What is the heartland of psychiatry?

Psychiatry has long identified schizophrenia as its definingdisorder, its heartland as it has been called. In the past20 years, this has had a number of negative consequences forpsychiatry as a medical specialty, which result from the uncertaintyof diagnosis and an increasing emphasis on demedicalising servicesin an attempt to provide social care outside hospital. Thesechanges have probably increased the stigma attached to psychiatricpractice and threaten to deskill doctors. They have also meantthat services for other disorders do not meet the needs ofpatients. To continue to allow schizophrenia to be the paradigmcondition is against the interests of psychiatrists and theirpatients.

INTRODUCTION

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INTRODUCTION

About 20 years ago, it was a commonplace to refer to schizophreniaas the heartland of psychiatry (see Bebbington & McGuffin, 1988).The reason for this curious use of an emotive reference toterritory seemed rather odd, but not terribly important, becauseit was in many ways an exciting time to do research in psychiatryor have a scientific interest in its progress and understanding.Unfortunately, the identification of schizophrenia in thisway has had largely negative consequences for the practiceof psychiatry as a distinctive medical specialty, the fulleffects of which are only fully being felt now.

WHY SCHIZOPHRENIA?

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WHY SCHIZOPHRENIA?

Why was schizophrenia so important to the generation that lookedto Aubrey Lewis, John Wing, Bob Kendell and others for leadership?It had a lot to do with diagnosis, and perhaps with beds. Schizophenia'srich phenomenology and arcane foreign language literature madeits diagnosis seem difficult and interesting. Moreover, makingthe diagnosis of schizophrenia came to seem very importantbecause psychotherapists had indulged in an almost unlimited extension of the `schizophrenia' concept in 1950s' America,to include most neurotic problems. The US–UK collaborativediagnostic project probably marked the highpoint of confidenceand international influence of British psychiatry (Kendell et al, 1971);its focus effectively defined what psychiatry was. It establishedthat psychiatrists could reliably play by operational rulesin making a diagnosis and led directly to the DSM and ICD classifications. Furthermore, schizophrenia was restored as a core disorderthat trumped other diagnoses in a notional hierarchy of importance.This was fundamental. The prevailing view was that schizophreniacould be reliably recognised on the basis of symptoms suchas thought insertion. Thought insertion was taken to have theproperty that Jaspers required of a true delusion: it can betraced back to an `irreducible and non-understandable experience' (Wing, 1978). It is not an extreme experience of a normalkind. When dominated by such phenomena, a mental state is thusqualitatively different from the normal. Finally, despite appearancesto the contrary (comorbid anxiety, depression, mood elevationand cognitive impairment were commonly present), schizophreniawas held to be a unitary diagnosis. Just how unreasonable thiswas, and remains, seems still to be poorly appreciated.

The first and most obvious problem was that an emphasis on diagnosis delivered psychiatrists into very uncomfortable arguments aboutthe status of schizophrenia. To suppose a qualitatively abnormalmental state is, first, foremost and inevitably, stigmatising.It echoes the sane/insane legal distinction and to this daymany psychiatrists are reluctant to tell their patients thattheir diagnosis is schizophrenia. Second, it throws up a boundaryproblem: however confident one may be about its more severeforms, schizophrenia has rather friable edges, and the diagnosisat its most friable too often hinges on what people say theydo and do not believe, and might or might not do on the basisof such belief. A clinical diagnosis of schizophrenia could,when based on partial delusions alone, be a social constructand the antipsychiatry argument, in all its pompous certainty, proceeds from that. Finally, patients frequently disagree withthe psychiatrist's interpretation of their mental state, andmay have to be detained against their will. Historically, Englishpsychiatrists have probably been too enmeshed in the workingsof the Mental Health Act and their diagnosis has been too centralin deciding detention of patients with schizophrenia. Thisis rarely the best basis for a positive therapeutic alliance.So, by clinging to schizophrenia as a heartland, psychiatristshave helped define and strengthen the negative view othershave, both of psychiatry and of themselves.

Then there was the matter of beds. The system of large asylumsmay have originally been a humane innovation, but by the 1960sit had come to be an increasing cause for scandal. The institutionsmirrored the chronicity of schizophrenia and seemed to amplifyrather than correct the disabilities in everyday living thatso many sufferers experience. Far too many patients languishedin long-stay beds with minimal dignity and very little medical attention. However, the reaffirmation of the status of schizophreniaseemed to impede rather than facilitate the creation of reallynew services, as radicals of the time such as William Sarganthad argued were needed in general hospitals to treat affectivedisorder (see Sargant, 1967). Possession of beds was alsoa perverse measure of a doctor's individual power within the existing administrative structure, and the mentality of manypsychiatrists was undeniably too hospital orientated. So, althoughthe possession of some in-patient beds for acute treatmentor respite remained and remains essential for good care, therewas a failure to distinguish between this need and the cushionof longer-stay facilities.

MODERNITY: SCHIZOPHRENIA PLUS SOCIOLOGY

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MODERNITY: SCHIZOPHRENIA PLUS...

The shape of the `modern' psychiatric service has, therefore,been defined as much by what it was against, as by what itwas for. As a corrective to the hospital-based treatment ofschizophrenia, there had to be a transfer of resources awayfrom in-patient services. Although this was reasonable in the age of the physically remote asylum, it has continued wellafter long-stay beds have disappeared, with predictably direconsequences for the quality of acute in-patient care. Moreover,avoiding hospital admission irrespective of illness outcomehas, almost unthinkingly, become an objective for psychiatric services – and highly inappropriate if the patient actuallyneeds hospital care.

Just as beds defined what was to be avoided, so the emphasison diagnosis has acquired an unwanted flavour. The problemsthat patients with schizophrenia face were reformulated as`social'. So what the patients need is `social care'; thisremains the Department of Health's `big idea' for the futureof psychiatry and the sociologically correct answers were formulatedin the National Service Framework for Mental Health (Department of Health, 1999). This formalised and extended in a surprisingly concrete waythe services required for severe mental illness in England.Psychiatrists were notable only by their exclusion from theprocess whereby the Framework was developed. Bipolar disorderwas not mentioned at all, and the National Service Framework, largely unmodified, remains the dogmatic top-down blueprintagainst which targets managers continue to measure themselvestoday. The idea that there might be specific conditions thatrequire specific effective treatments obviously echoes in aghostly way through proliferating guidance from the NationalInstitute for Health and Clinical Excellence (NICE), but somethingis lost in translation to the block contract of psychiatriccare. The policy guarantees only a mass of non-specific caringmeasures for people whose severity of `mental health problem'is largely measured by their disinclination to engage withthe services provided.

AN ALTERNATIVE PERSPECTIVE

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AN ALTERNATIVE PERSPECTIVE

Might things have been different? Bipolar disorder was usuallymisdiagnosed as schizophrenia before it was also rescued fromthe diagnostic shambles by the US–UK collaborative diagnosticproject. What if it had been the dominant paradigm –the heartland condition? Bipolar disorder is no less debilitating,on comparable measures of morbidity and mortality, than schizophrenia(Clement et al, 2003) and is much more common. Moreover, inalmost every respect it would have afforded psychiatry a modelwithin which the medical role is easier to define. The developmentof this model could have informed psychiatric services in generalwith a greater balance between medical, psychological and socialcare.

First, the diagnosis of bipolar I disorder characterised bymania is largely uncontroversial because it is based on observableand obvious changes in behaviour. At least, we have yet tohear anyone claim that mania does not exist. Second, bipolardisorder is, exactly like schizophrenia, a complex phenotypethat can include virtually all the key phenomenological entitieswe recognise in psychiatry – depression, mania, psychosis,anxiety, substance misuse, cognitive impairment, neuroendocrineabnormality, sleep disturbance and distinctively variable illnesscourse. The difference is that we do not pretend otherwise,and the fact that these apparently independent dimensions clusterwithin the single diagnosis of bipolar disorder is accepted as very challenging. Does it mean that the dimensions are themselvesrelated to each other and severity in one will entail severityin the other – perhaps because of common developmentalvariations in biology or the cumulative effects of illness?Or are cases of bipolar disorder simply represented by thosepeople who sit on the wrong end of these multiple domains,all of which can behave relatively independently? Can diagnosis usefully continue to be categorical without measuring the dimensionsthat characterise the disease? These are interesting questionsthat could also reasonably be asked of schizophrenia, but seldomare. Finally, we are not embarrassed to tell patients theyhave bipolar disorder. They are often grateful to have a diagnosisthat explains more than it obscures.

There are other contrasts with the schizophrenia model whichare equally important to clinical practice. The course of illnessin bipolar disorder allows a much more meaningful distinctionbetween the needs of patients for sympathetic in-patient respitecare when acutely ill and for out-patient-based interventionswhen comparatively well. The treatment of bipolar disorder is also much less amenable to one-size-fits-all social care, which,like most such provision for dependent groups, tends with timeand inattention more to reflect the needs of staff than patients:staff become rather more willing to assess patients' needsthan to try and satisfy them. Bipolar disorder is more likelyto challenge clinicians to understand the illness and its treatmentin relation to individual and autonomous patients.

Finally, treatment of bipolar disorder demonstrably requiresthe medical expertise which we should take a pride in. Themedications that we have available seem often to require usein combination, which probably reflects the complexity of thephenotype. Therefore, prescribing for patients with bipolardisorder requires knowledge, skill and experience. We make a distinction between acute and long-term medication and seekactive involvement by patients in managing acute exacerbationsof symptoms. Psychological treatments complement the medicalapproach, and enhanced care is an objective for all patients(Goodwin, 2003). Psychological interventions can reduce therisk of relapse when added to treatment as usual, and havea pragmatic emphasis on self-monitoring, self-management andeducation about the illness. Moreover, the indication for thecontent and the timing of treatment is being rationally definedand refined in controlled trials (Vieta & Colom, 2004).The confusion around whether cognitive–behavioural therapy(CBT) is really useful for schizophrenia is telling (Turkington & McKenna, 2003;Durham et al, 2005). Moreover, although being adopted by NICE,as one might say, for the nation, the relevance of CBT forpsychosis has been wildly amplified at grass roots level ina way that could never have occurred for bipolar disorder –common sense would prevail when the greatest therapeutic optimistmet their first patient with florid mania.

DO PSYCHIATRISTS HAVE A FUTURE AS MEDICAL SPECIALISTS?

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DO PSYCHIATRISTS HAVE A...

These differences illustrate what can occur in psychiatry whenmodern medical treatments are allowed to develop unhamperedby ideology, compared with what happens when they are not.The social model of schizophrenia was the minority, left-wing,`show biz' cause of the 1960s, a formative time for our late-middle-agedpolicy makers, who have their own curious heartlands. Its currentdominance is neither measured, nor moderate. Its essentially totalitarian spirit has even required a new language –an Orwellian `newspeak' where no one must be said to have anillness, comply with treatment or be a patient. The only possiblesurprise is that the use of the word schizophrenia has notyet been banned from the National Health Service.

Other losses have been more subtle. Can it be sensible to investa tenth of what we do on schizophrenia on research in bipolardisorder (Neurosciences and Mental Health Board Strategy and Portfolio Overview Group, 2005)?Why do so many junior doctors leave psychiatry because of therole it currently offers them (Lambert et al, 2006)? Mostdoctors may feel marginalised by managers with regard to resource allocation: psychiatry appears to us unusual in the extentto which managers literally think they know how we should doour jobs. Doctors have a training that brings scientific rigourto what they observe and how they treat. As doctors we alsohave a broader base in general medicine than most other disciplinesinvolved in psychiatry. A good doctor must be able to make a difference to an individual patient. However, our assumptionsand allegiances – our heartland – must be fruitful,not a barren wilderness of good intentions.

We could still develop a more interesting role for doctors inpsychiatry because there are effective evidence-based treatmentsfor a wide range of specific conditions, not just bipolar disorder.We happen to know bipolar disorder best and we have been appalledby the difficulties faced by people with bipolar disorder inthe current model of secondary services. However, little seemslikely to change if schizophrenia continues to occupy such a central and distorting position in our thinking. Why shouldone condition continue to be so dominant? In general medicine,it would seem ludicrous if the decision was made by the Departmentof Health to restructure all care around the model of diabetes.To continue to make schizophrenia the paradigm condition inpsychiatry is against the interests of psychiatrists and, more importantly, of our patients.

REFERENCES

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