Psychiatric services

‘Psychiatric services’ is concerned with the provision of psychiatric care for populations. It deals mainly with the needs of and provisions for people aged 18–65 years (‘adults of working age’), and focuses on the situation in the United Kingdom. (A more global perspective is provided in Chapter 23.) The chapter begins with an account of the historical development of psychiatric services, followed by descriptions of the commonly available psychiatric services and of the problems they encounter. It outlines the components of services, both those within primary care and those within specialized secondary care. These include services for acute disorders and those for complex long-term disorders (rehabilitation services). Service adaptations for patient groups with special needs (e.g. deafness, eating disorders) are also presented. The difficulties encountered by community care services are examined, as are emerging international service principles.

Global psychiatry

‘Global psychiatry’ discusses the global mental health movement. Across the globe, and especially in low- and middle-income settings, there is a high prevalence of untreated psychiatric illness. In lower resourced settings there is often the need to address the added influence of poverty. The chapter discusses the question of how to scale up services and models, including using lay mental health workers and also integration of mental health care into primary health care settings to better meet the needs of those suffering from psychiatric illnesses across the globe. Four areas are discussed in more detail—the HIV/AIDS pandemic, perinatal mental illness, child and adolescent mental health, and humanitarian emergencies.

Eating, sleep, and sexual disorders

‘Eating, sleep, and sexual disorders’ covers these three areas of psychiatry, all of which are characterized by disturbances of bodily functioning. The section on eating disorders includes recent developments in how these conditions are classified, and improvements in their treatment. Disorders of sleep and circadian rhythm are increasingly recognized to be important in psychiatry beyond the involvement of sleep disturbance as a symptom, and their recognition and management are discussed at greater length than in previous editions of this book. The extent and nature of psychiatric involvement in sexuality and sexual disorders has also changed markedly in recent years, and this section has been revised accordingly; for example, with regard to how gender identity disorders are conceptualized and managed.

Reactions to stressful experiences

‘Reactions to stressful experiences’ covers emotional and physiological elements of the response to stress and the way in which maladaptive coping patterns and inappropriate defence mechanisms can lead to clinical disorders. Stress reactions are often short-lived and respond to support from friends and family. However, particularly severe stresses can lead to the condition of post-traumatic stress disorder (PTSD), an important source of morbidity and disability, whose clinical features, psychology, neurobiology, and treatment are described in detail. The chapter also covers adjustment to threatening and traumatic life events, such as childhood abuse, sexual assault in women, the refugee experience, serious physical illness, and bereavement. These events can produce various kinds of adverse psychological consequences over the lifespan, and the chapter shows how these psychiatric sequelae can be recognized, theoretically understood, and best managed according to current evidence-based practice.

Evidence-based approaches to psychiatry

‘Evidence-based approaches to psychiatry’ describes the application of evidence-based medicine (EBM) to psychiatric practice. The chapter covers the key processes in EBM, including the formulation of a clinically relevant question, the systematic search for high-quality evidence and the meta-analytic synthesis of data. It demonstrates how evidence-based approaches to psychiatry have led to important developments showing quantitative effects of different treatments through advanced meta-analysis of data from randomized trials. This has underpinned the development of clinical guidelines that have the aim of improving the reliability and quality of treatments that patients receive. The chapter also describes how meta-analyses should be critically reviewed, as well as their problems and limitations. Not all relevant questions in psychiatric research are susceptible to the quantitative approach offered by EBM, and the chapter also outlines how qualitative methodologies can play a key role in answering important questions related, for example, to the patient experience.

Assessment

The psychiatric interview is at the heart of psychiatry, since it provides the cornerstone of diagnostic assessment as well as being central to establishing a therapeutic relationship. This chapter, ‘Assessment’, describes the goals, principles, and practice of psychiatric interviewing. There is a detailed review of the various components of a full psychiatric assessment (the history, mental state examination, physical examination and investigations), as well as descriptions of how the assessment process is tailored to suit different situations (e.g. in emergency departments, in primary care, or in the community). The chapter proceeds to discuss how the information collected during the assessment is recorded and communicated. The chapter ends with a description of the major standardized assessment methods and ratings scales used in psychiatry.

The misuse of alcohol and drugs

‘Misuse of alcohol and drugs’ covers the clinical and scientific aspects of substance misuse and dependence, including definitions and classifications in ICD-10 and DSM-5, as well as the important issue of comorbidity with other psychiatric disorders (‘dual diagnosis’). The first section covers alcohol use problems, ranging from epidemiology, aetiology, and public health to the identification and evidence-based management of individual patients. There follows a description of substance use problems associated with a range of other drugs, including those medically prescribed, such as opiates, benzodiazepines, and gabapentin, as well as recreational substances such as stimulants, MDMA, psychedelics, and ‘legal highs’. The clinical features of problem drug use are linked to the pharmacology and neural effects of particular substances together with descriptions of current strategies designed to lessen the harms of substance use for both the individual and society.

Psychiatry of the elderly

‘Psychiatry of the elderly’ covers the disorders which most affect older people. After an introduction to normal ageing and its psychological and biological correlates, the epidemiology of psychiatric disorders in the elderly is outlined. The principles and practice of psychiatry of the elderly are then described, focusing on the major disorders (other than dementia, which was covered in Chapter 14). We summarise the main features of assessments, services, and treatments, and how these differ from younger age groups. The treatment and management of dementia is an important aspect of psychiatry in the elderly, and both pharmacological and behavioural interventions are covered in detail.

Paranoid symptoms and syndromes

‘Paranoid symptoms and syndromes’ focuses on the recognition and significance of paranoid symptoms, and on paranoid syndromes (delusional disorders). The latter are related to, but usually considered to be distinct from, schizophrenia. The area has a complicated conceptual and terminological history, and this is outlined before explaining how paranoid symptoms and syndromes are currently defined and classified. Specific paranoid syndromes, such as morbid jealousy, erotomania (de Clérambaut’s syndrome), and several other eponymous syndromes, are then described. Finally, the principles of assessment and treatment of delusional disorders are outlined

Bipolar disorder

‘Bipolar disorder’ provides an account of the clinical and scientific aspects of bipolar disorder (‘manic depressive illness’). Identification of varying degrees of mood elevation is critical to the diagnosis of bipolar disorder to allow its distinction from unipolar depression, and the phenomenology and classification of manic states is described in detail. The range of aetiological factors involved in the development of bipolar illness is covered, from genetics and brain structure to psychology and life events. The efficacy of treatments both psychological and pharmacological in bipolar disorder is assessed, including new approaches with psychoeducation, atypical antipsychotic drugs, and anticonvulsant mood stabilizers. An additional section covers the clinically challenging treatment of bipolar depression. The evidence from clinical trials is then placed in the context of good clinical management of both the acute phases of bipolar illness as well as longer-term maintenance treatment.