Discrimination starts with adjectives.

Discrimination starts with adjectives.

Dear Editor,

Recently, Ferinauli et al.[1] published a study on the relationship between psychotropic drugs, orthostatic hypotension, and falls in people who meet the criteria for schizophrenia. The research is highly relevant for the epidemiological surveillance of the side effects of psychoactive drugs, particularly those that can be particularly severe due to the possibility of severe injury or death in people diagnosed with schizophrenia. These people who meet the criteria for mental disorders are systematically marginalized, and they are at high risk of premature death.

Ferinauli et al.’s article,[1] the title powerfully struck us due to the detail of using the adjective “schizophrenics” to specify the diagnosis of the study participants. The adjective “schizophrenics” is used 24 times more in the document, not counting the number of times it appears in the references. Similarly, the word “schizophrenia” is used nine times as an adjective.

This observation may seem like a minor detail. However, in 2010, the World Psychiatric Association (WPA) published an extensive document to reduce stigma-discrimination towards people who meet the criteria for a mental disorder. The WPA recommends avoiding adjective diagnoses for mental disorders because that process is the first step in stigmatization; that is, discrimination begins in the language.[2] Since then, it should be used “people with”, “people diagnosed with”, “people who have”, “people who suffer from”, “people who meet criteria for the diagnosis of schizophrenia”, or “people who live with schizophrenia”. The most appropriate and precise is the last denomination, given that the diagnostic criteria tend to vary periodically and, consequently, the people who can be included in that category. Consequently, Ferinauli et al.[1] should have used, for example, the name “people diagnosed with schizophrenia” to introduce the acronym “PDS” and to use the acronym throughout the paper.

The diagnosis of “schizophrenia” is so stigmatizing that the criteria diagnosis change, and stigma persists even without meeting criteria for any clinical issue. It must be borne in mind that in psychiatry, the principle is to classify symptoms and not people. Diagnoses may have some practical utility; but, the validity is limited.

The stigma-discrimination complex (SDC) is a concept that includes stigma (a characteristic with negative social connotation), prejudice (an unfavourable personal attitude that is difficult to modify with the evidence), stereotype (a shared social representation), and discrimination (all behaviours that violate rights based on the previous concept and implication exclusion).[3]

The SDC is a much more significant stressor than the condition or diagnosis of a mental disorder.[3] The SDC has important implications for public mental health because it is configured as a barrier to access mental health services: it undermines the request for promotion, prevention, care, counselling and rehabilitation in mental health, prolongs the suffering of individuals and families and reduces adherence to therapeutic plans. Additionally, the SDC condemns people who meet the criteria for a mental disorder to a spiral of adversities and inequalities that limit the possibilities of rehabilitation and inclusion.[2] Consequently, citizens who meet the criteria for schizophrenia are called to be part of social groups immersed in situations of poverty. This syndemic increases the possibility of other adversities such as substance use, an incursion into crime, and physical and psychological abuse. People diagnosed with schizophrenia should be considered a highly vulnerable group of citizens.[3] Citizens and institutions must work together to lessen the exclusion of people who meet the criteria for a mental disorder diagnosis; this can start with names that do not imply SDC.

Small details make significant differences. Authors and editors must use a more inclusive language in all contexts to decrease the negative social impact of SDC in people who meet the criteria for mental disorders, especially schizophrenia, a condition with a high negative impact on the global functioning of individuals with the diagnosis.