Stigma is leading to under-treatment of mental health conditions, says leading psychiatrist

BMJ 2016; 353 doi: (Published 21 April 2016) Cite this as: BMJ 2016;353:i2316
  1. Nigel Hawkes
  1. London

Progress in treating mental health conditions is too recent for them to have taken their place alongside other conditions that are treatable, says the past president of the American Psychiatric Association (APA), Jeffrey Lieberman.

At an expert encounter at the Science Media Centre in London, Lieberman told journalists that, as a result, this unwarranted stigma still persists, is as profound as racism or religious intolerance, and leads to widespread neglect and under-treatment of patients.

Lieberman, who was in London to give a lecture at the Royal College of Psychiatrists on the future of the specialty, said that a revolution in attitudes as profound as that achieved by AIDS activists in the early 1980s was needed.

How had this neglect come about? He blamed the history of psychiatry itself, which had become a scientific enterprise only after the second world war. In the 19th century patients were moved out of sight into asylums—“which turned into snake pits”—and the few remedies that were tried were largely ineffective. The rise of Sigmund Freud, whose theories turned out to be suited only to the “worried well” but were applied injuriously to others, provided a further obstacle.

“Bad things were done,” said Lieberman. “Now things have changed. The field has changed, the capacity to help people has changed. The vast majority of patients respond dramatically compared to those in other disease categories, but old prejudicial attitudes remain.

“We don’t need scientific breakthroughs, we simply have to apply better what we already have—but policies, public attitudes, and the infrastructure don’t facilitate that.”

He said that his views had become radicalised as a result of serving as president of the APA in 2013-14, after an academic career that included research into treatments for schizophrenia and the early development of the antipsychotic drug clozapine. He is also the author of a history of psychiatry, published in 2015.1

Lieberman’s experience of health policy making had convinced him that psychiatric disorders were “vastly misunderstood and neglected to the detriment of patients.” His term of office at the APA also coincided with the publication of the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5), the latest iteration of the US psychiatric bible, which critics have accused of “medicalising” minor conditions for the benefit of the psychiatric profession.

Lieberman denied this. All of medicine, not just psychiatry, showed a steady rise in the number of diagnoses, he argued, as diseases that were previously lumped together were progressively dissected and defined. He defended the inclusion in DSM-5 of such conditions as binge eating disorder, premenstrual dysphoric disorder, and hoarding disorder as being simply more precise descriptions of conditions that had long existed.

“It’s cynical to say that these are included to drum up business,” he said. “There are some bad apples [in the profession], but it’s a bum rap.”

If the process was one of dissecting broad categories of disease into precise diagnoses, he was asked, why had DSM-5 done the opposite in the case of autism, where four different diagnoses—autism, Asperger syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS)—been rolled into one? He responded by saying that cancer comes in many forms, but it is still called cancer.

What was needed to disperse the stigma, Lieberman was asked? He said that precise tests that could categorise conditions unambiguously would be a big help. But at present, of the 265 recognised mental illnesses, such tests existed for only two: Alzheimer’s disease and narcolepsy.

“One day we’ll have them for schizophrenia, depression, and other conditions,” he said. How soon? “In 10 years’ time, hopefully five.”


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