EDITORIAL: The need to clarify professional terminology in psychiatry
In a recent issue of Psychiatric Times, Jeffrey Geller, president of the American Psychiatric Association at the time, published an article with the provocative title “Is the term ‘psychiatric’ becoming extinct?”1 This article was prompted by concerns that the term “psychiatric”—a term embodying the field of psychiatry that specializes in the treatment of psychiatric disorders—is falling into disuse, largely in favor of the term “mental.”
The use of the term “mental” in psychiatry is hardly a recent phenomenon. In his article, Geller reviewed the relevant history of this terminology in our field. It originated with the first recognition of psychiatry as a medical specialty in the United States in 1844 by the Association of Medical Superintendents of American Institutions for the Insane. In 1921, this name was changed to the American Psychiatric Association (APA).1,2 Geller’s article noted that in 1923, the APA, the National Committee on Mental Hygiene, and the Committee on Statistics jointly published an authoritative source of mental disorders entitled the Statistical Manual for the Use of Hospitals for Mental Disease. The National Committee on Mental Hygiene and the Committee on Statistics was subsequently renamed the National Association for Mental Health (an organization with broader inclusion of nonpsychiatric mental health professionals). This history is provided in the introductory section of the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I).3 Over the next 3 decades, different psychiatric treatment facilities and teaching centers developed and used their own diagnostic systems, which precluded effective communication and statistical comparison across institutions.1,2
In 1952, the APA assumed national leadership in psychiatric nomenclature and statistical classification with its publication of what was to be the first edition of the DSM.3 This foundational moment cemented the use of the term “mental” in reference to psychiatric disorders in official psychiatric nomenclature, and this has not changed in the 7 decades since then. It is perplexing that an organization of psychiatrists representing “psychiatric” concerns would choose the term “mental” in its foremost organizational document. Geller1 noted that the decision to use the word “mental” rather than “psychiatric” in the title was “significantly influenced by individuals who were not psychiatrists and organizations that were not psychiatric” in early efforts to establish a formal knowledge base of psychiatric disorders. The publication of the second edition of the DSM (DSM-II)4 in 1968 was designed to increase compatibility with criteria from the International Classification of Diseases (ICD), which at the time was in its eighth edition (ICD-8). Similarly, the publication of the third edition of the DSM (DSM-III)5 was originally intended to bring the American criteria in line with the current international criteria of the time (ICD-9), but in the end, the ICD criteria were modified to be consistent with the DSM criteria.2
Since then, we have seen growing desires for psychiatrists to differentiate themselves from others who provide care for “mental” disorders. In this environment, it is curious that the APA has not moved to change its terminology from “mental” to “psychiatric” in the title of its diagnostic manual and in the formal language throughout this document.1 Concerns epitomized by ambiguities in the prevailing terminology simmered at low levels over the decades, punctuated by occasional protest, such as the classic article and book “Why psychiatry is a branch of medicine” by Samuel B. Guze.6,7 Geller1 pointed to costs incurred by the field of psychiatry as a result of this history, costs that may include both missed financial opportunities and the diminished reputation and perceived value of the profession.
Another twist in the terminology crept into this history with the term “behavioral health,” which first appeared in PubMed in 1976.8 “Behavioral health” was first introduced as an umbrella term encompassing behavioral contributions to health and medical illness9 in the context of health promotion and health care delivery and financing.10 Over time, the original application of this term to the business aspects of health care grew to be interchangeable with the term “mental health.” This term only compounds the concerns raised in association with the substitution of the word “mental” for “psychiatric” by introducing further conceptual inclusiveness and distancing from activities of the psychiatric profession.
The downstream effects of the use of the term “mental” as a moniker for the diseases treated by psychiatric professionals were compounded by further erosion of psychiatric terminology creeping into the field in more recent decades. Newer terminology springing from the term “mental” has since watered down the term by inserting the word “health” into language for psychopathology. The names “mental health” (referring to wellness and lack of psychopathology) and “mental illness” (addressing the disease aspect of psychopathology) have been intermingled to yield illogical terms such as “mental health disorder” and “mental health diagnosis.” These terms appear nowhere in any version of the DSM. Geller1 considers “mental health disorder” to be an oxymoron because of the contradictory and incompatible combination of opposite concepts of health and illness within the same term. It is illogical to combine the words “disorder” and “diagnosis” with “mental health” because “mental health” is not about disorders or diagnoses, and the term “disorders” corresponds to illness, not to health. The irrationality of this combination is suitably illustrated by the juxtaposition of words to create the absurd term “mental health illness.”
Geller1 assumed that the emergence of nonprofessional terminology such as “mental illness” and “mental health disorder” likely reflects desires to destigmatize the illnesses defining the field of psychiatry. Avoiding the stark-sounding term “mental disorder” by replacing it with the softer-sounding “mental health disorder” may have felt like movement to less jarring terminology, but the end result is likely a worsening of stigma by refusal to bring ourselves to say “mental disorder,” and similarly for the avoidance of the term “psychiatric disorder.” Geller1 pointed out that such substitution of terminology is “doing just what we are trying to avoid.” It removes the psychiatric disorders that define our profession from the rest of the medical field, stigmatizing not only our patients, but ourselves. In another domain of medical care, a tooth abscess does not bring a patient to visit a dentist for a “dental health disorder,” but rather for a dental disorder. Dental patients and the dentists who treat them have apparently not felt a need to distance themselves from stigma in their field as psychiatry has done. The term “mental health disorder” first appeared in PubMed in 199011 and 97 articles on “mental health disorder” were found in a 2021 PubMed search, with a total number of 812 since 1990. This unfortunate term appears to be catching on.
Related issues in psychiatric terminology have arisen in language referring to practitioners and the individuals they serve. The term “provider” came into use in 1965 to refer to health care professionals qualified to receive Medicare reimbursement for their services12 and reflects the commercial and business side of medical practice. In the following decades, the use of this term has expanded to physicians and other health care professionals in general. The term “consumer,” long used to refer to individuals purchasing products for their consumption or use, was applied to medical patients in a 1963 article about payment plans for medical care13 and to the regulation of systems of mental health care in a 1971 PubMed-listed article.14 Thus, the terms “provider” and “consumer” were both initially applied in the context of business aspects such as financing of medical care, but their use has spread beyond psychiatry to other mental health practices, and their application broadened substantially. These terms fail to address professionalism inherent in psychiatric practice and to recognize the fiduciary aspect of the doctor-patient relationship that establishes a duty of care. Additional terms found in use include “client,” “customer,” “recipient,” “attendee,” “participant,” and “user,” reflecting dissatisfaction with prevailing terminology in some sectors that have elected to substitute them.15 Variants of these alternative terms have been embraced by some mental health organizations15 but none have been well accepted by the psychiatric profession. The term “consumer” in particular has generated considerable controversy.12,16
Given the extensive substitution of traditional terms for “psychiatry,” “psychiatric disorders,” and “mental illness” in common usage as well as in the fields of mental health (including psychiatry specifically), one might conclude that the war of words has been lost. However, Geller1 did not see the situation as hopeless when he urged psychiatrists and other physicians to use the language specific to psychiatry in reference to the practice of psychiatry, those who provide care, and those who receive that care. Building on these recommendations, we encourage practicing psychiatrists and educators to use the preferred and traditional terminology with their patients, colleagues, students, policymakers, and the public. Beasley et al12 warned that failure to correct our terminology could ultimately lead to greater confusion, dissatisfaction, and expense. These authors noted that restoring use of traditional terminology in psychiatry will likely entail effort and expense required to reword regulations, policies, and electronic health record interfaces. They urged medical journal editors to promote correct and preferred usage of medical terms, and this includes psychiatric terminology. Beasley’s group further urged leadership of professional societies to support these efforts. Perhaps these advances in our conceptualization of psychiatric terminology also indicate that it is time to consider changing the name of the American diagnostic manual to refer to “psychiatric disorders” specifically rather than to “mental disorders.”
Carol S. North, MD, MPE, DLFAPA
The University of Texas Southwestern Medical Center
5323 Harry Hines Blvd, Ste NE 5.102
Dallas, TX 75390-9070 USA
- Geller J. Is the term “psychiatric” becoming extinct? Psychiatric News. January 5, 2021. Accessed June 15, 2022. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2021.1.34
- Surís A, Holliday R, North CS. The evolution of the classification of psychiatric disorders. Behav Sci (Basel). 2016;6:5.
- American Psychiatric Association. Diagnostic and Statistical Manual: Mental Disorders. 1st ed. American Psychiatric Association; 1952.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 2nd ed. American Psychiatric Association; 1968.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. American Psychiatric Association; 1980.
- Guze SB. Nature of psychiatric illness: why psychiatry is a branch of medicine. Compr Psychiatry. 1978;19:295-307.
- Guze SB. Why Psychiatry is a Branch of Medicine. Oxford University Press; 1992.
- Kahn MW, Henry J, Cawte J. Mental health services by and for Australian aborigines. Aust N Z J Psychiatry. 1976;10:221-228.
- Agency for Healthcare Research and Quality. What is integrated behavioral health? 2021. Accessed June 15, 2022. https://integrationacademy.ahrq.gov/about/integrated-behavioral-health
- Substance Abuse and Mental Health Services Administration. Behavioral health integration. 2021. Accessed June 15, 2022. https://www.samhsa.gov/sites/default/files/samhsa-behavioral-health-integration.pdf
- Feehan M, Stanton W, McGee R, et al. Parental help-seeking for behavioural and emotional problems in childhood and adolescence. Community Health Stud. 1990;14:303-309.
- Beasley JW, Roberts RG, Goroll AH. Promoting trust and morale by changing how the word provider is used: encouraging specificity and transparency. JAMA. 2021;325:2343-2344.
- Dearing WP. Quality of medical care. Calif Med. 1963;98:331-335.
- Tischler GL. The effects of consumer control on the delivery of services. Am J Orthopsychiatry. 1971;41:501-505.
- Dickens G, Picchioni M. A systematic review of the terms used to refer to people who use mental health services: user perspectives. Int J Soc Psychiatry. 2012;58:115-122.
- Costa DSJ, Mercieca-Bebber R, Tesson S, et al. Patient, client, consumer, survivor or other alternatives? A scoping review of preferred terms for labelling individuals who access healthcare across settings. BMJ Open. 2019;9: e025166.