities such as assertive community treatment community reinforcement substance abuse treatment and supported employment Treatment may be delivered on an inpatient or outpatient basis depending on the severity of functional impairment or risk to the individual or community Research within psychiatry is conducted on an interdisciplinary basis with other professionals such as epidemiologists nurses social workers occupational therapists and clinical psychologists Contents 1 Etymology 2 Theory and focus 2 1 Scope of practice 2 2 Ethics 2 3 Approaches 2 4 Practitioners 2 4 1 As a career choice in the US 2 5 Subspecialties 2 6 Research 3 Clinical application 3 1 Diagnostic systems 3 2 Potential use of MRI fMRI in diagnosis 3 3 Diagnostic manuals 4 Treatment 4 1 General considerations 4 2 Inpatient treatment 4 3 Outpatient treatment 4 4 Telepsychiatry 5 History 5 1 Earliest knowledge 5 2 Medical specialty 6 Controversy and criticism 7 See also 8 Notes 9 References 9 1 Citations 9 2 Cited texts 10 Further readingEtymology edit nbsp The word psyche comes from the ancient Greek for soul or butterfly 8 The fluttering insect appears in the coat of arms of Britain s Royal College of Psychiatrists 9 The term psychiatry was first coined by the German physician Johann Christian Reil in 1808 and literally means the medical treatment of the soul psych soul from Ancient Greek psykhe soul iatry medical treatment from Gk iatrikos medical from iasthai to heal A medical doctor specializing in psychiatry is a psychiatrist for a historical overview see Timeline of psychiatry Theory and focus edit 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 Psychiatry refers to a field of medicine focused specifically on the mind aiming to study prevent and treat mental disorders in humans 10 11 12 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 13 People who specialize in psychiatry often differ from most other mental health professionals and physicians in that they must be familiar with both the social and biological sciences 11 The discipline studies the operations of different organs and body systems as classified by the patient s subjective experiences and the objective physiology of the patient 14 Psychiatry treats mental disorders which are conventionally divided into three general categories mental illnesses severe learning disabilities and personality disorders 15 Although the focus of psychiatry has changed little over 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 other medical fields 16 Scope of practice edit Further information Neurology Overlap with psychiatry nbsp Disability adjusted life year for neuropsychiatric conditions per 100 000 inhabitants in 2002 no data less than 10 10 20 20 30 30 40 40 50 50 60 60 80 80 100 100 120 120 140 140 150 more than 150Though the medical specialty of psychiatry uses research in the field of neuroscience psychology medicine biology biochemistry and pharmacology 17 it has generally been considered a middle ground between neurology and psychology 18 Because psychiatry and neurology are deeply intertwined medical specialties all certification for both specialties and for their subspecialties is offered by a single board the American Board of Psychiatry and Neurology one of the member boards of the American Board of Medical Specialties 19 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 18 Psychiatrists also differ from psychologists in that they are physicians and have post graduate training called residency usually four to five years in psychiatry the quality and thoroughness of their graduate medical training is identical to that of all other physicians 20 Psychiatrists can therefore counsel patients prescribe medication order laboratory tests order neuroimaging and conduct physical examinations 3 Ethics edit See also Ethical issues in psychiatry disambiguation The World Psychiatric Association issues an ethical code to govern the conduct of psychiatrists like other purveyors of professional ethics 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 the broader Madrid Declaration in 1996 The code was further revised during the organization s general assemblies in 1999 2002 2005 and 2011 21 The World Psychiatric Association code covers such matters as confidentiality the death penalty ethnic or cultural discrimination 21 euthanasia genetics the human dignity of incapacitated patients media relations organ transplantation patient assessment research ethics sex selection 22 torture 23 24 and up to date knowledge In establishing such ethical codes the profession has responded to a number of controversies about the practice of psychiatry for example surrounding the use of lobotomy and electroconvulsive therapy Discredited psychiatrists who operated outside the norms of medical ethics include Harry Bailey Donald Ewen Cameron Samuel A Cartwright Henry Cotton and Andrei Snezhnevsky 25 page needed Approaches edit 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 26 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 27 28 29 In this notion the word model is not used in a strictly scientific way though 27 Alternatively a Niall McLaren acknowledges the physiological basis for the mind s existence but identifies cognition as an irreducible and independent realm in which disorder may occur 27 28 29 The biocognitive approach includes a mentalist etiology and provides a natural dualist i e non spiritual revision of the biopsychosocial view reflecting the efforts of Australian psychiatrist Niall McLaren to bring the discipline into scientific maturity in accordance with the paradigmatic standards of philosopher Thomas Kuhn 27 28 29 Once a medical professional diagnoses a patient there are numerous ways that they could choose to treat the patient Often psychiatrists will develop a treatment strategy that incorporates different facets of different approaches into one Drug prescriptions are very commonly written to be regimented to patients along with any therapy they receive There are three major pillars of psychotherapy that treatment strategies are most regularly drawn from Humanistic psychology attempts to put the whole of the patient in perspective it also focuses on self exploration 30 Behaviorism is a therapeutic school of thought that elects to focus solely on real and observable events rather than mining the unconscious or subconscious Psychoanalysis on the other hand concentrates its dealings on early childhood irrational drives the unconscious and conflict between conscious and unconscious streams 31 Practitioners edit Main article Psychiatrist This section relies largely or entirely upon a single source Relevant discussion may be found on the talk page Please help improve this article by introducing citations to additional sources at this section August 2017 Learn how and when to remove this template message All physicians can diagnose mental disorders and prescribe treatments utilizing principles of psychiatry Psychiatrists are trained physicians who specialize in psychiatry and are certified to treat mental illness They may treat outpatients inpatients or both they may practice as solo practitioners or as members of groups they may be self employed be members of partnerships or be employees of governmental academic nonprofit or for profit entities employees of hospitals they may treat military personnel as civilians or as members of the military and in any of these settings they may function as clinicians researchers teachers or some combination of these Although psychiatrists may also go through significant training to conduct psychotherapy psychoanalysis or cognitive behavioral therapy it is their training as physicians that differentiates them from other mental health professionals As a career choice in the US edit Psychiatry was not a popular career choice among medical students even though medical school placements are rated favorably 32 This has resulted in a significant shortage of psychiatrists in the United States and elsewhere 33 Strategies to address this shortfall have included the use of short taster placements early in the medical school curriculum 32 and attempts to extend psychiatry services further using telemedicine technologies and other methods 34 Recently however there has been an increase in the number of medical students entering into a psychiatry residency There are several reasons for this surge including the intriguing nature of the field growing interest in genetic biomarkers involved in psychiatric diagnoses and newer pharmaceuticals on the drug market to treat psychiatric illnesses 35 Subspecialties edit The field of psychiatry has many subspecialties that require additional training and certification by the American Board of Psychiatry and Neurology ABPN Such subspecialties include 36 Addiction psychiatry addiction medicine Brain injury medicine 37 38 Child and adolescent psychiatry Clinical neurophysiology Consultation liaison psychiatry 39 Forensic psychiatry Geriatric psychiatry Hospice and palliative medicine Sleep medicine 40 nbsp Wikibooks has a book on the topic of Psychiatry nbsp Wikiquote has quotations related to Psychiatry nbsp Look up psychiatry in Wiktionary the free dictionary nbsp Wikiversity has learning resources about Psychiatry nbsp Wikimedia Commons has media related to Psychiatry Additional psychiatry subspecialties for which the ABPN does not provide formal certification include 41 Biological psychiatry Cognitive diseases as in various forms of dementia Community psychiatry Cross cultural psychiatry Emergency psychiatry Evolutionary psychiatry Global mental health Learning disabilities Military psychiatry Neurodevelopmental disorders Neuropsychiatry Social psychiatryAddiction psychiatry focuses on evaluation and treatment of individuals with alcohol drug or other substance related disorders and of individuals with dual diagnosis of substance related and other psychiatric disorders Biological psychiatry is an approach to psychiatry that aims to understand mental disorders in terms of the biological function of the nervous system Child and adolescent psychiatry is the branch of psychiatry that specializes in work with children teenagers and their families Community psychiatry is an approach that reflects an inclusive public health perspective and is practiced in community mental health services 42 Cross cultural psychiatry is a branch of psychiatry concerned with the cultural and ethnic context of mental disorder and psychiatric services Emergency psychiatry is the clinical application of psychiatry in emergency settings Forensic psychiatry utilizes medical science generally and psychiatric knowledge and assessment methods in particular to help answer legal questions Geriatric psychiatry is a branch of psychiatry dealing with the study prevention and treatment of mental disorders in the elderly Global mental health is an area of study research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide 43 although some scholars consider it to be a neo colonial culturally insensitive project 44 45 46 47 Liaison psychiatry is 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 is a branch of medicine dealing with mental disorders attributable to diseases of the nervous system Social psychiatry is a branch of psychiatry that focuses on the interpersonal and cultural context of mental disorder and mental well being In larger healthcare organizations psychiatrists often serve in senior management roles where they are responsible for the efficient and effective delivery of mental health services for the organization s constituents For example the Chief of Mental Health Services at most VA medical centers is usually a psychiatrist although psychologists occasionally are selected for the position as well citation needed In the United States psychiatry is one of the few specialties which qualify for further education and board certification in pain medicine palliative medicine and sleep medicine Research edit Psychiatric research is by its very nature interdisciplinary combining social biological and psychological perspectives in attempt to understand the nature and treatment of mental disorders 48 Clinical and research psychiatrists study basic and clinical psychiatric topics at research institutions and publish articles in journals 17 49 50 51 Under the supervision of institutional 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 52 page needed Clinical application editDiagnostic systems edit See also Diagnostic classification and rating scales used in psychiatry 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 with pathological psychopathological or psychosocial histories obtained and sometimes neuroimages or other neurophysiological measurements are taken or personality tests or cognitive tests administered 53 54 55 56 57 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 58 Some clinicians are beginning to utilize genetics 59 60 61 and automated speech assessment 62 during the diagnostic process but on the whole these remain research topics Potential use of MRI fMRI in diagnosis edit In 2018 the American Psychological Association commissioned a review to reach a consensus on whether modern clinical MRI fMRI will be able to be used in the diagnosis of mental health disorders The criteria presented by the APA stated that the biomarkers used in diagnosis should have a sensitivity of at least 80 for detecting a particular psychiatric disorder should have a specificity of at least 80 for distinguishing this disorder from other psychiatric or medical disorders should be reliable reproducible and ideally be noninvasive simple to perform and inexpensive proposed biomarkers should be verified by 2 independent studies each by a different investigator and different population samples and published in a peer reviewed journal The review concluded that although neuroimaging diagnosis may technically be feasible very large studies are needed to evaluate specific biomarkers which were not available 63 Diagnostic manuals edit See also Diagnostic and Statistical Manual of Mental Disorders Three main diagnostic manuals used to classify mental health conditions are in use today The ICD 11 is produced and published by the World Health Organization includes a section on psychiatric conditions and is used worldwide 64 The Diagnostic and Statistical Manual of Mental Disorders produced and published by the American Psychiatric Association APA is primarily focused on mental health conditions and is the main classification tool in the United States 65 It is currently in its fifth revised edition and is also used worldwide 65 The Chinese Society of Psychiatry has also produced a diagnostic manual the Chinese Classification of Mental Disorders 66 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 65 67 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 68 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 69 The DSM has attracted praise for standardizing psychiatric diagnostic categories and criteria It has also attracted controversy and criticism Some critics argue that the DSM represents an unscientific system that enshrines the opinions of a few powerful psychiatrists There are ongoing issues concerning the validity and reliability of the diagnostic categories the reliance on superficial symptoms the use of artificial dividing lines between categories and from normality possible cultural bias medicalization of human distress and financial conflicts of interest including with the practice of psychiatrists and with the pharmaceutical industry political controversies about the inclusion or exclusion of diagnoses from the manual in general or in regard to specific issues and the experience of those who are most directly affected by the manual by being diagnosed including the consumer survivor movement 70 71 72 73 Treatment editGeneral considerations edit nbsp NIMH federal agency patient room for Psychiatric research Maryland USIndividuals receiving psychiatric treatment 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 countries such as the UK and Australia by sectioning under a mental health law A psychiatrist or medical provider evaluates people through a psychiatric assessment for their 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 personnel 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 that may be contributing to the alleged psychiatric problems A physical examination may also serve to identify any signs of self harm this examination is often performed by someone other than the psychiatrist especially if blood tests and medical imaging are performed Like most medications psychiatric medications can cause adverse effects in patients and some require ongoing therapeutic drug monitoring for instance full blood counts serum drug levels renal function liver function or thyroid function Electroconvulsive therapy ECT is sometimes administered for serious conditions such as those unresponsive to medication The efficacy 74 75 and adverse effects of psychiatric drugs may vary from patient to patient Inpatient treatment edit This section needs additional citations for verification Please help improve this article by adding citations to reliable sources in this section Unsourced material may be challenged and removed August 2017 Learn how and when to remove this template message 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 Average inpatient psychiatric treatment stay has decreased significantly since the 1960s a trend known as deinstitutionalization 76 77 78 79 Today in most countries 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 80 However in Japan psychiatric hospitals continue to keep patients for long periods sometimes even keeping them in physical restraints strapped to their beds for periods of weeks or months 81 82 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 United States 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 or others Bed availability is often the real determinant of admission decisions to hard pressed public facilities People may be admitted voluntarily if the treating doctor considers that safety is not compromised by this less restrictive option For many years controversy has surrounded the use of involuntary treatment and use of the term lack of insight in describing patients Internationally mental health laws vary significantly but in many cases involuntary psychiatric treatment is permitted when there is deemed to be a significant risk to the patient or others due to the patient s illness Involuntary treatment refers to treatment that occurs based on a treating physician s recommendations without requiring consent from the patient 83 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 pharmacists 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 put in physical restraints or medicated People on inpatient wards may be allowed leave for periods of time either accompanied or on their own 84 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 Even in developed countries programs in public hospitals vary widely Some may offer structured activities and therapies offered from many perspectives while others may only have the funding for medicating and monitoring patients This may be problematic in that the maximum amount of therapeutic work might not actually take place in the hospital setting This is why hospitals are increasingly used in limited situations and moments of crisis where patients are a direct threat to themselves or others Alternatives to psychiatric hospitals that may actively offer more therapeutic approaches include rehabilitation centers or rehab as popularly termed citation needed Outpatient treatment edit Outpatient treatment involves periodic visits to a psychiatrist for consultation in his or her office or at a community based outpatient clinic During initial appointments a psychiatrist generally conducts a psychiatric assessment or evaluation of the patient Follow up appointments then focus on making medication adjustments reviewing potential medication interactions considering the impact of other medical disorders on the patient s mental and emotional functioning and counseling patients regarding changes they might make to facilitate healing and remission of symptoms The frequency with which a psychiatrist sees people in treatment varies widely from once a week to twice a year depending on the type severity and stability of each person s condition and depending on what the clinician and patient decide would be best Increasingly psychiatrists are limiting their practices to psychopharmacology prescribing medications as opposed to previous practice in which a psychiatrist would provide traditional 50 minute psychotherapy sessions of which psychopharmacology would be a part but most of the consultation sessions consisted of talk therapy This shift began in the early 1980s and accelerated in the 1990s and 2000s 85 A major reason for this change was the advent of managed care insurance plans clarification needed which began to limit reimbursement for psychotherapy sessions provided by psychiatrists The underlying assumption was that psychopharmacology was at least as effective as psychotherapy and it could be delivered more efficiently because less time is required for the appointment 86 87 88 89 90 91 a excessive citations Because of this shift in practice patterns psychiatrists often refer patients whom they think would benefit from psychotherapy to other mental health professionals e g clinical social workers and psychologists 92 Telepsychiatry edit This section is an excerpt from Telepsychiatry edit nbsp Telemental health sessionTelepsychiatry or telemental health refers to the use of telecommunications technology mostly videoconferencing and phone calls to deliver psychiatric care remotely for people with mental health conditions It is a branch of telemedicine 93 94 Telepsychiatry can be effective in treating people with mental health conditions In the short term it can be as acceptable and effective as face to face care 95 It can improve access to mental health services for some but might also represent a barrier for those lacking access to a suitable device the internet or the necessary digital skills Factors such as poverty that are associated with lack of internet access are also associated with greater risk of mental health problems making digital exclusion an important problem of telemental health services 95 During the COVID 19 pandemic mental health services were adapted to telemental health in high income countries It proved effective and acceptable for use in an emergency situation but there were concerns regarding its long term implementation 96 History editMain article History of psychiatry Earliest knowledge edit The earliest known texts on mental disorders are from ancient India and include the Ayurvedic text Charaka Samhita 97 98 The first hospitals for curing mental illness were established in India during the 3rd century BCE 99 Greek philosophers including Thales Plato and Aristotle especially in his De Anima treatise also addressed the workings of the mind As early as the 4th century BC the Greek physician Hippocrates theorized that mental disorders had physical rather than supernatural causes In 387 BCE Plato suggested that the brain is where mental processes take place In 4th to 5th century B C Greece Hippocrates wrote that he visited Democritus and found him in his garden cutting open animals Democritus explained that he was attempting to discover the cause of madness and melancholy Hippocrates praised his work Democritus had with him a book on madness and melancholy 100 During the 5th century BCE mental disorders especially those with psychotic traits were considered supernatural in origin 101 a view which existed throughout ancient Greece and Rome 101 as well as Egyptian regions 102 page needed Alcmaeon believed the brain not the heart was the organ of thought He tracked the ascending sensory nerves from the body to the brain theorizing that mental activity originated in the CNS and that the cause of mental illness resided within the brain He applied this understanding to classify mental diseases and treatments 17 103 Religious leaders often turned to versions of exorcism to treat mental disorders often utilizing methods that many consider to be cruel or barbaric methods Trepanning was one of these methods used throughout history 101 In the 6th century AD Lin Xie carried out an early psychological experiment in which he asked people to draw a square with one hand and at the same time draw a circle with the other ostensibly to test people s vulnerability to distraction It has been cited that this was an early psychatric experiment 104 The Islamic Golden Age fostered early studies in Islamic psychology and psychiatry with many scholars writing about mental disorders The Persian physician Muhammad ibn Zakariya al Razi also known as Rhazes wrote texts about psychiatric conditions in the 9th century 105 As chief physician of a hospital in Baghdad he was also the director of one of the first bimaristans in the world 105 The first bimaristan was founded in Baghdad in the 9th century and several others of increasing complexity were created throughout the Arab world in the following centuries Some of the bimaristans contained wards dedicated to the care of mentally ill patients 106 During the Middle Ages Psychiatric hospitals and lunatic asylums were built and expanded throughout Europe Specialist hospitals such as Bethlem Royal Hospital in London were built in medieval Europe from the 13th century to treat mental disorders but were used only as custodial institutions and did not provide any type of treatment It is the oldest extant psychiatric hospital in the world 107 An ancient text known as The Yellow Emperor s Classic of Internal Medicine identifies the brain as the nexus of wisdom and sensation includes theories of personality based on yin yang balance and analyzes mental disorder in terms of physiological and social disequilibria Chinese scholarship that focused on the brain advanced during the Qing Dynasty with the work of Western educated Fang Yizhi 1611 1671 Liu Zhi 1660 1730 and Wang Qingren 1768 1831 Wang Qingren emphasized the importance of the brain as the center of the nervous system linked mental disorder with brain diseases investigated the causes of dreams insomnia psychosis depression and epilepsy 104 Medical specialty edit The beginning of psychiatry as a medical specialty is dated to the middle of the nineteenth century 108 although its germination can be traced to the late eighteenth century In the late 17th century privately run asylums for the insane began to proliferate and expand in size In 1713 the Bethel Hospital Norwich was opened the first purpose built asylum in England 109 In 1656 Louis XIV of France created a public system of hospitals for those with mental disorders but as in England no real treatment was applied 110 During the Enlightenment attitudes towards the mentally ill began to change It came to be viewed as a disorder that required compassionate treatment In 1758 English physician William Battie wrote his Treatise on Madness on the management of mental disorder It was a critique aimed particularly at the Bethlem Royal Hospital where a conservative regime continued to use barbaric custodial treatment Battie argued for a tailored management of patients entailing cleanliness good food fresh air and distraction from friends and family He argued that mental disorder originated from dysfunction of the material brain and body rather than the internal workings of the mind 111 112 nbsp Dr Philippe Pinel at the Salpetriere 1795 by Tony Robert Fleury Pinel ordering the removal of chains from patients at the Paris Asylum for insane women The introduction of moral treatment was initiated independently by the French doctor Philippe Pinel and the English Quaker William Tuke 101 In 1792 Pinel became the chief physician at the Bicetre Hospital Patients were allowed to move freely about the hospital grounds and eventually dark dungeons were replaced with sunny well ventilated rooms Pinel s student and successor Jean Esquirol 1772 1840 went on to help establish 10 new mental hospitals that operated on the same principles 113 Although Tuke Pinel and others had tried to do away with physical restraint it remained widespread into the 19th century At the Lincoln Asylum in England Robert Gardiner Hill with the support of Edward Parker Charlesworth pioneered a mode of treatment that suited all types of patients so that mechanical restraints and coercion could be dispensed with a situation he finally achieved in 1838 In 1839 Sergeant John Adams and Dr John Conolly were impressed by the work of Hill and introduced the method into their Hanwell Asylum by then the largest in the country 114 115 page needed The modern era of institutionalized provision for the care of the mentally ill began in the early 19th century with a large state led effort In England the Lunacy Act 1845 was an important landmark in the treatment of the mentally ill as it explicitly changed the status of mentally ill people to patients who required treatment All asylums were required to have written regulations and to have a resident qualified physician 116 full citation needed In 1838 France enacted a law to regulate both the admissions into asylums and asylum services across the country In the United States the erection of state asylums began with the first law for the creation of one in New York passed in 1842 The Utica State Hospital was opened around 1850 Many state hospitals in the United States were built in the 1850s and 1860s on the Kirkbride Plan an architectural style meant to have curative effect 117 page needed At the turn of the century England and France combined had only a few hundred individuals in asylums 118 By the late 1890s and early 1900s this number had risen to the hundreds of thousands However the idea that mental illness could be ameliorated through institutionalization ran into difficulties 119 Psychiatrists were pressured by an ever increasing patient population 119 and asylums again became almost indistinguishable from custodial institutions 120 In the early 1800s psychiatry made advances in the diagnosis of mental illness by broadening the category of mental disease to include mood disorders in addition to disease level delusion or irrationality 121 The 20th century introduced a new psychiatry into the world with different perspectives of looking at mental disorders For Emil Kraepelin the initial ideas behind biological psychiatry stating that the different mental disorders are all biological in nature evolved into a new concept of nerves and psychiatry became a rough approximation of neurology and neuropsychiatry 122 Following Sigmund Freud s pioneering work ideas stemming from psychoanalytic theory also began to take root in psychiatry 123 The psychoanalytic theory became popular among psychiatrists because it allowed the patients to be treated in private practices instead of warehoused in asylums 123 nbsp Otto Loewi s work led to the identification of the first neurotransmitter acetylcholine By the 1970s however the psychoanalytic school of thought became marginalized within the field 123 Biological psychiatry reemerged during this time Psychopharmacology and neurochemistry became the integral parts of psychiatry starting with Otto Loewi s discovery of the neuromodulatory properties of acetylcholine thus identifying it as the first known neurotransmitter Subsequently it has been shown that different neurotransmitters have different and multiple functions in regulation of behaviour In a wide range of studies in neurochemistry using human and animal samples individual differences in neurotransmitters production reuptake receptors density and locations were linked to differences in dispositions for specific psychiatric disorders For example the discovery of chlorpromazine s effectiveness in treating schizophrenia in 1952 revolutionized treatment of the disorder 124 as did lithium carbonate s ability to stabilize mood highs and lows in bipolar disorder in 1948 125 Psychotherapy was still utilized but as a treatment for psychosocial issues 126 This proved the idea of neurochemical nature of many psychiatric disorders Another approach to look for biomarkers of psychiatric disorders is 127 Neuroimaging that was first utilized as a tool for psychiatry in the 1980s 128 In 1963 US president John F Kennedy introduced legislation delegating the National Institute of Mental Health to administer Community Mental Health Centers for those being discharged from state psychiatric hospitals 129 Later though the Community Mental Health Centers focus shifted to providing psychotherapy for those with acute but less serious mental disorders 129 Ultimately there were no arrangements made for actively following and treating severely mentally ill patients who were being discharged from hospitals resulting in a large population of chronically homeless people with mental illness 129 Controversy and criticism editMain article Controversy surrounding psychiatry The institution of psychiatry has attracted controversy since its inception 130 47 Scholars including those from social psychiatry psychoanalysis psychotherapy and critical psychiatry have produced critiques 130 47 It has been argued that psychiatry confuses disorders of the mind with disorders of the brain that can be treated with drugs 130 53 47 that its use of drugs is in part due to lobbying by drug companies resulting in distortion of research 130 51 and that the concept of mental illness is often used to label and control those with beliefs and behaviours that the majority of people disagree with 130 50 and that it is too influenced by ideas from medicine causing it to misunderstand the nature of mental distress 130 Critique of psychiatry from within the field comes from the critical psychiatry group in the UK Double argues that most critical psychiatry is anti reductionist Rashed argues new mental health science has moved beyond this reductionist critique by seeking integrative and biopsychosocial models for conditions and that much of critical psychiatry now exists with orthodox psychiatry but notes that many critiques remain unaddressed 131 237 The term anti psychiatry was coined by psychiatrist David Cooper in 1967 and was later made popular by Thomas Szasz The word Antipsychiatrie was already used in Germany in 1904 132 The basic premise of the anti psychiatry movement is that psychiatrists attempt to classify normal people as deviant psychiatric treatments are ultimately more damaging than helpful to patients and psychiatry s history involves what may now be seen as dangerous treatments such as psychosurgery an example of this being the frontal lobectomy commonly called a lobotomy 133 The use of lobotomies largely disappeared by the late 1970s See also editGlossary of psychiatry Medical psychology Biopsychiatry controversy Child and adolescent psychiatry Telepsychiatry Psychiatry Innovation Lab Anti psychiatry Controversies about psychiatryNotes edit This article does not enter into that debate or seek to summarize the comparative efficacy literature It simply explains why managed care insurance companies stopped routinely reimbursing psychiatrists for 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18142718 Shorter 1997 p 239 sfn error no target CITEREFShorter1997 help Shorter 1997 p 246 sfn error no target CITEREFShorter1997 help Shorter 1997 p 270 sfn error no target CITEREFShorter1997 help a b c Shorter 1997 p 280harvnb error no target CITEREFShorter1997 help a b c d e f Middleton H Moncrieff J 2019 Critical psychiatry a brief overview BJPsych Advances 25 47 54 doi 10 1192 bja 2018 38 S2CID 149547063 Rashed MA 2020 The critique of psychiatry as we enter the third decade of the 21st century Commentary on Critical psychiatry BJPsych Bulletin 44 6 236 238 doi 10 1192 bjb 2020 10 ISSN 2056 4694 PMC 7684776 PMID 32102717 Bangen Hans Geschichte der medikamentosen Therapie der Schizophrenie Berlin 1992 ISBN 3 927408 82 4 page 87 Citizens Commission on Human Rights Expands its Activities to Expose and Handle Psychiatric Abuse in Clearwater Tampa Bay via New Center Scientology Archived from the original on 2018 03 11 Retrieved 2018 03 10 Cited texts edit Gask L 2004 A Short Introduction to Psychiatry London SAGE Publications Ltd ISBN 978 0 7619 7138 2 OCLC 56009828 Guze SB 1992 Why Psychiatry Is a Branch of Medicine New York Oxford University Press ISBN 978 0 19 507420 8 OCLC 25315637 Lyness JM 1997 Psychiatric Pearls Philadelphia F A Davis Company ISBN 978 0 8036 0280 9 OCLC 807453406 Shorter E 1998 1997 A History of Psychiatry From the Era of the Asylum to the Age of Prozac New York John Wiley amp Sons Inc ISBN 978 0 471 24531 5 OCLC 60169541 Further reading editBerrios GE Porter R eds 1995 The History of Clinical Psychiatry London Athlone Press ISBN 978 0 485 24211 9 OCLC 1000559759 Berrios GE 1996 History of Mental symptoms The History of Descriptive Psychopathology since the 19th century Cambridge Cambridge University Press ISBN 978 0 511 52672 5 OCLC 668203298 Ford Martin PA 2002 Psychosis In Longe JL Blanchfield DS eds Gale Encyclopedia of Medicine Vol 4 2nd ed Detroit Gale Group OCLC 51166617 Francis Gavin Changing Psychiatry s Mind review of Anne Harrington Mind Fixers Psychiatry s Troubled Search for the Biology of Mental Illness Norton 366 pp and Nathan Filer This Book Will Change Your Mind about Mental Health A Journey into the Heartland of Psychiatry London Faber and Faber 248 pp The New York Review of Books vol LXVIII no 1 14 January 2021 pp 26 29 M ental disorders are different from illnesses addressed by other medical specialties T o treat them as purely physical is to misunderstand their nature C are needs to be based on distress and cognitive emotional and physical need rather than on psychiatric diagnos is which is often uncertain erratic and unreplicable p 29 Halpern Sue The Bull s Eye on Your Thoughts review of Nita A Farahany The Battle for Your Brain Defending the Right to Think Freely in the Age of Neurotechnology St Martin s 2023 277 pp and Daniel Barron Reading Our Minds The Rise of Big Data Psychiatry Columbia Global Reports 2023 150 pp The New York Review of Books vol LXX no 17 2 November 2023 pp 60 62 Psychiatrist Daniel Barron deplores psychiatry s reliance largely on subjective impressions of a patient s condition on behavioral pattern recognition whereas other medical specialties dispose of a more substantial armamentarium of objective diagnostic technologies A psychiatric patient s diagnoses are arguably more in the eye of the physician An anti psychotic works if a psychiatric patient looks and feels less psychotic Barron also posits that talking an important aspect of psychiatric diagnostics and treatment involves vague subjective language and therefore cannot reveal the brain s objective workings He trusts though that Big Data technologies will make psychiatric signs and symptoms more quantifiably objective Sue Halpern cautions however that When numbers have no agreed upon scientifically derived extrinsic meaning quantification is unavailing p 62 Hirschfeld RM Lewis L Vornik LA February 2003 Perceptions and impact of bipolar disorder how far have we really come Results of the 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