Why study psychiatry?

As this is an introductory text, many students reading this book will not go on to become psychiatrists. However, the principles in the general chapters and the specific information about mental illness in the other parts of the book are essential for all doctors and potential health professionals.

Consideration of the psychological aspects of the doctor–patient relationship may well affect its outcome (Chapter 4). Many complaints about doctors do not concern technical mistakes (although these may be involved), but originate because of a patient’s or relative’s dissatisfaction with the way psychological aspects have been managed. For example, a family complained not about the caring, compassionate GP who delayed making a diagnosis of deep vein thrombosis in their father, but were vociferous in berating the technically perfect intensive care unit doctors who treated the family in a busy, but brusque manner, while managing the subsequent pulmonary embolus.

It has been estimated that up to one in five people at any one time may suffer from unwanted psychological symptoms such as anxiety, despondency, irritability and insomnia. One in six of the UK population receive treatment from their GP each year for primarily psychiatric disorders. In a further one-sixth, psychological factors are important contributors to illness.

At any one time, one in 20 people is suffering from depression. One in 25 women and one in 50 men are admitted to hospital with depression at some time in their lives (Chapter 9). The lifetime incidence of schizophrenia is one in 100 (Chapter 8). The prevalence of dementia (Chapters 6 and 20) in those over the age of 65 is one in 20, and over the age of 80 is double that. If one also includes admissions to hospital for deliberate overdoses of medication and other episodes of self-harm, and psychological problems as a result of physical disorder and delirium, then it is clear that a large part of a doctor’s work in most fields may be concerned with psychological or psychiatric problems.

In physical conditions, performing a competent mental state examination can be an essential part of an assessment and reveal problems in other organ systems. For example, a London medical student was surprised to be asked in his medical exam to examine the mental state of a woman with mitral valve disease. When he did so, he discovered a significant impairment in cognitive functioning, which was resolved with judicious use of extra oxygen to deal with her hypoxia.

In general hospital practice, a junior doctor in training may be the most likely to be called to see a disturbed, confused patient at night. The doctor will need to be well aware of the myriad causes of such a state (from alcohol withdrawal to infection or a ‘silent’ myocardial infarct).

Whereas the busy orthopaedic surgeon may be concerned mainly with healing of fractures, mobility and so on, the psychological effects of trauma and chronic debility are being increasingly recognized.

There is a considerable influence of psychoactive substance use disorders (most notably alcohol dependence) on medical practice. The 1998 General Household Survey in England recorded that 27% of men and 14% of women drink alcohol at a level known to be harmful. The 1993 Health Survey (England) found that 7.5% of males and 2.1% of females reported symptoms indicative of alcohol dependence. Six out of 10 people admitted to hospital with serious head injuries have raised bloodalcohol levels, on average two and a half times the legal limit. Alcohol consumption is implicated in 20% of deaths by drowning and 40% of deaths by fire.

Although a developmental perspective is useful in dealing with patients at all stages of the life cycle (Chapter 2), this is particularly the case for children and adolescents. In a UK questionnaire study of 7- to 12-year-old general practice attenders, 22% were found to be suffering from a child psychiatric disorder. The figure for frequent attenders in the same age range rose to 29%. Similar figures were produced in a WHO study in four ‘developing’ countries and in an American study in ‘pediatric primary care’. Disorders of the brain increase the frequency of child psychiatric disorders by five times.

Knowledge of psychiatric treatments and their side-effects is also important. In the UK, psychotropic drugs are the most commonly prescribed group of medication.

Models of mental illness

Table 1.2 summarizes the various models of mental illness. It must be emphasized that these are different theoretical frameworks, which are by no means mutually exclusive. Their usefulness depends on their respective abilities to predict outcome, prognosis and response to treatment. Each approach has, to a large extent, derived from modes of treatment. For example, an organic approach may be more associated with drug or physical treatments, and a psychodynamic approach in psychotherapy. However, it is important to note that research is increasingly showing that combinations of approaches are most helpful in treating mental illness. An example would be the combination of working with the family of a person with schizophrenia and providing appropriate medication: each reduces the risk of relapse, but a combination has an additive effect.

Table 1.2 Models of mental illness

* Can be regarded as a medical model in which diagnosis (label) of a disease is made on symptoms, the disease has a cause (organic and/or environmental) and the diagnosis leads to specific treatment. Does not have to be impersonal.

Table 1.2 lists current models, and it must be remembered that these are the currently acceptable approaches and many others have fallen by the wayside throughout history.