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Psychiatric care and politics.

Rates of readmission to psychiatric hospitals have increased in the past decade despite what are generally regarded as marked improvements in the quality of care. This is sufficient cause for us to re-examine the effectiveness and scope of current modes of treatment and to assess the value of the therapeutic efforts relevant to the patient's ability to function in his or her social system. Dr. George Voineskos' article in this issue of the Journal (page 247) deals with this problem. It is a timely article because, apart from confirming for Canada what recently has been shown in England and Scandinavia about factors affecting the former patient's adjustment in the community, the subject of readmission rates brings into focus some of the more critical issues of our professional history. I will examine some of these issues and review the importance of understanding relations and interactions of biologic, psychologic and social factors in the work of hospital-based psychiatrists. Medical school training before this decade usually took little account of the importance of the interaction of psyche and soma. Research, however, slowly is changing this situation. Factors that differentiate subgroups with high and low susceptibility to illness have been described by Hinckle and colleagues.1 They include the way in which situations are perceived and the personality of each person. Roghmann and Haggerty2 have linked stress to illness, and Holmes and Rahe3 have associated important events or changes in the person's life with physical illness. Friedman and Rosenman4 have studied the so-called type A and type B personalities and their differential association with cardiovascular disorders. A number of authors have noted that "5% of first contacts with primary care physicians have a primary diagnosis that is psychiatric, while 30% have a problem involving a significant psychiatric component" (C.B. Robinowitz: unpublished data, 1977). Bain and Spaulding2 have listed the 10 most common physical symptoms in order of their frequency in 400 patients seen consecutively in a medical outpatient clinic, and have shown that for 4 of these symptoms the cause was psychiatric in nearly 50% of patients. Large epidemiologic studies, such as Leighton's,6 have shown that in a population there are subgroups at high risk for illnesses of all types. These groups can be defined by an analysis of social and demographic variables. It is clear that patients are no less physically ill when the etiologic or sustaining factors responsible for their distress are psychosocial rather than biologic. Indeed, in many instances symptoms are merely the end-point of myriad possible etiologic pathways. All family practitioners deal with complex interactions of psyche and soma and usually are successful. However, a small number of patients require specialist consultation. The psychiatrist, as a medical specialist whose expertise lies in understanding the manner in which biologic, psychologic, social, cultural and environmental factors govern thinking and feeling and how they are subsequently expressed in behaviour, is trained for this task. The interaction of biopsychosocial factors is also of importance in the work of mental hospital psychiatrists. These physicians deal mainly with persons in our society who have incapacitating mental illnesses, many of which have a genetic basis.7 The extent of the problem with which the psychiatrists deal is attested to by large epidemiologic studies that have shown that approximately 5% of the population are functionally incapacitated by mental illness for long periods, while a much higher percentage are functioning at significantly less than optimal capacity.8-10 For example, a schizophrenic illness will affect approximately 1% . of the population and 10% of the offspring of two persons, one of whom is schizophrenic.12'" The toll of this suffering on the individual as well as on the national economic welfare is great. Usually the patient repeatedly admitted to a mental hospital has one of these "incapacitating" illnesses. He may, for example, hear alien voices or have thoughts and feelings that are beyond his control. At times his sense of helplessness, hopelessness and despair will reach such depths that self-destruction may seem the only means of relief. To talk of "the myth of mental illness" and the absolute necessity of consent with reference to this group of patients is not only specious, but also inhumane. These persons should have the right to be treated when their judgement and insight are so severely impaired that they are unable to ascertain that their symptoms differ from the norm, and when they are unable to carry out the simple activities of daily living or function in a manner that is not threatening to their health and welfare or that of others. Also, relatives should have the right to expect us to treat, for example, the paranoid patient, without being coerced into the undeniably dangerous position of giving permission for treatment to take place. These rights seem forgotten by today's self-styled libertarians. However, their demand that we be accountable for our work is valid. What has psychiatry to offer and how effective are our therapeutic endeavours? We can show a reduction in frequency of certain specific symptoms through the application of specific pharmacologic regimens neuroleptics, lithium, antidepressants and, to some extent, anxiolytics. However, we have not been able to prove that this reduction correlates with improved community adjustment and increased self-sufficiency. Estimates of rates of readmission to psychiatric facilities range from 20%