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ABC Listen. Podcasts, radio, news, music and more. Hi Norman. Hello. So we’re here in the Health Report

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in the Health Report feed on a day when we wouldn’t usually have an episode because there’s been a lot of news coverage about a horrendous attack that happened in Bondi Junction over the weekend and part of that coverage has focused on the potential mental health history of the attacker. And one of the disorders that has been speculated about with this person is that they may have had a diagnosis of schizophrenia. And so not really to speak about this particular person’s medical history, but more to just focus on schizophrenia, a really stigmatized condition with a lot of misinformation around it, and just remind people about what we do know about the history and course of this mental illness.

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Yeah, I think it’s just an opportunity to put some facts on the table, irrespective of what may turn out to be the case with the situation in Bondi Junction.

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So what is schizophrenia?

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This is a disabling condition where the features include delusion. So you’re imagining things that are not real. Sometimes these things have a paranoid quality that you feel the world is against you or specific people or institutions are against you based not on reality. You can have auditory hallucinations where you hear things that are not real. Your mood can change. You can have depression or anxiety. And what’s not commonly realized is that this is almost certainly what’s called a neurodevelopmental problem. In other words, when they’ve looked at people who are diagnosed, and it’s mostly diagnosed the first time in adolescence, a little bit later in girls, because estrogen may well moderate schizophrenia a little bit because estrogen has brain effects. But when you go back, you can find a history of children whose IQ has dropped off in early childhood or middle childhood, where their school performance might have dropped off, where they may have had in really early childhood delayed milestones. So something going on with a lot of these kids which predate the onset of psychotic behavior. And it’s thought that it may well start even in pregnancy. So West Australian research, Scottish research has identified that viral infections may be a risk factor in the mother. Maternal malnutrition, say in famine, may do that. Genes do play a role, but not an absolute role. So if it’s 100% genetic, you would expect identical twins. If one has schizophrenia, the other one will. It’s 50%. So there’s a significant contribution from genes, but it’s not 100%. So if

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if we do know this about it, is there opportunities to do a better job of treating people if they’re identified early?

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Yes, and that’s been the work, the signature work of Pat McGorry at Origin Melbourne, where he’s pioneered the early intervention, which really what he’s pioneered is the identification of a prodrome. So just like you’ve got a prodrome in viral infections where you might have a fever, feel unwell, a bit of a headache and a sore throat, before it becomes clear you’ve actually got a full-blown virus or the spots come out or what have you. So there’s a thought to be a prodrome with schizophrenia in some kids. And that prodrome starts with school performances being going down, the young persons becoming socially isolated, staying in their room more than you would otherwise expect. When you talk to them, they seem to have bizarre ideas that don’t have a relationship with reality. You might hear them talking to themselves. Now, some of those young people are on cannabis, and it may be drug-induced, or it may just be the first episode of psychosis, which never happens again. It’s not inevitable that they develop schizophrenia. But Pat and others believe that you intervene at that point, you can actually slow down deterioration or even prevent deterioration in the psychotic condition in schizophrenia and stop the brain effects, brain damage in some senses continuing, although brain damage is an emotive term. Right. So

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what do we know about what’s actually happening inside the brain here?

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Researchers have been in the past over-simplistic. So they’ve looked at what’s called the dopamine system in the brain. So there’s a set of chemical transmitters and the antipsychotic medications, many of them act on this dopamine system. And the drugs are actually quite good at controlling what are called the positive symptoms. Those are the delusional symptoms. And that’s what people have obsessed about. So positive because they’re kind of outward facing.

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what people have obsessed about. So positive because they’re kind of outward facing.

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That’s exactly right. And some people believe it’s wrong to have focused solely on the positive symptoms because it leaves people quite disabled. And I’ll come back to that in a minute. So these drugs are actually quite good at controlling the psychotic element, the delusional element of schizophrenia. But they have side effects. You can put on weight, you can develop type 2 diabetes. People don’t like taking them. And the drug industry has not been good at developing alternatives. Now, there are what are called atypical antipsychotics, which have fewer side effects and are, in that sense, less toxic. But we’re really short of medications that work, which is partly because they don’t fully understand what’s going on in the brain. But what’s really disabling for people with schizophrenia are what are called the negative symptoms. So the negative symptoms are there’s a loss of cognitive ability and some thinking ability in some of these people. They’ve got what’s called poverty of thought. They’re not thinking a lot. They sit in a corner staring into space. They’re not motivated. They’re incredibly socially isolated. They can lose social skills. And so that affects their ability to stay in society, stay in the community, get work, be active contributors to the community. These negative symptoms, the only treatments that we’ve got for these negative symptoms are psychological therapies, social therapies like community-based activities, which reteach social skills and help people get rehabilitated and have some work and actually get something as basic as housing. 20% of homeless people in some communities have actually got serious persistent chronic mental illness. Housing is a huge issue. Can we put some numbers around it?

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some numbers around it? The statistics that I’m looking at say potentially 1% of the population. 1% has been

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1% has been bandied about a lot internationally. It varies according to community. And South London, for example, where there’s a lot of cannabis use or has been in the past, it’s much more than 1%. So it depends on drug use. It depends on the genes in the population. There’s lots of things going on that may increase or decrease the incidence of schizophrenia but they keep on using this one percent it’s probably highly variable but it’s not 15 or 20 percent but as an

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an absolute number that’s actually quite a lot of australians living with this diagnosis and hearing their diagnosis kind of used in coverage of really horrendous crimes.

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Yeah. And this is where stigma and fear in the community emerge and also really quite regressive conversations can occur, which is one of the reasons for us having this conversation. Because in the bad old days, people were locked up with schizophrenia. They were put in locked wards. They were secluded. And seclusion is incredibly controversial, and it hurt around the world. In India, people with schizophrenia may still happen, but within living memory, people were chained to a cart and brought to the doctor in chains. So worldwide stigma has been huge in this area. And seclusion in locked wards sometimes is necessary, but it’s associated with bad outcomes. It’s associated with increased death rates. And talking about death rates, with schizophrenia, people with schizophrenia are much more likely to be harmed and self-harm than harm others. They are not prominent in criminal violence statistics internationally. That is not the major problem. The major problem with people with schizophrenia is them being harmed, them being harmed when they’re homeless and attacked or self-harming or taking their own lives. So that’s not to deny that violence is a risk in a very small proportion. Now, there are some people who their delusions are either hard to control or they don’t follow therapy or

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them being

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or the community services lose touch with them, whatever the reason. But it is possible to actually identify somebody who’s at risk of being at risk to others, remembering this is a tiny proportion of people with schizophrenia. And it’s where their paranoid delusions are starting to spin out of control. It’s where there’s anger associated with their paranoid delusions. It’s more common in men than in women. It’s more common when their mood is affected. They’ve got depression, anxiety. More common when they’re using other drugs, particularly alcohol, amphetamines, and so on. It is possible to, when you’re monitoring people in the community, to identify people who might be going off and therefore might need to go under a community treatment order or maybe have a spell in hospital where they get back under control before they’re sent back out into the community. So it is about risk management. But the overwhelming issue with schizophrenia is just finding out what causes it, getting better treatments, and getting people rehabilitated back into life in general.

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And getting people in contact with the health system. And we heard the New South Wales Health Minister say that they are going to be looking into health care and mental health support and how that’s delivered to make sure that people aren’t slipping through the cracks, just in case that was a factor with this case in Bondi Junction. Yeah. There’s always a problem politically when the drumbeat starts to beat

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always a problem politically when the drumbeat starts to beat about, well, why aren’t we locking up these people? Why weren’t they under lock and key? Is anyone actually saying that?

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anyone actually saying that?

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I haven’t heard that but this is a really yet, difficult, awkward, risk-managed situation, and tragedies like this should not happen if indeed this has anything to do with it whatsoever. But the risk is that we over-respond in a negative way to this. Yeah, because I think this discussion is really not about the particular

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because I think this discussion is really not about the particular person at the heart of this tragedy. It’s about the language that’s been used around it and other people who do have that diagnosis who perhaps are already struggling with stigma, maybe not getting the help that they need and not making the situation even harder for them.

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Because one of the things that precipitates a worsening in your condition with schizophrenia is stress. For some reason, it’s really bad for precipitating a relapse. Stress management is incredibly important. And the language is really important. It’s interesting that the Japanese had changed the name of schizophrenia in Japanese from split mind disorder to an integration disorder. And when they changed the name from split-mind disorder to integration disorder, stigma seemed to drop. So words do matter.

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We rarely hear stories about schizophrenia unless it does come up in these sorts of stories, although it is something that we have covered a fair bit on the health report before, including about the harms that can come to people with schizophrenia and their high risk of other health problems.

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Yeah. There’s a 15 to 25 year life expectancy gap in people with schizophrenia. In that they die earlier than average.

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earlier than average.

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than average. Yes. And suicide is only a small part of that. It’s diabetes, it’s heart disease, it’s cancer. They get poor medical care for their other conditions and they also have high risk behaviors like smoking so this is a disease that affects the whole body not just the brain so what needs to change well there’s a nobel prize in that question but essentially all we have in austral Australia is a problem with community-based mental health

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brain so what needs to change

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well there’s

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in that question but essentially all we have in austral Australia is a problem with community-based mental health services. They’re under stress, they’re under-resourced, there’s a workforce problem to get people working in those areas, and to actually institute the kinds of interventions that work for these negative symptoms, which are social, psychological, community-based training, almost retraining and getting people back into the swing of community life rather than being isolated. Enormous challenges. And the research challenges are to find out what else might be going on in the brain that might help. So

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again, this chat really about giving some context to a word that’s been bandied about in the coverage of this. And as we said, Norman, there’s actually been a lot of coverage on schizophrenia, the disorder, on the health report in the past, and we’ll put some links to some of those recent research papers and our discussions about them in the show notes for this episode.

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And we’ll see you on our regular health report feed later in the week.

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We will indeed.