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Psychiatry

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Psychiatry is the branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders.[1] It is a medical specialty, a research field, and a subject of long public debate. This page presents mainstream and critical views. This page is general information, not medical or legal advice. Talk with a licensed professional about personal health decisions.

What psychiatry is

A psychiatrist is a physician, with an M.D. or D.O. degree, who specializes in mental health. Psychiatrists can order medical tests, prescribe medications, and provide psychotherapy.[1] The field is often described as a middle ground between neurology and psychology.[2] Neurology treats diseases of the nervous system.[3] Psychologists, including clinical psychologists, usually hold a doctoral degree and focus on research, testing, and psychotherapy, while counselors usually hold a graduate degree and provide therapy.[1]

A short history

  • Asylums and moral treatment. In the late 18th century, Philippe Pinel in France and William Tuke in England promoted humane care in asylums.[4]
  • Classification and psychoanalysis. Emil Kraepelin stressed classification, and psychoanalysis moved much treatment into private practice.[4]
  • The 1950s. Chlorpromazine was found to help in schizophrenia in 1952, the year of the first DSM.[4][5]
  • Deinstitutionalization. US psychiatric hospital beds fell from 340 per 100,000 people in 1955 to 17 in 2005.[6]
  • Diagnostic reform. In 1973 the APA trustees voted to remove homosexuality as a category of disorder, and members confirmed it in 1974. DSM-III in 1980 stressed operational criteria and reliability.[5]
  • Biopsychosocial and evidence based care. In 1977 George Engel proposed a model joining biological, psychological, and social factors.[7] Practice now leans on randomized trials.[8]

How diagnosis works

A clinician combines an interview, a history, observation, and sometimes tests. In the United States, diagnoses follow the DSM-5-TR, published in March 2022.[5] Many countries use the World Health Organization ICD-11, in effect since 1 January 2022.[9] A diagnostic category is a named pattern of symptoms and impairment. For DSM-IV, expert work groups reviewed literature, reanalyzed data, and ran field trials.[5]

Two ideas drive the debate. Reliability asks whether clinicians agree. A 1974 reanalysis found DSM-II unreliable,[10] while DSM-5 field trials rated most tested diagnoses good to very good.[11] Validity asks whether a category tracks something real. A 2023 review found most candidate biomarkers not yet useful enough for clinical adoption.[12]

Common treatments

  • Psychotherapy. Talk therapy helps a person identify and change troubling emotions, thoughts, and behaviors.[13]
  • Medication classes. Named classes include antidepressants, antipsychotics, mood stabilizers, anxiolytics, hypnotics, and stimulants.[1]
  • Neuromodulation. Examples are electroconvulsive therapy, transcranial magnetic stimulation, and vagus nerve stimulation, delivered by trained teams.[14]
  • Hospital and community care. Settings include inpatient units, clinics, and community services.[15]

Treatment choices belong in a conversation between a person and a licensed clinician. For urgent help in the United States, call or text the 988 Suicide and Crisis Lifeline at 988, or contact local emergency services.[16]

Training and licensing

In the United States, a psychiatrist completes medical school, passes licensing examinations, and finishes a four year residency. Most then earn board certification from the American Board of Psychiatry and Neurology.[1]

Law and ethics

Informed consent rests on disclosure, capacity, and voluntariness.[17] Standards for involuntary treatment vary, and some jurisdictions limit it to danger to self or others.[18] The US Supreme Court held in 1975 that a state cannot confine, without more, a nondangerous person who can live safely in freedom.[19]

A psychiatric advance directive records treatment preferences ahead of time. Oregon regulates declarations for mental health treatment in ORS 127.700 to 127.737.[20] See How to write a psychiatric advance directive.

The UN Convention on the Rights of Persons with Disabilities is disputed. Its committee issued General Comment No. 1 in 2014, which appears to call for ending substitute decision making and involuntary mental health care.[21] Ireland declared that it reads the Convention to allow compulsory treatment as a last resort with safeguards.[22]

Critiques and debates

  • Anti-psychiatry. Thomas Szasz (1920 to 2012) argued that illness requires demonstrable bodily pathology, so he viewed mental illness as a metaphor.[23] R. D. Laing held that experiences labeled schizophrenia could be meaningful,[24] and Michel Foucault wrote a history of madness in Europe.[25] See Anti-psychiatry and Critical views of mental illness.[26]
  • Critical psychiatry. The Critical Psychiatry Network formed in the United Kingdom in 1999.[27]
  • Survivor and voice hearing movements. Consumer and survivor movements grew from the civil rights era.[28] The Hearing Voices Movement began in the Netherlands in the late 1980s and treats voices as meaningful experiences.[29]
  • Defenses of the field. The World Health Organization says effective treatment exists for mental disorders, though most people lack access.[30]

On evidence, one analysis found small drug versus placebo differences that grew with severity.[31] Another found 94 percent of published trials looked positive, against 51 percent in FDA reviews.[32] A 2018 meta-analysis of 522 trials found all 21 antidepressants more effective than placebo.[33] Defenders cite a review finding the effects of psychiatric drugs broadly comparable with those of general medical drugs.[34] On the chemical imbalance idea, a 2022 umbrella review found no consistent support for low serotonin as a cause of depression.[35]

How to study the topic

  • Use primary sources, such as the DSM-5-TR, the ICD-11, and works by Szasz, Laing, Foucault, and Engel.
  • Read mainstream and critical authors side by side.
  • To read a trial, ask who joined, what the comparison group was, whether people were blinded, which outcome was set in advance, and who paid.
  • To check a claim, find the original source and note whether it is one study or a review. Look for replications, critiques, and conflicts of interest. Open research explains preregistration.

Discussion questions

  • Is a diagnosis a discovery or a useful convention?
  • How should a society weigh liberty against protection?

Essay ideas

  • Compare one critical author and one mainstream author on the meaning of validity.

AI prompt ideas

  • Explain reliability and validity in diagnosis, then quiz me with five questions.
  • Help me build a checklist for reading a clinical trial, and ask me questions where my checklist is vague.

Readings from Wikipedia

See also

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 What Is Psychiatry?, American Psychiatric Association
  2. ↑ Psychiatry, Wikipedia
  3. ↑ Neurology, Wikipedia
  4. ↑ 4.0 4.1 4.2 History of psychiatry, Wikipedia
  5. ↑ 5.0 5.1 5.2 5.3 Diagnostic and Statistical Manual of Mental Disorders, Wikipedia
  6. ↑ Deinstitutionalisation, Wikipedia
  7. ↑ Biopsychosocial model, Wikipedia
  8. ↑ Evidence-based medicine, Wikipedia
  9. ↑ ICD-11, Wikipedia
  10. ↑ Spitzer, R. L., and Fleiss, J. L. (1974). A re-analysis of the reliability of psychiatric diagnosis. British Journal of Psychiatry, 125(587), 341 to 347.
  11. ↑ Regier, D. A., et al. (2013). DSM-5 field trials in the United States and Canada, part II: test-retest reliability of selected categorical diagnoses. American Journal of Psychiatry, 170(1), 59 to 70. doi:10.1176/appi.ajp.2012.12070999
  12. ↑ Abi-Dargham, A., et al. (2023). Candidate biomarkers in psychiatric disorders: state of the field. World Psychiatry, 22(2), 236 to 262.
  13. ↑ Psychotherapies, National Institute of Mental Health
  14. ↑ Brain Stimulation Therapies, National Institute of Mental Health
  15. ↑ Guidance on community mental health services, World Health Organization
  16. ↑ 988 Suicide and Crisis Lifeline
  17. ↑ Informed consent, Wikipedia
  18. ↑ Involuntary commitment, Wikipedia
  19. ↑ 422 U.S. 563 (1975), Legal Information Institute, Cornell Law School
  20. ↑ Oregon Revised Statutes, chapter 127
  21. ↑ Mental capacity, human rights, and the UN Convention on the Rights of Persons with Disabilities, Journal of the American Academy of Psychiatry and the Law
  22. ↑ Declarations and reservations, Ireland, United Nations Treaty Collection
  23. ↑ Szasz, T. S. (1960). The myth of mental illness. American Psychologist, 15(2), 113 to 118.
  24. ↑ R. D. Laing, Wikipedia
  25. ↑ Madness and Civilization, Wikipedia
  26. ↑ Anti-psychiatry, Wikipedia
  27. ↑ Critical Psychiatry Network, Wikipedia
  28. ↑ Psychiatric survivors movement, Wikipedia
  29. ↑ Hearing Voices Movement, Wikipedia
  30. ↑ Mental disorders, World Health Organization
  31. ↑ Kirsch, I., et al. (2008). Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Medicine, 5(2), e45.
  32. ↑ Turner, E. H., et al. (2008). Selective publication of antidepressant trials and its influence on apparent efficacy. New England Journal of Medicine, 358(3), 252 to 260. doi:10.1056/NEJMsa065779
  33. ↑ Cipriani, A., et al. (2018). Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder. The Lancet, 391(10128), 1357 to 1366.
  34. ↑ Leucht, S., et al. (2012). Putting the efficacy of psychiatric and general medicine medication into perspective. British Journal of Psychiatry, 200(2), 97 to 106.
  35. ↑ Moncrieff, J., et al. (2022). The serotonin theory of depression: a systematic umbrella review of the evidence. Molecular Psychiatry, 28(8), 3243 to 3256.
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