Has psychiatric diagnosis labelled rather than enabled patients?BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f4312 (Published 25 July 2013) Cite this as: BMJ 2013;347:f4312
- Felicity Callard, senior lecturer in social science for medical humanities1,
- Pat Bracken, clinical director2,
- Anthony S David, professor of cognitive neuropsychiatry3,
- Norman Sartorius, president 4
- 1Durham University, Durham, UK
- 2West Cork Mental Health Service, Bantry, Co Cork, Ireland
- 3 Institute of Psychiatry, King’s College London, UK
- 4Association for the Improvement of Mental Health Programmes, Geneva, Switzerland
- Correspondence to: F Callard , A S David
Yes—Felicity Callard and Pat Bracken
A Head to Head about diagnosis? Are we serious? It is hard to imagine cardiologists or endocrinologists debating whether medical diagnosis has enabled or labelled their patients. Is the fact that we are debating the benefits of diagnosis in 2013, shortly after the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–5), a sign of psychiatry’s infancy as a science? Are psychiatrists doomed to be regarded as poor doctors? We argue not. These debates might be a sign that psychiatry is really starting to grapple with the complexity of its role as a medical discipline. Indeed, we argue that psychiatry’s contributions to the enablement of patients lie—in both the past and the future— outside of the development and use of diagnostic classifications.
Enablement does not require diagnosis
To enable a person is to empower her, to support her in exerting her capacities. However, psychiatric diagnosis is not fundamental to the enablement of people with mental illness. As the title of Sayce’s From Psychiatric Patient to Citizen1 made clear, the route to empowerment lies through socially just welfare systems, appropriate forms of support for people with disabilities, and legal frameworks that protect people’s rights and combat discrimination.2
The rise of the service user movement, alongside peer support and voluntary sector initiatives, has been central.3 4 Although many psychiatrists have promoted or contributed to such developments, use of psychiatric diagnoses has too often contributed to maintaining people as “psychiatric patients.” In addition, within the mental health system, the interventions that have arguably empowered people the most, such as innovative community services, have not been diagnosis specific.5 People with mental illnesses have been enabled, in other words, through healthcare, social, legal, and policy innovations that have little or nothing to do with psychiatric diagnosis.
Harms of diagnosis
The ways in which psychiatric diagnosis can disempower people with mental illness outweigh the ways in which diagnosis might have enabled them. The examples are numerous; we focus on just two. Firstly, the problem of “diagnostic overshadowing,” whereby a psychiatric diagnosis can lead to a person’s physical symptoms being misattributed to mental illness with many potentially harmful consequences.6 Secondly, across much of central and eastern Europe, poor psychiatric diagnosis is the lynchpin that leads to long term institutionalisation, where the conditions mean that care is inadequate at best and, according to a number of European Court of Human Rights judgments, “inhuman and degrading” at worst.7 The Mental Disability Advocacy Centre has brought to light the widespread phenomenon of “civil death,” when people are deprived of their legal capacity and therefore their rights to work, live in the community, have family life, access courts, etc.
Across the European region, a million people are estimated to be deprived of their legal capacity.8 9 How does this happen? A sloppily made medical report that specifies a psychiatric diagnosis—schizophrenia is common, here—is relied on by a judge, who rubberstamps guardianship. Rather than enabling patients, psychiatric diagnosis is underpinning their profound disempowerment.
We may, at last, be reaching a degree of maturity and beginning to emerge from the neo-Kraepelinian dogma that has dominated psychiatric thinking for the past 30 years.10 Our argument is not against diagnosis in psychiatry. All doctors need to be aware of the various organic syndromes that can cause patients’ suffering, and psychiatrists need to do appropriate medical investigations and make medical diagnoses part of their assessments. But psychiatry is not neurology, and a psychiatrist’s job is to make sense of the reality of mental distress, in all its complexity. This is a territory that demands debate and negotiation; it cannot be grasped with simple causal models and our current, categorical forms of classification. The common argument that diagnosis is vital for communication and explanation in psychiatry is not supported bv the poor reliability and lack of established validity of current classification systems.11
A substantial proportion of mainstream academic psychiatry has, in the past 30 years, turned away from serious consideration of the importance of relationships, meanings, contexts, social issues, and values. Enchanted by the neo-Kraepelinian dream of creating a psychiatry modelled on a medicine of the tissues, it has tried to force the world of mental health into a narrow conceptual straitjacket and asserted that psychiatry should become simply a form of “applied neuroscience.”12 But mental illnesses “are problems of persons, not of brains.”13
When we place the word “mental” in front of the word “illness,” we delineate a territory of human suffering that has to do with the mind, and, whatever it is, the mind is not simply another organ of the body. Whether we like it or not, when we speak of mental illness, we speak of a territory that is relational and value laden. It is a world that cannot be grasped with the same form of medical epistemology that has worked well in cardiology or endocrinology. Psychiatry’s historical task is to develop a medical discourse that can take this on board.14
Many pronounce psychiatry to be in a state of crisis. But a crisis, as psychiatrists tell their patients, can be turned into an opportunity. What would it take for psychiatry not to model itself on other branches of medicine but to have the courage and imagination to think differently about the form assessments should take, about the nature of interventions, and about the role psychiatry might play in the lives of its patients?
No—Anthony S David and Norman Sartorius
The recent publication of DSM-515 has revived older concerns about psychiatric diagnosis.16 This debate is not about a particular system of classification. No sensible mental health professional thinks such systems are anywhere near perfect or complete; they are interim summaries with practical aims awaiting clarification.
Most critics readily accept the value of medical diagnoses but distinguish these from psychiatric ones. Mental health problems are not like scurvy or haemorrhoids, they say, but are the result of complex interplay between biology, psychology, and culture. We fully endorse the “biopsychosocial model,” although we caution against a position that says it cannot be applied to the majority of medicine.
Psychiatric diagnoses are different from physical ones for which there is clear cut histopathology. But even the simplest expression of germ theory includes an interaction between agent, host, and environment. Furthermore, for most of today’s common diseases a committee decides the cut-off on a continuum of, say, blood pressure or blood sugar concentration that denotes when a risk-benefit analysis favours treatment. Psychiatric diagnoses apply the same principles in determining say, clinical depression. Such cut-offs require constant adjustment in the light of evidence, and different thresholds may be set depending on the clinical question posed (hospital admission? medication?). Diagnosis therefore facilitates joint, rational decision making between doctor and patient.
Risk of overmedicalisation
Overmedicalisation is often cited as an adverse consequence of diagnostic labels, with the evil hand of “big pharma” seemingly pulling the strings. In fact there are many powerful cultural forces behind medicalisation; it is part of our response to scientific advances in understanding biology and the universe. But this is too broad a phenomenon to lay at the door of psychiatry. Think of the cosmetics and food industries: sports drinks, anti-ageing creams, diets, and the rest. But note, responsible family planning is one area of medicalisation that is highly valued. So why shouldn’t mental health professionals use their knowledge and skills offer to help others deal with loss or serious worries?17
Diagnosis provides boundaries
Without a firm anchor in physical pathology, how can psychiatry maintain its integrity? How does it avoid labelling people just because they are different or inconvenient? How can it resist the temptation to stray into areas outside its expertise? The answer is diagnosis: rational, careful, respectful, diagnosis. Diagnosis is a tool. It is a form of reasoning; a piece of software. Like all tools it requires training to be used appropriately and can be misused. In this it is no different from a scalpel or antibiotics.
A diagnosis also provides a proper means to remove a wrong or inappropriate label and is the best strategy we have against overmedicalisation. Not every teenager intent on playing computer games all day is autistic, has attention deficit hyperactivity disorder, or is psychotic. Sometimes after careful consideration, being placed below the cut-off is just as important as being placed above it, if not more so. As Clare wrote at a time of Soviet abuses of psychiatry: “What protects the dissident, the deviant, and the outsider from being labelled ‘mentally ill’ is not the psychiatrist who does not believe in psychiatric classifications . . . but rather the psychiatrist who acknowledges that . . . symptoms can be grouped and defined in such a way as to produce a reasonable degree of agreement about their validity and reliability, and that those people who do not show such symptoms cannot be classified as mentally ill.”16
Alternatively, a mother who neglects her newborn baby because she believes him to be the devil might have puerperal psychosis diagnosed. This might mean the difference between the district nurse knocking on the door offering help instead of the police offering handcuffs. An elderly person who lacks motivation and starts to neglect himself may be depressed or have Alzheimer’s disease. It is important to try to discover which, so that we can help the person and their family to obtain the right help and treatment, and plan for the future.
Gateway to research
Without diagnosis, every problem appears as if for the first time—every solution has to be hard earned and new. It facilitates learning and provides the framework to disseminate the knowledge gained. But we should pause here to acknowledge that enabling or empowering psychiatric patients is a difficult goal to achieve and is not something diagnosis, psychiatry, or even an entire healthcare system can achieve on its own. We argue that it is a necessary first step. Diagnosis allows problems to be quantified and tracked over time and space. A diagnostic classification, well defined, is the starting point to research into causes, consequences, and solutions and it is a bulwark against superstition and moralism. The precise terminology used in diagnosis should not become fixed in the past, and professionals should acknowledge that diagnostic terms may add to stigma and fear. Encouraging attempts have been made to find the right words to describe certain disorders that chime with the culture—for example, the Japanese have replaced the term schizophrenia with something akin to integration disorder.18
Finally, mental health has to compete with other health areas to gain the attention of politicians and non-governmental organisations, and information about diagnosis can be used to lever resource and to redress inequalities of provision. At the very least, diagnosis enables patients to see that they are not alone.
Cite this as: BMJ 2013;347:f4312
Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare FC is chair of the board of the Mental Disability Advocacy Centre and is supported by the Wellcome Trust.
The 48th Maudsley Debate (“This House believes that psychiatric diagnosis has improved the care of people with mental health problems”) was held on 5 June 2013.
Provenance and peer review: Commissioned; not externally peer reviewed.