in Misc., Thinking about psychiatry

Why has psychiatry become so dominant in mental health services?

Although psychiatrists cannot claim to ‘run’ mental health services, as things stand they take ultimate responsibility for the individual care of most patients in the mental health system. But good practice in mental health care involves more than just psychiatrists, and other professions such as psychologists and mental health nurses, could also make a valid claim to be in charge of patient care.*

The status of doctors in the treatment of mental health is actually historic. At the time of the establishment of asylums there were no effective treatments on offer for psychiatric disorders so doctors’ medical qualifications were irrelevant. However doctors’ social standing and accountability meant it was felt that they would be effective guardians of against abuse of patients.

One argument for the continuing prominence of psychiatry is the overlap between mental and physical diseases. For instance, thyroid problems can mimic depression and the argument runs that a psychiatrist should be on hand to identify these instances. This argument is not especially solid, as although physical problems are occasionally picked up by psychiatrists, general practitioners should sift these problems out before referring to psychiatrists.

A second argument is that ‘medical model’ of psychiatry is successful at treating mental illness. This is not just simply prescribing drugs for patients, as this could be done by doctors without their current status, but also that a doctor brings to the table a pragmatic approach to the treatment of patients that draws on scientific method. Although the medical model is much maligned, as being too narrow and too dominant, it also entails a benign paternalism and a willingness to accept responsibility, which some, but of course not all, in their time of sickness may welcome.

Consultation by a doctor is often valued by patients and staff alike despite the fact that a lot of patients are seen by psychiatrists do not have problems related to anything that could be characterized as an ‘illness’. Why this should be so has societal roots beyond the scope of this piece. It has not been unusual for me to be asked to give a ‘doctor’s opinion’ on matters of importance when there is no obvious reason for why I should be qualified to do this, except a willingness to stick my neck out. When working in the community I have often felt that, as many people with mental health problems often have very unsatisfactory social situations, patients would be better off seeing a social worker once a month who could then refer onto me if necessary rather than the current situation which is the other way around.

* I am aware the situation is more nuanced than this paragraph portrays. In a CMHT, many patients will go nowhere near a psychiatrist; furthermore the new mental health act contains provision for other professions to become patient RMOs.

Someone who doesn’t agree with this post….

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  1. I’m also sold that doctors aren’t deific in their input into mental health care.

    Still, psychiatrists do have useful roles to contribute.

    In April I mused over this and still I feel we’ve a mix of unique and high competency skills that mean we can enrich mental health care for many of our patients.

  2. You’re dead right FP.
    As of November it’s “death to the Responsible Medical Oficer, long live the Responsible Clinician”
    The thing is, from my non-evidence based, anecdotal straw poll of non-medical colleagues, I haven’t met a soul who wants to step up and take the mantle.

    Now I don’t begrudge this change in the law per se. I think that the vast majority of patients will still have psychiatrists as their RC, however I can see how some clinicians eg. Psychologists in a Personality Disorder services, or Occupational Therapists in Learning Disability could well be in a good position to take over responsibility for their patient – whether they will or not is yet to be seen.

  3. I saw this very interesting website:
    survive and thrive:
    and went to one of their workshops, which was an amazing experience.
    Dr Eden Fazel has written several interewsting books which are on the website…
    thought to share