Is the Term ‘Psychiatric’ Becoming Extinct?

Is psychiatry losing the term “psychiatric”? To what degree should APA and its members take responsibility for this evolution (or perhaps better labeled devolution)? Is there value in not only holding onto the term, but also taking every opportunity to put forward that we are an association of psychiatrists who treat psychiatric disorders?

Loss of Use of ‘Psychiatric’: An Illustrative Example

The print version of the Boston Globe on November 28, 2020, carried a front-page article headed “Recent Police Shootings Show Mental Health Concern.” This article had been posted on November 27 with a headline that did not mention “mental” illness but that carried a subheading, “All of the suspects had been treated for mental illness”. There were four victims, all White; two were wounded fatally. The article makes the point that there were a significant number of police shootings in Massachusetts in a short period—a 10-day span—in a state that averaged 15 lethal and nonlethal police shootings annually between 2005 and 2015 and nine in 2019. There have been, however, 16 police shootings in Massachusetts in 2020 through the date of the Globe article. None of the shootings occurred in Boston; the four cities where the killings occurred were north of Boston at a distance of 4.3 miles to 10.8 miles (average 7.7 miles) and with populations ranging from about 22,000 to about 95,000. Massachusetts has one psychiatrist per 2,100 population, a rate surpassed only by Washington, D.C.

What struck me in reading the article was the total absence of the word “psychiatric.” If this omission occurs in the coverage of events in the greater Boston area, is it even more likely to be occurring in other places?

Terms that are used (while “psychiatric” is not) include “mental illness,” “mentally ill,” “mental health crises,” “mental health problems,” “mental health issues,” “mental health calls,” “mental health training,” and “mental health professionals.”

What psychiatrists would refer to as psychiatric disorders were not so identified but labeled as “mental illness”: “depression,” “bipolar disorder,” “schizoaffective disorder” (not one of these four cases). Substance use disorders were referred to as “drug abuse” and “cocaine abuse.” One of the surviving victims was described as having had bipolar disorder.

How do we account for the media’s avoidance of the word “psychiatric”?

History of APA’s Use of ‘Psychiatric’ in Its Name

A review of APA’s history and its name shows that in 1844, the Association was founded following a meeting in Philadelphia and named the Association of Medical Superintendents of American Institutions for the Insane. (Only superintendents could be members.) In 1891, the members discussed the need to shorten the name and make it more inclusive, and in 1892 they changed the name to the American Medico-Psychological Association. Dating as far back as 1891, members had discussed using the name American Psychiatric Association, thinking it would better reflect the membership and be more inclusive than the name at the time, and in 1920 decided to make the change. The new name was adopted in 1921. For a century, “Psychiatric” has been in our Association’s name. Will that still have meaning in the future?

Development of DSM and Its Name

Every version of the DSM since the first in 1952 (DSM-I) has been called a manual of “mental disorders.” In the first and second editions of DSM, the font size for “Mental Disorders” on the cover was twice as large as the rest of the title.

Before medicine began the modern classification of diseases, APA was at work on its own classification scheme. Information from the foreword in DSM-I and from the APA Archives indicates that at the 1913 Annual Meeting, there was a plea for a system of uniform statistical reports from “mental” hospitals. APA appointed a committee chaired by Dr. Thomas Salmon, medical director of the National Committee on Mental Hygiene (NCMH). NCMH was founded in 1909 through the efforts of Clifford W. Beers, a former psychiatric patient, and Adolf Meyer, who went on to become APA president for the 1927-1928 term. The central mission of the NCMH was to develop measures that would prevent maladjustment and “mental” illness.

At the 1917 Annual Meeting, the Committee on Statistics presented a nomenclature and classification scheme with heavy NCMH input, and it was adopted. Though primarily statistical, the report filled a void with its classification of psychiatric disorders.

This scheme was also adopted by NCMH. In 1923 NCMH and APA’s Committee on Statistics published the Statistical Manual for the Use of Hospitals for Mental Disease. “Mental” may well have come from the NCMH through Dr. Salmon.

Up through the late 1920s, each large teaching center had its own system of disease nomenclature initially tailored to meet its own needs. These systems spread to other facilities as faculty and trainees relocated. The result was a “polyglot of diagnostic labels and systems” that prohibited both effective communication about diagnoses and the collection of medical statistics that could be aggregated and studied. In 1927 the New York Academy of Medicine initiated an effort to create a nationally recognized, standard nomenclature of diseases. In 1928 the first National Conference on Nomenclature of Disease convened and created a nomenclature that subsequently went through a series of trial editions at different hospitals. In 1933, the first edition of The Standard Classified Nomenclature of Disease was published.

Subsequently, these two streams of nomenclature development came together when joint efforts by the New York Academy of Medicine and APA resulted in a revised nomenclature. However, the NCMH, with APA’s collaboration, continued to publish the Statistical Manual for the Use of Hospitals for Mental Disease. In the system developed by the academy, psychiatric disorders were referred to as “Diseases of the Psychobiologic Unit.” DSM-I indicates that this section became the basis for DSM-I, but it appears the historical contributions to DSM-I were much more complex.

For the next decade, the process of developing a scheme for nomenclature and classification seemed to be heading toward clarification. With NCMD’s agreement, APA became responsible for future publication of the Statistical Manual. During World War II, there was a lapse in efforts to develop a uniform classification scheme. By the war’s end, there were three classification systems for psychiatric disorders—Standard, Armed Forces, and Veterans Administration—and none was compatible with the International Statistical Classification’s section on “Mental, Psychoneurotic, and Personality Disorders.”

After the war, APA asserted its leadership in developing a classification system for psychiatric disorders with consultation from the Biometric Branch of the National Institute of Mental Health and worked from prior classification schemes, carrying along the “mental” terminology. From 1948 to 1952, APA’s Committee on Nomenclature and Statistics worked on what APA expected to be official nomenclature. In 1952 the first DSM was published.

Even though there is a considerably more detailed history of DSM-I’s development in the foreword to DSM-I, this document indicates that the APA Committee on Nomenclature and Statistics, without providing any documented explanation, pronounced in 1952 that the new name of APA’ system of nomenclature and statistical classification was the Diagnostic and Statistical Manual of Mental Disorders, and that name continues to be used today. This history should note that the use of the word “mental” reflects the development of a document in 1952 significantly influenced by individuals who were not psychiatrists and organizations that were not psychiatric.

One wonders why APA did not discontinue the use of “mental” in DSM’s title and use “psychiatric” instead. There is no evidence to indicate that APA had ever considered such a change. But has there been a cost to psychiatry, and does the price we pay seem to be escalating?

Looking Ahead

Maybe the “psychiatric” versus “mental” disorder distinction didn’t matter so much 70 years ago when psychiatrists dominated the treatment of psychiatric disorders. And maybe we don’t care that “mental” is heard loud and clear these days and “psychiatric” is becoming a whisper. This is true even among psychiatrists and across a diverse array of settings. But now, when we want to be identified as psychiatrists and distinguish ourselves from others who provide treatment for “mental” disorders and psychiatrists are examining how we should be referred to, it is time we did consider how we use the terms “mental” and “psychiatric.”

Our profession will be ill served if “psychiatric” becomes an archaic word, if DSM-6 slides into being the Diagnostic and Statistical Manual of Mental Health Issues, and the name of the publication you are reading becomes Mental News. If we psychiatrists are more conscientious about our language, can we perhaps educate our nonpsychiatrist colleagues in medicine and the media to use “psychiatric diagnosis” or “psychiatric disorder” instead of “mental illness” or “mental health disorder”? Language in medicine can change. During the lifetime of some of our members, “cancer” was a word no one said out loud.

One term that has never made sense to me is the use of “mental health disorder” because it’s an oxymoron. Using the terms “mental Illness” and “mental health disorder” were probably efforts to destigmatize the disorders that psychiatrists treat, but not using “psychiatric” pulls the disorders we treat out from the rest of medicine and stigmatizes patients and psychiatrists. We are doing just what we are trying to avoid.

But of course the issue is more than about how we use words. It’s about our identification and role as psychiatrists. It’s about the disorders we treat. And it’s about what we want the profession of psychiatry to be. ■