British psychiatry faces an identity crisis. A major contributory
factor has been the recent trend to downgrade the importance
of the core aspects of medical care. In many instances, this has
resulted in services that are better suited to delivering non-
specific, psychosocial support rather than a process of thorough,
broad-based diagnostic assessment with formulation of aetiology,
diagnosis and prognosis followed by specific treatments aimed at
recovery with maintenance of functioning. These changes have
been driven in part by government, but there has been both active
collusion and passive acquiescence by psychiatrists themselves.
Our contention is that this creeping devaluation of medicine is
damaging our ability to deliver excellent psychiatric care. It is
imperative that we specify clearly the key role of psychiatrists in
the management of people with mental illnesses.
Psychiatric illness and ‘mental health’
How many of us have, in clinical discussions, been aware of
uneasiness in colleagues in defending ‘the medical model of care’1
or been the only one using the word ‘patient’ when discussing
service delivery or planning? However, despite the recent
misguided tendency by many to caricature a medical psychiatric
approach as being narrow, biological and reductionist, we are
struck by how keen other members of staff are for themselves or
their relatives to be seen by an experienced psychiatrist when
mental illness affects them. Moreover, when patients were asked
how they would prefer to be described by a psychiatrist, 67%
preferred ‘patient’ and only 9% preferred ‘service user’.2This
disjunction cannot be a healthy state of affairs and aggravates
publicand healthprofessionals’ difficulties
psychiatric illness and the psychiatrist’s role.
One key issue is that the concept of mental illness has
broadened considerably since Reil first coined the term psychiatry
200 years ago.3,4As a result, many people with mild psychiatric
symptoms have developed exaggerated and unrealistic expectations
of psychiatry. Indeed, psychiatric services may not be best placed
to manage the majority of individuals with such mild symptoms,
who would be better served by other more general services. It is
probably in the best interest of such individuals to avoid
medicalising both the terminology and the type of help that they
may require or want.
Certain circumstances do, however, require professionals with
medical training to diagnose and treat underlying psychiatric or
non-psychiatric physical disorders. Further, those with severe
mental disorders can and do benefit from the process of a medical
psychiatric assessment, diagnosis and treatment.5–7For those with
severe mental illness, to avoid medicalisation is at best confusing
and at worst damaging or even life-threatening. These individuals,
the very people for whom Reil argued that psychiatry was
needed,3,4are being let down by the current state of affairs. These
considerations about the nature and breadth of psychiatry bear
upon the fundamental issue as to where its appropriate
boundaries lie, and whether practitioners can and should continue
to try to span such a broad spectrum of skills, knowledge and in-
We have spoken naturally about psychiatrists treating mental
illness: use of the term ‘mental health’ to describe services for
those with mental illness risks undermining the real importance
and impact of these conditions on patients. The recent renaming
of one Welsh trust’s psychiatric out-patient clinic to ‘Mental
Health Well-Being Clinic’ takes this confusion one step further.
Using such terminologies may in turn undermine the priority of
psychiatric illness for health commissioners and politicians.
Psychiatry is more or less alone among medical specialties in
the extent to which it has adopted this approach that so distorts
its original purpose.
The influences that encourage demedicalising the care of those
with severe mental illness are legion and apply in part to other
fields of medicine. They probably include political drives to cut
Wake-up call for British psychiatry
Nick Craddock, Danny Antebi, Mary-Jane Attenburrow, Anthony Bailey, Alan Carson, Phil Cowen,
Bridget Craddock, John Eagles, Klaus Ebmeier, Anne Farmer, Seena Fazel, Nicol Ferrier, John Geddes,
Guy Goodwin, Paul Harrison, Keith Hawton, Stephen Hunter, Robin Jacoby, Ian Jones, Paul Keedwell,
Mike Kerr, Paul Mackin, Peter McGuffin, Donald J. MacIntyre, Pauline McConville, Deborah Mountain,
Michael C. O’Donovan, Michael J. Owen, Femi Oyebode, Mary Phillips, Jonathan Price, Prem Shah,
Danny J. Smith, James Walters, Peter Woodruff, Allan Young and Stan Zammit
The recent drive within the UK National Health Service
to improve psychosocial care for people with mental
illness is both understandable and welcome: evidence-based
psychological and social interventions are extremely
important in managing psychiatric illness. Nevertheless,
the accompanying downgrading of medical aspects of
care has resulted in services that often are better suited
to offering non-specific psychosocial support, rather than
thorough, broad-based diagnostic assessment leading to
specific treatments to optimise well-being and functioning.
In part, these changes have been politically driven, but
they could not have occurred without the collusion, or at
least the acquiescence, of psychiatrists. This creeping
devaluation of medicine disadvantages patients and is very
damaging to both the standing and the understanding of
psychiatry in the minds of the public, fellow professionals
and the medical students who will be responsible for the
specialty’s future. On the 200th birthday of psychiatry, it is
fitting to reconsider the specialty’s core values and renew
efforts to use psychiatric skills for the maximum benefit of
Declaration of interest
All authors are members or fellows of the Royal College
of Psychiatrists and currently work within, or have recently
worked within, the UK National Health Service. We hope
that both of these organisations will be influenced by this
The British Journal of Psychiatry (2008)
193, 6–9. doi: 10.1192/bjp.bp.108.053561
psychiatrists towards biomedical explanations of illness9and
service development predicated on the false assumption that
severe psychiatric illness equates only to chronicity and poor
treatment response.10The net effect of these influences, however,
is the same: to obstruct our primary medical duty towards
patients with severe psychiatric disorders. Hence, it is imperative
that we take action to ensure that patients with mental illness
are not disadvantaged compared with others within the National
Health Service (NHS).
interprofessionalrivalries,the scepticismof some
Patients have a right to expect more than
non-specific psychosocial support
The drive within the NHS to improve psychosocial care for those
with mental illness has been both understandable and welcome:
extremely important in managing psychiatric illness. However,
an unintended adverse effect is that there is an increasing tendency
for many services to be based on non-specific psychosocial
support with extremely limited therapeutic ambition.10In order
to follow clinical guidance (such as that provided by the National
Institute for Health and Clinical Excellence (NICE))7to develop
excellent ‘mental health’ care (for those with mental illness), it is
important to recognise that a biomedical component, with access
to appropriate facilities and appropriate service pathways, is
usually crucial. Many recent NHS changes, including, for example,
those outlined within the National Service Framework for Mental
Health,11have provided an extensive discussion of important
generic issues, including social inclusiveness, stigma and access.
What they have not done, however, is to place sufficient weight
on medical fundamentals such as the need to distinguish the
major forms of mental disorder, the implementation of
appropriate evidence-based treatments, the subsequent monitoring
of mental state for optimal outcome and the importance of
addressing the physical morbidity and mortality associated with
almost all types of psychiatric illness.
For example, in some crisis intervention teams, the focus on
the general practicalities of a crisis can lead to patients not
receiving the benefit of a thorough diagnostic assessment at the
time of acute illness. The effect of this may be to have a negative
impact on the outcome of the acute episode. Even if the episode
resolves, lack of a thorough diagnostic assessment, including
inappropriate, suboptimal or ineffective management between
episodes and a failure of relapse prevention. Such a scenario could
have major consequences for the life experiences of the patient as
well as implications for ‘service costs’.
One of the great strengths of medicine, when practised well, is
its focus on making a demonstrable difference for the patient and
its willingness to be pragmatic in using whatever approaches are
shown to be effective. We should seek to minimise the unhelpful
influences of political idealism or rigid adherence to particular
schools of practice or thought and must strive to ensure that
the effectiveness of all therapeutic modalities is judged using similar
standards of evidence.12We must face up to our professional
responsibilities to ensure that all aspects of management are as
good as possible. This includes advocating the maintenance of the
skills, facilities and resources to provide excellence in biomedical
care for patients with psychiatric illness. Given our training and
our statutory position as prescribers of medication, psychiatrists
have a particular responsibility to ensure that pharmacological
interventions as well as other interventions are used appropriately
and according to the best available evidence. We must not
contribute to stigmatising and disadvantaging psychiatric patients
by denying them access to treatments that work.
Patients referred by their general practitioner
should be assessed by a named psychiatrist
rather than an anonymous team
Psychiatry is a medical specialty. We believe that psychiatry should
behave like other medical specialties. When a general practitioner
is confident that a psychiatric assessment is not needed, it should
be possible for a referral to be made directly to a relevant non-
psychiatric professional. However, where the general practitioner
is unclear about diagnosis or treatment, the patient should be
assessed by the most appropriately skilled and experienced
professional on the team, the psychiatrist. This is analogous to
managing back pain, where in many instances a general
practitioner is confident that a medical orthopaedic opinion is
not needed and will refer directly to a physiotherapist or an
alternative therapist such as an osteopath or chiropractor.
However, in severe, persistent or otherwise complex cases an
orthopaedic referral should be made, because an assessment by
an orthopaedic surgeon is required to ensure accurate diagnosis
and exclude or treat causes that are remediable, thereby improving
the patient’s quality of life and minimising the risk of
complications such as paralysis.
In psychiatry, it is psychiatrists, who are trained in diagnosing
physical and mental illness, who are competent to formulate
diagnoses that incorporate physical, mental and social factors
and, where appropriate, recommend initiation of one or more
of a range of possible medical treatments. As in other medical
contributions from other non-medical members of the team,
and may include relevant medical investigations such as blood
tests or imaging investigations. Assessment, in many cases, may
lead the psychiatrist, as a leader in the clinical team, to conclude
that the most suitable treatment is a psychological or social
intervention delivered by the member of the team with the most
appropriate skills. This approach allows the patient the benefit
of a thorough, broad-based assessment by a highly trained
professional in order that the most appropriate management is
implemented at the earliest opportunity.
This approach contrasts in important ways with an alternative
model advocated in the move to New Ways of Working.13This is
an initiative developed jointly by the UK government’s National
Institute for Mental Health in England and the Royal College of
Psychiatrists. The report New Ways of Working for Psychiatrists:
Enhancing Effective, Person-centred Services through New Ways of
Working in Multidisciplinary and Multi-agency Contexts claims to
be ‘about a big culture change; it is not just tinkering at the edges
of service improvement’. Within the New Ways of Working model
of distributed responsibility and leadership, a secondary care
patient may never see a psychiatrist or may see one only when
problems are identified by other team members. This means
that many patients will not benefit from a thorough psychiatric
diagnostic assessment before starting treatment. Given the
complex relationship between psychiatric and non-psychiatric
disorders,14and their common co-occurrence,15providing sub-
optimal or inappropriate treatment may have detrimental
consequences for patients. For example, a patient may receive
psychological therapy for symptoms best treated pharmaco-
logically, or caused by an unrecognised treatable organic con-
dition; or, potentially just as damaging, a patient may continue
on inappropriate medication when, with correct assessment, a
psychological or social intervention would have been indicated.
may alsoinvolve important
Wake-up call for British psychiatry
Craddock et al
It is easy to understand how we have arrived at the model of
distributed responsibility and leadership as a pragmatic, short-
term response to recent crises in staffing and morale in general
However, we should not assume that this
pragmatic emergency ‘solution’ is an ideal, or even desirable, state
of affairs.20Although distributed responsibility may make life
easier for psychiatrists and appears to be the cheaper option, it
does not follow that this is in the best interests of patients. Should
we not be arguing for better evidence-based services and the
resources and workforce to deliver these services?
We suggest a useful thought experiment: if a member of your
family were a patient, is a distributed responsibility model the one
for which you would opt?
Recruitment into psychiatry
One of the major problems confronting contemporary British
psychiatry is difficulty with recruitment into, and retention
within, the specialty.21–24Reil argued that only the best doctors
should become psychiatrists. We would assume that the most able,
broad-minded and enthusiastic students, who may become the
best doctors, would be attracted to specialties in which it is clear
that they are able to make best use of their skills and knowledge
within a service that values their extensive broad-based training.
Would such individuals be attracted to a specialty in which skills
that have been acquired over a long period of training are at a high
risk of early disuse atrophy? In this context of a devaluation of
specialist medical skills, it is commonplace in the UK to hear
non-psychiatrists – and frequently psychiatrists themselves –
referring to psychiatrists as not being ‘proper doctors’. This lack
of professional confidence and self-confidence contributes to the
retention problems in psychiatry.25,26
In contrast to this negative view, it is much more accurate, and
fully consistent with Reil’s original suggestions, to think of
psychiatry as being the only specialty in which its practitioners
are fully trained doctors, incorporating psychology and social-
based knowledge and skills as major components of training.
The absence of such skills in other medical specialties is a common
cause of patient dissatisfaction. It is interesting to note that the
distinguished neurologist Henry Miller said: ‘the psychiatrist must
be first and foremost and all the time a physician . . . In fact,
psychiatry is neurology without physical signs, and calls for
diagnostic virtuosity of the highest order . . . The simple fact
(is) that a psychiatrist is a physician who takes a proper history
at the first consultation’.27Indeed, Henry Miller went one step
further in emphasising this polymath function: ‘the psychiatrist
should not only first be a physician but ideally a superlative
To embrace this more positive and self-confident view of
psychiatry would, of course, require a commitment by psych-
iatrists to aim for excellence in the core medical aspects of their
role. This would include excellence in the prescribing of psycho-
tropic medications as well as maintaining and developing
expertise in the relevant aspects of assessment and management
of the non-psychiatric illnesses that so commonly co-occur with
psychiatric disorder and which are associated with decreased life
expectancy of psychiatric patients.14,29Although this may not
appeal to some practising psychiatrists, it is interesting to note
that consultants are much more likely to believe that recruitment
problems arise because our specialty is ‘too psychosocial’ rather
than ‘too biological’.26Whatever the personal preferences of some
current psychiatrists, for the sake of the health of our patients29
and our specialty we need to ensure that these skills are expected
of future psychiatrists.
All too often in British psychiatry, thinking is dominated by
the need to respond to the short-term practical constraints of
whatever initiative is current at the time. However, as a profession
we should be thinking with a longer-term vision of the needs of
patients with psychiatric illness and how those can best be
delivered now and over the coming years. Such strategic thinking
should inform the profession’s advice to the health service and
government as well as shaping training and recruitment initiatives
for the specialty.
It is hard to imagine that psychiatry will not assume increasing
importance over the coming decades. Mental illnesses are, and will
continue to be, major causes of human suffering and mortality.
Mood disorders on their own are predicted to be second only to
ischaemic heart disease as a cause of disability across the globe
by 2020.30Major advances in molecular biology and neuroscience
over recent years have provided psychiatry with powerful tools
that help to delineate the biological systems involved in psycho-
pathology and impairments suffered by patients.31We can be
optimistic that over the coming years these advances will facilitate
the development of diagnostic approaches with improved bio-
logical validity and enhanced clinical utility in terms of predicting
treatment response. We can expect that completely novel treat-
ments will be developed based on detailed understanding of
With this, we need to have appropriately skilled and
knowledgeable psychiatrists working within services that can
accommodate the processes of diagnosis and management
involved. Patients should expect prompt and accurate diagnosis
followed by implementation of appropriate evidence-based treat-
ment – much as is expected by the cardiology patients of today.
We can anticipate that this will involve biological and psycho-
logical tests and neuroimaging as well as detailed clinical
assessment (analogous to the enzyme tests, exercise electrocardio-
grams and cardiac perfusion studies that currently constitute
assessment of cardiac patients). Psychological and social inter-
ventions will, of course, continue to be crucially important in
managing psychiatric illness (as they are also in non-psychiatric
disorders). However, in addition, patients have the right to expect
that biological factors are fully considered and, where appropriate,
evidence-based interventions delivered.
A great deal has changed in the 200 years since Reil introduced the
term ‘psychiatry’ into medicine. It is a welcome advance that
current management of psychiatric illness seeks to take a broad
approach to care, embrace the benefits of multidisciplinary
working and make optimal use of the skills of our colleagues
trained in other disciplines. However, in recent years changes in
psychiatric practice and thinking within the UK NHS are in
danger of throwing the baby out with the bathwater. This is
now to the potential disadvantage of many of our patients. Unless
steps are taken to redress this balance we believe it will not be
possible to translate the improving scientific understanding of
psychiatric illness into clinical benefits for patients. There is a very
real risk that as the understanding of complex human diseases
steadily increases, recent moves away from biomedical approaches
to psychiatric illness will further marginalise patients in
comparison with those suffering from physical illness.
We believe it is fitting that, on the 200th birthday of our
specialty, we should reconsider our core values and renew our
Wake-up call for British psychiatry Download full-text
efforts to use our psychiatric skills to the maximum benefit of our
patients. Psychiatric patients deserve nothing less.
The authors are grateful to the following for helpful discussions and comments that have
informed the article: Drs Maria Atkins, Jonathan Bisson, Martin Gee, Claire Jones, Izabella
Jurewicz, Malcolm Liddell, Rob Potter, Ajay Thapar, Martin Williams and Professors Peter
Jones and Anita Thapar.
Nick Craddock, FRCPsych, Department of Psychological Medicine, Medical School,
Cardiff University, UK; Danny Antebi, FRCPsych, Gwent Healthcare NHS Trust,
Newport, UK; Mary-Jane Attenburrow, MRCPsych, Anthony Bailey, MRCPsych,
University of Oxford, Department of Psychiatry, The Warneford Hospital, UK; Alan
Carson, FRCPsych, Royal Edinburgh Hospital, Edinburgh, UK; Phil Cowen, FRCPsych,
University of Oxford, Department of Psychiatry, The Warneford Hospital, UK; Bridget
Craddock, FRCPsych, ABM University NHS Trust, Bridgend, UK; John Eagles,
FRCPsych, Royal Cornhill Hospital, Aberdeen, UK; Klaus Ebmeier, FRCPsych,
University of Oxford, Department of Psychiatry, The Warneford Hospital, UK; Anne
Farmer, FRCPsych, Institute of Psychiatry, London, UK; Seena Fazel, MRCPsych,
University of Oxford, Department of Psychiatry, The Warneford Hospital, UK; Nicol
Ferrier, FRCPsych, Institute of Neuroscience (Psychiatry), Newcastle University, Royal
Victoria Infirmary, UK; John Geddes, FRCPsych, Guy Goodwin, FRCPsych, Paul
Harrison, FRCPsych, Keith Hawton, FRCPsych, University of Oxford, Department of
Psychiatry, The Warneford Hospital, UK; Stephen Hunter, FRCPsych, Gwent
Healthcare NHS Trust, Cwmbran, Torfaen, UK; Robin Jacoby, FRCPsych, University of
Oxford, Department of Psychiatry, The Warneford Hospital, UK; Ian Jones,
MRCPsych, Paul Keedwell, MRCPsych, Mike Kerr, MRCPsych, Department of
Psychological Medicine, Medical School, Cardiff University, UK; Paul Mackin,
MRCPsych, Institute of Neuroscience (Psychiatry), Newcastle University, Royal Victoria
Infirmary, UK; Peter McGuffin, FRCPsych, Institute of Psychiatry, London, UK;
Donald J. MacIntyre, MRCPsych, Pauline McConville, MRCPsych, Deborah
Mountain, MRCPsych, Royal Edinburgh Hospital, Edinburgh, UK; Michael C.
O’Donovan, FRCPsych, Michael J. Owen, FRCPsych, Department of Psychological
Medicine, Medical School, Cardiff University, UK; Femi Oyebode, FRCPsych,
Department of Psychiatry, University of Birmingham, Queen Elizabeth Psychiatric
Hospital, UK; Mary Phillips, MRCPsych, Department of Psychological Medicine,
Medical School, Cardiff University, UK, and Department of Psychiatry, Western
Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh,
Pennsylvania, USA; Jonathan Price, MRCPsych, University of Oxford, Department of
Psychiatry, The Warneford Hospital, UK; Prem Shah, MRCPsych, Royal Edinburgh
Hospital, Edinburgh, UK; Danny J. Smith, MRCPsych, James Walters, MRCPsych,
Department of Psychological Medicine, Medical School, Cardiff University, UK; Peter
Woodruff, FRCPsych, Department of Academic Clinical Psychiatry, Sheffield
University, UK; Allan Young, FRCPsych, Department of Psychiatry, University of
British Columbia, Vancouver, British Columbia, Canada; Stan Zammit, MRCPsych,
Department of Psychological Medicine, Medical School, Cardiff University, UK
Correspondence: Nick Craddock, Department of Psychological Medicine,
Medical School, Cardiff University, Heath Park, Cardiff CF14 4XN, UK; Email:
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