Psychiatry as a medical specialty: challenges and opportunities

The question of the identity of psychiatry as a medical profession has been the subject of much discussion in this first decade of the new century. Technological advances in detecting brain signals via magnetoencephalography, magnetic resonance imaging, positron emission tomography and other methods, and advances in psychiatric therapy also increased the need to define the specialty and its specific diagnostic and therapeutic methods. It must be emphasized that psychiatry is an integral part of medicine. As G. Gabbard put it in 1999, psychiatrists occupy a “unique niche” among the medical specialties, in that they are “the integrator par excellence of the biological and psychosocial in both diagnosis and treatment” 1. The psychiatrist is thus the physician best qualified to disentangle the often complex relationship between biological, psychological, and social factors in both somatic and mental disorders. While next to this idea of the psychiatrist as a “biopsychosocial generalist” further differentiations and specializations are advisable in order to cope with the growing diagnostic and therapeutic complexities of the field, it is important that the identity of the profession and its integrative strength are further advanced. Certain topics in contemporary psychiatry take center stage on the background of this ongoing discussion about the identity of psychiatry and the psychiatrist. In Europe, with its increasing political unification, psychiatry is becoming increasingly “Europeanized”. The Union of European Medical Specialists defined the core competencies of a psychiatrist in 2005 2 and now offers a certification of psychiatry specialist training programs. National psychiatric societies are beginning to develop a more internationally oriented view, such as the German Association for Psychiatry and Psychotherapy (DGPPN), which has hosted several assemblies and discussions of presidents of other European psychiatric societies in a Forum of European Leaders during its annual congress in Berlin since 2007. In the past two years, the European Psychiatric Association (EPA) has been exploring new opportunities, for example by venturing on an international program to develop a European Guidance with the objective to improve the quality of mental health care and minimize health care gaps in Europe by providing evidence-based information and advice. In addition, the development of international guidelines is an important aspect of finding common ground in psychiatry on a European or even a global level, exemplified by the ADAPTE collaboration 3, which promotes the development and use of international guidelines through the adaptation of existing guidelines. The WPA promotes international collaboration and research in mental health care. Two new international research programmes dealing with the important questions of how to recruit more young medical doctors into psychiatry, and how to overcome the stigmatization of psychiatry and psychiatrists, were initiated by the WPA in 2009 and have recently begun their work 4–5. Recruiting the young medical work-force into psychiatry and retaining them is of central importance for the specialty, and national psychiatric societies such as the DGPPN have begun initiatives including funding medical studentś participation in the annual congress and a mentee programme with expert guidance of young colleagues into psychiatry. While extensive research has been conducted concerning medical students’ attitudes towards psychiatry and the stigma and public image of people with mental illnesses, there is a lack of literature addressing the stigma of psychiatrists and psychiatry as a medical specialty. A further neglected aspect is the self-stigmatization of psychiatrists. As Katschnig mentions, these issues are currently being addressed by the WPA. Young medical doctors are often attracted into psychiatry because the integrative work between “mind” and “brain” lies at the heart of the specialty. Research in this area is advancing at an astonishing pace and not only involves imaging studies, but also the conceptualization of mental disorders and the development of an integrative theory of psychiatry as one of the major scientific challenges of the future. In this context, the current scientific discussions in the framework of developing DSM-V and ICD-11 play an important role, as they touch on central aspects of psychiatry as a medical specialty. Some of these major conceptual issues include the question of adding risk syndromes, the question whether dimensional in addition to categorical assessments are warranted, whether neurobiological foundations of the pathophysiology of mental disorders are sufficiently known to warrant their inclusion in diagnostic criteria, whether new categories for overarching symptom clusters (such as a “psychosis” cluster) may be useful, or how to operationally redefine course and outcome specifiers. Considering the globalization of psychiatric research, with increasing numbers of international studies, a harmonization of criteria in the two classification systems would be highly desirable. Psychiatric research and the conceptualization of mental disorders are important topics beyond the operationalization of classification systems. Psychopathology is one of the core competencies of a psychiatrist, and this needs to be refocused, as N. Andreasen rightly pointed out 6. Recent trends in the neurosciences support this view, as it becomes increasingly clear that the brain utilizes different functional modules to sub-serve its normal functions, and that the disturbance of such modules may be viewed as the root of mental disorders 7, as already proposed by the late Kraepelin 8. But beyond such research issues that may well extend into the next decades, there is a pressing need to improve mental health care in the near future. Integrated care is of increasing importance. However, the need for delegation of psychiatric competencies to other non-medical professionals cannot be equivalent with a substitution of psychiatrists in these areas, which should be avoided 9. Mental health care research needs to gain more support by funding agencies besides that for neuroscientific and pharmacological research. Moreover, evidence-based research in psychotherapy is clearly a hitherto neglected field of research. Thus, coordinated and integrated progress in all these aspects of mental health care will hopefully be fueled from several sides and should lead to reduced stigmatization, better health care and improved outcome for patients with mental disorders. National and international psychiatric societies play a central part in this endeavor, since integrating research and care of the body and the mind has been the central tenet of psychiatry in the last century. Psychiatry seems to be well on its way to achieving this integration and successfully facing the challenges from inside and outside as an integral part of medicine in the 21st century. Psychiatrists are not in danger if they actively face these challenges.