Psychiatrization in mental health care: The emergency department

Abstract

Background: In the light of high incidences of diagnosed mental disorders and the growing utilization of mental healthcare services, a progressing psychiatrization of society has been hypothesized as the underlying dynamic of these developments. Mental healthcare institutions, such as psychiatric hospitals, may play a decisive role in this. However, there is a scarcity of research into how psychiatrization emerges in hospital settings. This paper explores whether the emergency department (ED) can be considered as a site where psychiatrization happens, becomes observable, and which factors in the context of the ED may be its potential drivers.

Methods: Two cases as encountered in an interdisciplinary ED will be presented in the following in an anonymized way. Although the cases originate from individual consultations, they can be considered as prototypical. The cases were collected and discussed using the method of interactive interviewing. The results will be analyzed against the backdrop of current theoretic concepts of psychiatrization.

Findings: The ED can be seen as an important area of contact between society and psychiatry. Decisions whether to label a certain condition as a "mental disorder" and to therefore initiate psychiatric treatment, or not, can be highly difficult, especially in cases where the (health) concerns are rather moderate, and clearly associated with common life problems. Psychiatrists' decisions may be largely influenced in favor of psychiatrization by a wide array of disciplinary, institutional, interpersonal, personal, cultural, and social factors.

Conclusions: The ED appears to be a promising field for research into the mechanisms and motives through which psychiatrization may emerge in mental healthcare settings. Psychiatrists in the ED work within a complex sphere of top-down and bottom-up drivers of psychiatrization. Encounters in the ED can be an important step toward adequate support for many individuals, but they also risk becoming the starting point of psychiatrization by interpreting certain problems through the psychiatric gaze, which may induce diagnoses of questionable validity and treatment of little use.

Keywords: case study; emergency care; health system research; medicalization; overdiagnosis; psychiatric epidemiology; psychiatrization; transdisciplinary research.

Figure 1

Top-down and bottom-up psychiatrization. Main protagonists and vectors of psychiatrization consisting of heterogeneous sub-processes, of which the most important are listed on the right side of the figure. First published in Beeker et al. (2021a).

Figure 2

Drivers of bottom-up and top-down psychiatrization in the ED. Bottom-up drivers: (a) Help-seekers' expectations, encompassing their own diagnostic assumptions, and more or less specific desires for psychiatric diagnosis and treatment. (b) Help-seekers' understanding of their own problems that may have been shaped by psychiatric concepts and delineated by means of psychiatric vernacular. (c) Help-seekers' striving for immediate help, that may create an atmosphere of urgency even when watchful waiting would be suitable. (d) Help-seekers' appeal to psychiatry for non-medical functions, which may be related to its implicit (pedagogical, symbolic, ritualistic, mediating, etc.) dimensions. (e) Treatment experiences of help-seekers' relatives who may act as multiplicators of psychiatric expertise by providing psychiatric interpretations and giving recommendations based on how they were previously treated and what they were told by psychiatric professionals. (f) The internet as a repository of psychiatric knowledge, which is easily accessible and often consists of strongly simplified, popularized versions of expert-knowledge. Top-down drivers: (a) The diagnostic vagueness of psychiatric classificatory systems, that encourages ascribing diagnoses when operating in the gray area and opens up a space for negotiation between professionals and help-seekers. (b) Clinical routines that favor medication or hospitalization, e.g., when alternatives are not available in the ED-setting and finding individual pathways for psycho-social help is more time-consuming than following standardized medical procedures. (c) Organizational structures that impede watchful waiting and, thus, encourage diagnosis and the immediate initiation of (pharmacological) treatment, e.g., when psychiatrists working in the ED have no means to make follow-up appointments or cannot be sure if help-seekers will be able to see an out-patient psychiatrist soon. (d) Diagnosis as requirement for the reimbursement of services, putting economic pressures on hospitals and EDs, which increases the likelihood that people seeking help in situations of distress will receive a psychiatric diagnosis. (e) Professionals striving for risk reduction, including (their own) legal risks when underestimating or missing potential dangers, which may considerably lower the threshold for hospitalizations, diagnosis and treatment. (f) Professionals' inclination to avoid conflicts, which are likely to arise when help-seekers' (or their relatives') expectations and desires for a certain diagnosis or treatment are not met. (g) Professionals' wish to acknowledge and dignify human suffering through diagnosis and treatment, e.g., when watchful waiting would cause disappointment and feel like disregarding the problem causal for coming to the ED.