Relatively little progress has been made in understanding the causes of psychotic conditions, writes Justin Thomas
To tackle mental health issues, we need to focus on prevention and education
Across time and place, people have struggled to understand the bizarre, frightening and sometimes tragic human experience we commonly call madness. The signs of this state include things like hearing voices, holding strange and sometimes dangerous beliefs, and perhaps laughing and crying at nothing. There can be fewer sights more painful than seeing "true madness” in the eyes of a loved one.
Our ideas about madness have varied widely and wildly across time and place. Our theories have pointed the finger at septicemia (blood poisoning), the effects of the moon (lunacy) and demons (majnoon), to name just a few unusual suspects.
Today, however, the dominant view of madness or psychosis, as we now call it, is rooted in the biomedical sciences. Madness is viewed, ultimately, as a consequence of biological malfunction. Specifically, structural or functional brain abnormalities, such as too much dopamine or too little serotonin. Madness – hearing voices, holding bizarre beliefs, exhibiting strange behaviour – is lumped together and perhaps given a label such as schizophrenia or bipolar disorder.
Despite the dominance of this biomedical approach, and more than a century of research, relatively little progress has been made in understanding the causes of psychotic conditions such as schizophrenia and bipolar disorder. Furthermore, we have hit-and-miss treatments, some with potentially horrendous side-effects.
We have now reached a point where many leading mental health professionals believe that one of the key reasons for our lack of progress, is the assumption that madness (psychotic states) can be meaningfully divided into easily identifiable illness categories. The suffering of the person diagnosed as “schizophrenic” is real, but how real is schizophrenia as a category of illness?
Decades of research have shown that clinicians will often differ on the diagnosis to be assigned to a patient with a severe mental health problem. In one study the diagnostic disagreement between psychiatrists over the same patient was as high as 64 per cent. Another study found that two-fifths of psychiatric diagnoses were changed over the study’s two-year duration; that is, people initially diagnosed as suffering from, let’s say, schizophrenia or depression had their diagnosis changed to bipolar or schizoaffective disorder or vice versa.
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The idea that our biomedical system of classification is fatally flawed has damning implications for treatment and research. Consider, for example, attempting to investigate the causes of “schizophrenia”. How can we draw firm conclusions if we don’t have certainty in the accuracy and stability of the diagnosis assigned to the individuals recruited into the study?
An alternative approach is to focus on the specific symptoms of psychotic experience - such as hallucinations, grandiosity, persecution - rather than assumed disease concepts, such as schizophrenia. This approach is already helping us to better understand certain psychotic symptoms in relation to our every day thinking errors and biases. This approach also helps identify the possible social and developmental origins of such processes and symptoms.
Understanding the social and psychological roots of such problems allows us to focus on preventive interventions. This emphasis on understanding developmental pathways and the various psycho-social and biological risk factors for psychotic symptoms can help us identify individuals who will potentially benefit from early, or even preventive, interventions. One Australian study was able to identify high-risk individuals and impressively, within six months, 40 per cent of the “at risk” individuals went on to experience a full-blown psychotic episode.
Early identification of psychosis is invaluable; the longer that psychosis goes untreated, the worse and costlier the outcome. For this reason, many healthcare systems insist on the development of early intervention services.
Psychosis prevention research is still in its infancy, however, exploring symptoms rather than hypothetical illnesses is the way forward. Wisely, the National Institute for Mental Health in the US will no longer fund research based on the old illness categories such as schizophrenia or bipolar disorder.
This same symptom-focused approach can also be applied to milder forms of mental health problem, such as depression and anxiety. The high prevalence of these relatively milder complaints would suggest that prevention initiatives should be broad-based. The obvious place for this to happen would be at school. Rather than just prepare students for “jobs that don’t exist yet”, perhaps we can also prepare them for the inevitable and well-known social and emotional challenges ahead.