Sir: We were interested to read the report by Clafferty et al (Psychiatric Bulletin, September 2001, 25, 336-339). Although some psychiatrists avoid giving an accurate diagnosis of schizophrenia, we would disagree with their main conclusion that psychiatrists collude with a conspiracy of silence. They found 89% of psychiatrists disclose a diagnosis of schizophrenia if it is a recurrent episode, compared to 59% for a first episode. As 20% of patients only have a single episode of psychosis this discrepancy may reflect concern about misleading patients. The diagnosis of schizophrenia implies a long-standing disability, with marked implications for the patient's sense of identity, employment and relationships. With this in mind, we can understand why some psychiatrists would only use the term schizophrenia when the prognosis is clearer.

A striking finding in this paper was that less than half of psychiatrists would tell their patients about a diagnosis of dementia (significantly lower than for other mental illnesses). This is in contrast to the consistent finding that most patients with dementia wish to know their diagnosis (Reference Holroyd, Snustad and ChalifouxHolroyd et al, 1996; Reference Erde, Nadal and SchollErde et al, 1988; Reference Jha, Tabet and OrrellJha et al, 2001). This is the only survey published since the National Institute for Clinical Excellence approval of cholinesterase inhibitors for Alzheimer's disease. If the findings are applicable to Alzheimer's disease as well as to dementia as a whole, this would imply that patients are denied treatment for their condition purely because of reticence among psychiatrists to tell them their diagnosis. It seems the main conspiracy of silence is not in schizophrenia but in dementia.