psychiatry

psychiatry A medical speciality, whose boundaries have always been contested, which focuses on the care and treatment of mental disorders. It developed as a professional grouping in the first half of the nineteenth century: the term was coined in Germany in 1808 and was more widely used in Europe and America from the 1840s. Medical interest and specialization in insanity was not new. However, the establishment of lunatic hospitals and asylums (first voluntary then public) from the mid-eighteenth century onwards, provided a solid foundation for the emergence of psychiatry as a profession. The asylum offered new opportunities for observation, treatment, and training, and new powers like certification that facilitated professionalization. Associations of asylum doctors were founded in Britain in 1841, the United States in 1844, and France in 1847; the first journals were published in Britain in 1854, the United States in 1844, France in 1843, and somewhat earlier in Germany.

In the 1820s to 1840s, medical interest in lunacy and therapeutic optimism were both high. Practitioners were often eclectic, many supporting moral treatment, which emphasized the therapeutic value of an ordered environment in building up inmates' capacities for self-control and self-esteem. However, higher-status practitioners were soon deterred from asylum work by the residency requirements in larger institutions, which restricted the opportunities for private practice, and by the predominance of pauper patients. Moreover, as the asylums grew and were increasingly filled with inmates having chronic and intractable problems, the medical role became primarily custodial rather than therapeutic. Increasing medical emphasis on the natural sciences was largely reflected in routine autopsies in the effort to identify brain pathology.

Two major changes occurred in the first half of the twentieth century. First, psychiatric work outside the asylums expanded, much of it on a private basis for more affluent patients, many with problems that Sigmund Freud identified as psychoneurotic. His influence on office psychiatry was considerable, especially in the United States, where private practice flourished. Second, there were major efforts to transform asylums into proper hospitals, and in the 1930s physical treatments such as electro-convulsive therapy (ECT) and psychosurgery (to be followed in the 1950s by new drug therapies) were developed, encouraging a new therapeutic optimism.

Both developments underpinned the acceptance of a policy of community care in the 1950s, initially as a supplement to asylum care, then as an alternative—the one representing a diversification of the locus of care and an increased role for psychiatry across a wider spectrum of conditions, the other a break with old pro-institutional and custodial models of care, a change facilitated by the introduction of voluntary admission in Britain in 1930 and the resulting decline in compulsory detention.

The implications for psychiatry of the subsequent run-down of mental hospitals and the shift to work in the community cannot yet be fully assessed. The loss of the old empire of the mental hospital has undoubtedly reduced psychiatrists' power, as has (to some extent) the development of multi-disciplinary teams. The power of psychiatrists now resides largely in their rights over prescribing and their expertise in the natural sciences. However, developments in biological psychiatry and the neurosciences could cut back the domain of illnesses deemed mental, to the advantage of neurologists and at the expense of psychiatry.