Amisulpride

Value of diagnosis of schizophrenia remains in dispute

EDITOR--Proponents of clinical effectiveness in mental health argue that the problems of psychiatry Mil be solved by more focused research and a better flow of information from academics to clinicians. A good example of the limitations of this approach is McGrath and Emmerson's review article on the treatment of schizophrenia.[1] The authors fail to note that the diagnosis of schizophrenia remains in dispute. The concept has little explanatory power and is scientifically suspect.[2] Inclusion in the Cochrane Library does not make it any less controversial.

We are not convinced by their calls for prompt diagnosis. In recent years the word schizophrenia has increasingly taken on negative connotations in the public imagination. Telling a young person that he or she has schizophrenia can have devastating results. In our clinical work with patients we manage perfectly well without using the diagnosis at all. McGrath and Emmerson's review is devoted almost entirely to drug treatments, with only a small section on psychosocial interventions. Users complain that drugs are often all they receive when they are in crisis and in need of human interaction and practical support. Perhaps the affiliations noted as the authors' competing interests--substantial links with the pharmaceutical industry--go some way towards explaining their narrow vision.

We believe that the clinical effectiveness paradigm in mental health will do more harm than good if it is not balanced by a discourse on what we would call ethical issues. These issues are an examination of the values underlying diagnoses and treatments; a questioning of priorities in our work with people in crisis; an examination of the burden we often inflict with our diagnoses and treatments; and a genuine attempt to listen to what service users are telling us about the nature of care.

Pat Bracken consultant psychiatrist P.Bracken@Bradford.ac.uk

Philip Thomas consultant psychiatrist Department of Applied Social Studies, University of Bradford, Bradford BD7 1DP

[1] McGrath J, Emmerson WB. Treatment of schizophrenia. BMJ 1999;319:1045-8. (16 October.)

[2] Boyle M. Schizophrenia: a scientific delusion. London: Routledge, 1993.

What in fact is schizophrenia?

EDITOR--Without doubt the question "What is schizophrenia?" is a fascinating one. In their review article McGrath and Emmerson are bold enough to give an answer to the question,[1] but in my view it misses the mark by a mile. They attempt to list various neuropsychiatric symptoms and use broad terms (for example, "a group of illnesses"). They hope that one day the "cause of schizophrenia" will be made clear by the advances expected in the neurosciences. "Watch this space" they cry. But this will not do.

At the Bradford Home Treatment Service I have been involved in the care of people with acute and severe mental health problems, including those who would ordinarily be considered to have schizophrenia. The service has been able to work with, and help, these people without using the notion of schizophrenia at all. This has been done by taking a step back from the concept of a syndrome called schizophrenia and instead focusing on what the client is actually feeling, thinking, and experiencing.

Instead of trying to discover if a person has auditory hallucinations in an attempt to support a possible diagnosis of schizophrenia, we would want to learn of the person's voice hearing experience (asking such questions as "Can he or she describe the identity of the voices?", "What do the voices say?", "How does he or she cope with them?", "What is helpful and unhelpful in coping with them?"). Attempts are made to see a person's symptoms in the context of his or her life, not as evidence of some underlying neurochemical abnormality. This approach is certainly valued by our clients, and they report that it is more helpful and less abusive and stigmatising than traditional medical approaches.

I would recommend that the authors read Boyle's critique of the notion of schizophrenia.[2] In it she shows that the notion of schizophrenia is unsupported by scientific evidence and is unsustainable. Maintaining that schizophrenia exists is dishonest. It would be of more help to those in distress, and move forward the research effort to understand madness, if we stopped trying to fit their symptoms into a bogus diagnostic category.

J King clinical medical officer Bradford Home Treatment Service, Edmund Street Clinic, Bradford BD5 0BJ

[1] McGrath J, Emmerson WB. Treatment of schizophrenia. BMJ 1999;319:1045-8. (16 October.)

[2] Boyle M. Schizophrenia: a scientific delusion? New York: Routledge, 1990.

Review should have paid more attention to psychosocial interventions

EDITOR--I was concerned that McGrath and Emmerson's review on the treatment of schizophrenia focused mainly on the pharmacological management of schizophrenia, and in particular on the atypical antipsychotic drugs.[1] This presumably largely reflects the research and other stated interests of the authors in these more recently introduced agents.

I am certainly a proponent of many of these drugs, particularly because their greater tolerability compared with the tolerability of standard drugs should produce enhanced compliance. But other treatment modalities seem to have been given short shrift. In this enlightened age psychosocial interventions should surely not be "outside the scope" of any review on the treatment of schizophrenia. The authors could have usefully outlined some of the techniques used in cognitive behavioural interventions and considered the role of family interventions, although a recent Cochrane review casts doubt on the efficacy of family interventions.[2] As the article focused on the atypical antipsychotics, it was surprising that only some of the agents currently available were considered, notable exceptions being amisulpride and zotepine. Because of the authors' stated links with companies producing many of these products, these omissions might lay them open to criticism. In addition, while commenting on the advantages of the atypical antipsychotics, the authors neglect to mention the cost implications of their widespread use.

Certainly in the United Kingdom, as long as rationing exists, there will be pressure on doctors to think twice before prescribing new treatments that are considerably more expensive than standard treatments.

Erik C R Milner locum consultant in psychiatry Michael Carlisle Centre, Nether Edge Hospital, Sheffield S11 9BF E.Milner@Sheffield.ac.uk

[1] McGrath J, Emmerson WB. Treatment of schizophrenia. BMJ 1999;319:1045-8. (16 October.)

[2] Pharoah FM, Mari JJ, Streiner D. Family intervention for schizophrenia (Cochrane review). In: Cochrane Collaboration. Cochrane library. Issue 3. Oxford: Update Software, 1999.

Review was based on fashion, not evidence

EDITOR--In reviewing the treatment of schizophrenia McGrath and Emmerson make several statements that are difficult to justify.[1] At best their review is based on a selective reading of the literature; at worst it reflects how fashion can have a greater impact on prescribing than evidence from randomised controlled trials, systematic reviews, and meta-analyses (grade I evidence). This probably relates to their use of a series of clinical practice guidelines that consist of non-systematically gathered evidence and the opinions of distinguished experts (grade IIIb evidence).

The authors state that new antipsychotic drugs should be prescribed as early in the course of schizophrenia as possible, are the treatment of first choice for schizophrenia of recent onset, "obviously" improve quality of life, may reduce the rate of relapse, and should be continued for at least five years in those with two or more episodes. There is no good evidence for any of these statements.

None of the Cochrane reviews they cite addresses any of these issues. The new antipsychotics may reduce side effects, but most, or even all, of this apparent benefit may be attributable to comparisons of relatively low doses of new and high doses of old antipsychotics in the randomised controlled trials. A sensitivity analysis in one of the meta-analyses they cite makes this clear.[2] There is certainly no evidence that the new drugs improve quality of life or reduce relapse rates. Maintenance treatment can only be justified for 9-12 months on evidence from systematic reviews of randomised controlled trials (of old antipsychotics).[3] There are no published randomised controlled trials that directly address the value of early treatment in schizophrenia or its prodrome.

In short, McGrath and Emmerson recommend dramatically extending the indications for antipsychotic treatment to before schizophrenia develops and for five years after a second episode. They advocate new and relatively unproved treatments, rather than the cheaper and more thoroughly assessed older drugs, on the basis of dubious claims of fewer side effects.

Andrew McIntosh lecturer, Edinburgh University Department of Psychiatry andrew.mcintosh@ed.ac.uk

Sanjay Rao senior house officer

Stephen Lawrie senior clinical research fellow, Edinburgh University Department of Psychiatry Royal Edinburgh Hospital, Edinburgh EH9 1RJ

[1] McGrath J, Emmerson WB. Treatment of schizophrenia. BMJ 1999;319:1045-8. (16 October.)

[2] Kennedy E, Song F, Hunter R, Clark A, Gilbody S. Risperidone versus typical antipsychotic medication for schizophrenia. In: Cochrane Collaboration. Cochrane library. Oxford: Update Software, 1999.

[3] Gilbert PL, Harris MJ, McAdams LA, Jeste DV. Neuroleptic withdrawal in schizophrenic patients. A review of the literature. Arch Gen Psychiatry 1995;52:173-88.

Authors' reply

EDITOR--We are pleased that several correspondents agree with our recommendations about the importance of psychosocial treatments for schizophrenia. As clinicians delivering and evaluating psychosocial treatments we share the correspondents' advocacy for these interventions on the basis of the robust evidence supporting their use. But to suggest that the relative amount of text we devoted to the new antipsychotic drugs versus psychosocial treatments is proportional to the quality of the evidence base for each, or even the strength of our recommendations of each, is inaccurate. Our article is described in the opening sentence as a selective review, with the scope of the article clearly outlined in the first paragraph.

Bracken and Thomas and King question the validity of schizophrenia as a diagnosis. As in many areas of medicine with an imperfect knowledge base, we have to use interim diagnostic labels based on best available evidence. We are not sure why they link the imprecision of current diagnostic practice with "ethical issues" and with the importance of understanding the impact of psychotic illness on the individual. We agree that good clinical practice should be able to balance uncertainty of diagnosis and the broad range of "meta-issues" related to designing optimal mental health services, and that the input of consumers is essential to this process.

Other topics related to care in schizophrenia are equally deserving of detailed review. In particular, both psychosocial interventions and drugs need to be embedded in a balanced and integrated programme of mental health services, accommodation services, vocational rehabilitation, and disability support. Many patients remain symptomatic and very disabled despite optimal treatment, and reducing their suffering requires a whole community approach.[1] This report also draws attention to the unmet needs of those with psychosis and substance abuse or dependence. This topic alone warrants a separate, detailed review.

We regret that we could not cover all the recently introduced antipsychotic drugs available worldwide in the space available. Readers who have access to drugs not included in our review are urged to consult the Cochrane Library for updates on these products. Cochrane reviews will soon be available on sertindole, ziprasidone, molindole, loxapine, and amisulpride. There will also be new reviews of psychosocial and service related interventions in future editions, including one on the efficacy of cognitive rehabilitation in schizophrenia cowritten by one of us (JM).

McIntosh et al correctly show that many of the areas of treatment of schizophrenia lack evidence derived from randomised controlled trials. We agree that such data are needed.[2] Meanwhile, wide confidence intervals should be placed on much of what we do in caring for people with schizophrenia.

John McGrath director Queensland Centre for Schizophrenia Research, Wolston Park Hospital, Wacol, Q4076, Australia jjm@brain.wph.uq.edu.au

W Brett Emmerson director Division of Mental Health Services, Royal Brisbane Hospital and District Health Service, Herston, Q4029, Australia

[1] Jablensky A, McGrath J, Herrman H, Castle D, Gureje O, Morgan V, et al. People living with psychotic illness: an Australian study 1997-98. Commonwealth of Australia, 1999. (This report can be downloaded from www.health.gov.au/hsdd/mentalhe/pubs/psych.htm.)

[2] McGrath J, McGlashan T. Improving outcomes for recent-onset psychoses: disentangling hope, speculation and evidence. Acta Psychiatrica Scand 1999;100:83-4.

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