Psychiatrists treat patients privately and in hospital settings through a combination of psychotherapy and medication. There are about 41,000 practicing psychiatrists in the United States. Their training consists of four years of medical school, followed by one year of internship and at least three years of psychiatric residency.
Psychiatrists may receive certification from the American Board of Psychiatry and Neurology (ABPN), which requires two years of clinical experience beyond residency and the successful completion of a written and an oral test. Unlike a medical license, board certification is not legally required in order to practice psychiatry.
Psychiatrists may practice general psychiatry or choose a specialty, such as child psychiatry, geriatric psychiatry, treatment of substance abuse, forensic (legal) psychiatry, emergency psychiatry, mental retardation, community psychiatry, or public health. Some focus their research and clinical work primarily on psychoactive medication, in which case they are referred to as psychopharmacologists.
Psychiatrists may be called upon to address numerous social issues, including juvenile delinquency,family and marital dysfunction, legal competency in criminal and financial matters, and treatment of mental and emotional problems among prison inmates and in the military.
Psychiatrists treat the biological, psychological, and social components of mental illness simultaneously. They can investigate whether symptoms of mental disorders have physical causes, such as a hormone imbalance or an adverse reaction to medication, or whether psychological symptoms are contributing to physical conditions, such as cardiovascular problems and high blood pressure.
Because they are licensed physicians, psychiatrists, unlike psychologists and psychiatric social workers, can prescribe medication; they are also able to admit patients to the hospital. Other mental health professionals who cannot prescribe medication themselves often establish a professional relationship with a psychiatrist.
Psychiatrists may work in private offices, private psychiatric hospitals, community hospitals, state and federal hospitals, or community mental centers. Often, they combine work in several settings. As of 1988, 15 percent of psychiatrists belonged to group practices. In addition to their clinical work, psychiatrists often engage in related professional activities, including teaching, research, and administration.
The American Psychiatric Association, the oldest medical specialty organization in the United States, supports the profession by offering continuing education and research opportunities, keeping members informed about new research and public policy issues, helping to educate the public about mental health issues, and serving as an advocate for people affected by mental illness.
Traditional psychiatry has been challenged in a variety of ways since the end of World War II. The most widespread and significant change has been the removal of the psychiatric hospital from its central role in the practice of psychiatry.
This development resulted from a number of factors: the financial inability of state governments to remedy the deteriorating condition of many institutions; the discovery of new, more effective drugs enabling patients to medicate themselves at home; social activists’ charges of abuse and neglect in state mental facilities; and activism by former mental patients protesting involuntary institutionalization and treatment. In addition, a growing movement, led by Karl Menninger, sought to replace state mental hospitals with community mental health centers.
The Community Mental Health Centers Act of 1963 allotted federal funds for the establishment of community treatment centers, which provide a variety of services, including short-term and partial hospitalization. The establishment of these centers has contributed to the growing trend toward the deinstitutionalization of mental patients.
In the 1960s and 1970s radical critics within the profession, such as Thomas Szasz and R. D. Laing, challenged basic assumptions about psychiatric treatment and about the medical model of mental illness itself.
Sociologists, including Erving Goffman and Thomas Scheff, produced critiques of mental institutions as a form of social control, and the anti-psychiatry ideas of French philosopher Michel Foucault gained currency among American intellectuals. Psychiatry also came under fire from the feminist movement, which saw it as a vehicle for controlling women.
Feminist authors Kate Millett and Shulamith Firestone have portrayed psychoanalysis as instrumental in suppressing the original feminist movement of the late 19th and early 20th centuries by labeling women’s legitimate dissatisfaction and agitation as hysteria and providing an intellectual theory that aided in legitimizing society’s continuing subordination of women. Published in 1972, Phyllis Chesler’s Women and Madness was a landmark in feminist criticism.
Advances in neuroscience, endocrinology, and immunology have had a major effect on the way psychiatry is practiced today. The study of neurotransmitters— chemicals in the brain that are related to anxiety, depression, and other disorders—have been significant both in the development of new medications and in the way psychiatrists think about mood, personality, and behavior.
Currently, a major (and highly publicized) issue in psychiatry is the use of Prozac and other specialized serotonin reuptake inhibitors (SSRIs), a new class of antidepressants that has fewer side effects than drugs previously used to treat depression.
These drugs have become controversial because of their potential use for “cosmetic psychopharmacology,” the transformation of mood and personality in persons with no diagnosable mental disorder. Both psychiatrists and others in the medical and mental health professions must confront the issue of using psychoactive drugs as “mood brighteners” to make clinically healthy individuals more energetic, assertive, and resilient.
Another contemporary development with wideranging implications for psychiatry is the growth of health maintenance organizations (HMOs) and managed care programs, whose cost-containment policies have already had a significant effect on the way psychiatry is practiced.
Expensive long-term psychotherapy is discouraged by such organizations, and medication is generally favored over therapy. Recently, concern has been expressed over the practice of promoting cheaper medications over more expensive ones, even when those that cost more offer greater benefits.