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,[16] it has generally been considered a middle ground between neurology and psychology.[17] 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.[18] 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.[17] Psychiatrists also differ from psychologists in that they are physicians and have post-graduate training called residency (usually 4 to 5 years) in psychiatry; the quality and thoroughness of their graduate medical training is identical to that of all other physicians.[19] Psychiatrists can therefore counsel patients, prescribe medication, order laboratory tests, order neuroimaging, and conduct physical examinations.[3]

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.[20]

The World Psychiatric Association code covers such matters as confidentiality, the death penalty, ethnic or cultural discrimination,[20] euthanasia, genetics, the human dignity of incapacitated patients, media relations, organ transplantation, patient assessment, research ethics, sex selection,[21] torture,[22][23] 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.[24]

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[25] 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.[26][27][28] In this notion the word model is not used in a strictly scientific way though.[26] Alternatively, a "biocognitive model" acknowledges the physiological basis for the mind's existence but identifies cognition as an irreducible and independent realm in which disorder may occur.[26][27][28] 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.[26][27][28]

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.[29] 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.[30]

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.

Psychiatry was not a popular career choice among medical students, even though medical school placements are rated favorably.[31] This has resulted in a significant shortage of psychiatrists in the United States and elsewhere.[32] Strategies to address this shortfall have included the use of short 'taster' placements early in the medical school curriculum [31] and attempts to extend psychiatry services further using telemedicine technologies and other methods.[33] 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 interesting nature of the field, growing interest in genetic biomarkers involved in psychiatric diagnoses, and newer pharmaceuticals on the drug market to treat psychiatric illnesses.[34]

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:[35]

• Addiction psychiatry
• Brain Injury Medicine[36][37]
• Child and adolescent psychiatry
• Clinical neurophysiology
• Consultation-liaison psychiatry, also known as psychosomatic medicine[38]
• Epilepsy[39][40]
• Forensic psychiatry
• Geriatric psychiatry
• Hospice and palliative medicine
• Pain medicine[41]
• Sleep medicine[42]

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Additional psychiatry subspecialties, for which ABPN does not provide formal certification, include:[43]

• Biological psychiatry
• Cognition diseases as in various forms of dementia
• Community psychiatry
• Cross-cultural psychiatry
• Emergency psychiatry
• Global Mental Health
• Learning disabilities
• Military psychiatry
• Neurodevelopmental disorders
• Neuropsychiatry
• Social psychiatry

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.[44] 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,[45] although some scholars consider it to be a neo-colonial, culturally insensitive project.[46][47][48][49] 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.

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.

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.[50] Clinical and research psychiatrists study basic and clinical psychiatric topics at research institutions and publish articles in journals.[16][51][52][53] 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.[54]

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.[55][56][57][58][59] 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.[60] Some clinicians are beginning to utilize genetics[61][62][63] and speech[64] during the diagnostic process but on the whole these remain research topics.

Three main diagnostic manuals used to classify mental health conditions are in use today. The ICD-10 is produced and published by the World Health Organization, includes a section on psychiatric conditions, and is used worldwide.[65] The Diagnostic and Statistical Manual of Mental Disorders, produced and published by the American Psychiatric Association, is primarily focused on mental health conditions and is the main classification tool in the United States.[66] It is currently in its fifth revised edition and is also used worldwide.[66] The Chinese Society of Psychiatry has also produced a diagnostic manual, the Chinese Classification of Mental Disorders.[67]

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.[66][68] 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.[69] 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.[70]

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.[71][72][73][74] The publication of the DSM, with tightly guarded copyrights, now makes APA over $5 million a year, historically adding up to over $100 million.[75]

NIMH federal agency patient room for Psychiatric research, Maryland, USA.

Individuals with mental health conditions are commonly referred to as patients but may also be called clients, consumers, or service recipients. They may come under the care of a psychiatric physician or other psychiatric practitioners by various paths, the two most common being self-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 the UK and Australia, by sectioning under a mental health law.

Persons who undergo a psychiatric assessment are evaluated by a psychiatrist 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 and disabling conditions, such as those unresponsive to medication. The efficacy[76][77] and adverse effects of psychiatric drugs may vary from patient to patient.

For many years, controversy has surrounded the use of involuntary treatment and use of the term "lack of insight" in describing patients. Mental health laws vary significantly among jurisdictions, but in many cases, involuntary psychiatric treatment is permitted when there is deemed to be a risk to the patient or others due to the patient's illness. Involuntary treatment refers to treatment that occurs based on the treating physician's recommendations without requiring consent from the patient.[78]

Mental health issues such as mood disorders and schizophrenia and other psychotic disorders were the most common principle diagnoses for Medicaid super-utilizers in the United States in 2012.[79]

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.[80][81][82][83] 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.. 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.[84][85]

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. European Human Rights legislation restricts detention to medically certified cases of mental disorder, and adds a right to timely judicial review of detention.

People may be admitted voluntarily if the treating doctor considers that safety isn't compromised by this less restrictive option. Inpatient psychiatric wards may be secure (for those thought to have a particular risk of violence or self-harm) or unlocked/open. Some wards are mixed-sex whilst same-sex wards are increasingly favored to protect women inpatients. Once in the care of a hospital, people are assessed, monitored, and often given medication and care from a multidisciplinary team, which may include physicians, 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.[86]

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.

Outpatient treatment involves periodic visits to a psychiatrist for consultation in his or her office, or at a community-based outpatient clinic. Initial appointments, at which the psychiatrist conducts a psychiatric assessment or evaluation of the patient, are typically 45 to 75 minutes in length. Follow-up appointments are generally shorter in duration, i.e., 15 to 30 minutes, with a 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 (e.g., exercise, cognitive therapy techniques, sleep hygiene—to name just a few). 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.[87] A major reason for this change was the advent of managed care insurance plans, 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.[88][89][90][91][92][93] For example, most psychiatrists schedule three or four follow-up appointments per hour, as opposed to seeing one patient per hour in the traditional psychotherapy model.[lower-alpha 1] 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.[94]