Psychiatry is the medical specialty devoted to the study and treatment of mental disorders. These mental disorders include various affective, behavioural, cognitive and perceptual abnormalities. The term was first coined by the German physician Johann Christian Reil in 1808, and literally means the 'medical treatment of the mind' (psych-: mind; from Ancient Greek psykhē: soul; -iatry: medical treatment; from Gk. iātrikos: medical, iāsthai: to heal). A medical doctor specializing in psychiatry is a psychiatrist.
Psychiatric assessment typically starts with a mental status examination and the compilation of a case history. Psychological tests and physical examinations may be conducted, including on occasion the use of neuroimaging or other neurophysiological techniques. Mental disorders are diagnosed in accordance with criteria listed in diagnostic manuals such as the widely used Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, and the International Classification of Diseases (ICD), edited and used by the World Health Organization. The fifth edition of the DSM (DSM-5) is scheduled to be published in 2013, and its development is suspected to be of significant interest to many medical fields.[3]
Psychiatric treatment applies a variety of modalities, including psychoactive medication, psychotherapy and a wide range of other techniques such as transcranial magnetic stimulation. Treatment may be delivered on an inpatient or outpatient basis, depending on the severity of functional impairment or on other aspects of the disorder in question. Research and treatment within psychiatry as a whole are conducted on an interdisciplinary basis, sourcing an array of sub-specialties and theoretical approaches.
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Although one may trace its germination to the late eighteenth century, the beginning of psychiatry as a medical specialty is dated to the middle of the nineteenth century.[4]Starting in the 5th century BCE, mental disorders, especially those with psychotic traits, were considered supernatural in origin.[5] This view existed throughout ancient Greece and Rome.[5] Early manuals about mental disorders were created by the Greeks.[4] In the 4th century BCE, Hippocrates theorized that physiological abnormalities may be the root of mental disorders.[5][5] Religious leaders often turned to versions of exorcism to treat mental disorders often utilizing cruel and barbarous methods.[5]
Specialist hospitals were built in Baghdad in 705 AD, followed by Fes in the early 8th century, and Cairo in 800 AD.
Physicians who wrote on mental disorders and their treatment in the Medieval Islamic period included Muhammad ibn Zakarīya Rāzi (Rhazes), the Arab physician Najab ud-din Muhammad, and Abu Ali al-Hussain ibn Abdallah ibn Sina, known in the West as Avicenna.[6]
Specialist 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.[7] Founded in the 13th century, Bethlem Royal Hospital in London is one of the oldest lunatic asylums.[7] By 1547 the City of London acquired the hospital and continued its function until 1948.[8] It is now part of the National Health Service and is an NHS Foundation Trust.
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 applied.[8] In 1713 the Bethel Hospital Norwich was opened, the first purpose built asylum in England, founded by Mary Chapman [1] . In 1758 English physician William Battie wrote his Treatise on Madness which called for treatments to be utilized in asylums.[9] Thirty years later, then ruling monarch in England George III was known to be suffering from a mental disorder.[5] Following the King's remission in 1789, mental illness was seen as something which could be treated and cured.[5] French medic Philippe Pinel introduced humane treatment approaches to those suffering from mental disorders.[5] In 1793, in Parice psychiatric hospital “Bisetr”, Pinel released mental patients of chains beginning what has been called the bright epoch of psychiatry.[10] William Tuke adopted the methods outlined by Pinel and that same year Tuke opened the York Retreat in England.[5] Tuke's Retreat became a model throughout the world for humane and moral treatment of patients suffering from mental disorders.[11] The York Retreat inspired similar institutions in the United States, most notably the Brattleboro Retreat and the Hartford Retreat (now the Institute of Living).
At the turn of the century, England and France combined had only a few hundred individuals in asylums.[12] By the late 1890s and early 1900s, this number had risen to the hundreds of thousands.[12] The United States housed 150,000 patients in mental hospitals by 1904.[12] German speaking countries housed more than 400 public and private sector asylums.[12] These asylums were critical to the evolution of psychiatry as they provided places of practice throughout the world.[12]
On the continent, universities often played a part in the administration of the asylums[13] and, because of the relationship between the universities and asylums, scores of psychiatrists were being educated in Germany.[13]. 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.[12] The United Kingdom, unlike Germany, possessed a national body for asylum superintendents - the Medico-Psychological Association - established in 1866 under the Presidency of William A.F. Browne.[14]
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 England's York Retreat, it would be followed by specialty institutions of every treatment philosophy.
In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country. This was the year in which William A.F. Browne achieved his appointment as Superintendent of the Crichton Royal at Dumfries in southern Scotland.
However, the new idea that mental illness could be ameliorated during the mid-nineteenth century were disappointed.[15] Psychiatrists were pressured by an ever increasing patient population.[15] The average number of patients in asylums in the United States jumped 927%.[15] Numbers were similar in England and Germany.[15] Overcrowding was rampant in France where asylums would commonly take in double their maximum capacity.[16] 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.[17][18] 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[19] and the reputation of psychiatry in the medical world had hit an extreme low.[20]
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.[21] Kraepelin initially was very attracted to psychology and ignored the ideas of anatomical psychiatry.[21] 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.[22][23] Kraepelin began to study and promote the ideas of disease classification for mental disorders, an idea introduced by Karl Ludwig Kahlbaum.[23] 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.[24] However, Kraepelin was criticized for considering schizophrenia as a biological illness in the absence of any detectable histologic or anatomic abnormalities.[25]:221 While Kraepelin tried to find organic causes of mental illness, he adopted many theses of positivist medicine, but he favoured the precision of nosological classification over the indefiniteness of etiological causation as his basic mode of psychiatric explanation.[26]
Following Sigmund Freud's death, ideas stemming from psychoanalytic theory also began to take root.[27] The psychoanalytic theory became popular among psychiatrists because it allowed the patients to be treated in private practices instead of warehoused in asylums.[27] By the 1970s the psychoanalytic school of thought had become marginalized within the field.[27]
Biological psychiatry reemerged during this time. Psychopharmacology became an integral part of psychiatry starting with Otto Loewi's discovery of the neuromodulatory properties of acetylcholine; thus identifying it as the first-known neurotransmitter.[28] Neuroimaging was first utilized as a tool for psychiatry in the 1980s.[29] The discovery of chlorpromazine's effectiveness in treating schizophrenia in 1952 revolutionized treatment of the disease,[30] as did lithium carbonate's ability to stabilize mood highs and lows in bipolar disorder in 1948.[31] Psychotherapy was still utilized, but as a treatment for psychosocial issues.[32] Genetics were once again thought to play a role in mental illness.[28] Molecular biology opened the door for specific genes contributing to mental disorders to be identified.[28]
The introduction of psychiatric medications and the use of laboratory tests altered the doctor-patient relationship between psychiatrists and their patients.[33] Psychiatry's shift to the hard sciences had been interpreted as a lack of concern for patients.[33] 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.[34] 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.[35]
Electroconvulsive therapy (ECT) was one treatment that the anti-psychiatry movement wanted eliminated.[36] They alleged that ECT damaged the brain and was used as a tool for discipline.[36] While some believe there is no evidence that ECT damages the brain,[37][38][39] there are some citations that ECT does cause damage.[40][41] Sometimes ECT is used as punishment or as a threat and there have been isolated incidents where the use of ECT was threatened to keep the patients "in line".[36] The prevalence of psychiatric medication helped initiate deinstitutionalization,[42] the process of discharging patients from psychiatric hospitals to the community.[43] The pressure from the anti-psychiatry movements and the ideology of community treatment from the medical arena helped sustain deinstitutionalization.[42] Thirty-three years after deinstitutionalization started in the United States, only 19% of the patients in state hospitals remained.[42] 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.[42] 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.
Psychiatrists around the world have been involved in the suppression of individual rights by states wherein the definitions of mental disease had been expanded to include political disobedience.[44]:6 Nowadays, in many countries, political prisoners are sometimes confined to mental institutions and abused therein.[45]:3 Psychiatry possesses a built-in capacity for abuse which is greater than in other areas of medicine.[46]:65 The diagnosis of mental disease can serve as proxy for the designation of social dissidents, allowing the state to hold persons against their will and to insist upon therapies that work in favour of ideological conformity and in the broader interests of society.[46]:65 In a monolithic state, psychiatry can be used to bypass standard legal procedures for establishing guilt or innocence and allow political incarceration without the ordinary odium attaching to such political trials.[46]:65 In Nazi Germany in the 1940s, the 'duty to care' was violated on an enormous scale: A reported 300,000 individuals were sterilized and 100,000 killed in Germany alone, as were many thousands further afield, mainly in eastern Europe.[47] From the 1960s up to 1986, political abuse of psychiatry was reported to be systematic in the Soviet Union, and to surface on occasion in other Eastern European countries such as Romania, Hungary, Czechoslovakia, and Yugoslavia.[46]:66 A "mental health genocide" reminiscent of the Nazi aberrations has been located in the history of South African oppression during the apartheid era.[48] A continued misappropriation of the discipline was subsequently attributed to the People's Republic of China.[49]
The concept of medicalization is created by sociologists and used for explaining how medical knowledge is applied to a series of behaviors, over which medicine exerts control, although those behaviors are not self-evidently medical or biological.[50] According to Kittrie, a number of phenomena considered "deviant", such as alcoholism, drug addiction and mental illness, were originally considered as moral, then legal, and now medical problems.[51]:1[52] As a result of these perceptions, peculiar deviants were subjected to moral, then legal, and now medical modes of social control.[51]:1 Similarly, Conrad and Schneider concluded their review of the medicalization of deviance by supposing that three major paradigms may be identified that have reigned over deviance designations in different historical periods: deviance as sin; deviance as crime; and deviance as sickness.[51]:1[53]:36 According to Franco Basaglia and his followers, whose approach pointed out the role of psychiatric institutions in the control and medicalization of deviant behaviors and social problems, psychiatry is used as the provider of scientific support for social control to the existing establishment, and the ensuing standards of deviance and normality brought about repressive views of discrete social groups.[54]:70 As scholars have long argued, governmental and medical institutions code menaces to authority as mental diseases during political disturbances.[55]:14
In 1963, US 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.[42] Later, though, the Community Mental Health Center's focus was diverted to provide psychotherapy sessions for those suffering from acute but mild mental disorders.[42] Ultimately there were no arrangements made for actively and severely mentally ill patients who were being discharged from hospitals.[42] Some of those suffering from mental disorders drifted into homelessness or ended up in prisons and jails.[42][56] Studies found that 33% of the homeless population and 14% of inmates in prisons and jails were already diagnosed with a mental illness.[42][57]
In 1972, psychologist David Rosenhan published the Rosenhan experiment, a study questioning the validity of psychiatric diagnoses.[58] 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.[58] 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.[59]
Psychiatry, like most medical specialties has a continuing, significant need for research into its diseases, classifications and treatments.[60] Psychiatry adopts biology's fundamental belief that disease and health are different elements of an individual's adaptation to an environment.[61] But psychiatry also recognizes that the environment of the human species is complex and includes physical, cultural, and interpersonal elements.[61] In addition to external factors, the human brain must contain and organize an individual's hopes, fears, desires, fantasies and feelings.[61] Psychiatry's difficult task is to bridge the understanding of these factors so that they can be studied both clinically and physiologically.[61]
"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 (Greek "ψυχιατρική", psychiatrikē), coined by Johann Christian Reil in 1808, comes from the Greek "ψυχή" (psychē: "soul or mind") and "ιατρός" (iatros: "healer").[62][63][64] It refers to a field of medicine focused specifically on the mind, aiming to study, prevent, and treat mental disorders in humans.[65][66][67] 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.[68]
Those who pees psychiatry are different than most other mental health professionals and physicians in that they must be familiar with both the social and biological sciences.[66] 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.[69] Psychiatry exists to treat mental disorders which are conventionally divided into three very general categories: mental illness, severe learning disability, and personality disorder.[70] 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.[71]
While the medical specialty of psychiatry utilizes research in the field of neuroscience, psychology, medicine, biology, biochemistry, and pharmacology,[72] it has generally been considered a middle ground between neurology and psychology.[73] 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.[73] 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.[74] Psychiatrists can therefore counsel patients, prescribe medication, order laboratory tests, order neuroimaging, and conduct physical examinations.[75]
Like other purveyors of professional ethics, 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 Hawaii 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,[76] organ transplantation, torture,[77][78] the death penalty, media relations, genetics, and ethnic or cultural discrimination.[79] 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:
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 conceptualised in a number of different ways. The biomedical approach examines signs and symptoms and compares them with diagnostic criteria. Mental illness can be assessed, conversely, through a narrative which tries to incorporate symptoms into a meaningful life history and to frame them as responses to external conditions. Both approaches are important in the field of psychiatry,[81] but have not sufficiently reconciled to settle controversy over either the selection of a psychiatric paradigm or the specification of psychopathology. The notion of a "biopsychosocial model" is often used to underline the multifactorial nature of clinical impairment.[82][83][84] Alternatively, a "biocognitive model" acknowledges the physiological basis for the mind's existence, but identifies cognition as an irreducible and independent realm in which disorder may occur.[82][83][84] The biocognitive approach includes a mentalist etiology and provides a dualist revision of the biopsychosocial view, reflecting the efforts of psychiatrist Niall McLaren to bring the discipline into scientific maturity in accordance with the paradigmatic standards of philosopher Thomas Kuhn.[82][83][84]
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;[85] or (2) scientists in the academic field of psychiatry who 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.[85]
Psychiatric research is, by its very nature, interdisciplinary. It combines social, biological and psychological perspectives to understand the nature and treatment of mental disorders.[87] Clinical and research psychiatrists study basic and clinical psychiatric topics at research institutions and publish articles in journals.[72][88][89][90] 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.[91]
See also Diagnostic classification and rating scales used in psychiatry
Psychiatric diagnoses take place in a wide variety of settings and are performed by many different health professionals. 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 or psychosocial histories obtained, and sometimes neuroimages or other neurophysiological measurements are taken, or personality tests or cognitive tests administered.[92][93][94][95][96][97][98] In some cases, a brain scan might be used to rule out other medical illnesses, but at this time relying on brain scans alone cannot accurately diagnose a mental illness or tell the risk of getting a mental illness in the future.[99] A few psychiatrists are beginning to utilize genetics during the diagnostic process but on the whole this remains a research topic.[100][101][102]
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.[103] 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 States.[104] It is currently in its fourth revised edition and is also used worldwide.[104] The Chinese Society of Psychiatry has also produced a diagnostic manual, the Chinese Classification of Mental Disorders.[105]
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.[104][106] 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.[107] 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.[108]
Individuals with mental health conditions are commonly referred to as patients but may also be called clients, 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.
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 efficacy[109][110] and adverse effects of psychiatric drugs have been challenged.[111]
The close relationship between those prescribing psychiatric medication and pharmaceutical companies has become increasingly controversial[112] along with the influence which pharmaceutical companies are exerting on mental health policies.[113][114]
Also controversial are forced drugging and the "lack of insight" label. According to a report published by the US 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".[115]
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.[116]
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.
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 little or no time devoted to psychotherapy or "talk" therapies, or behavior modification. Psychiatrists who serve the lower end of the market, which is dependent on insurance reimbursements, do not receive insurance payments for lengthy psychotherapy sessions which is competitive with that offered for the brief consultations needed for prescribing and monitoring medication. Psychotherapy in such situations is performed by a lower paid psychologist or social worker.[117] 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.
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