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Beyond clinical staging of psychiatric disorders

2015; Elsevier BV; Volume: 2; Issue: 10 Linguagem: Inglês

10.1016/s2215-0366(15)00377-6

2215-0374

Philipp Baumann, Régis Marion‐Veyron, Sabrina Bardy, Alessandra Solida, Philippe Conus,

Mental Health and Patient Involvement

Clinical staging is based on the concept that psychiatric illnesses progress over time through successive stages marked by symptoms of increased clarity and intensity.1McGorry P van Os J Redeeming diagnosis in psychiatry: timing versus specificity.Lancet. 2013; 381: 343-345Summary Full Text Full Text PDF PubMed Scopus (143) Google Scholar This model, which creates a framework in which mechanisms and early markers of illness can be studied,2Mcgorry PD Keshavan MS Goldstone S et al.Biomarkers and clinical staging in psychiatry.World Psychiatry. 2014; 3: 211-223Crossref Scopus (195) Google Scholar has also been proposed as a basis for the definition of safer and more proportionate treatments.1McGorry P van Os J Redeeming diagnosis in psychiatry: timing versus specificity.Lancet. 2013; 381: 343-345Summary Full Text Full Text PDF PubMed Scopus (143) Google Scholar, 2Mcgorry PD Keshavan MS Goldstone S et al.Biomarkers and clinical staging in psychiatry.World Psychiatry. 2014; 3: 211-223Crossref Scopus (195) Google Scholar Some have argued that the clinical staging model is, however, still a work in progress and it remains a theoretical exercise.3Malhi GS Rosenberg DR Gershon S Staging a protest!.Bipolar Disord. 2014; 16: 776-779Crossref PubMed Scopus (10) Google Scholar Although substantial benefits could be derived from this approach, we noted, when trying to apply it in a clinical setting, that current staging models could benefit from enrichment by methods borrowed from other areas of psychiatry. First, a potential consequence of attempting to classify patients according to stages in a medically oriented approach is to focus exclusively on symptoms and so-called problems rather than on resources,4Andresen R Oades L Caputi P The experience of recovery from schizophrenia: towards an empirically validated stage model.Aust N Z J Psychiatry. 2003; 37: 586-594Crossref PubMed Scopus (578) Google Scholar neglecting other dimensions that are nevertheless crucial to build recovery. Informing a patient about their “stage of illness” when it is still unclear whether downgrading is possible might be taken as a “prognosis of doom”, withdrawing hope of recovery or prospect of a fulfilling life.4Andresen R Oades L Caputi P The experience of recovery from schizophrenia: towards an empirically validated stage model.Aust N Z J Psychiatry. 2003; 37: 586-594Crossref PubMed Scopus (578) Google Scholar Second, stage-based models proposed so far are built mainly from a treatment provider's perspective and have put little emphasis on the crucial issue of the patient's attitude towards illness. Kenneth Kendler, in 2014, outlined the importance of shifting from a third-person to a first-person perspective and from explaining to understanding;5Kendler KS The structure of psychiatric science.Am J Psychiatry. 2014; 171: 931-998Crossref PubMed Scopus (67) Google Scholar this change is important in all domains of medicine, but probably more essential in psychiatry in which patients' disturbances can be central to their sense of identity.5Kendler KS The structure of psychiatric science.Am J Psychiatry. 2014; 171: 931-998Crossref PubMed Scopus (67) Google Scholar Along the same lines and perhaps even more crucial is that although staging should guide therapeutic choices, a patient's willingness or not to accept treatment will determine what can actually be put into action. Clinical staging models should therefore propose a set of strategies adapted to the various extents of insight and willingness to engage in treatment that a patient could display. People using early intervention methods are very much aware of this difficulty and have developed strategies based on youth friendly and flexible approaches6Bertolote J Mcgorry P Early intervention and recovery for young people with early psychosis: consensus statement.Br J Psychiatry. 2005; 187: s116-s119Crossref Scopus (223) Google Scholar to promote patient engagement. However, to the best of our knowledge, practical ways to adapt to this challenge have not been clearly detailed and incorporated in the clinical staging models reported so far. The recovery model might offer an interesting solution in this context. Developed by consumer movements in the 1980s, it emerged in response to the failure of mental health professionals to encourage a sense of hope and optimism in treatment, and aimed to promote the development of a positive partnership with consumers and family members.4Andresen R Oades L Caputi P The experience of recovery from schizophrenia: towards an empirically validated stage model.Aust N Z J Psychiatry. 2003; 37: 586-594Crossref PubMed Scopus (578) Google Scholar The recovery of a fulfilling life and a positive sense of identity does not necessarily depend on symptom remission,4Andresen R Oades L Caputi P The experience of recovery from schizophrenia: towards an empirically validated stage model.Aust N Z J Psychiatry. 2003; 37: 586-594Crossref PubMed Scopus (578) Google Scholar, 7Slade M Bird V Clarke E et al.Supporting recovery in patients with psychosis through care by community-based adult mental health teams (REFOCUS): a multisite, cluster, randomised, controlled trial.Lancet Psychiatry. 2015; 2: 503-514Summary Full Text Full Text PDF PubMed Scopus (88) Google Scholar and the results from Mike Slade and colleagues' recent trial7Slade M Bird V Clarke E et al.Supporting recovery in patients with psychosis through care by community-based adult mental health teams (REFOCUS): a multisite, cluster, randomised, controlled trial.Lancet Psychiatry. 2015; 2: 503-514Summary Full Text Full Text PDF PubMed Scopus (88) Google Scholar suggest that training staff to approach patients in a recovery perspective might improve functional outcome and reduce needs. The various stages of the recovery trajectory would provide the framework of an additional dimension (the patient's point of view) for which clinical approaches could be defined. In summary, we think that there is a need for a convergence of clinical staging and recovery models to take into account both of these dimensions when approaching a patient's illness. We thank the National Center of Competence in Research (NCCR) for the Synaptic Bases of Mental Diseases (SYNAPSY) financed by the Swiss National Science Foundation (number 51AU40_125759). We declare no competing interests.