How Psychiatric Nosology can advance Prevention in Mental Health.
Professor S. Rajkumar University of Newcastle Bloomfield Hospital – Australia
Presented in the symposium entitled: “The Construction Of Future International Classification and Diagnostic Systems” Part 1
World Psychiatric Association Athens Conference on Advances in Psychiatry 12-15 March 2005
Classification and prevention
Focus of presentation 1. Where are we in regard to classification? 2. What is the current state of knowledge on prevention? 3. How can nosology contribute to better prevention strategies?
Where are we in regard to classification?
Historical perspective Emerging concepts and trends towards DSM V and ICD-11 How best to make it relevant to prevention?
Historical perspective
Despite the plurality of perspectives and serial revisions, psychiatric classification has contributed significantly to the understanding of illness, its diagnosis, course and outcome. Foundations in ontology of disease, rise of mechanistic philosophy and application to medicine increased applicability to a range of countries and cultures.
DSM and ICD Classification
Progressive and changing and yet “moving targets” in some regard. Prodromal, early features of illness (e.g. Psychosis) Ethical ramifications on commencing treatment, based on probabilities. Issues relating to caseness – staging – outcome.
Controversies in psychiatric nosology
Mad vs bad Drug & alcohol – dealt often as addictive disorders Disorder vs disease concept State vs trait Emotional vs mental well-being Medical / psychiatric / social diagnosis Psychiatric vs neurologic disorders
Health and well-being
Disease is a biological event characterised by anatomic, physiologic or biochemical changes or by a mixture of these Illness is a subjective experience consisting of an array of discomforts and psychosocial dislocations, resulting from the interactions of a person with the environment
Complex issues in classification
Several behavioural, psychological, social problems need mental health intervention and yet are not discrete mental illnesses. Violence; teenage pregnancy; borderline personality and poor adjustment. Children – saddled with adult diagnostic criteria – complicated behaviours; multiple causal factors. The complex issues of co-morbidity (Issues re: drugs & alcohol, and other physical illness).
Prevention
Essentially aims to reduce burden and enhance well-being. Historically known for 100 years- mental hygiene movement Science based intervention emerged in 1980, based on risk and protective factors. Hence primary prevention, as seen in modern days, focuses on malleable individual, social and environmental determinants.
Prevention
Earlier times, primary prevention meant intervention before the outset of symptoms. Presently the classification has subtypes of universal, selective and indicated prevention. It incorporates mental health promotion, early intervention, continuing care
The spectrum for interventions of mental health problems and mental disorders
What next ?
The full reports
Promoting Mental Health: Concepts, Emerging Evidence, Practice. A Report from the World Health Organisation, Department of Mental Health and Substance Abuse in collaboration with the Victorian Health Promotion Foundation (VicHealth) and The University of Melbourne
Herrman H, Saxena S & Moodie R. Geneva, WHO
Prevention of Mental Disorders: Effective Interventions and Policy Options. A Report of the World Health Organization, Department of Mental Health and Substance Abuse in collaboration with the Prevention Research Centre of the Universities of Nijmegen and Maastricht. Eds Oxford, Oxford University Press.
Clemens Hosman, Eva Jané-Llopis, Shekhar Saxena
Challenging issues
Personality problems Co-morbidity Minimise logical errors of causation
A before B does not mean A causes B.
Patho physiology versus patho etiology Depression as an example.
Spectrum of depression disorders
Consensus conference on MDD Clinical continuum, extending from SD symptoms through minor depression to major depression
Spectrum on depression disorders
Spectrum of mood disorders Soft bipolar spectrum redefined Cyclothymic Anxious-sensitive Impulse dyscontrol Binge eating
Spectrum of depression disorders
Mood incongruent bipolar psychosis Bipolar 1 (mania) Mixed manic state (> 2 depressive symptoms) Bipolar II (hypomania > 2 days) Somatic treatment – induced hypomania or mania (bipolar III) Cyclo thymic disorder (borderline personality) Recurrent brief hypomania
Akiskal, et al.(2001)
Spectrum of depression disorders
Strong confluence of scientific evidence, bases on community and patient populations, that SD symptoms are associated with significant increases in psycho-social impairment
Spectrum of depression disorders
Subthreshold depressions
Subsyndromal depressive (SD) symptoms Associated with psychosocial impairment and disability
Spectrum of depression disorders
Shifting concepts in depression Reactive Neurotic Dysthymias Major/Endogenous Psychotic MDD
Relevance of nosology for preventive intervention
Focus ought to be on risk factors
possibly attributable risk
Protective factors
genetic/ biologic markers or social capital and social support
Incorporate disability/ burden and quality of life Need for conceptual clarity on comorbidity; positive health versus illness.
Relevance of nosology for preventive intervention
Disease specific clarity required
Prodrome / early psychosis (when to treat or not)
Stressors contributing to the clinical conditions need calibration –
individual, interactional and community stressors (such as causal trajectories operating for diverse cultures).
Relevance of nosology to prevention
Major advances in valid and reliable psychiatric classifications is a pre-requisite in the understanding of mental disorders across life span. These are empirically derived and somewhat arbitrary, and do not necessarily improve the process of making a diagnosis for a particular individual.
P12. Mrazek P.J and Haggerty (Ed) Reducing Risk for Mental Disorders. Institute of Medicine 1994
Relevance of nosology for preventive intervention
Need for measures of positive mental health and illness – to differentiate medical / social problems, trait versus syndromal state; vulnerability to suicide and violence. Need to minimise theoretical controversies and conflicts on Axis 1 and Axis 2.
Relevance of nosology for preventive intervention
Need for a classification valid and relevant global intervention programs.
(450 million people suffer from mental disorder the world over)
The need for a classification that can be used effectively to promote mental health globally.
(>6 billion people in the world)