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Psychiatry is a medical specialty officially devoted to the treatment and study of mental disorders. The term was first coined by the German physician Johann Christian Reil in 1808.

Psychiatric assessment typically involves a mental status examination, the taking of a case history. Psychological tests may also be conducted. Physical examinations may be carried out and on occasion neuroimaging or other neurophysiological studies are performed. Mental disorders are diagnosed based on criteria listed in diagnostic manuals, such as the widely used Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, the International Classification of Diseases (ICD), and the World Health Organization.

Psychiatric treatment employs a variety of therapeutic modalities including medications, psychotherapy, and a wide variety of other treatments such as transcranial magnetic stimulation. Depending upon the disorder being treated, the severity of the symptoms, and level of impaired functioning, treatment may be conducted on an inpatient or outpatient basis. Research and the clinical application of psychiatry are conducted on an interdisciplinary basis involving various sub-specialties and theoretical approaches.

Historical origins

In the West, treatment of emotional and cognitive dysfunction may be said to have its origins at least as far back as the 5th century BC. The first hospices for the mentally ill appeared in the Middle Ages. The early 19th century saw the development of psychiatry as a recognized field. Mental health institutions came to utilize more elaborate and, over the course of time, more humane treatment methods. The 19th century saw a huge increase in the number of patients.

The 20th century saw an upsurge of biological understanding of mental disorders, as well as the introduction of more systematic disease classification, and the advent of sophisticated psychiatric medication. An anti-psychiatry movement, hostile to most of the fundamental assumptions and practices of the discipline, emerged in the 1960s. A shift in emphasis in several Western societies led to the dismantling of state psychiatric hospitals in favor of more community-based treatment.

Theory and focus

"Psychiatry, more than any other branch of medicine, forces its practitioners to wrestle with the nature of evidence, the validity of introspection, problems in communication, and other long-standing philosophical issues" (Guze, 1992, p.4).

The term psychiatry (ψυχιατρική), coined by Johann Christian Reil in 1808, comes from the Greek “ψυχή” (soul or mind) and “ιατρός" (healer).It refers to a field of medicine focused specifically on the mind, aiming to study, prevent, and treat mental disorders in humans. It has been described as an intermediary between the world from a social context and the world from the perspective of those who are mentally ill.

Those who practice psychiatry are different than most other mental health professionals and physicians in that they must be familiar with both the social and biological sciences. The discipline is interested in the operations of different organs and body systems as classified by the patient's subjective experiences and the objective physiology of the patient. Psychiatry exists to treat mental disorders which are conventionally divided into three very general categories; mental illness, severe learning disability, and personality disorder. While the focus of psychiatry has changed little throughout time, the diagnostic and treatment processes have evolved dramatically and continue to do so. Since the late 20th century, the field of psychiatry has continued to become more biological and less conceptually isolated from the field of medicine.

Scope of practice

[[Image:Neuropsychiatric conditions world map - DALY - WHO2002.svg|thumb|Disability-adjusted life year for neuropsychiatric conditions
per 100,000 inhabitants in 2002.

]]While the medical specialty of psychiatry utilizes research in the field of neuroscience, psychology, medicine, biology, biochemistry, and pharmacology, it has generally been considered a middle ground between neurology and psychology. 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. Psychiatrists also differ from psychologists in that they are physicians and the entirety of their post-graduate training is revolved around the field of medicine. Psychiatrists can therefore counsel patients, prescribe medication, order laboratory test, utilize neuroimaging in a research setting, and conduct physical examinations.


Like other professions, the World Psychiatric Association issues an ethical code to govern the conduct of psychiatrists. The psychiatric code of ethics, first set forth through the Declaration of Hawaiimarker in 1977, has been expanded through a 1983 Vienna update and, in 1996, the broader Madrid Declaration. The code was further revised in Hamburg, 1999. The World Psychiatric Association code covers such matters as patient assessment, up-to-date knowledge, the human dignity of incapacitated patients, confidentiality, research ethics, sex selection, euthanasia, organ transplantation, torture, the death penalty, media relations, genetics, and ethnic or cultural discrimination. In establishing such ethical codes, the profession has responded to a number of controversies about the practice of psychiatry.


Various subspecialties and/or theoretical approaches exist which are related to the field of psychiatry. They include the following:
  • Biological psychiatry; an approach to psychiatry that aims to understand mental disorder in terms of the biological function of the nervous system.
  • Child and adolescent psychiatry; a branch of psychiatry that specialises in work with children, teenagers, and their families.
  • Community psychiatry; an approach that reflects an inclusive public health perspective and is practiced in community mental health services.
  • Cross-cultural psychiatry; a branch of psychiatry concerned with the cultural and ethnic context of mental disorder and psychiatric services.
  • Emergency psychiatry; the clinical application of psychiatry in emergency settings.
  • Forensic psychiatry; the interface between law and psychiatry.
  • Geriatric psychiatry; a branch of psychiatry dealing with the study, prevention, and treatment of mental disorders in humans with old age.
  • Liaison psychiatry; 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; branch of medicine dealing with mental disorders attributable to diseases of the nervous system.
  • Orthomolecular psychiatry; describes the practice of preventing and treating disease by providing the body with optimal amounts of substances which are natural to the body.
  • Social psychiatry; a branch of psychiatry that focuses on the interpersonal and cultural context of mental disorder and mental wellbeing.

In the United States, psychiatry is one of the specialties which qualify for further education and board-certification in pain medicine, palliative medicine, and sleep medicine.


Psychiatric illnesses can be approached in a number of different ways. The biomedical approach examines signs and symptoms and compares them with diagnostic criteria. Psychiatric illness can also be assessed through a narrative which tries to understand symptoms as a part of a meaningful life history and as a responses to external conditions. Both approaches are important in the field of psychiatry. A lack of consensus between these often opposing view has contributed in part to the biopsychiatry controversy. It has also played a role in controversies over specific psychiatric illness, such as ADHD and multiple personalities. The biopsychosocial model is often used to understand psychiatric illness.


Ancient times

Starting in the 5th century BC, mental disorders, especially those with psychotic traits, were considered supernatural in origin. This view existed throughout ancient Greece and Rome. Early manuals written about mental disorders were created by the Greeks. In 4th century BC, Hippocrates theorized that physiological abnormalities may be the root of mental disorders.. Religious leaders and others returned to using early versions of exorcisms to treat mental disorders which often utilized cruel, harsh, and barbarous methods.

Middle Ages

The first psychiatric hospitals were built in the medieval Islamic world from the 8th century. The first was built in Baghdadmarker in 705, followed by Fesmarker in the early 8th century, and Cairomarker in 800. Unlike medieval Christian physicians who relied on demonological explanations for mental illness, medieval Muslim physicians relied mostly on clinical observations. They made significant advances to psychiatry and were the first to provide psychotherapy and moral treatment for mentally ill patients, in addition to other forms of treatment such as bath, drug medication, music therapy and occupational therapy. In the 10th century, the Persian physician Muhammad ibn Zakarīya Rāzi (Rhazes) combined psychological methods and physiological explanations to provide treatment to mentally ill patients. His contemporary, the Arab physician Najab ud-din Muhammad, first described a number of mental illnesses such as agitated depression, neurosis, priapism and sexual impotence (Nafkhae Malikholia), psychosis (Kutrib), and mania (Dual-Kulb).

In the 11th century, another Persian physician Avicenna recognized 'physiological psychology' in the treatment of illnesses involving emotions, and developed a system for associating changes in the pulse rate with inner feelings, which is seen as a precursor to the word association test developed by Carl Jung in the 19th century. Avicenna was also an early pioneer of neuropsychiatry, and first described a number of neuropsychiatric conditions such as hallucination, insomnia, mania, nightmare, melancholia, dementia, epilepsy, paralysis, stroke, vertigo and tremor.

Psychiatric hospitals were built in medieval Europe from the 13th century to treat mental disorders but were utilized only as custodial institutions and did not provide any type of treatment. Founded in the 13th century, Bethlem Royal Hospitalmarker in Londonmarker is one of the oldest psychiatric hospitals. By 1547 the City of London acquired the hospital and continued its function until 1948. It is now part of the British NHS Foundation Trust.

Early modern period

In 1656, Louis XIV of France created a public system of hospitals for those suffering from mental disorders, but as in England, no real treatment was being applied. In 1758 English physician William Battie wrote the Treatise on Madness which called for treatments to be utilized in asylums. Thirty years later the new ruling monarch in England, George III, was known to be suffering from a mental disorder. Following the King's remission in 1789, mental illness was seen as something which could be treated and cured. By 1792 French physician Philippe Pinel introduced humane treatment approaches to those suffering from mental disorders. William Tuke adopted the methods outlined by Pinel and that same year Tuke opened the York Retreatmarker in England. That institution became known as a model throughout the world for humane and moral treatment of patients suffering from mental disorders. It inspired similar institutions in the United States, most notably the Brattleboro Retreat and the Hartford Retreat (now the Institute of Living).

19th century

At the turn of the century, England and France combined only had a few hundred individuals in asylums. By the late 1890s and early 1900s, this number skyrocketed to the hundreds of thousands. The United States housed 150,000 patients in mental hospitals by 1904. German speaking countries housed more than 400 public and private sector asylums. These asylums were critical to the evolution of psychiatry as they provided a universal platform of practice throughout the world.

Universities often played a part in the administration of the asylums. Due to the relationship between the universities and asylums, scores of competitive psychiatrists were being molded in Germany. Germany became known as the world leader in psychiatry during the nineteenth century. The country possessed more than 20 separate universities all competing with each other for scientific advancement. However, because of Germany's individual states and the lack of national regulation of asylums, the country had no organized centralization of asylums or psychiatry. Britain, like Germany, also lacked a centralized organization for the administration of asylums. This deficit hindered the diffusion of new ideas in medicine and psychiatry.

In the United States in 1834, Anna Marsh, a physician's widow, deeded the funds to build her country's first financially-stable private asylum. The Brattleboro Retreat marked the beginning of America's private psychiatric hospitals challenging state institutions for patients, funding, and influence. Although based on Englandmarker's York Retreatmarker, it would be followed by speciality institutions of every treatment philosophy.

In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country. By 1840, asylums as therapeutic institutions existed throughout Europe and the United States.

However, the new and dominating ideas that mental illness could be "conquered" during the mid-nineteenth century all came crashing down. Psychiatrists and asylums were being pressured by an ever increasing patient population. The average number of patients in asylums in the United States jumped 927%. Numbers were similar in England and Germany. Overcrowding was rampant in France where asylums would commonly take in double their maximum capacity. Increases in asylum populations may have been a result of the transfer of care from families and poorhouses, but the specific reasons as to why the increase occurred is still debated today. No matter the cause, the pressure on asylums from the increase was taking its toll on the asylums and psychiatry as a specialty. Asylums were once again turning into custodial institutions and the reputation of psychiatry in the medical world had hit an extreme low.

20th century

Disease classification and rebirth of biological psychiatry

The 20th century introduced a new psychiatry into the world. Different perspectives of looking at mental disorders began to be introduced. The career of Emil Kraepelin reflects the convergence of different disciplines in psychiatry. Kraepelin initially was very attracted to psychology and ignored the ideas of anatomical psychiatry. Following his appointment to a professorship of psychiatry and his work in a university psychiatric clinic, Kraepelin's interest in pure psychology began to fade and he introduced a plan for a more comprehensive psychiatry. Kraepelin began to study and promote the ideas of disease classification for mental disorders, an idea introduced by Karl Ludwig Kahlbaum. The initial ideas behind biological psychiatry, stating that the different mental disorders were all biological in nature, evolved into a new concept of "nerves" and psychiatry became a rough approximation of neurology and neuropsychiatry. Following Sigmund Freud's death, ideas stemming from psychoanalytic theory also began to take root. The psychoanalytic theory became popular among psychiatrists because it allowed the patients to be treated in private practices instead of warehoused in asylums. By the 1970s the psychoanalytic school of thought had become marginalized within the field.
Biological psychiatry reemerged during this time. Psychopharmacology became an integral part of psychiatry starting with Otto Loewi's discovery of the first neurotransmitter, acetylcholine. Neuroimaging was first utilized as a tool for psychiatry in the 1980s. The discovery of chlorpromazine's effectiveness in treating schizophrenia in 1952 revolutionized treatment of the disease, as did lithium carbonate's ability to stabilize mood highs and lows in bipolar disorder in 1948. Psychotherapy was still utilized, but as the treatment for psychosocial issues. Genetics were once again thought to play a role in mental illness. Molecular biology opened the door for specific genes contributing mental disorders to be identified. By 1995 genes contributing to schizophrenia had been identified on chromosome 6 and genes contributing to bipolar disorder on chromosomes 18 and 21.

Anti-psychiatry and deinstitutionalization

The introduction of psychiatric medications and the use of laboratory tests altered the doctor-patient relationship between psychiatrists and their patients. Psychiatry's shift to the hard sciences had been interpreted as a lack of concern for patients. Anti-psychiatry had become more prevalent in the late twentieth century due to this and publications in the media which conceptualized mental disorders as myths. Others in the movement argued that psychiatry was a form of social control and demanded that institutionalized psychiatric care, stemming from Pinel's thereapeutic asylum, be abolished. Incidents of physical abuse by psychiatrists took place during the reign of some totalitarian regimes as part of a system to enforce political control with some of the abuse even continuing to our present day. Historical examples of the abuse of psychiatry took place in Nazi Germany , in the Soviet Unionmarker under Psikhushka, and in the apartheid system in South Africa.

Electroconvulsive therapy was one treatment that the anti-psychiatry movement wanted eliminated. They alleged that electroconvulsive therapy damaged the brain and it was used as a tool for discipline. While some believe there is no evidence that electroconvulsive therapy damages the brain, there are some citations that ECT causes damage. Sometimes ECT is used as punishment or as a threat and there have been isolated incidents where the use of electroconvulsive therapy was threatened to keep the patients "in line." The prevalence of psychiatric medication helped initiate deinstitutionalization, the process of discharging patients from psychiatric hospitals to the community. The pressure from the anti-psychiatry movements and the ideology of community treatment from the medical arena helped sustain deinstitutionalization. Thirty-three years after deinstitutionalization started in the United States, only 19% of the patients in state hospitals remained. Mental health professionals envisioned a process wherein patients would be discharged into communities where they could participate in a normal life while living in a therapeutic atmosphere. Psychiatrists were criticized, however, for failing to develop community-based support and treatment. Community-based facilities were not available because of the political infighting between in-patient and community-based social services, and an unwillingness by social services to dispense funding to provide adequately for patients to be discharged into community-based facilities.

Transinstitutionalization and the aftermath

In 1963, United States president John F. Kennedy introduced legislation delegating the National Institute of Mental Health to administer Community Mental Health Centers for those being discharged from state psychiatric hospitals. Later, though, the Community Mental Health Center's focus was diverted to provide psychotherapy sessions for those suffering from acute but mild mental disorders. Ultimately there were no arrangements made for actively and severely mentally ill patients who were being discharged from hospitals. Some of those suffering from mental disorders drifted into homelessness or ended up in prisons and jails. Studies found that 33% of the homeless population and 14% of inmates in prisons and jails were already diagnosed with a mental illness.

In 1972, psychologist David Rosenhan published the Rosenhan experiment, a study analyzing the validity of psychiatric diagnoses. The study arranged for eight individuals with no history of psychopathology to attempt admission into psychiatric hospitals. The individuals included a graduate student, psychologists, an artist, a housewife, and two physicians, including one psychiatrist. All eight individuals were admitted with a diagnosis of schizophrenia or bipolar disorder. Psychiatrists then attempted to treat the individuals using psychiatric medication. All eight were discharged within 7 to 52 days. In a later part of the study, psychiatric staff were warned that pseudo-patients might be sent to their institutions, but none were actually sent. Nevertheless, a total of 83 patients out of 193 were believed by at least one staff member to be actors. The study concluded that individuals without mental disorders were indistinguishable from those suffering from mental disorders. Critics such as Robert Spitzer placed doubt on the validity and credibility of the study, but did concede that the consistency of psychiatric diagnoses needed improvement.

Psychiatry, like most medical specialties has a continuing, significant need for research into its diseases, classifications and treatments. Psychiatry adopts biology's fundamental belief that disease and health are different elements of an individual's adaptation to an environment. But psychiatry also recognizes that the environment of the human species is complex and includes physical, cultural, and interpersonal elements. In addition to external factors, the human brain must contain and organize an individual's hopes, fears, desires, fantasies and feelings. Psychiatry's difficult task is to bridge the understanding of these factors so that they can be studied both clinically and physiologically.

Industry and academia


All physicians can diagnose mental disorders and prescribe treatments utilizing principles of psychiatry. Psychiatrists are either: 1) clinicians who specialize in psychiatry and are certified in treating mental illness. or (2) scientists in the academic field of psychiatry and are qualified as research doctors in this field. Psychiatrists may also go through significant training to conduct psychotherapy, psychoanalysis and cognitive behavioral therapy, but it is their training as physicians that differentiates them from other mental health professionals.


Psychiatric research is, by its very nature, interdisciplinary. It combines social, biological and psychological perspectives to understand the nature and treatment of mental disorders. Clinical and research psychiatrists study basic and clinical psychiatric topics at research institutions and publish articles in journals. 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.

Clinical application

Diagnostic systems

Psychiatric diagnoses take place in a wide variety of settings and are performed by many different health professional. 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, pathological, psychopathological and psychosocial histories obtained, neuroimages or other neurophysiological measurements are taken, and personality tests or cognitive tests may be administered. In addition psychiatrists are beginning to utilize genetics during the diagnostic process. Some endophenotypes being researched may predispose certain individuals to certain conditions.

Diagnostic manuals
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 Organisation, includes a section on psychiatric conditions, and is used worldwide. 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 Statesmarker. It is currently in its fourth revised edition and is also used worldwide. The Chinese Society of Psychiatry has also produced a diagnostic manual, the Chinese Classification of Mental Disorders.

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. 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. 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.

Treatment settings

General considerations
Individuals with mental health conditions are commonly referred to as patients but may also be called client, 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.
A psychiatric patient room in the United States.

Whatever the circumstance of a person's referral, a psychiatrist first assesses the person's 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 and 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, such as thyroid dysfunction or brain tumors, or identify any signs of self-harm; this examination may be done by someone other than the psychiatrist, especially if blood tests and medical imaging are performed.

Like all medications, psychiatric medications can cause adverse 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, renal and thyroid function. Electroconvulsive therapy (ECT) is sometimes administered for serious and disabling conditions, especially those unresponsive to medication. The efficacity and adverse effects of psychiatric drugs have been challenged

The close relationship between those prescribing psychiatric medication and pharmaceutical companies has become increasingly controversial along with the influence which pharmaceutical companies are exerting on mental health policies.

Also controversial are forced drugging and the "lack of insight" label. According to a report published by the U.S. National Council on Disability,
Involuntary treatment is extremely rare outside the psychiatric system, allowable only in such cases as unconsciousness or the inability to communicate.
People with psychiatric disabilities, on the other hand, even when they vigorously protest treatments they do not want, are routinely subjected to them anyway, on the justification that they "lack insight" or are unable to recognize their need for treatment because of their "mental illness."
In practice, "lack of insight" becomes disagreement with the treating professional, and people who disagree are labeled "noncompliant" or "uncooperative with treatment."

Inpatient treatment
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. Today, 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.

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 USA 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 and/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.

Patients 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, 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 physically restrained or medicated. People on inpatient wards may be allowed leave for periods of time, either accompanied or on their own.

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.

Outpatient treatment
People may receive psychiatric care on an inpatient or outpatient basis. Outpatient treatment involves periodic visits to a clinician for consultation in his or her office, usually for an appointment lasting thirty to sixty minutes. These consultations normally involve the psychiatric practitioner interviewing the person to update their assessment of the person's condition, and to provide psychotherapy or review medication. The frequency with which a psychiatric practitioner sees people in treatment varies widely, from days to months, depending on the type, severity and stability of each person's condition, and depending on what the clinician and client decide would be best. Increasingly, psychiatrists are limiting their practices to psychopharmacology (prescribing medications) with less time devoted to psychotherapy or "talk" therapies, or behavior modification. The role of psychiatrists is changing in community psychiatry, with many assuming more leadership roles, coordinating and supervising teams of allied health professionals and junior doctors in delivery of health services.

See also



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General references

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  • McGorry PD, Mihalopoulos C, Henry L et al. (1995) Spurious precision: procedural validity of diagnostic assessment in psychiatric disorders. American Journal of Psychiatry 152 (2) 220-223
  •, Psychologist, Viewed 20 September, 2006
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  • Hiruta, Genshiro. (edited by Dr. Allan Beveridge) " Japanese psychiatry in the Edo period (1600-1868)." History of Psychiatry, Vol. 13, No. 50, 131-151 (2002).

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