The burden of mental health is in the community
For several centuries, the mentally ill were locked away from society and placed in in asylums for life, for example the Bethlem asylum which first admitted psychiatric patients in 1357. It has become increasingly apparent that mental health problems are not unique to a small proportion of the population, but are pervasive throughout the population to varying degrees.
Mental illness is on a spectrum, and and the tip of the iceberg is hospitalised patients. It has also become apparent that much of psychiatry needs to be practised in the community, where the burden of mental illness is present.
Over the last 50 years, asylums have started to close down, with resultant emphasis on community services and de-institutionalisation of inpatients.
The adequate planning of community services has not always followed hot on the heels of the closure of inpatient services and there have been recent catch-up initiatives to cope with the burden of community mental illness, including the recent initiative of Crisis Resolution and Treatment Teams in the 1990s.
Modern biological treatments
Effective treatments for mental illness are also relatively recent in development. The first drug developed with a specific antipsychotic action, namely chlorpromazine, was synthesised in 1950. Since then, a number of other safe and effective pharmacalogical and psychological treatments have been developed, but many advancements have been very recent in comparison with other branches of medicine.
Modern electroconvulsive therapy (ECT) is practiced in a very safe manner, unlike that portrayed in films such as 'One flew over the cuckoo's nest' and 'Changeling'. The public view of safe biological treatments is still predominantly negative, and psychiatrists spend considerable time explaining how treatment has progressed in safety and efficacy.
Psychotherapy within psychiatry
Freud, the father of psychoanalysis and a neurologist by training, started to publish his work in 1900 and used scientific rigour in testing hypotheses. Freudian ideas were used as a springboard for the development of understanding human subconscious processes and relationships. In the UK, psychotherapy still plays an important part in modern psychiatry, and trainee psychiatrists are expected to become familiar with the major psychological treatment modalities, taking on cases, and learning to be reflective in thinking.
The holistic model approach
As an example, consider a young female with anorexia nervosa who presents as very underweight. In terms of biological factors, you may need to monitor her physical state for complications, for example hypotension, arrhythmias, electrolyte abnormalities, and you will need to monitor her weight.
In terms of psychological factors, you need to consider the psychological causes which led to her condition, and you may work with therapists to offer a suitable psychological treatment, for example family therapy and cognitive behavioural or analytic therapy (CBT or CAT).
In terms of social factors, you will need to work out the strength of current social support system, liaise with colleagues to ensure she is receiving benefits, and ensure she can manage her day-to-day activities.
Mulitidisciplinary teams are the cornerstones to effective functioning on wards and in community mental health teams (CMHTs). It is essential to be able to work with a range of professionals both through mental health services, and also through other organisations, including social services and non-statutory organisations.
Professionals you may come across in your attachment are: nurses, occupational therapists, social workers, psychologists and specialist therapists (for example, family therapists, drama therapists, etc).
Dr Meinou Simmons