Happy World Mental Health Day, well, sort of happy

on_the_beach.jpgToday is World Mental Health Day, and what could be a better way to celebrate a day of mental calm and tranquility than to ignite a blazing row at the core of psychiatry?

A group of mental health activists are pushing for the diagnosis of schizophrenia to be abolished.

Actually, the idea that schizophrenia is a single separate disorder is in a pretty shoddy state, but the argument is a textbook example of mixed agendas as the people who want to reject the label also reject the use of biological explanations in theories of mental illness, and those who argue most forcefully for the diagnosis of schizophrenia are usually heavily committed to biological psychiatry.

What gets lost, is that the validity of schizophrenia as a concept, and whether biological theories are useful, are separate issues.

This is probably because both sides seem to spend so much time trying to make us think that they’re not.

To get a good idea of what the diagnosis of schizophrenia describes in terms of our scientific understanding, the entry for schizophrenia on the OMIM database of medical conditions with genetic influences really says it all:

Schizophrenia is a psychosis, a disorder of thought and sense of self. Although it affects emotions, it is distinguished from mood disorders in which such disturbances are primary. Similarly, there may be mild impairment of cognitive function, and it is distinguished from the dementias in which disturbed cognitive function is considered primary. There is no characteristic pathology, such as neurofibrillary tangles in Alzheimer disease. Schizophrenia is a common disorder with a lifetime prevalence of approximately 1%. It is highly heritable but the genetics are complex. This may not be a single entity.

In other words, very little can be said with certainty. Any definition that finishes with the ominous “This may not be a single entity” suggests we really don’t understand much about the associated experiences.

So why does the argument over schizophrenia persist?

Mainly because the medical and legal systems are far more comfortable with cut-and-dry “you have it or you don’t” conditions than ones in which you might have a bit of this and a bit of that.

This is often due to the fact that the medical and legal systems have to make cut and dry decisions. To treat or not to treat, to detain or not to detain, and so on. These decisions become a lot easier when the supporting information is as simple as possible.

It also becomes a lot easier to market treatments for specific disorders. In fact, in many countries, drugs can only be licensed for specific disorders.

So, no diagnosis means that there’s no way of getting drugs licensed. This is why pharmaceutical companies have a vested interest in supporting the concept of schizophrenia.

In other words, the usefulness of the diagnosis of schizophrenia rests not only upon the supporting medical research, but also on its social function.

In fact, one of the ironies of the debate, is that the most recent research in molecular genetics (exactly the sort of biological approach that those against the diagnosis of schizophrenia are also opposed to) shows some of the best evidence that schizophrenia is not a discrete condition.

You can imagine that neither the drug companies nor the anti-schizophrenia-diagnosis mental health activists plaster these findings across their leaflets.

Link to article on molecular genetics of mental illness.
Link to Asylum Online on ‘Abolition of the Schizophrenia Label’.
Link to BBC News article on the debate.

2 thoughts on “Happy World Mental Health Day, well, sort of happy”

  1. In my view schizophrenia was, and still is, a very useful concept. As the amount of the data increases, and (as more as better) the way we understand the dynamic of human mental life and its biological underpinnings is changing, the concepts such as schizophrenia and depression are going to evolve into what will be practical and useful in the given future. I think that these activists have a problem with schizophrenia seeing it as a label that psychiatrists put on the people. However, wheather the diagnosis should be abolished or not is itself so ephemeric question compared to the screaming need for help that these same people will need regardless of the label they have or they are stripped off. Such help can only come from readiness to pursue any way or concept that the scientific data point to and from translation of this understanding into practical procedures and therapies.

  2. Here’s another take on the issue:
    Distinguishing Between the Validity and Utility of Psychiatric Diagnoses (Am J Psychiatry 160:4-12, January 2003)
    “CONCLUSIONS: It is important to distinguish between validity and utility in considering psychiatric diagnoses. Diagnostic categories defined by their syndromes should be regarded as valid only if they have been shown to be discrete entities with natural boundaries that separate them from other disorders. Although most diagnostic concepts have not been shown to be valid in this sense, many possess high utility by virtue of the information about outcome, treatment response, and etiology that they convey. They are therefore invaluable working concepts for clinicians.”

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