What does it mean to say that Stephen Fry's diagnosis has been changed from cyclothymia to bipolar I?

In the recent documentary, The not so secret life of the manic depressive: 10 years on, (see previous post), Stephen Fry's psychiatrist changes his diagnosis from cyclothymia to bipolar I. The implication seem to be that Fry's problems, which may have previously been put down to his personality, are now seen as being due to a real mental illness, whatever that is. 

Does this make any sense? Psychiatric formulation should be about more than a single word diagnosis (see previous post). This doesn't always happen in practice (see another previous post) and patients often complain that psychiatrists don't listen to their story and are just interested in "the diagnosis" and medication. I have also mentioned before my concern about how the diagnosis of bipolar disorder has expanded over recent years (see eg. another previous post), so that its meaning is less clear. Maybe Stephen Fry should resist the extension of his diagnosis. 

The programme makes a distinction between Stephen Fry's symptoms, which tend to be internal to himself, and the presentation of Alika (see his story), which led to him being detained under the Mental Health Act in a manic state. By the way, Alika recovered from this episode, whereas Fry still talks about the problems he has with his "mood swings". Maybe it's better not to classify Fry's presentation in the same way as Alika's, which is what the change to bipolar I might imply. 

Whether Stephen Fry's diagnosis is better understood as cyclothymia or bipolar I, the psychological formulation of his problems in terms of aetiology is still the same. In a way, the single-word diagnosis is the less important part of a formulation. It's only a word used to try and pigeon-hole his difficulties. It doesn't really help him to make sense of them.

Complaining about the dominance of the biomedical model

There have been complaints about the coverage of mental health problems in the recent BBC series In the mind (see open letter). This is because of the lack of challenge to the idea that mental health problems are necessarily manifestations of biological illness. For example, Richard Bentall has also published his open letter to Stephen Fry, who presented the keynote documentary in the series, The not so secret life of the manic depressive: Ten years on. The other main documentary was My baby, psychosis and me. 

This blog has been written to critique the biomedical way of understanding mental health problems. So, you might think I would want to join the list of complainants about the programmes. However, I do not think the Stephen Fry programme explicitly stated that mental health problems are distinct brain conditions. True, psychiatrists are featured in the programme who almost certainly hold that view and the programme did not question this. But I think the programmes were designed to show what's happening in mental health services and, to my mind, the two documentaries did that. However much I wish it wasn't the case, the biomedical view of mental illness is clearly dominant in current practice. Furthermore, the publication of my edited book Critical psychiatry: The limits of madness was intended to try to move beyond the polarisation in the debate about mental illness. I just think that complaining about the programmes is not the most constructive way forward and, in a way, misses the point. 

After all, the documentaries clearly allowed the patients, including Stephen Fry, to explain their perspectives. In particular, I thought the story of Alika Agidi-Jeffs (see clip) was very positive. I also thought Stephen Fry was very brave to talk about the Ugandan incident and the association of his suicide attempt with the stigma of his homosexuality. The complainants believe that patients are experts in their own condition and should be allowed to express their views, so at this level they should welcome the programmes, even if the patients in the programmes themselves may not totally agree with their views. But we shouldn't be surprised by that if they have been treated in a biomedical way.

At one point in the Stephen Fry film, the voiceover said that with her early diagnosis, Cordelia, one of the patients who featured in the programme, knew why she had mood swings. Actually, there's a sense in which just having a diagnostic label like bipolar didn't really help her to understand the reasons for her problems. As I've pointed out in a previous post, the evidence is that patients are ambivalent about a diagnosis of bipolar disorder. A biomedical diagnosis doesn't give a psychological formulation of people's problems, leaving them feeling they haven't really got an explanation. The voiceover in the programme actually in a way acknowledges this by saying that having the diagnosis hasn't helped Cordelia to live with her mood swings.

At another point, the voiceover also says that there is no guarantee of another patient's, Scott's, condition easing. I just wonder if that might be too pessimistic a prognosis. One of the problems with biomedical diagnosis is that it can encourage the sense that one does not have agency to deal with one's problems. Scott's treatment seems to have been primarily medication. It is possible he might have done better with a more psychological approach. 

I think we should applaud Stephen Fry in trying to improve understanding of mental illness in his role as President of Mind. I would encourage him to do even more in this respect by promoting a psychological perspective. Of course it can be difficult to understand why we have the mental health problems that we do. But that shouldn't stop us trying to make sense of them. There was little attempt to do that in the two documentaries. 

Abandon the notion of mental illness as a distinct, genetic brain disease

Jim van Os makes a case for abandoning the term "schizophrenia" because of its association with suggestions that it is a distinct, genetic brain disease (see BMJ article). He suggests that no such language is associated with other categories of psychotic illness, but I'm not sure this is right, because bipolar disorder may be seen in this way. Van Os also points out that research publications on psychosis tend to concentrate on schizophrenia, although again, I think he probably underestimates the extent of the literature on bipolar disorder. He suggests removing the term "schizophrenia" from psychiatric classifications and recognising the existence of the broad and heterogeneous psychosis spectrum syndrome.

I've previously pointed out (see post) that psychosis has already tended to replace schizophrenia in everyday clinical practice. However, as I've also said, psychiatrists do tend to believe that psychosis is a brain disease (see previous post). I'm all for abandoning the notion of "schizophrenia" if it leads to mental illness not being seen as a brain disease. I agree that language does matter (see another previous post), but what's more important is to change conceptual understanding.