Schizophrenia in New Orleans

Ian Banks reports on schizophrenia at the American Psychiatry Association meeting in New Orleans (May 2001)

A black guy smoking something which faintly resembled tobacco, explained jazz to me. "It's like your mind" he exhaled, "You start out with it altogether, gradually it goes all to hell and then it gets itself all back together, man". By a strange twist of fate, New Orleans was also the venue for the annual conference of the American Psychiatric Association, where schizophrenia and barriers to care was high on the agenda.

Barriers to care

Delegates at that APA discussed how perhaps the biggest barriers to progress in mental health are stigma and ignorance. Contrary to fatalistic attitude, seen even among some medical practitioners, over 85% of patients can be treated successfully.

The media has a great deal to answer for with constant negative portrayal of mental illness. George Gerbner, professor of telecommunications at Temple University, said: "On television 45% of all characters are violent compared with 72% of the mentally ill characters. Mental illness is the only label on TV that renders women as violent as men. Most soaps are run on a shoe string budget so time is limited and mental illness provides a handy stereotype to establish a motive, but in realty, mental illness is a poor indicator of potential violence."

Even children's books are not innocent when it comes to stigmatising mental illness. In the highly acclaimed Harry Potter books, one character is termed 'mad' and hence 'a danger to anyone who crosses him'. Batman fights 'insane' criminals on a regular basis, from the Joker to the Penguin, and being insane is their hallmark.

In reality, people with a mental illness commit violent acts at about the same rate as people without mental illness. So it seems that the media are in need of education about mental illness and whilst conveying positive messages might be more time consuming, they could provide an interesting twist, for example, mentally ill people are seen to be an asset because of their personal experience by giving insight into the way people feel and think while in the throws of mental illness.

But there is also room for better management of mental illness. Patients with schizophrenia tend to be either reluctant or unable, in some cases, to report other problems and so tend to appear later for treatment. This is compounded by the male predilection for delayed presentation. They also tend to have less social support and can find conditions like diabetes and asthma deteriorating.

Treatment

Treating schizophrenia is not always straightforward. Some of our drugs might help the mental state but can add their own cocktail of problems, not least in weight gain and type II diabetes. Its not just that mental health services are still the Cinderella of the NHS which presents barriers to preventing co-morbidity in patients suffering from schizophrenia, it can be difficult to recognise, intervene and provide good healthcare for a battery of reasons.

Similarly, these patients suffer from a disproportionate level of health factors influencing their overall health and life expectancy, often only loosely linked to the mental state itself. Obesity is more common than in the general population only partly explained by the known weight gain effects of some drugs used in treating the mental illness. Diabetes and heart disease are also more prevalent. Again, there are known diabetogenic effects of medication but obesity is a significant factor. As they also tend to smoke more than the general population, it is not surprising that hypertension is also more common than average in this group. Detecting these conditions and influencing lifestyle for their prevention is not always easy.

A vicious cycle can build up with obesity, rising blood sugars and hypertension which then all need medical attention. Not surprisingly, this can adversely affect the mental state of the patient so that compliance falls and they end up as an acute admission. Some newer, so-called, 'atypical antipsychotics' such as ziprasidone, as yet unlicensed in the UK, have neutral effects on weight and diabetes. Their use can break this vicious cycle enabling maintenance in the community rather than all too frequent admission via the A&E department.

What came out very clearly from the APA conference was that the treatment of schizophrenia, from the first presentation, often in A&E, managing the immediate post acute phase and ensuring stability once they are returned to the community, needs joined up cooperation between A&E staff, psychiatrists and GPs. At the same time all the life-style issues must be addressed.

Cost will be a big factor for their use and a cynical cold knot inside me says that older cheaper drugs may still be around while suicides and death from diabetes, heart disease and hypertension all continue to rise in the mentally ill population. Louis Armstrong knew a thing or two about music that 'was like your mind going to hell'. He probably also had a few less musical things to say about inequality and stigma.