Letter to the editor
Reply DOI: 10.1111/acps.12246
DSMs are no more than a useful communication tool and guide to diagnosis. They were never meant to be worshipped as a ‘bible’ of psychiatry or to reduce the complexity of diagnostic evaluation into a mindless checklist of symptoms. Hippocrates said, ‘it is just as important to know the patient who has the disease as the disease the patient has’. And experience teaches that DSM diagnosis captures populations that are too heterogeneous for optimal biological research. Simpler symptom targets may provide clearer answers, for example it may be more fruitful to study the generation of auditory hallucinations than to try to understand the varied presentations of we now call ‘schizophrenia’. All this said, a DSM approach is a necessary way station until we have a clearer understanding of psychopathology, and this will be the slow work of many decades. The brain is the most complicated thing in the universe and reveals its secrets slowly. In the meantime, we need a DSM to provide a common language and to help guide treatment and clinical research. I would not trust a clinician who relied exclusively on DSM (or ICD) definitions, but I would also worry about one who didn’t know them at all.
All psychiatric diagnosis is to some degree culture bound. The Talmud says: ‘we don’t see things as they are; we see things as we are’. Mental disorders are provisional constructs very much influenced by the time, place and social context in which they are formulated. Human beings are much more alike everywhere than we are different, but the best way of understanding and sorting symptoms may vary and cultural insensitivity can lead to bad mistakes and overdiagnosis. DSM 5 erred by adding a number of untried new diagnoses that will be very common in the general population. We already have diagnostic inflation and excessive use of psychotropic medicine for milder and self-limited problems that are better left alone or treated with brief psychotherapy. DSM 5 threatens to turn this into diagnostic hyperinflation. I therefore caution against using any of the new diagnoses introduced by DSM 5. A. Frances Department of Psychiatry, Duke University, Chair DSM IV Task Force, Durham, NC, USA E-mail: [email protected]
Improving somatic health in severe mental illness DOI: 10.1111/acps.12232 We read with interest the article titled ‘Evaluating interventions to improve somatic health in severe mental illness: a systematic review’ published in your journal in the October 2013 issue (1). The authors have not mentioned why they chose to include studies published between the years 2000 and 2011. We presume that it might have been related to paucity of studies prior to the year 2000 and varying methodologies of studies over time leading to decreased comparability. Of the 22 studies that were reviewed, 11 described cardiometabolic risk factors as one of the outcome measures of which six clearly mention weight change as well. We wonder why some of these cardiometabolic risk factors, say weight change, could not have been the focus of review if other measures were totally incomparable. Even if summary effects could not be calculated, based on their review, the authors could have provided some conclusions regarding the relative efficacy of the four interventions described in the paper. For instance, Das et al. (2) critically reviewed studies on weight gain in schizophrenia and the impact of behavioural and pharmacological interventions on the same. They went on to do a meta-analysis and were able to conclude that among the behavioural interventions, nutritional
236
counselling and exercise had the most evidence although efficacy was modest. A Cochrane review by Gorczynski & Faulkner (3) examined the impact of exercise in patients with schizophrenia. Although the authors noted that studies included in their review were small and used various measures of physical and mental health, it was still possible to conclude that exercise was possible and beneficial in schizophrenia. However, the authors of the current paper chose to conclude by merely suggesting that the studies are not comparable, and hence, no conclusions can be drawn. Also, besides the study summary provided in the tables, there is no discussion of the reasons why apparently similar outcome measures (e.g. cardiometabolic risk factors/weight changes) across studies were not similar enough to provide even preliminary conclusions. Limitations of individual studies as well as the author’s assessment of the methodological rigour of individual studies are also not mentioned. Thus, besides brief conclusions of the individual quoted studies, one does not get to know more including whether these conclusions are indeed valid. So from a clinician’s perspective, the reader is left disappointed at the end of the paper without any kind of clinically useful message. Thus, the paper does not seem to deliver what the title seems to suggest.
Letter to the editor S. Prakash and P. Mandal Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India E-mail: [email protected]
References 1. van Hasselt FM, Krabbe PFM, van Ittersum DG, Postma MJ, Loonen AJM. Evaluating interventions to improve
somatic health in severe mental illness: a systematic review. Acta Psychiatr Scand 2013;128:251–260. 2. Das C, Mendez G, Jagasia S, Labbate LA. Second-generation antipsychotic use in schizophrenia and associated weight gain: a critical review and meta-analysis of behavioural and pharmacologic treatments. Ann Clin Psychiatry 2012;24:225–239. 3. Gorczynski P, Faulkner G. Exercise therapy for schizophrenia. Cochrane Database Syst Rev 2010;5:1–45.
Reply DOI: 10.1111/acps.12237 Drs Prakash and Mandal’s comment on our study reviewing interventions to improve somatic health in severe mental illness (1) raises an important question, namely why we have not focused in our review study more on the weight and/or metabolic syndrome. However, we have deliberately chosen to present an overview of interventions improving the physical health of patients with SMI from a broad perspective. For clinical practice, the need to approach the somatic health of these patients from a broad perspective has been clearly stated earlier (2). We think this should also be applied to research. This perspective should be chosen because the somatic health of these patients is reduced due to multiple factors; patient- and illness-related, treatment-related, psychiatrist/physician-related and service-related factors (3). These factors lead to an increased risk of not only cardiovascular disease but other diseases like sexual dysfunction, infectious disease and impaired lung function as well (4). Our review shows the diverse efforts to reduce the development of these diseases through health education, exercise, smoking cessation and changes in healthcare organisation (1). Concluding, patients with SMI are more at risk to have multiple interrelated risk factors that potentially lead to multiple diseases which can be reduced with several types of interventions. This is reflected in the multiple types of interventions and the broad array of outcome measures, which is clearly shown in our review. Reducing this to a meta-analysis of the effect on weight would be an oversimplification of this complex reality. We share their disappointment that we cannot give a clear advice on which of these interventions is best to
implement as a clinician. However, this is not due to our methods, but due to the lack of comparable outcome measures in the empirical studies conducted so far. A. J. M. Loonen University of Groningen, Groningen, the Netherlands E-mail: [email protected]
References 1. van Hasselt F, Krabbe P, van Ittersum D, Postma M, Loonen A. Evaluating interventions to improve somatic health in severe mental illness: a systematic review. Acta Psychiatr Scand 2013;128:251–260. 2. Fleischhacker WW, Cetkovich Bakmas M, De Hert M et al. Comorbid somatic illnesses in patients with severe mental disorders: clinical, policy, and research challenges. J Clin Psychiatry 2008;69:514–519. 3. de Hert M, Cohen D, Bobes J et al. Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level. World Psychiatry 2011;10:138–151. 4. de Hert M, Correll CU, Bobes J et al. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry 2011;10:52–77.
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Reply DOI: 10.1111/acps.12246
DSMs are no more than a useful communication tool and guide to diagnosis. They were never meant to be worshipped as a ‘bible’ of psychiatry or to reduce the complexity of diagnostic evaluation into a mindless checklist of symptoms. Hippocrates said, ‘it is just as important to know the patient who has the disease as the disease the patient has’. And experience teaches that DSM diagnosis captures populations that are too heterogeneous for optimal biological research. Simpler symptom targets may provide clearer answers, for example it may be more fruitful to study the generation of auditory hallucinations than to try to understand the varied presentations of we now call ‘schizophrenia’. All this said, a DSM approach is a necessary way station until we have a clearer understanding of psychopathology, and this will be the slow work of many decades. The brain is the most complicated thing in the universe and reveals its secrets slowly. In the meantime, we need a DSM to provide a common language and to help guide treatment and clinical research. I would not trust a clinician who relied exclusively on DSM (or ICD) definitions, but I would also worry about one who didn’t know them at all.
All psychiatric diagnosis is to some degree culture bound. The Talmud says: ‘we don’t see things as they are; we see things as we are’. Mental disorders are provisional constructs very much influenced by the time, place and social context in which they are formulated. Human beings are much more alike everywhere than we are different, but the best way of understanding and sorting symptoms may vary and cultural insensitivity can lead to bad mistakes and overdiagnosis. DSM 5 erred by adding a number of untried new diagnoses that will be very common in the general population. We already have diagnostic inflation and excessive use of psychotropic medicine for milder and self-limited problems that are better left alone or treated with brief psychotherapy. DSM 5 threatens to turn this into diagnostic hyperinflation. I therefore caution against using any of the new diagnoses introduced by DSM 5. A. Frances Department of Psychiatry, Duke University, Chair DSM IV Task Force, Durham, NC, USA E-mail: [email protected]
Improving somatic health in severe mental illness DOI: 10.1111/acps.12232 We read with interest the article titled ‘Evaluating interventions to improve somatic health in severe mental illness: a systematic review’ published in your journal in the October 2013 issue (1). The authors have not mentioned why they chose to include studies published between the years 2000 and 2011. We presume that it might have been related to paucity of studies prior to the year 2000 and varying methodologies of studies over time leading to decreased comparability. Of the 22 studies that were reviewed, 11 described cardiometabolic risk factors as one of the outcome measures of which six clearly mention weight change as well. We wonder why some of these cardiometabolic risk factors, say weight change, could not have been the focus of review if other measures were totally incomparable. Even if summary effects could not be calculated, based on their review, the authors could have provided some conclusions regarding the relative efficacy of the four interventions described in the paper. For instance, Das et al. (2) critically reviewed studies on weight gain in schizophrenia and the impact of behavioural and pharmacological interventions on the same. They went on to do a meta-analysis and were able to conclude that among the behavioural interventions, nutritional
236
counselling and exercise had the most evidence although efficacy was modest. A Cochrane review by Gorczynski & Faulkner (3) examined the impact of exercise in patients with schizophrenia. Although the authors noted that studies included in their review were small and used various measures of physical and mental health, it was still possible to conclude that exercise was possible and beneficial in schizophrenia. However, the authors of the current paper chose to conclude by merely suggesting that the studies are not comparable, and hence, no conclusions can be drawn. Also, besides the study summary provided in the tables, there is no discussion of the reasons why apparently similar outcome measures (e.g. cardiometabolic risk factors/weight changes) across studies were not similar enough to provide even preliminary conclusions. Limitations of individual studies as well as the author’s assessment of the methodological rigour of individual studies are also not mentioned. Thus, besides brief conclusions of the individual quoted studies, one does not get to know more including whether these conclusions are indeed valid. So from a clinician’s perspective, the reader is left disappointed at the end of the paper without any kind of clinically useful message. Thus, the paper does not seem to deliver what the title seems to suggest.
Letter to the editor S. Prakash and P. Mandal Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India E-mail: [email protected]
References 1. van Hasselt FM, Krabbe PFM, van Ittersum DG, Postma MJ, Loonen AJM. Evaluating interventions to improve
somatic health in severe mental illness: a systematic review. Acta Psychiatr Scand 2013;128:251–260. 2. Das C, Mendez G, Jagasia S, Labbate LA. Second-generation antipsychotic use in schizophrenia and associated weight gain: a critical review and meta-analysis of behavioural and pharmacologic treatments. Ann Clin Psychiatry 2012;24:225–239. 3. Gorczynski P, Faulkner G. Exercise therapy for schizophrenia. Cochrane Database Syst Rev 2010;5:1–45.
Reply DOI: 10.1111/acps.12237 Drs Prakash and Mandal’s comment on our study reviewing interventions to improve somatic health in severe mental illness (1) raises an important question, namely why we have not focused in our review study more on the weight and/or metabolic syndrome. However, we have deliberately chosen to present an overview of interventions improving the physical health of patients with SMI from a broad perspective. For clinical practice, the need to approach the somatic health of these patients from a broad perspective has been clearly stated earlier (2). We think this should also be applied to research. This perspective should be chosen because the somatic health of these patients is reduced due to multiple factors; patient- and illness-related, treatment-related, psychiatrist/physician-related and service-related factors (3). These factors lead to an increased risk of not only cardiovascular disease but other diseases like sexual dysfunction, infectious disease and impaired lung function as well (4). Our review shows the diverse efforts to reduce the development of these diseases through health education, exercise, smoking cessation and changes in healthcare organisation (1). Concluding, patients with SMI are more at risk to have multiple interrelated risk factors that potentially lead to multiple diseases which can be reduced with several types of interventions. This is reflected in the multiple types of interventions and the broad array of outcome measures, which is clearly shown in our review. Reducing this to a meta-analysis of the effect on weight would be an oversimplification of this complex reality. We share their disappointment that we cannot give a clear advice on which of these interventions is best to
implement as a clinician. However, this is not due to our methods, but due to the lack of comparable outcome measures in the empirical studies conducted so far. A. J. M. Loonen University of Groningen, Groningen, the Netherlands E-mail: [email protected]
References 1. van Hasselt F, Krabbe P, van Ittersum D, Postma M, Loonen A. Evaluating interventions to improve somatic health in severe mental illness: a systematic review. Acta Psychiatr Scand 2013;128:251–260. 2. Fleischhacker WW, Cetkovich Bakmas M, De Hert M et al. Comorbid somatic illnesses in patients with severe mental disorders: clinical, policy, and research challenges. J Clin Psychiatry 2008;69:514–519. 3. de Hert M, Cohen D, Bobes J et al. Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level. World Psychiatry 2011;10:138–151. 4. de Hert M, Correll CU, Bobes J et al. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry 2011;10:52–77.
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