Psychiatry
Psychiatry is a medical speciality whose primary goal is to improve people’s mental well-being. This can be by managing and improving the symptoms of specific mental illness, as well as assisting people to gain insight into themselves and their relationships with others.
The name derives from the Greek for “healer of the spirit”. In the United States, it is practised by people, termed psychiatrists, holding M.D. or D.O. degrees.
While all clinicians encounter patients with mental illnesses and any of them may treat it, psychiatrists specialize in these areas. They are specifically trained in the differential diagnosis (the distinguishing of various forms) and treatment of mental illness. Treatment can involve medication, psychotherapy (such as cognitive behaviour therapy, interpersonal therapy, and psychodynamic psychotherapy), and psychosocial interventions.
Practice of psychiatry:
Psychiatry is one of the clinical medical disciplines that involve the diagnosis, treatment and prevention of mental and behavioral disorders such as clinical depression, bipolar disorder, schizophrenia and anxiety disorders.
Most psychiatric illnesses cannot currently be cured. While some have short time courses and only minor symptoms, many are chronic conditions which can have a significant impact on a patients’ quality of life and even life expectancy, and as such may require long-term or life-long treatment. Efficacy of treatment for any given condition is also variable from patient to patient, with some patients having complete resolution of symptoms and others unfortunately having poor or minimal response to even the strongest measures. The majority of patients will fall somewhere in between.
In general, psychiatric treatments have improved over the past several decades, beginning with the advent of modern psychiatric medications (see History section, below). In the past, psychiatric patients were often hospitalized for six months or more, with some cases involving hospitalization for many years. Today, most psychiatric patients are managed as outpatients. If hospitalization is required, the average hospital stay is around two to three weeks, with only a small number of cases involving long-term hospitalization.
The field of psychiatry itself can be divided into various subspecialties. These include:
* Child and adolescent psychiatry
* Adult psychiatry
* Psychiatry of Old Age (Psychogeriatrics)
* Learning disability
* Consultation-liaison psychiatry
* Emergency psychiatry
* Addiction psychiatry
* Forensic psychiatry
Practicing psychiatrists may specialize 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 behavioral therapy.
Individuals with mental illness are commonly referred to as patients when seen by physicians but may also be called clients, especially when treated privately by allied healthcare professionals. They may come under the care of a psychiatrist or other psychiatric practitioners by various paths, 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 condition. This usually involves interviewing the patient and often obtaining information collated from other sources such as other health and social care professionals, relatives, associates, law enforcement and emergency medical personnel and psychiatric rating scales. Physical examination is usually performed to establish or exclude other illnesses (e.g. thyroid dysfunction or brain tumors) or identify any signs of self-harm. Blood tests and medical imaging may be also performed. However, a study of the CAT scans of 397 psychiatric patients found no anomaly clinically related to the patients’ psychiatric condition and concluded, “the pretest probability of finding a space-occupying lesion or other pertinent abnormality in patients presenting with psychiatric illnesses in this retrospective study appears not to be greater than that of the general population. The outcome of this study could be implemented to develop a clinical pathway for limiting assessment by CT for possible organic pathology in acute psychiatric illness.”
Various forms of medication, therapy and counseling deal with mental and behavioral conditions. Psychotherapy may be used for many conditions, either exclusively or in combination with medication. In the United States, only physicians, medical psychologists, nurse practitioners, or physician assistants may prescribe mental health medication. In some countries, mental health medication may only be prescribed by physicians. 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. Like all medications, 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 or 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, and depending on what the psychiatrist and patient decide would be best.
Psychiatric inpatients are patients admitted to a hospital to receive psychiatric care, sometimes involuntarily. In North America, the criteria for involuntary admission vary 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.
Once in the care of a hospital, patients are monitored, given medication and tested by a psychologist. If necessary, they are prevented from harming themselves or others. Hospitalized 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.
Further considerations:
Anti-psychiatry:
Unlike most other areas of medicine, there exist movements opposed to the practices of – and, in some cases, the existence of – psychiatry. These movements mostly originated in the 1960s and 1970s, led by figures such as David Cooper, Thomas Szasz and R. D. Laing. In 1999, psychiatrist Peter Breggin founded a scholarly journal devoted exclusively to criticism of bio-psychiatry, Ethical Human Psychology and Psychiatry.
Some mental health professionals sympathetic to anti-psychiatric views claim that there are no known biological markers for many if not all the disorders the DSM purportedly identifies[5]. Also, though psychiatrists generally accept a medical model of mental disorders, some professionals and patients advocate a trauma model, especially as regards schizophrenia.
Other criticisms:
* Criticism has been made regarding the need for improvement in psychiatric medications, as illustrated by studies of pharmacogenetic polymorphism showing that people of various ethnicities, for example one third of African American and Asian groups, have an increased risk of side effects and toxicity.
* As in any medical specialty, different individuals respond differently to a given drug. Unfortunately, side effects to psychiatric drugs are common and sometimes severe. Combined with the time period of therapeutic effect which generally takes between two and six weeks (but can draw out to several months), this can lead to prolonged periods where patients are sufferring distressing side effects.
* Critics also question whether psychiatric drugs are disorder- or problem-specific in the way that is claimed (Moncrieff and Cohen, 2005).
* The high rate of methylphenidate (Ritalin) use among school children in the U.S. has come under greater scrutiny[citation needed]. However this may be partly due to the shortage of child and adolescent psychiatrists (A Report of the Surgeon General, 2001) who are able to regulate such prescriptions.
* Critics claim that there are problems in terms of diagnostic reliability, including misdiagnosis (Williams et al, 1992; McGorry et al, 1995; Hirschfeld et al, 2003]), especially when comparing the criteria of the different psychiatric manuals (van Os et al, 1999). Some critics add that the criteria for many “mental illnesses” are openly culturally biased, or are extremely subjective and create essentially random diagnoses. See Schizophrenia.
* Another concern centers on the issue of involuntary commitment, which centers on issues of civil liberties and personal freedoms. In the U.S. someone may be involuntarily detained for psychiatric examination for a period of time (usually 24 to 72 hours depending on the state) if a government official declares the subject to be a danger to himself or others. With the attestation of an examining physician that a patient meets strict criteria of dangerousness to himself or others resulting from symptoms of mental illness, a judge may extend this commitment. Opposition to involuntary commitment is diverse and includes simple arguments that involuntary commitment is now or is inherently unconstitutional. The laws regarding the involuntary treatment of children vary widely from state to state[10].
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