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Psychiatry

Psychiatry is the branch of medicine that studies, diagnoses and treats mental illness and behavioural disorders. While all physicians will encounter patients with mental illnesses and any of them may treat it, psychiatrists specialise in these areas.

They are more extensively trained in the differential diagnosis (the distinguishing of various forms) and treatment of mental illness and are required to keep up to date on the newest developments in the field. Psychologists, nurse practitioners and social workers may also provide mental healthcare, though of these none may prescribe medication in the United Kingdom and only nurse practitioners may prescribe medication in the United States.

Practice of psychiatry

Psychiatry is one of the clinical medical disciplines which involves the diagnosis, treatment and prevention of mental and behavioural disorders such as clinical depression, schizophrenia and anxiety disorders. In addition to face-to-face consultation, psychiatrists use information collated from other sources such as other health and social care professionals, psychiatric rating scales and medical investigations such as laboratory tests to rule out non-psychiatric conditions such as thyroid dysfunction or brain tumour.

The field of psychiatry itself can be divided into various subspecialties. These include:

  • Child and adolescent psychiatry
  • Adult psychiatry
  • Old-age psychiatry (Geriatric psychiatry)
  • Learning disability
  • Consultation-liaison psychiatry
  • Emergency psychiatry
  • Addiction and substance abuse psychiatry
  • Forensic psychiatry

Practicing psychiatrists may specialise in certain areas of interest such as psychopharmacology, mood disorders, neuropsychiatry, eating disorders, psychiatric rehabilitation, crisis assessment and treatment, early psychosis intervention, community psychiatry (home treatment and outreach) and various forms of psychotherapy such as psychodynamic therapy and cognitive behavioural therapy.

Individuals with mental illness are commonly referred to as patients (particularly in the UK) but may also be called clients, especially when treated privately. There are various paths by which they may come under the care of a psychiatrist or other psychiatric practitioners, the two most common being self-referral or referral by a primary-care physician. Alternatively, a patient may be referred by hospital medical staff, by court order, involuntary commitment, or, in the UK and Australia, by sectioning under a mental health law.

Whatever the circumstance of their patient’s referral, a psychiatrist first assesses their patient’s mental and somatic (i.e. general medical) condition. This usually involves interviewing the patient and/or obtaining information from relatives, associates, carers, law enforcement personnel, nursing staff or other healthcare professionals. Physical examination is usually performed to establish or exclude other illnesses or identify any signs of self-harm. Blood tests and medical imaging may be also performed and their associated medical specialists consulted.

Mental and behavioural conditions are dealt with by various forms of medication, therapy and counselling. Psychotherapy may be used for many conditions, either exclusively or in combination with medication. Commencing treatment with medication requires the patient to agree to this treatment (although in many countries the law provides overriding circumstances) and that they will follow the dosage prescribed.

Many psychiatric medications can produce side-effects in patients and hence often involve ongoing therapeutic drug monitoring, for instance full blood counts or, for patients taking lithium salts, serum levels of lithium. Electroconvulsive therapy (ECT) is sometimes administered for serious and disabling conditions, especially those unresponsive to medication. ECT has drawn criticism from anti-psychiatry groups despite evidence for its efficacy.

Psychiatric patients may be either inpatients and outpatients. Psychiatric outpatients periodically visit their psychiatrist for consultation in his or her office, usually for an appointment lasting thirty to sixty minutes. These consultations normally involve the psychiatrist interviewing the patient to update their assessment of the patient’s condition and management of any medication. The psychiatrist may also provide psychotherapy. The frequency with which a psychiatrist sees patients varies widely, from days to months, depending on the type, severity and stability of each patient’s condition.

Psychiatric inpatients are patients admitted to a hospital to receive psychiatric care. In some cases this admission is voluntary, and in other cases it is involuntary. In North America, the criteria for involuntary admission varies with jurisdiction. It may be as broad as having a mental disorder and being capable of mental or physical deterioration or as narrow as a patient being considered to be an immediate danger to themselves or others. In the UK, involuntary admission is limited to this narrow criterion. Some jurisdictions give psychiatrists the sole authority to forcibly admit patients, while others require a trial.

Once in the care of a hospital, patients are monitored, given medication and psychologically tested. If necessary, they are prevented from harming themselves or others. Hospitalised patients are increasingly being managed in a multidisciplinary fashion, meaning patients may encounter a variety of nursing staff, occupational therapists, psychotherapists, social workers and other healthcare professionals.

Historically, particularly before the advent of psychiatric medication, hospital stays averaged six months or more, with a significant number of cases involving hospitalisation for many years. Today the average hospital stay is around two to three weeks, with only a small number of cases involving long term hospitalisation. On being discharged from the hospital, inpatients often become outpatients.

The DSM system

In the United States, the standard system of psychiatric diagnoses is given in the Diagnostic and Statistical Manual of Mental Disorders (known as the DSM), overseen and revised by the American Psychiatric Association. It is currently in its fourth revised edition (IV-TR, published 2000) and is based on five axes:

  • Axis I: Psychiatric disorders
  • Axis II: Personality disorders / mental retardation
  • Axis III: General medical condition
  • Axis IV: Social functioning and impact of symptoms
  • Axis V: Global Assessment of Functioning (described using a scale from 100 to 0)

Common axis I disorders include substance dependence and abuse (e.g. alcohol dependence); mood disorders (e.g. depression, bipolar disorder); psychotic disorders (e.g. schizophrenia, schizoaffective disorder); and anxiety disorders (e.g. post-traumatic stress disorder, obsessive-compulsive disorder). Common axis II disorders include borderline personality disorder, schizotypal personality disorder, avoidant personality disorder and antisocial personality disorder.

The intention is to create a set of diagnoses that are replicable and meaningful, although the categories are broad and many of the symptoms overlap. While the system was originally intended to enhance research into both diagnosis and treatment, the nomenclature is now one of two standards widely used by clinicians, it has been used by administrators and insurance companies in many countries. The other standard, the ICD-10 (International Classification of Diseases-10), is less specific in its criteria for each illness. However, it has been critiqued for being vague, poorly defined, and lacking proper scientific foundation. [1]

These standards have been given legal weight within the criminal justice system and for involuntary commitment. This has lead to heated controversy over defining standards. As an example, homosexuality was previously included as a diagnosis in the DSM, but it has since been taken out.

Contrast with psychology

Psychiatry is practised by psychiatrists, who are medical doctors specialising in mental illness and who are therefore trained to prescribe drugs in addition to any psychosocial treatment they may recommend. Psychiatrists ideally evaluate patients from a biopsychosocial perspective before prescribing treatment.

Psychology is the larger study of human behaviour and thought processes. Psychology is as much an academic field of study (like biology or sociology) as a profession, and as a whole, is concerned with the study of normal everyday human behaviour as much as it is the study of mental illness. Not all psychologists work with or study the mentally ill. Some psychologists are involved in the study of how drugs or other chemical agents effect the brain, but generally are not themselves trained to prescribe or administer drugs.

Clinical psychology is the branch of psychology that specialises in the study of health-related behavior and the treatment of mental illness. Clinical psychologists have extensive training in psychotherapy and psychological testing and are often found working in similar settings and with the same kinds of patients or clients as psychiatrists.

Clinical psychologists are generally not allowed to prescribe medications in the United States (exceptions have been made in the Department of Defence, Guam, New Mexico, and Louisiana, but the psychologist must complete a postdoctoral training program in clinical psychopharmacology and practicum, and pass a licensing examination prior to doing so). The turf battle over prescribing privileges is ongoing in the U.S. A significant subset of psychologists argue that there is an inadequate number of psychiatrists to treat all of the nation’s psychiatricaly ill and that focused education in psychopharmacology is adequate to provide expert medication management. The American Psychiatric Association has long argued that psychologists lack the medical training to make the sometimes difficult diagnostic, therapeutic and potentially life-threatening decisions that accompany the pharmacologic treatment of the seriously mentally ill.

Professional requirements

In the United States, psychiatrists are board certified as specialists in their field. After completing four years of medical school, physicians practice as psychiatry residents for four years. Psychiatry residents are required to complete at least four months of medicine (internal medicine or pediatrics) and two months of neurology during these four years. After completing their training, psychiatrists take written and then oral board examinations, each of which has a failure rate that approaches 50%, before becoming board certified. In the United Kingdom, people work as a senior house officer (SHO) in psychiatry for 2-3 years while sitting postgraduate exams, after which they may apply for a specialist registrar post, which may be in any one of several areas of specialisation within psychiatry. In other countries, similar rules usually apply.

Some psychiatrists specialise in helping certain age groups; child and adolescent psychiatrists work with children and teenagers in addressing psychological problems. Those who work with the elderly are called geriatric psychiatrists, or in the UK, psychogeriatricians. Those who practise psychiatry in the workplace are called industrial psychiatrists (this is a term used in the US but not the UK); those working in the courtroom and reporting to the judge and jury (in both criminal and civil court cases) are forensic psychiatrists. Forensic psychiatrists also treat mentally disordered offenders and other patients whose condition is such that they have to be treated in secure units.

In the United Kingdom there are several different areas of specialisation in which one may train as a specialist registrar (the 3-4 final years of training required before becoming a senior doctor or consultant). They are: general adult psychiatry, child and adolescent psychiatry, psychogeriatrics, forensic psychiatry, psychotherapy, and drugs and alcohol. After this period as a specialist registrar, one has to be approved by the Royal College of Psychiatrists as an approved specialist in the chosen field before going on to apply for a consultant post in that field.

History

Psychiatric illnesses are sometimes characterised as disorders of the mind rather than the brain, although the distinction is not always obvious and has changed in the last few decades as understanding of the treated illnesses grew. Many conditions have been linked to biological or chemical abnormalities in the brain’s psychology, but for some conditions the etiology and pathogenesis are still the subject of intense research.

For a long period of history, neurology and psychiatry were a single discipline, and following their division the tremendous advances in neurosciences (especially in genetics and neuroimaging) recently are bringing areas of the two disciplines back together. Indeed, in a 2002 review article in the American Journal of Psychiatry, Professor Joseph B. Martin, Dean of Harvard Medical School and a neurologist by training, wrote that “the separation of the (neurological versus psychiatric disorders) is arbitrary, often influenced by beliefs rather than proven scientific observations. And the fact that the brain and mind are one makes the separation artificial anyway” (Martin 2002). One example of this is the overlap between the two fields in the treatment of illnesses such as Alzheimer’s disease.

Psychiatry was at first a pragmatic discipline that was part of general medicine, combining medicine and practical psychology. The work of Emil Kraepelin laid the foundations of scientific psychiatry. A neurologist, Sigmund Freud, used these same powers of medically-based observation to develop the field of psychoanalysis. For many years, Freudian theories dominated psychiatric thinking.

The discovery of lithium carbonate as a treatment for bipolar disorder (and shortly thereafter after by the development of typical antipsychotics for treatment of schizophrenia), followed by the development of fields such as molecular biology and tools such as neuroimaging has led to psychiatry re-discovering its origins in physical and observational medicine without losing sight of its humane dimension.

Opposition to and criticism of psychiatry

Anti-psychiatry

Unlike most other areas of medicine, there is an anti-psychiatry movement opposed to the practices of, and in some cases the existence of, psychiatry. This phenomenon mainly originated in the 1960s and 1970s under the leadership of David Cooper, Thomas Szasz and R. D. Laing.

Other criticisms

Others have problems with a number of aspects of the profession as practiced today. Some believe that psychiatrists, like physicians in most fields, have a tendency to over-diagnose disorders and to prescribe medication in cases where it is not necessary. Drug companies spend large amounts of money marketing drugs. There is evidence this leads some physicians to prescribe advertised drugs instead of more appropriate, better, or cheaper drugs (or prescribing them when drugs are not needed at all).

The training and techniques of psychiatrists can vary and (according to critics) patients often have to switch psychiatrists a few times before they find one they are satisfied with. Critics also contend that training is unduly influenced by the drug industry. Misdiagnosis (e.g., unipolar instead of bipolar depression) remains a problem in some cases, prolonging the suffering for those patients. Also (as in any medical specialty) different individuals respond differently to a given drug; this can lead to some patients experiencing a prolonged trial-and-error process.

Another concern regarding the practice of psychiatry centres on the issue of involuntary treatment. Such concerns centre on issues of civil liberties and personal freedoms. In the US there are many restrictions in place to attempt to maximise the desires of the patient with the need for treatment. Most states allow involuntary treatment only in the most severe cases where a person poses an immediate threat to themselves or others or if they are unable to provide for themselves basic needs such as food, clothing, or shelter. Furthermore, children are allowed to be placed into an institution at the will of their parents or legal guardians. [2]

Related terms

  • “Alienist” was a somewhat derogatory and now obsolete term for a psychiatrist or psychologist.
  • “Shrink”, derived from “head shrinker”, is a slang term for a psychiatrist or psychotherapist, sometimes treated as derogatory or offensive.

References

  • Martin J. B. “The integration of neurology, psychiatry and neuroscience in the 21st century”. Am. J. of Psychiatry 2002; 159:695-704. Full text. PMID 11986119.

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