Psychiatry

Psychiatry is the branch of Medicine that diagnoses, treats, and studies Mental illness and behavioral conditions. While all physicians will encounter patients with mental illnesses and any of them may treat it, psychiatrists specialize in these areas, being more extensively trained in the Differential diagnosis (distinguishing various forms) and treatment of mental illness and are professionally required to keep up to date on the newest developments in the field of mental illness. Additionally psychologists, nurse practitioners, and social workers can provide mental health care though of these only the nurse practitioners may prescribe Medication.

Practice of psychiatry

Psychiatry has proven to be a malleable term, which today refers to the branches of medicine which associate with the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders, such as major depression, Schizophrenia, and anxiety disorders. Psychiatry uses laboratory and imaging studies, medication, and psychotherapy in diagnosing and treating psychiatric conditions.

The field of psychiatry itself can be divided into various subspecialities. These include: Child and Adolescent Psychiatry, Geriatric Psychiatry, Consultation-Liaison Psychiatry, Emergency Psychiatry, Addiction Psychiatry and Forensic Psychiatry. Other areas of focus include mood disorders, neuropsychiatry, and various forms of psychotherapy. Some areas of psychotherapy include Psychodynamic Therapy, Cognitive Behavioral Therapy, and supportive therapy.

Individuals with mental illness, typically referred to as patients (or, sometimes, clients) may come under the care of a psychiatrist or other psychiatric practitioners through various processes. This may be by self-referral or referral by a primary care physician (the two most common methods in the United States) or by hospital medical staff, by Sectioning under the Mental Health Act (in the UK) or Involuntary commitment by law or after a Court order. In all circumstances, the psychiatrist makes an assessment of the patient's mental and somatic (general medical) functioning, through conversation with the patient and/or by obtaining information from relatives and associates, carers, law enforcement personnel or the nursing staff and therapists of institutions (if the client is admitted or sectioned). Physical examination is usually performed to establish or exclude physical illness and identify subtle signs of Self-harm, and blood tests and Medical imaging may be performed, which may lead to the involvement of other medical specialists in a patient's care (e.g. if Thyroid or another hormonal problem is diagnosed).

Mental and behavioral conditions are treated with various forms of therapy and counseling, and often with medication. Psychotherapy, of which one type is cognitive behavioral therapy, may be used in many conditions, either exclusively or in combination with medication. In general, commencing a patient on medication requires that the patient agrees to this treatment (although in many countries the law provides overriding circumstances) and that the patient will remain compliant with the treatment. In addition, many psychiatric medications may have side-effects and therefore the patient may require ongoing monitoring (e.g. a frequent full blood count for patients on Clozapine, an Antipsychotic, or monitoring of serum levels of Lithium in patients on lithium salts); many psychiatric hospitals and institutions have facilities for Therapeutic drug monitoring. Electroconvulsive therapy, a controversial practice despite its proven Efficacy, is occasionally administered in serious and disabling conditions, especially those that are unresponsive to pharmacotherapy.

Psychiatric patients can be broadly grouped into inpatients and outpatients. Outpatients live in their normal community, and come in periodically to the psychiatrist’s office for care, typically for a 30-60 minute appointment. These office sessions generally involve an update in condition and assessment, medication management, and in some cases psychotherapy. The length of time between sessions varies widely, depending on the severity of the condition and the patient’s stability.

Inpatients are confined to a hospital where they receive their psychiatric care (voluntarily in the majority of cases, but sometimes involuntarily in severe or dangerous cases). In a hospital setting, patients can be more carefully monitored, treated more rapidly, and better protected from self-harm or harming others. Hospitalized patients are increasingly being managed in a multidisciplinary fashion, where nursing staff, occupational therapists, psychotherapists, social workers and other health care professionals offer their input in the care for a patient. Historically, particularly before the advent of psychiatric medication, hospital stays averaged six months or more with a large number of cases requiring hospitalization for many years. Today the average hospital stay is on the order of two to three weeks, with only a small number of cases requiring long term hospitalization. Upon release from the hospital, inpatients typically become outpatients.

The DSM system

The Diagnostic and Statistical Manual of Mental Disorders, presently in its fourth revised (IV-TR, 2000) edition, systemises psychiatric diagnosis in 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 (on a scale from 100 to 0)

Common axis I disorders include substance dependance 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. (PTSD, Obsessive-compulsive disorder). Common axis II disorders include Borderline personality disorder, Schizotypal personality disorder, Avoidant personality disorder, and Antisocial personality disorder.

The contents of the DSM are determined by experts whose mandate is to create a set of diagnoses that are replicable and meaningful. While the classification system was originally intended to enhance research into both diagnosis and treatment, the nomenclature is now widely used by clinicians, coding professionals, hospital administrators and insurance companies. It is published by the American Psychiatric Association. It is one of two standards used in many countries. Other other being the ICD-10 (International Classification of Diseases). The ICD-10 is less specific in the criteria for each illess.

Contrast with psychology

Psychiatry is practiced by psychiatrists, who are medical doctors specializing in mental illness and who may prescribe drugs. Psychiatrists evaluate patients from a biopsychosocial perspective before prescribing treatment. In contrast, Psychology is the broader study of human behaviour and thought processes, not just in the context of mental health. Clinical psychologists specialize in mental health and have extensive training in psychotherapy and psychological testing.

Psychologists are generally not allowed to prescribe medications in the United States (exceptions have been made in the Department of Defense, Guam, New Mexico, and Louisiana, but the psychologist must complete a postdoctoral training program in clinical Psychopharmacology and practicum, and pass a licensing examination prior to doing so). The turf battle over prescribing privileges is ongoing in the U.S. A significant subset of psychologists argue that there is an inadequate number of psychiatrists 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 and therapeutic 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 will practice as psychiatry residents for 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 specialize in helping certain age groups; child and adolescent psychiatrists work with children and teenagers in addressing psychological problems. Those who work with the elderly are called geriatric psychiatrists, or in the UK, psychogeriatricians. Those who practice psychiatry in the workplace are called industrial psychiatrists (this is a term used in the US but not the UK); those working in the courtroom and reporting to the judge and jury (in both criminal and civil court cases) are forensic psychiatrists. Forensic psychiatrists also treat mentally disordered offenders and other patients whose condition is such that they have to be treated in secure units.

In the United Kingdom there are several different areas of 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 were for some time characterised as disorders of function of the Mind rather than the Brain, although the distinction is not always obvious. In the current state of knowledge this distinction does not always hold true, as many psychiatric conditions have physical etiologies.

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).

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 Brain imaging has led to psychiatry re-discovering its origins in physical and observational medicine without losing sight of its humane dimension.

Opposition

Anti-psychiatry

Main article: Anti-psychiatry

Unlike most other areas of medicine, there is a politicised Anti-psychiatry movement opposed to the practices of, and in some cases the existence of, psychiatry. Some opponents of psychiatry state that selective financing by large multinational drug companies of both high ranking professional psychiatrists, research and educational material has led the practice of psychiatry to be subversively, and in some cases inhumanely, misled.

One of the chief complaints of the anti-psychiatry movement is that most mental illnesses lack a simple, biologically-based test. There are a number of people trained in the field who have stated that physical tests cannot distinguish between a normal person and a mentally ill person, though these criticisms tend to ignore the rising body of evidence from neuroimaging that identifies such illnesses as schizophrenia and major depression. At the same time, critics are right to contend that psychiatrists tend to rely upon theories of causation that are uncertain (e.g., the idea that dysregulation of dopamine causes schizophrenia stems from the proven fact that dopamine-regulating medications help people with psychotic hallucinations. This clinical fact does not, however, prove that schizophrenia is caused by altered dopamine regulation). Psychiatrists are aware of this problem, however, and point out that most medical illnesses lack clear theories of causation.

There are also criticisms based on what is perceived as political motivations on the part of psychiatrists as opposed to objective scientific criteria. An example often cited is the inclusion and then the removal of Homosexuality from the list of mental illnesses in the DSM. Thus, some critics contend a mental illness label such as Schizophrenia has no etiology and is only a matter of opinion. If the addition or removal of mental illnesses from the DSM is politically based, then the DSM can not be held by all as an objective standard. However, it is possible to argue that even if the removal or addition of psychiatric conditions to/from the DSM has been politically motivated, the initial inclusion or exclusion may have been a result of politics, creating something of an equalization effect. Morever, many would hold it logically fallacious to argue all DSM diagnoses are categorically invalid simply because one or some may be politically motivated or otherwise invalid.

Recent news articles and other columns have noted and commented on the creation and marketing of new diseases (as seen in this August 2005 article from Mother Jones magazine)

From a pharmaceutical company's perspective, the big money can be made not only by selling drugs to the sick, but by selling drugs to the healthy, the people who don't even know that they need drugs yet. A recent Reuters Business Insight report, designed for drug company executives, suggested that the drug companies can reap billions by "creat[ing] new disease markets." That involves convincing people that "problems they may previously have accepted as, perhaps, an inconvenience"—such as, for instance, the distress that can accompany PMS—are in fact "worthy of medical intervention." In other words, nothing short of the medicalization of everyday troubles. Cheerfully, the report believes that drug companies are up to the task: "The coming years will bear greater witness to the corporate sponsored creation of disease."

A specific example involves a repackaging of prozac, in order to prolong the market for the drug.

In 1998, Lilly, one of the world's largest pharmaceutical companies, was on the verge of losing its patent on fluoxetine (more commonly known as Prozac) worth over $2 billion annually. However, if Lilly could find a new use for the drug, the patent could be extended. That year, Lilly helped fund a "roundtable" of researchers to gather in Washington D.C., along with staff from the Food and Drug Administration to discuss a scientifically controversial condition called "premenstrual dysphoric disorder" (PMDD), which had only recently, and after much controversy, been included in the appendix of the Diagnostic and Statistical Manual—the bible of psychiatric disorders—as a disorder "under evaluation." But the Lilly-funded researchers soon published an article in a small medical journal suggesting, falsely, that the debate was over and that PMDD could now be considered a "distinct clinical entity," distinct from the stress and tension that can accompany ordinary PMS.
Lilly has not said what role it played in turning the "roundtable" into a journal article, but by 1999, the article helped convince the FDA to approve the use of fluoxetine to treat PMDD—and extended the patent until 2007. Lilly simply repackaged the drug in lavender pill-form, renamed it Serafem, and began marketing it to women. Never mind that independent researchers questioned whether PMDD even existed as a condition. Never mind that Europe's drug regulators raised serious questions about PMDD and criticized Lilly's clinical trials that purported to show the benefits of Serafem. Never mind that even the industry-friendly FDA was appalled at Lilly's television ads, with their too-vague tagline: "Think it's PMS? It could be PMDD." Undaunted, Lilly continued its advertising barrage, trying to convince women who thought they were experiencing regular PMS-related distress that, actually, they might well have a serious disorder that required heavy medication. Soon thereafter, both Pfizer and GSK got their own anti-depressants approved for treating PMDD. For all intents and purposes, the "debate" over whether PMDD was a disorder—let alone requiring medication with serious side-effects—was over. Industry money had carried the day.

Also, some people criticize the psychiatric profession for treatments that transition into and out of usage. An example is Electroconvulsive therapy (ECT), which some within the psychiatric profession considered a barbarous practice during the 1970s, only to be revived following well-conducted clinical trials as a treatment for Clinical depression. Psychiatrists point out that ECT, as practised today, bears little to no resemblance to horror stories from the past or popular depictions, such as that in One Flew Over the Cuckoo's Nest, and remains the most effective treatment for some severe cases of mental illness.

A few prominent critics of psychology and mental illness in general include Thomas Szasz, the author of "The Myth of Mental Illness", who founded an organization in 1969 together with the Church of Scientology (though soon afterwards he disavowed further association with them) called the Citizens Commission on Human Rights (CCHR), Peter Breggin, the author of Prozac Backlash, as well as other books criticizing the use of psychiatric drugs, Elliott Valenstein, Douglas C. Smith, Bruce Levine, and David Keirsey. In the United States and some other countries, Scientologists have been among the most vocal and prominent opponents of psychiatry in recent decades; members believe that psychiatry is a corrupt profession and present scientology as an alternative. Many are highly skeptical of the motives of Scientologists and the accuracy of the information they supply.

Despite criticism of psychiatry, the specialty is accepted as a core part of medical education in all medical schools in the U.S. and most around the world. Medical students typically spend four to six weeks studying psychiatry in addition to other medical specialties such as internal medicine and pediatrics.

Other criticisms

Others, probably a considerably larger number than those who oppose psychiatry altogether, still have problems with a number of aspects of the profession as practiced today. Many believe that psychiatrists have a tendency to over-diagnose mental disorders and to prescribe medication in cases where it is not necessary (or in some cases even when medically contraindicated). Many critics question the current DSM diagnostic labels, finding some or all labels arbitrary, vague, and/or lacking in firm biological basis, leading some to describe them as pseudoscientific. However, it could be argued that many psychiatrists share such concerns, thus helping to guide the profession forward from within.

Drug companies spend large amounts of money marketing psychiatric drugs. There is evidence this leads some psychiatrists 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 substantially, according to critics, and patients often have to switch psychiatrists a few times before they find one they are satisfied with. Critics also contend training is unduly influenced by the drug industry.

Misdiagnosis (one common example, unipolar depression 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.

Famous figures in psychiatry

Psychiatrists

Others:

  • Kay Redfield Jamison - a psychologist who, whilst not a psychiatrist herself, is professor of psychiatry at Johns Hopkins University School of Medicine and a MacArthur Fellow.

Psychiatrists in fiction

Related terms

Alienist is an old term for a psychiatrist, but is now used more specifically to refer to a psychiatrist who specializes in the legal aspects of mental illness. The term shrink (from head shrinker) is a (sometimes offensive) slang term for a psychotherapist.

See also

Potato   Index

This page is based on the Wikipedia article ''Psychiatry''. It is licensed under the GNU free documentation license.

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