Education & Debate

Objective-To compare the first admission rates for schizophrenia in England and France, and to compare the concept of schizophrenia held by practising British and French psychiatrists. Design-Comparative study of incidence rates in England and France; and postal questionnaire survey of a sample of about 1 in 30 psychiatrists in the United Kingdom and in l'Aquitaine, France. Subjects-All first admissions for schizophrenia to psychiatric hospitals in Engnd and France 1973-82; 92 psychiatrists in the United Kingdom and 69 in France. Main outcome measures-Age adjusted first admission rates for schizophrenia between 1973-82; and opinions on the aetiology, diagnosis, and management ofschizophrenia. Results-First admission rates were much higher in France than in England before the age of 45, but lower after that age. Rates were falling in England over the 10 year period, while they were rising in France. In the questionnaire study English and French psychiatrists showed prominent differences of opinion for 31 out of 38 statements. The French sample did not diagnose schizophrenia after the age of45 and endorsed psychoanalytical concepts. Conclusions-British and French psychiatrists use different diagnostic criteria and contrasting methods oftreatment for schizophrenia. Differences in diagnostic criteria probably contribute towards the disparity in administrative incidence rates and time trends for schizophrenia in the two countries. Doctors in the European Community can now work in any country. Further work is needed to ensure psychiatrists are talking a common language. Department of Psychological Medicine, Institute ofPsychiatry, London SES 8AF Jim van Os, research psychiatrist Glyn Lewis, senior lecturer Anthony Mann, professor, department ofepidemiology and generalpractice Centre HospitaloUniversitaire de Bordeaux, Centre Carreire, 33076 Bordeaux C6dex, France Paloma Galdos, registrar Mark Bourgeois, professor Correspondence to: Dr van Os. BMY 1993;307:489-92 Introduction Economic and political union are high on the agenda in the European Community, and medical doctors can work in any member state. Nevertheless, widespread differences in medical practice exist in Europe, ranging from the diagnosis and treatment of low blood pressure' to the treatment of testicular cancer.2 Psychiatric practice seems to have been particularly affected by the traditional divide between Anglo Saxon empiricism and continental rationalism-between trying to reach the truth through experiment and trying to reach it through ideas. This is perhaps most apparent in the psychiatric traditions of the United Kingdom and France. Psychoanalysis, focusing on "unconscious" conflicts, has been much more influential in France,3 whereas in the United Kingdom psychiatry has enjoyed a close relation with physical medicine. In the United Kingdom the old diagnostic dichotomy between affective and schizophrenic psychoses has survived, with the category of "other psychoses" accommodating those psychotic disorders not considered to belong to either category. The International Classification of Diseases category "paranoid states" (ICD 297) is traditionally considered to be part of the schizophrenic spectrum in the United Kingdom,4 and is combined with schizophrenic disorders in national mental health statistics. In France diagnostic practice appears more refined, not unlike DSM III-R, the Diagnostic and Statistical Manual of Mental Disorders III, revised of the American Psychiatric Association." Apart from schizophrenia and manic-depressive psychoses, separate categories exist to accommodate acute, good outcome, non-affective psychotic states (psychoses delirantes aigues), and the delusional disorders (delires chroniques). The "heboidophrenic" (pseudopsychopathic) schizophrenia subtype is encountered in psychiatric textbooks in France,9 but is not recognised in the United Kingdom. Deniker's classification of antipsychotic agents into "incisive," "alerting," and "sedating" subtypes'0 does not appear to be recognised in the United Kingdom, which presumably indicates that there are differences in the clinical use of these compounds in the two countries. Given the prospect of European union, it is opportune to define more precisely the psychiatric concepts of schizophrenia as currently held in France and the United Kingdom. The aims of this study were to compare, firstly, the incidence of schizophrenia in France and the United Kingdom as recorded by national statistics on hospital admissions and, secondly, the concept (aetiology, diagnosis, and management) of schizophrenia as assessed by a postal survey of a random sample of practising French and British psychiatrists.