Psychiatry

• 1. Introduction

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  Psychiatry is the medical specialty devoted to diagnosing, treating, and preventing mental disorders, the conditions that touch cognition, perception, mood, emotion, and behavior. Its name was coined by the German physician Johann Christian Reil in 1808. Literally, it means the medical treatment of the soul, joining the Greek word for soul with the word for healing. That tender origin sits uneasily beside a harder truth. This field has been controversial since its inception, criticized from both inside and outside its own ranks. Why would a branch of medicine built to relieve suffering attract accusations of social control, pseudoscience, and pharmaceutical fraud? Why does it still lack the objective laboratory tests that other specialties take for granted? And how did a discipline once practiced in dungeons come to argue over brain scans and neurotransmitters? The answers run from ancient gardens where animals were cut open to modern debates over whether grief itself should count as a disease.

• 2. Soul And Brain

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  Alcmaeon argued that the brain, not the heart, was the organ of thought. He traced the ascending sensory nerves from the body up to the brain. From there he reasoned that mental activity began in the central nervous system, and that the cause of mental illness lived within the brain itself. He used this idea to classify mental diseases and their treatments. As early as the 4th century BC, the Greek physician Hippocrates theorized that mental disorders had physical causes rather than supernatural ones. Hippocrates wrote that he once visited Democritus and found him in his garden cutting open animals. Democritus explained he was trying to discover the cause of madness and melancholy, and he kept a book on the subject with him. Hippocrates praised the work. In 387 BCE, Plato suggested the brain was where mental processes take place. Yet during the 5th century BCE, mental disorders with psychotic traits were widely seen as supernatural in origin, a view that ran through ancient Greece, Rome, and Egyptian regions. Religious leaders often turned to forms of exorcism, sometimes using methods many would consider cruel. Trepanning, the cutting of holes into the skull, was one such method used throughout history. The earliest known texts on mental disorders, however, come from ancient India, including the Ayurvedic work the Charaka Samhita, and the first hospitals for curing mental illness were established in India during the 3rd century BCE.

• 3. Asylums And Reform

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  Bethlem Royal Hospital in London is the oldest extant psychiatric hospital in the world, built in medieval Europe from the 13th century to treat mental disorders. In practice it served only as a custodial institution and offered no treatment at all. The first bimaristan was founded in Baghdad in the 9th century, where the Persian physician Muhammad ibn Zakariya al-Razi, known as Rhazes, served as chief physician and director, and wrote texts about psychiatric conditions. Some of these institutions contained wards dedicated to the mentally ill. In 1758, the English physician William Battie wrote his Treatise on Madness, a critique aimed at the conservative, custodial regime of Bethlem. Battie argued for tailored care built on cleanliness, good food, fresh air, and distraction from friends and family. He held that mental disorder came from dysfunction of the material brain and body. Moral treatment was then introduced independently by the French doctor Philippe Pinel and the English Quaker William Tuke. In 1792, Pinel became chief physician at the Bicetre Hospital, where patients were allowed to move freely and dark dungeons gave way to sunny, well-ventilated rooms. His student and successor Jean Esquirol, who lived from 1772 to 1840, helped establish 10 new mental hospitals run on the same principles. At the Lincoln Asylum in England, Robert Gardiner Hill, supported by Edward Parker Charlesworth, devised a mode of care that dispensed with mechanical restraint entirely, a goal he finally reached in 1838. In England, the Lunacy Act 1845 changed the legal status of the mentally ill to patients who required treatment.

• 4. The Biological Turn

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  Emil Kraepelin carried the early ideas of biological psychiatry, holding that the different mental disorders are all biological in nature. His thinking evolved toward a concept of nerves, and psychiatry became a rough approximation of neurology and neuropsychiatry. Following Sigmund Freud's pioneering work, ideas from psychoanalytic theory took root in the field. Psychoanalysis grew popular among psychiatrists because it let patients be treated in private practice rather than warehoused in asylums. By the 1970s, that psychoanalytic school became marginalized, and biological psychiatry reemerged. Psychopharmacology and neurochemistry became integral, beginning with Otto Loewi's discovery of the neuromodulatory properties of acetylcholine, identified as the first known neurotransmitter. Researchers later linked individual differences in neurotransmitter production, reuptake, and receptor density to specific psychiatric disorders. The discovery of chlorpromazine's effectiveness against schizophrenia in 1952 transformed treatment of that disorder. Lithium carbonate's ability to stabilize the highs and lows of bipolar disorder, found in 1948, did the same. Neuroimaging was first used as a tool for psychiatry in the 1980s, a further search for the biological markers of mental disorders.

• 5. What A Psychiatrist Is

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  Postgraduate training called residency, usually four to five years, is what turns a physician into a psychiatrist. The quality and thoroughness of that medical training is identical to that of all other physicians, which sets psychiatrists apart from psychologists. Because they are physicians, psychiatrists can counsel patients, prescribe medication, order laboratory tests, order neuroimaging, and conduct physical examinations. Some are trained in interventional psychiatry and deliver treatments such as electroconvulsive therapy, transcranial magnetic stimulation, vagus nerve stimulation, and ketamine. Psychiatry has generally been considered a middle ground between neurology and psychology, drawing on neuroscience, biology, biochemistry, and pharmacology. Because psychiatry and neurology are so deeply intertwined, certification in the United States for both specialties is offered by a single body, the American Board of Psychiatry and Neurology. That board also certifies subspecialties including addiction psychiatry, child and adolescent psychiatry, forensic psychiatry, geriatric psychiatry, consultation-liaison psychiatry, brain injury medicine, hospice and palliative medicine, and sleep medicine. Forensic psychiatry uses psychiatric assessment to help answer legal questions, while cross-cultural psychiatry concerns the cultural and ethnic context of mental disorder. For many years psychiatry was an unpopular career choice among medical students, producing a significant shortage of psychiatrists in the United States and elsewhere. Recently more students have entered psychiatry residency, drawn by interest in genetic biomarkers and newer pharmaceuticals on the market.

• 6. Diagnosis Without A Test

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  DSM-5, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, appeared in May 2013. Its release coincided with a striking statement from Thomas Insel, then director of the National Institute of Mental Health. Insel noted that the manual lacks validity compared with other medical specialties, because there are no objective laboratory measures, no biomarkers, to anchor its diagnoses. Three main diagnostic manuals are in use today. The ICD-11 is produced by the World Health Organization and used worldwide. The DSM is the main classification tool in the United States, while the Chinese Society of Psychiatry has produced the Chinese Classification of Mental Disorders. A psychiatric diagnosis typically uses a differential procedure built on a mental status examination, a physical examination, and a patient's pathological or psychosocial history. A brain scan might be used to rule out other medical illnesses. At this time, relying on brain scans alone cannot accurately diagnose a mental illness or predict the risk of getting one. In 2018, the American Psychological Association commissioned a review on whether modern clinical MRI and fMRI could be used in diagnosis. Its criteria demanded biomarkers with a sensitivity of at least 80 percent and a specificity of at least 80 percent, verified by two independent studies. The review concluded that while neuroimaging diagnosis may be technically feasible, the very large studies needed to evaluate specific biomarkers were not available.

• 7. Inside And Outside The Ward

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  In the past, psychiatric patients were often hospitalized for six months or more, with some cases lasting many years. Since the 1960s the average inpatient stay has dropped sharply, a trend known as deinstitutionalization. Today, if hospitalization is required, the average stay is around one to two weeks, and people are far more likely to be treated as outpatients. Japan stands out as an exception, where psychiatric hospitals keep patients for long periods and sometimes hold them in physical restraints, strapped to their beds for weeks or months. Italy has been a pioneer in reform through a no-restraint initiative that began nearly fifty years ago, heavily influenced by Franco Basaglia. One study found that 14 general hospital psychiatric units in Italy reported zero restraint incidents in 2022. Involuntary treatment, given on a physician's recommendation without the patient's consent, remains a long-running source of controversy, as does the term lack of insight used to describe patients. In countries such as the UK and Australia, a person may be admitted by sectioning under a mental health law. Outpatient care has shifted too. Psychiatrists increasingly limit their practice to psychopharmacology rather than the traditional 50-minute psychotherapy session. That change began in the early 1980s and accelerated through the 1990s and 2000s, driven largely by managed care insurance plans that limited reimbursement for psychotherapy. In 1963, President John F. Kennedy introduced legislation directing the National Institute of Mental Health to administer Community Mental Health Centers for those discharged from state hospitals. Without arrangements to follow and treat the severely ill after discharge, the result was a large population of chronically homeless people with mental illness.

• 8. The Long Argument

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  David Cooper, a psychiatrist, coined the term anti-psychiatry in 1967, and Thomas Szasz later made it popular, though the German word Antipsychiatrie was already in use in 1904. The basic premise of the movement is that psychiatrists try to classify normal people as deviant, and that some treatments do more harm than good. Its critics point to discredited methods such as the frontal lobectomy, commonly called a lobotomy, whose use largely disappeared by the late 1970s. The field also keeps a roster of practitioners who worked outside medical ethics, including Harry Bailey, Donald Ewen Cameron, Samuel A. Cartwright, Henry Cotton, and Andrei Snezhnevsky. A 2022 meta-analysis by Leichsenring and others found that the treatment effects of psychotherapies and psychiatric drugs are limited, despite half a century of research, thousands of randomized controlled trials, and millions of invested funds. The serotonin chemical imbalance theory once used to market antidepressants is no longer considered substantiated, leading to accusations of systemic pharmaceutical marketing fraud. Cosgrove, Logan, and Herrawi argued in 2022 that academic-industry financial conflicts of interest have biased research toward favorable risk-benefit ratios for psychiatric drugs. In a 2020 report associated with the UN Human Rights Council, the Special Rapporteur on the right to health warned that the dominance of the biomedical model has driven overmedicalization while ignoring the social, political, and existential contexts of distress. Cacciatore and Frances argued in 2022 that the diagnosis of Prolonged Grief Disorder pathologizes grief and offends the dignity of loving relationships, a charge that returns the field to the oldest question of all, whether a sorrow is a sickness.