Crisis in psychiatry

At first glance the new status of psychiatry seems to have taken firm root in the last three decades. It rests on the general acceptance of the medical definition of the concept of mental disease and of the progressive realization of a diversified but co-ordinated institutional system of mental health care. The biological perspective, even if it has taken a prominent place in research and therapy, is now combined with psychological and social approaches in the bio-psychosocial model. The psychiatrist, in accordance with his medical professional responsibilities, occupies a central position in a multidisciplinary team whose members contribute their special competences to the common goal.

This idyllic picture is far from a reflection of reality, even in the developed countries, and the existence of a crisis in psychiatry is evoked with increasing frequency. An indication of the loss of prestige of psychiatry in the medical profession is the alarming decrease of the proportion of American medical students choosing a psychiatric residency; it fell to 2 per cent in 1990, a level much too low to ensure the maintenance of the present demography. Under the pressure of economic constraints, efforts are made everywhere to control the rising burden of medical care. They have taken different forms according to the country—from the managed care system in the United States to the numerus clausus system in France, in which the number of internships available is determined by the government—but their common aim is to limit the number of psychiatrists and the cost of their activities. Paradoxically, the recognition of the frequency of the mental disorders and the growing demand for psychiatric treatments has been associated with a reduction if the domain of action of psychiatrists, who are now often vastly outnumbered by clinical psychologists and social workers. In the United States, by 1990, 80000 'clinical' social workers were active in the psychiatric socio-psychological domain, a quarter of them in part- or full-time private practice. The claims of these powerful professional groups are not limited to a completely autonomous status but, in the case of the clinical psychologists, extend to the demand for a legal recognition of such typical 'medical privileges' as the right to hospitalize patients and to prescribe drugs. Even within medicine, psychiatry is under attack. In Germany, a medical psychotherapeutic specialty distinct from psychiatry has been created. The most impressive change has been in the proportion of mental disorders now treated by general practitioners as a result of the availability of psychotropic drugs with fewer side-effects; in France, 60 per cent of antidepressants are now prescribed by general practitioners. These examples may not be a fair representation of the global picture, but there is undoubtedly a movement towards a limitation of the psychiatric specialty to the care of the most severe cases—in practice, the psychotic cases. However, some neuroscientists raise doubts about the usefulnesss of maintaining psychiatry as a specialty even in this field. Influential biologically oriented psychiatrists have recently proposed, on theoretical and practical grounds, that psychiatry should be absorbed into a new medical discipline, akin to the former neuropsychiatry, and all or most of its socio-psychological aspects should be left to non-medical professions.

Since psychiatry has emerged as a specialty, it has been submitted to conflicting forces. The demands of society, changes in the concept of mental disorder and of its limits, variations in the role played by different theoretical perspectives, and successive scientific discoveries have been responsible for an evolution reflected in the professional status and role of the psychiatrist. Displacements of the centre of gravity of a complex structure in which biological, psychological, and social factors interact have modified the image of psychiatry. The threat of being incorporated in other medical specialties or being deprived of its medical character is but another transitory episode in its history.

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