Why is psychiatry a medical activity?

  It is not accepted by everybody that mental health services should be run by psychiatrists (especially within the services themselves!). Are these ‘mental health services’ or ‘psychiatric services’? Much of the controversy focuses on the ‘medical model’ which is thought to be too narrow and too dominant (Chapter 3). Psychology and social care can both make a strong case to offer the lead, and mental health nursing often stresses its independence. It will be obvious from what has been said so far that good practice (whether called mental health or psychiatric) requires a broader focus than just medicine. So how did psychiatry become so dominant?

  One argument stems from the overlap between mental and physical diseases. Nearly all mental disease states can be mimicked by physical diseases and a failure to diagnose these may carry real risks. Thyroid disorders can present as depression (‘myxoedema madness’) or as an anxiety state. Deficiency of the B vitamin Niacin presents as dementia (Pellagra); myasthenia and early multiple sclerosis can easily be misdiagnosed as hysterical disorders. The list is extensive. This is, however, a pretty poor argument. Most patients come to mental health services via their family doctor who will filter out these physical problems. Where this doesn’t happen it soon becomes clear that a patient is ‘not like the other depressives’ and a medical or neurological opinion easily sought. This may have been a more convincing argument when psychiatric patients were isolated away from other medical care in large mental hospitals but is hardly relevant in the 21st century.

  A second argument is that many of the most successful treatments have been developed using a medical approach and, as many of these are drugs, you need a doctor to manage the treatment. The second part of this is not so convincing – psychiatrists attend and prescribe to residential facilities such as nursing homes and autism schools without being in charge. However, there is an argument that the ‘medical model’ has been very successful. By the medical model I mean an approach that, although drawing heavily on scientific theory and methods, is fundamentally pragmatic. If it works keep doing it; if it doesn’t, stop it; if you’re not sure conduct a careful experiment to find out. Psychiatry’s overall independence from a defining theory, and its broadly scientific approach, are probably its major virtues. There is also within it a benign paternalism and willingness to accept responsibility that, while publicly decried, is often privately welcomed.

  The status of doctors as the heads of mental hospitals arose, however, for quite other reasons. Certainly there was little doubt about the overlap between mental and physical disorders in the 19th century. Many mental hospital inpatients suffered from brain complications of syphilis that soon killed them and many more were severely physically ill. Doctors, however, did not establish mental hospitals but were put in charge of them (Chapter 2). This was not because they had effective treatments to offer but because their social standing and accountability made them effective guardians against abuse of patients. This abuse had been a widespread scandal throughout the madhouses the asylums replaced. At that time medical approaches to madness were probably more damaging than helpful. Doctors may have got their dominant position for surprising reasons but maintain it currently for more understandable ones. Whether they sustain it in the future is a different matter and will be returned to in Chapter 7.