No More Psychiatric Labels
Child psychiatrist Sami Timimi is calling for the abolition of formal psychiatric diagnostic systems because he says they have failed to advance our understanding or treatment of mental disorder. He outlines below his reasons for reaching this conclusion.Unlike the rest of medicine, psychiatric
diagnoses have failed to connect their diagnoses with any causes. There are no physical tests that can provide evidence
for a diagnosis. Diagnoses in psychiatry are descriptions of sets of behaviours that often go together. By itself a psychiatric
diagnosis cannot tell you about the cause, meaning or best treatment. Even the descriptions of behaviours have large
crossovers between them. For example, ‘distractibility’ can be found in diagnoses such as ADHD, anxiety, depression, and
autism, as can aggression, difficulties with making peer relationships, and agitation. This problem is predictable
when the basis for the categories is only symptoms (behaviours) and not signs (measurable physical differences). If, as
now seems likely, our diagnoses do not reflect real differences in our biology, then there is always a potential to do harm if we use them as if they tell us something about the cause. For example, if we believe that when a doctor makes a diagnosis of ADHD they have discovered some real life-long abnormality in
that child’s brain, we may accidentally lower everyone, including that child’s, expectation of what they can achieve.
Using psychiatric diagnosis does not aid treatment decisions
A positive outcome for treatment of psychiatric disorders is most strongly related to factors outside of treatment (such as social circumstances) and in treatment the strongest association is with developing a good therapeutic relationship with the clinician. Matching the diagnosis with a specific treatment
(whether a specific drug or specific psychotherapy) has an insignificant effect.
Long-term prognosis for mental health problems has got worse
Unlike the rest of medicine, no overall improvement in mental health outcomes has been achieved in developed countries
over the past half century. Some studies indicate the opposite; that compared to a few decades ago there are more patients
who have developed chronic conditions such as chronic schizophrenia than in the past. This is particularly so for young
people, more of whom are being labelled as having a long-term disability because of a mental condition than ever before,
with rates of psychiatric medication being prescribed to children rising year-on-year without any accompanying evidence that their long-term outcomes are improving.
Use of psychiatric diagnosis increases stigma.Surveys of public attitudes toward mental illness have found an increase in Western countries in the number of people who believe that mental illnesses are like other illnesses and caused by biological
abnormalities such as a “chemical imbalance” in the brain. However, the “illness like any other illness” model is overwhelmingly associated with stigmatising attitudes such as a belief that patients are unpredictable and dangerous, increasing the likelihood of wanting to avoid interacting with them.
It imposes Western beliefs about mental distress on other cultures. Countries around the world are being encouraged to adopt Western beliefs and to recognise diagnoses like
ADHD, depression and schizophrenia.
However, outcomes, particularly for more severe mental conditions, have been consistently better in developing
countries than developed ones. Several international studies have also concluded that the greater the inequality (in
economic and social resources) in any society, the poorer the mental health.
In the process of encouraging the adoption of Western psychiatric models, we not only imply that those cultures
that are slow to take up these ideas are‘backward’, but we may also undermine effective local practices and distract
attention from factors that do make a difference to mental health such as economic ones.
Alternative evidence-based models for organising effective mental health care are available. We already know about many factors associated with greater likelihood of developing mental distress such as trauma (particularly early childhood trauma), adversity, socio-economic inequality, lifestyle and family
functioning. In addition, rating levels of impairment and distress would provide a more accurate and less stigmatising wayo f categorising mental health problems than using psychiatric labels.
The message from research into outcomes from treatment of mental health problems is that using diagnosticcategories to choose treatment models makes little difference, but concentrating on developing meaningful relationships with service users does. Service users, including young people, need to be active collaborators in their recovery.
Furthermore, the biggest impact on outcomes comes from factors outside treatment such as the social circumstances
and levels of support. Evidence-based services need to learn how to work with the lived reality people experience, not
just the space between the ears.
A more mature understanding of mental distress that is not based on wishful thinking or prejudice will recognise that mental health concerns us all. Campaigns like ‘One in Four’ will then become redundant.
Mental health is a part of all our lives – the more important campaign is ‘One in One’ with psychiatric labels no longer used. !
For more see www.criticalpsychiatry.net
Sami Timimi is Consultant Child
and Adolescent Psychiatrist and Director of Medical Education
at Lincolnshire Partnership
Foundation NHS Trust