HIDDEN COSTS OF SCHIZOPHRENIA

Transcription

1 HIDDEN COSTS OF SCHIZOPHRENIA

2 WHAT IS SCHIZOPHRENIA? Described in 1890s by Emil Kraepelin as Dementia Praecox Named in 1908 as schizophrenia by Eugen Bleuler Operationally re-defined in 1980 in DSM-III (and again in DSM-IV & DSM-V) Renamed in Japan as Integration Disorder (Togo Shitcho Sho) in 2002 It s a hundred year old diagnosis looking for a pathology Stress, Trauma, Migration, Genetics, Brain function, Social labelling? We are unclear what schizophrenia means

3 THE BIOPSYCHOSOCIAL DEBATE Schizophrenia does not exist. There is no evidence of a specific brain disorder. Jim van Os. BMJ 2016 There are four distinct biotypes of psychosis that don t fit with diagnoses. Thomas Insel. Scientific American Mind 2016 Schizophrenia is due to increased presynaptic striatal dopaminergic function. Oliver Howes. Schizophrenia Bulletin Psychiatry needs to move beyond the dominance of the current, technological paradigm. Pat Bracken. B J Psych Social defeat hypothesis of schizophrenia. Migration, minority ethnic group, disability, childhood trauma, drug abuse, homosexuality lead to sensitisation of the mesolimbic dopamine system. Jean-Paul Selten. World Psychiatry. 2016

4 THE COST OF NOT USING OUTCOMES Psychiatrists in the UK do not use outcome measures. Gilbody. B J Psych Measures could be useful but are difficult to collect and present. Lewis. Advances in Psychiatric Treatment Commissioners don t know what to commission Harms are not monitored Ineffective treatment is not stopped Good results are unreported What s needed? A change in outlook and huge investment in IT

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6 Activity and Outcomes

7 THE COST OF OVERTREATMENT More antipsychotic exposure causes more brain grey matter loss in schizophrenia. Antonio Vita Biological Psychiatry 2015 Antipsychotics don t work for most patients if you set a threshold of 80% symptom reduction. Drop out rates are very high. Colin Ross. Ethical Human Psychology and Psychiatry People who continue antipsychotics over 3 years have worse functional outcomes than people who reduce and stop antipsychotics (20% v 46% in functional remission). Small RCT over 7 years. Lex Wunderink. JAMA Psychiatry. 2013

8 Mental Health Clustering vs Blocks Open Dialogue Soteria THE COSTS OF OTHER MODELS Medication discontinuation programmes

9 THE COST OF PHYSICAL ILL HEALTH People with schizophrenia in U.S. have over three times the mortality risk of the general population, with high risk of dying from cardiovascular and lung disease. Smoking, alcohol and drugs are modifiable risk factors. Olfson. JAMA Psychiatry In a Danish study ( ) the mortality gap is getting wider. Nielsen. Schizophrenia Research A diagnosis of schizophrenia lowers expectations of capability of patients, by providers, and reduces referrals to weight loss programmes. Greer Sullivan. J Clin Psych Bringing Together Physical and Mental Health. Naylor. The Kings Fund. 2016

10 SUMMARY OF HIDDEN COSTS The concept of schizophrenia is old and vague Schizophrenia is only ~30% of psychosis There is debate about the underlying causes of psychosis We don t even try to measure outcomes seriously We potentially over-treat with potentially toxic medications (Perhaps acute modes of treatment are continued too long) We may under-treat with psychological therapy and social activity (which is available in third sector) Physical health problems cause early death, probably in large part from avoidable causes like smoking and substance use