Push Is On to Reclassify Schizophrenia as a Neurologic Disease

Batya Swift Yasgur, MA, LSW

February 07, 2019

A mental health advocacy group has spearheaded a new initiative to reclassify schizophrenia as a neurologic, rather than a psychiatric, disease. The action is designed to reduce stigma and ultimately obtain more research funding from the Centers for Disease Control and Prevention (CDC).

In May 2018, the Schizophrenia and Related Disorders Alliance of America (SRDAA) submitted a request to have schizophrenia included in the implementation of the National Neurological Conditions Surveillance System (NNCSS) with the 21st Century Cures Act — a new CDC program that was allotted $5 million by Congress to collect data on the prevalence of and risk factors for neurologic conditions in the US population.

"At a basic level, the distinction between neurological and psychiatric conditions is artificial," Raymond Cho, MD, professor of psychiatry, Baylor College of Medicine, Houston, Texas, and chairman of the SRDAA, told Medscape Medical News.

"It's a 'no-brainer' that neurological and psychiatric disorders should be considered under the same umbrella, since everything is mediated by the brain, neural systems, and neurochemistry, but the problem is convincing the rest of society, lawmakers, insurance providers, family members, and patients of this," he said.

The "paradigm shift we seek will be treatment-focused and not finger-pointing, hopefully translating into how healthcare is delivered and paid for, because right now, despite mental health parity laws, how 'mental health' treatment is practiced and paid for is very different from the ideal," he added.

Curbing Stigma

"The term 'mental illness' carries discrimination and stigma and is often associated with the misperception that this [illness] is the fault of the patient or perhaps the family — such as the older description of the schizophrenogenic mother," Linda Stalters, MSN, APRN (ret), chief executive officer and founder of the SRDAA, told Medscape Medical News.

Cho described treating people with early psychosis and meeting first-episode schizophrenia patients and their families "who were trying to deal with the hardship and trauma that came along with that, wondering what they did wrong, so I had to do a lot of education about the brain and genetic nature of the disorder."

Stalters, who is as an intensive care nurse practitioner and a psychotherapist with a private practice, founded the SRDAA almost 11 years ago "to focus on the most seriously ill, who are the most underserved and misunderstood of our people and are maligned and maliciously treated," she said.

The organization, which takes a "biopsychosocial perspective," consists of clinicians, caregivers, and patients. Its reach extends beyond the United States; it provides support and resources in countries as far as the United Kingdom, Russia, Uruguay, India, Hungary, and Japan, said Stalters.

On board with the initiative is the Treatment Advocacy Center, a nonprofit organization that seeks to eliminate barriers to the treatment of mental illness, and the National Alliance on Mental Illness.

"We have created a movement. We have the support of other organizations, family members, and patients, and there are multiple private Facebook pages supportive of caregivers and patients — for example, one has over 7000 participants, including people who hadn't originally been supportive of this movement but are now," Stalters said.

"Mental Health Czar" Weighs In

In an interview with Medscape Medical News, Elinore McCance-Katz, MD, assistant secretary for mental health and substance use, Interdepartmental Serious Mental Health Illness Coordinating Committee, Substance Abuse and Mental Health Services Administration, agreed that schizophrenia is a "neurobiologically based disease, a brain disease, as are many mental illnesses, although they are called 'psychiatric.' "

Dubbed the "mental health czar," McCance-Katz, who was a practicing psychiatrist before assuming her current position, suggests there is "an artificial abyss between what's considered a physical disease or condition and what is a mental or substance use disorder."

This leads to a "wide chasm, so that people who have real diseases, real illnesses that are physically based but happen to manifest in behavior, are not actually treated in a manner that is at parity with individuals with recognized physical health conditions, which is very unfortunate," said McCance-Katz, who was copied on the SRDAA's request to the CDC.

The proposed reclassification of schizophrenia may "help to raise awareness that these illnesses are physiologically based, not just aberrant or bad behaviors, but with physical underpinnings."

Despite increasing recognition of the neurologic underpinnings of schizophrenia, many psychiatrists as well as the American Psychiatric Association (APA) are reluctant to support its reclassification as a neurologic disorder.

"Schizophrenia is and should continue to be treated as a mental disorder," the APA said in a statement to Medscape Medical News,

"Patients diagnosed with schizophrenia should be in the care of a psychiatrist, who is medically trained in the treatment of complex mental, emotional, and behavioral problems. Changes to its classification could inhibit access to care for this important population of patients," it added.

Straw Man?

Christoph Correll, MD, professor, Center for Psychiatric Neuroscience, the Feinstein Institute for Medical Research, Manhasset, New York, agrees.

"While I clearly welcome the public education efforts to point out that mental disorders also have biological underpinnings and causes, which is hoped to ultimately reduce the stigma of mental disorders, I see this discussion as another example of a well meaning but still somewhat unfortunately perpetuated mind-body dualism," said Correll, who is also the medical director of the Recognition and Prevention Program, Department of Psychiatry, the Zucker Hillside Hospital, Manhassett, New York.

Correll said "groups' lobbying for reclassification and inclusion of schizophrenia in the CDC surveillance...is like setting up a straw man."

Although "all mental disorders, like most neurological disorders that are not limited to peripheral nerve pathology, are brain-based," the "symptomatic expression of mental disorders is not predominantly via motor or sensory disturbances that are relatively unidimensional and that can be measured relatively easily," he said.

He noted that, "clearly, many neurological conditions of the central nervous system are also associated with emotional, cognitive, and behavioral disturbances, as some psychiatric disorders are associated with motor and sensory disturbances."

There is therefore "overlap from both ends, and that is why in my opinion simply reclassifying a mental disorder as a neurological disorder does not do justice to either or both."

He suggested instead reclassifying both neurologic and mental disorders as "disorders of the brain or the central nervous system, with varying dimensionally different symptom expressions across sensory, motor, affective/emotional, cognitive, and behavioral domains."

Stalters acknowledged that their request to the CDC was "a long shot, because there are at least 40 other organizations for different diagnoses that want to be in this very limited number of initially included diseases that will be covered in the neurological disease surveillance system."

Focus on MS, Parkinson's

Indeed, at present, schizophrenia will not be included in the NNCSS, William R. Mac Kenzie, MD, deputy director for science, Center for Surveillance, Epidemiology, and Laboratory Services, CDC, told Medscape Medical News.

Instead, the CDC will "begin planning and developing demonstration projects for two neurological conditions — multiple sclerosis (MS) and Parkinson's disease."

It will be a three-stage process, he said, and will be carried out "in association with partners and stakeholders, as resources allow."

The two neurologic conditions will be used to determine "how we can have the biggest impact by exploring innovative methods and complex data sources and capturing lessons learned to determine which approaches will help efficiently extend the NNCSS to other neurological conditions," said Kenzie.

The second step will be to "build out the NNCSS" for both conditions, using successful approaches from the demonstration projects and "checking methods, costs, and opportunities, as resources allow," he said.

The lessons learned from these demonstrations will be used "to extend the NNCSS to other neurological conditions, as resources allow," he said.

Kenzie noted that the "legislation surrounding the NNCSS does not reference any disease, disorders, or conditions by name."

However, he added, "As we move ahead with the surveillance system, CDC will engage multiple federal agencies, external subject matter experts, professional organizations, and other interested parties in determining specific conditions to include in the NNCSS."

He emphasized that "at this time, CDC understands reclassification of diseases as outside the scope of NNCSS work." It relies on the International Classification of Diseases, which is maintained by the World Health Organization (WHO), as the "international standard diagnostic tool for epidemiology, health management, and clinical purposes."

Stalters acknowledged that the SRDAA is aware that the CDC is now conducting a pilot study of MS and Parkinson's disease.

However, "we are gathering support from other advocacy, provider, professional, and government agencies for inclusion of schizophrenia in the extension of the NNCSS" and "we will continue our work so when the NNCSS has the funding, schizophrenia will be included in the system," she said.

"We understand that the CDC does not have the purview to reclassify, and we have submitted a request to the WHO regarding reclassification [of schizophrenia]," she added.

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