The Rationale of Psychiatry
Psychiatry exists fundamentally to reduce the substantial morbidity, mortality, and disability burden caused by complex brain disorders through evidence-based assessment, treatment, and prevention grounded in clinical neuroscience. 1, 2
Core Mission and Public Health Impact
Psychiatry addresses complex brain disorders including depression, bipolar disorder, anxiety disorders, schizophrenia, developmental disorders (such as autism), and neurodegenerative disorders (such as Alzheimer dementia), which collectively account for a substantial portion of the global burden of illness-related disability 2. The economic burden is staggering—schizophrenia alone costs more than $150 billion annually in the United States based on 2013 data 1.
The overarching goal is to prevent and alleviate the distress and impairment caused by these disorders, thereby reducing mortality, morbidity, and significant psychosocial and health consequences 1. Psychiatric disorders are associated with dramatically increased mortality, with standardized mortality ratios two to four times higher than the general population 1. Approximately 4-10% of persons with schizophrenia die by suicide, with rates highest among males in the early course of the disorder 1.
Scientific Foundation
Psychiatry is grounded in clinical neuroscience, and its core mission is best served within this context because advances in assessment, treatment, and prevention of brain disorders originate from studies of etiology and pathophysiology based in clinical and translational neuroscience 2. The field operates as a psychobiological discipline where biological interventions carry personal meanings, and relational transactions in the treatment setting represent a form of learning that results in lasting physiological changes in the brain 3.
Essential Clinical Functions
Comprehensive Assessment
The initial psychiatric evaluation serves multiple critical purposes 1:
- Identifying psychiatric signs and symptoms, psychiatric disorders (including substance use disorders), other medical conditions that could affect diagnostic accuracy, and patients at increased risk for suicidal or aggressive behaviors 1
- Enhancing clinical decision-making and enabling safe, appropriate treatment planning 1
- Promoting better treatment outcomes through collaborative decision-making between patients and clinicians 1
- Increasing coordination of psychiatric treatment with other clinicians involved in the patient's care 1
Systematic Evaluation Components
The American Psychiatric Association recommends that initial assessment include: the reason for presentation, patient's goals and preferences for treatment, review of psychiatric symptoms and trauma history, assessment of tobacco and substance use, psychiatric treatment history, assessment of physical health, assessment of psychosocial and cultural factors, mental status examination including cognitive assessment, and assessment of risk of suicide and aggressive behaviors 1.
The mental status examination must include assessment of general appearance, coordination and gait, involuntary movements, sight and hearing, speech fluency and articulation, mood and anxiety level, thought content and process, perception and cognition, hopelessness, and current suicidal or aggressive ideation 4.
Diagnostic Framework
The American Academy of Child and Adolescent Psychiatry recommends organizing psychiatric diagnostic formulation around five key factors—Predisposing, Precipitating, Perpetuating, Protective, and Presentation factors—to create a comprehensive biopsychosocial understanding of the patient's illness 5. This framework integrates:
- Biological factors such as family history of psychiatric disorders, acquired brain insults, autonomic hyperreactivity, and chronic medical conditions 5
- Psychological factors including insecure attachment patterns, maladaptive cognitive schemas, and ego deficits 5
- Social factors such as history of stressful or traumatic life events, anxiogenic parenting behaviors, and social skills deficits 5
Treatment Rationale
Patients with schizophrenia should be treated with an antipsychotic medication and monitored for effectiveness and side effects, with continuation of treatment when symptoms have improved 1. For treatment-resistant schizophrenia, clozapine is recommended 1. Patients should have a documented, comprehensive, and person-centered treatment plan that includes evidence-based nonpharmacological and pharmacological treatments 1.
Integration with Medical Care
Psychiatric problems are common in general medical practice and strongly influence medical utilization 6. The American College of Physicians supports increased integration of behavioral health care into primary care settings, recognizing that mental health, substance abuse, and other behavioral health conditions require coordinated management 1. This integration is essential because increases in morbidity and mortality related to physical health in individuals with psychiatric disorders are associated with obesity, diabetes, hyperlipidemia, greater use of cigarettes, reduced engagement in health maintenance, and disparities in access to preventive health care and treatment for physical conditions 1.
Public Health Perspective
To promote a public health approach, modern mental health professionals must: identify causes of mental disorders, refine diagnoses, promote social inclusion of patients, involve users and carers in mental health research and practice, and improve psychiatric treatments and services 7. Psychiatry must bridge science and service, ensuring that those who need the benefits of its science are also its beneficiaries 2.
Critical Pitfall
A focused medical assessment based on history and physical examination is superior to routine laboratory testing in psychiatric patients with normal vital signs and non-contributory examinations 4. However, careful attention to abnormal vital signs, complete history, and physical examination with particular focus on neurologic, cardiac, and respiratory systems is essential to detect underlying medical conditions that can present as psychiatric disorders 4.