Psychiatry and psychiatrists: Fourteen core statements

1. Introduction

The current portrait of psychiatry is, at best, problematic. In 2012, an article published in The Lancet [1] advised a realignment of psychiatry as a key biomedical specialty to avoid the common perceptions that it is “just not scientific enough, … often viewed negatively by other medical professionals”. In 2015, an article published in the New York Times [2] noted that, despite large investments in basic neuroscience research, no major breakthrough had occurred in psychopharmacology research since 1960s and, therefore, the allocation of research funds should prioritize psychotherapy instead of neurobiology/psychopharmacology. Recently, in his “Report on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health” [3], the United Nations Special Rapporteur refers to the biomedical paradigm as reductionist and responsible for the exclusion, neglect, coercion and abuse of people with intellectual, cognitive and psychosocial disabilities…”.

Should psychiatry be more biomedical than psychological? Should it be more social than biomedical? We believe that these are ill-posed questions, which generate misunderstandings and wrong answers.

In fact, psychiatry is not a biomedical discipline sensu strictu, if this means the medical discipline of the brain [4]. As stated by Bracken et al. [4], “although mental health problems undoubtedly have a biological dimension, in their very nature they reach beyond the brain to involve social, cultural and psychological dimensions”. Empirical evidence supporting this statement is available and includes, among others, studies showing that childhood maltreatment alters trajectories of brain development [5], or demonstrating that the interaction among genetic, environmental, psychological and psychopathological factors is highly complex and depends on a number of enduring personal characteristics [6]. Psychiatry, therefore, should keep its core identity and position itself at the intersection among natural, social and humanistic sciences.

The promotion of a unified identity of psychiatry within the complexity paradigm is a key factor to overcome ill-posed questions, as well as a problematic and misleading portrayal. To this aim, we need to consider the different approaches to mental health and mental disorders as complementary and not mutually exclusive.

In the present paper, we propose a recently formulated definition of mental health, a newly developed definition of mental disorders, and identify 14 core statements about psychiatry, which describe the role and values of psychiatry and psychiatrists in the 21st century and promote a unified identity.

2. Mental health

The World Health Organization defines mental health as “a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” [7].

The focus of this definition on positive feelings and productive functioning as necessary factors for mental health reflects a perspective based on idealistic norms or hedonic and eudemonic theoretical traditions; it may create unrealistic expectations, encourage people to mask negative emotions, while pretending constant happiness, and even favor their isolation when they feel sad, angry or worried.

A new definition that favours a more inclusive approach and reflects the complexity of human life experience was proposed recently [8]: “Mental health is a dynamic state of internal equilibrium that enables individuals to use their abilities in harmony with universal values of society. Basic cognitive and social skills; ability to recognize, express and modulate one’s own implicit dimension, as well as empathize with others; flexibility and ability to cope with adverse life events and function in social roles; and harmonious relationship between body and mind represent important components of mental health which contribute, to varying degrees, to the state of internal equilibrium”.

This new definition is in line with WHO definition in which mental health is more than just the absence of mental illness, and overcomes the perspective based on idealistic norms or hedonic and eudemonic theoretical traditions.

3. Mental disorder

The term “disorder” is used instead of “disease” as the latter one implies a known aetiology, through a common underlying aetiopathophysiology. Mental disorders represent a constellation of symptoms for which a common underlying causal mechanism has not been identified.

According to the WHO definition “Mental disorders comprise a broad range of problems, with different symptoms. However, they are generally characterized by some combination of abnormal thoughts, emotions, behaviour and relationships with others. Examples are schizophrenia, depression, intellectual disabilities and disorders due to drug abuse”. (http://www.who.int/mental_health/management/en/).

An alternative definition is proposed, based on the recently introduced definition of mental health [8]: “A mental disorder is a self-sustaining pattern of problematic thoughts, behaviours, emotions and relationships with self and others; the pattern is likely to arise from the persistent difficulty of a person to return, after a perturbing internal or external event has occurred, to the dynamic state of internal equilibrium which enables individuals to use their abilities in harmony with universal values of society.”

4. Fourteen basic statements about psychiatry and psychiatrists

1. 1. Psychiatry is a medical specialty. It shares its professional framework with the other medical specialties. Psychiatrists are physicians trained in medicine and subsequently in psychiatry.

2. 2. Psychiatry deals with the prevention, diagnosis, treatment and rehabilitation of mental disorders.

3. 3. Psychiatry is at the intersection among social, natural and humanistic sciences, as mental disorders involve an interaction of biological, psychological and environmental factors. The specificity of psychiatrists professional profile consists of the ability to combine competencies in natural, social and humanistic sciences.

4. 4. Psychiatry includes a number of sub-specialties; amongst others, those defined by age (e.g., Child Psychiatry, Old Age Psychiatry), setting (e.g., Forensic Psychiatry, Community Psychiatry), research and/or treatment approach (e.g., Biological Psychiatry, Social Psychiatry).

All these sub-specialties have common roots, and share standards of good clinical practice, research and training.

1. 5. Psychiatrists have to keep up with current medical knowledge and carefully consider all medical issues affecting their patients. If a patient with a mental illness requires a medical workup, the treating psychiatrist should implement the necessary diagnostic process and/or refer the patient to the appropriate specialist.

2. 6. Psychiatrists should have a good and updated knowledge of psychopathology. A trained psychiatrist should be able to perform a complete psychopathological assessment and should be familiar with at least the descriptive approach to psychopathology.

3. 7. Psychiatrists should have a good and updated knowledge of pharmacotherapy and other biological treatments. Treatment with psychotropic drugs has proven effective for most mental disorders, and is based on scientific principles of evidence-based medicine.

4. 8. Psychiatrists should be trained in psychotherapy and be able to apply at least one method. Effective psychotherapeutic approaches are available for most mental illnesses, and their effectiveness is based on scientific principles of evidence-based medicine.

5. 9. Psychiatrists should have a good and updated knowledge of the structure and function of the human central nervous system, including hypothesized pathophysiology of mental disorders, as well as mechanisms of action of psychotropic drugs and psychological treatments.

6. 10 Psychiatrists should have a good and updated knowledge of the social factors playing a key role in vulnerability, onset and persistence of mental disorders, and advocate wherever and whenever possible the implementation of social interventions and policies promoting mental health and the prevention of mental disorders.

7. 11 Psychiatrists should have a good and updated knowledge of psychosocial treatments whose effectiveness is supported by scientific evidence, and should be able to implement and coordinate integrated treatment plans, in collaboration with the team in charge of patient’s psychosocial treatment.

8. 12 When possible and appropriate, psychiatrists should collaborate with patients, families and carers to co-design and implement patient-centred, recovery-oriented treatment plans. Sharing decisions with the patient and her/his closest ones, whether relatives or friends, according to patients needs and wishes, will improve formulation, implementation and outcome of a treatment plan.

9. 13 A psychiatrist should be an advocate of patients rights in collaboration with patients, families and carers. This joint work aimed to protect most vulnerable people when exposed to stressful environmental or social factors is an important task of a psychiatrist; it includes information, education, recommendations, and advocacy for users’ rights.

10. 14 Psychiatrists should never put political matters ahead of the best interests of the patient, should never participate in or collude with torture, and should not be requested by authorities to detect and/or report on the potential risk of anti-government ideas and activities, such as radicalization of their patients in religious or political matters.

5. Summary and conclusions

In this paper we emphasize the need to re-affirm the identity of Psychiatry as a unified medical discipline, in which different approaches to mental health and mental disorders are complementary and not mutually exclusive.

We propose recently or newly developed definitions of mental health and mental disorders as a preliminary step for the identification of 14 core statements about psychiatry, which describe the role and values of psychiatry and psychiatrists in the 21st century, and promote a unified identity.

The principle underlying all statements is that humanistic, biological and social aspects of mental health and mental disorders are all indispensable to understand and promote mental health, treat people who suffer from a mental disorder, and counteract reductionist approaches. “Psychiatrists are, or should be, the integrators par excellence of the biopsychosocial model in medical practice” [9].