Transcending false dichotomies and diagnostic silos to reduce disease burden in mental disorders
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COMMENTARY
Transcending false dichotomies and diagnostic silos to reduce disease burden in mental disorders Patrick D. McGorry1,2 · Barnaby Nelson1,2 · Stephen J. Wood1,2,3 · Jai L. Shah4,5,6 · Ashok Malla4,5,6 · Alison Yung1,2,7 Received: 24 September 2019 / Accepted: 30 June 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020
Introduction The at-risk mental state (ARMS) strategy for psychosis, although highly influential, remains contested, with recent critiques suggesting that it should be replaced with a public health/primary prevention approach. Implicit in these is a pessimistic stance towards treatment, constrained by the tenacious bias of the “soft bigotry of low expectations”, which denies or discounts the positive evidence base that now exists. We argue that this is a classic example of the self-defeating false dichotomies and binary thinking that have impeded progress in psychiatry. In this commentary, we contend that secondary and tertiary prevention efforts have a crucial role in reducing disease burden through prevalence reduction and disease modification, and in no way conflict with the holy grail of primary prevention. We regard a preventive or public health strategy as essential for all stages of mental illness, just as it is in other non-communicable diseases (NCDs). We see the ARMS concept, as a prototype and gateway for the clinical staging model which represents * Patrick D. McGorry [email protected] 1
Orygen, 35 Poplar Rd (Locked Bag 10), Parkville, VIC 3052, Australia
2
Centre for Youth Mental Health, The University of Melbourne, Parkville, Australia
3
School of Psychology, University of Birmingham, Birmingham, UK
4
Department of Psychiatry, McGill University, Montreal, Canada
5
Prevention and Early Intervention Program for Psychosis (PEPP), Douglas Mental Health University Institute, Montreal, Canada
6
ACCESS Open Minds, Douglas Mental Health University Institute, Montreal, Canada
7
School of Health Sciences, University of Manchester, Oxford Rd, Manchester M13 9PL, UK
the basis for a viable public health strategy with the goal of reducing incidence, prevalence, and disease impact for not only psychotic disorders, but across the full spectrum of mental and substance use disorders.
Beyond binary Prevention and treatment in mental disorders have the same end goal as in physical illness, namely the reduction of disease burden and improvement of quality of life, personal wellbeing and productivity. However, psychiatry constantly falls into the trap of setting up false dichotomies and is plagued by binary thinking which the other major NCDs seem to have transcended. The most fundamental example is the mind–body split, which creates constant tension between biological and psychosocial perspectives on mental illness. Earlier critiques of early intervention for psychosis pitted it against treatment for chronic schizophrenia e.g., Castle [1], and more recently a series of critiques and metanalyses of the ARMS strategy perpetuate this conceptual erro
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