A fabulous, enlightened experiment in Berlin with humane treatment of patients suffering severe mental disorder that we cannot reproduce in the United States.
A fabulous, enlightened experiment in Berlin with humane treatment of patients suffering severe mental disorder that we cannot reproduce in the United States.
I visited the Soteria project at St Hedwig Hospital, Berlin at the invitation of Professor Andreas Heinz, Director and Chair of the Department of Psychiatry and Psychotherapy at the Charité— Universitätsmedizin Berlin.
I was actually coming to St Hedwig Hospital, Berlin to give a talk on scientific writing, and was surprised by an offer of a tour of their Soteria Project.
I came away with great respect for a wonderful experiment in the treatment of psychosis that must be protected.
I was also saddened to realize that such treatment could not conceivably be offered in the United States, even for patients with families who could pay large expenses out of pocket.
In Germany, financial arrangements allow months for the stabilization of acutely psychotic patients. The question is how best to use these resources.
In contrast, newly admitted patients in the United States generally are allowed only stays of 48 to 72 hours at the most to stabilize. Inpatient psychiatric beds are in short supply, and often unavailable to those who can afford to pay out of pocket.
The largest inpatient psychiatric facility in the United States is the Los Angeles County jail, where patients are thrown in with criminal populations or forced into anti-suicide smocks and isolated. Access to mental care in the jail is highly restricted.
In United States, the challenge is to get minimal resources to vulnerable severely disturbed population. Efforts to do so must compete with diversion of mental health funds to populations much less in need but amenable to outpatient psychotherapy.
It takes a mass killing to activate calls for better psychiatric care for the severely disturbed, on the false promise that better and more accessible care will measurably reduce mass killings. Of course, this is all a distraction from the need to restrict the firearms used in mass killings.
In my blog I was actually taking aim at Mental Elf’s pandering to the anti-psychiatry crowd with the goofy claim of the lack of “any compelling evidence that locking people up actually increases safety.” Sometimes vulnerable psychotic and suicidal persons need to be protected from themselves.
Furthermore, experimentation with unlocked wards frquently come to an end with the suicide of a single absconding patient.
In Germany, better staffing and time to develop better relationships with patients allow much more respect for patient autonomy and self-responsibility. But open wards are always vulnerable to these adverse events.
The original Soteria, Palo Alto Project
I came to St Hedwigs with negative feelings about the original Soteria Project. I was Director of Research at MRI Palo Alto in 1980s when it was housed there. I came away thinking its strong anti-psychiatry attitude was disastrous and led to much harm when it got disseminated.
Loren Mosher and Alma Menn were determined to demonstrate that antipsychotic medication was unnecessary in treatong psychotic patients.
Frankly, Moher and Menn were so committed to their ideological position, they distorted presentation of their data. They misprepresented comparisons between disparate community mental health and Soteria samples as randomized trials. They relied on a huge selection bias and unreliable diagnoses that lumped acutely maniac patients and personality disorders with patients with schizophrenia. They tortured their data with a variety of p- hacking techniques and still didn’t come up with much.
After Soteria Palo Alto closed, an effort to get an NIMH grant for follow-up failed because the initial presentations of patients was so badly recorded that no retrospective diagnosis was possible.
Subsequent Soteria projects around the world have had a full range of attitudes towards the role of medication in the treatment of vulnerable and highly disorganized patients.
St Hedwig has an enlightened, evidence informed approach that of course includes judicious use of antipsychotics. Antipsychotic medication is provided with acutely psychotic patients, but at an appropriate dosage. Patient response is closely monitored and tapering is attempted when there is improvement. Importantly, decisions about medication prioritize patient well-being, not staff convenience..
The best evidence is that patients who experiencing episodes of unmedicated psychosis are increasingly doomed to poor recovery of social and personal functioning. On the other hand, particularly with treatment of ambiguous acute first episodes, has to be a lot of monitoring and reconsideration of medication. In understaffed and underresourced American psychiatric settings, there is little monitoring antipsychotic medications and little efforts at tapering. Furthermore, dosages often excessively high because that makes patients more manageable for overwhelmed staff. Overmedicated patients are easier to handle
Unfortunately, the quality of care offered in Berlin is unimaginable in the US even for those who can afford to pay out of pocket.
Special thanks also to Psychiatrists Dr med Felix Bermpohl and Dr med Martin Voss Oberarzt.
Soteria’s program at the Charité’s Psychiatric University Clinic in the St. Hedwig Hospital is aimed at young people who are in an acute psychotic crisis, who are afraid of the onset of a psychosis, or who still need a professional stationary environment after a psychotic crisis.
There are 12 treatment rooms in the Soteria. Since the Soteria works within the scope of the compulsory supply, these places are intended exclusively for people from the districts of Wedding, Mitte, Tiergarten and Moabit.
[note from Prof Heinz: The difficult to translate passage refers to our hospital having a catchment area, from which we have to take every patient who wishes to be admitted and particularly every compulsory admission. We serve one of the poorest areas in Berlin, so we do not do “raisin picking” of easy to treat patients.]
“Soteria” (ancient Greek: healing, well-being, preservation, salvation) denotes a special treatment approach for people in psychotic crises with the so-called “milieutherapy”.
The residential environment, the co-patients, the attitude of the therapists as well as the orientation towards normality and “real life” outside the clinic represent the therapeutic milieu. Patients and employees meet in therapeutic communities on the same level and shape together – with the involvement of the social Environment – the day.
The psychosis treatment takes place in the form of active “being-yourself”, if necessary also in continuous 1: 1 care in the so-called “soft room”. The healing therapeutic milieu provides protection, calming and relief of tension, so that psychopharmaceuticals can be used very cautiously. This medication-saving effect of the soteria treatment is scientifically well documented, among other positive effects. (1)
1) Calton, T. et al. (2008): A Systematic Review of the Soteria Paradigm for the Treatment of People Diagnosed With Schizophrenia. Schizophrenia Bulletin 34,1:181-192;
2) L. Ciompi, H. Hoffmann, M. Broccard (Hrsg.), Wie wirkt Soteria? Online Ausgabe (2011), Heidelberg: Carl-Auer-System-Verlag.
3) Hl. Thérèse von Lisieux: Nonne, Mystikerin, KirchenlehrerinGeboren: 2. Januar 1873 in Alencon in der Normandie in Frankreich Verstorben: 30. September 1897 in Lisieux in Frankreich
The reports on the original Soteria, Palo Alto project
Mosher LR, Menn AZ, Matthew SM. Soteria: evaluation of a home-based treatment for schizophrenia. Am J Orthopsychiatry. 1975;45:455–467. [PubMed]
Mosher LR. Implications of family studies for the treatment of schizophrenia. Ir Med J. 1976;69:456–463. [PubMed]
Mosher LR, Menn AZ. Soteria: an alternative to hospitalisation for schizophrenia. Curr Psychiatr Ther. 1975;15:287–296. [PubMed]
Mosher LR, Menn AZ. Soteria House: one year outcome data. Psychopharmacol Bull. 1977;13:46–48.[PubMed]
Mosher LR, Menn AZ. Community residential treatment for schizophrenia: two-year follow-up. Hosp Community Psychiatry. 1978;29:715–723. [PubMed]
Mosher LR, Menn AZ. Soteria: an alternative to hospitalisation for schizophrenics. Curr Psychiatr Ther. 1982;21:189–203. [PubMed]
Matthews SM, Roper MT, Mosher LR, Menn AZ. A non-neuroleptic treatment for schizophrenia: analysis of the two-year post-discharge risk of relapse. Schizophr Bull. 1979;5:322–333. [PubMed]
Mosher LR, Vallone R, Menn AZ. The treatment of acute psychosis without neuroleptics: six-week psychopathology outcome data from the Soteria project. Int J Soc Psychiatry. 1995;41:157–173. [PubMed]
Mosher LR. Soteria and other alternatives to acute psychiatric hospitalisation. J Nerv Ment Dis. 1999;187:142–149. [PubMed]
About Professor Heinz
Andreas Heinz is Director and Chair of the Department of Psychiatry and Psychotherapy at the Charité— Universitätsmedizin Berlin.
A well-orchestrated publicity campaign for a Lancet Psychiatry article promoted the view that locked inpatient wards are ineffective in reducing suicide.
This interpretation is not supported by data in the actual paper, but plays to some entrenched political stances and prejudices.
Hype and distortions in conventional and social media about this article are traceable directly to quotes from the authors in press releases from Lancet and from their university.
Mental Elf posted a blog the day the embargo on reporting this study was lifted. The blog post and an associated Twitter campaign generated lots of social media attention. Yet, there is no indication that the blogger went beyond what was in press releases or compared the press releases to what was in the actual article.
Not many of the re-tweets and “likes” were likely from people who had read the original research.
The publicity orchestrated for this study raises issues about the ethics of promoting clinical and public policy with claims of being evidence-based when the audience does not have the ability to evaluate independently the claims by actually reading the peer-reviewed article.
I obtained the article from interlibrary loan and the supplementary material from the authors. I appreciate the authors’ immediate responsiveness to my request.
[I delayed this blog post for a week because of indications that the article would be released from behind the pay wall, but apparently it has not been freed.]
In this blog post I identify important contradictions between the authors’ claims in the article and what they promoted in the media. The contradictions are obvious enough that someone other than the authors – the Lancet Psychiatry editor and reviewers – should have immediately caught them.
Spoiler: Claims supposedly based on sophisticated multivariate techniques that were applied to data from hundreds of thousands of patients were actually based on a paltry 75 completed suicides. These were a subsample of at least 174 that occurred in 21 hospital settings in the course of 15 years. Throwing way a chunk of the data and the application of multivariate analyses to such a small, arbitrarily chosen subsample is grossly inappropriate.Any interpretations are likely to be invalid and unreliable.
No one else seems to be commenting on these key features of the study, nor the other serious problems of the study that I uncovered when I actually examine the paper and supplements. Join me in the discovery process and see if you agree with me. Please let me know if you don’t agree with my assessment.
The promotion of the study can be seen as a matter of ideologically-driven mistreatment of data with the intention of promoting clinical and public policies that put severely disturbed persons at risk for suicide.
Regardless of where one stands as to whether severely disturbed persons should be prevented from hurting or killing themselves, this attempted manipulation of public policy should be viewed as objectionable.
In presenting what may be controversial points, I’ll start with editorials that were easily accessible. I’ll then delve into the paywalled article itself.
The press release from the authors’ University of Basil
The study’s last author declared his agenda in promoting the study:
Focus on ethical standards
“Our results are important for the destigmatization, participation and emancipation of patients, as well as for psychiatric care in general,” comments last author Undine Lang, Director of the Adult Psychiatric Clinic at UPK Basel. The results will also have an influence on legal issues that arise when clinics adopt an open door policy. In future, treatment should focus more on ethical standards that ensure patients retain their autonomy as far as possible, says Undine Lang. Efforts should also be made to strengthen the therapeutic relationship and joint decision-making with patients.
The press release from The Lancet
Distributed while the article was still embargoed, Locking doors in mental health hospitals does not lower suicide rate provided more details of the study, but more editorializing grounded in direct quotes from the authors:
Locking the doors of mental health hospitals does not reduce the risk of suicide or of patients leaving without permission, according to a study published in The Lancet Psychiatry.
Authorities around the world are increasingly using locked-door policies to keep patients safe from harm, but locked doors also restrict personal freedom.
European countries tend to follow traditional approaches in caring for patients in psychiatric care, because there has been little evidence so far that one method is better than another.
Similar outcomes whether doors are open or locked.
Of 349,574 patients, they selected 72,869 cases from each hospital type, or 145,738 cases altogether. Creating matched pairs enabled a direct comparison between hospitals.
Translation: to prepare the data for the statistical analyses the authors had planned, they threw away 203,836 cases, or 58.3% of the available cases.
And they concluded:
Findings revealed similar rates of suicide and attempted suicide, regardless of whether a hospital had a locked door policy or not. Furthermore, hospitals with an open door policy did not have higher rates of absconding, either with or without return. Patients who left an open door hospital without permission were more likely to return than those from a closed facility.
The press release next raised a dramatic question. But could these data answer it?
Do locked doors unnecessarily create a sense of oppression?
Given the similarity of outcomes between the two types of hospital, the researchers propose that an open door policy might be preferable.
“These findings suggest that locked door policies may not help to improve the safety of patients in psychiatric hospitals, and are not generally successful in preventing people from absconding. In fact, a locked door policy probably imposes a more oppressive atmosphere, which could reduce the effectiveness of treatments, resulting in longer stays in hospital. The practice may even lend motivation for patients to abscond.” -Dr. Christian Huber, of the Universitäre Psychiatrische Kliniken Basel, Switzerland
Of course, the study did not assess anything like “sense of oppression” and so cannot answer this question. As we will see when I discuss what I found in the actual paper, Dr. Huber’s characterization of his findings is untrue. Patients on locked wards did actually not have longer stays.
Since each hospital serves a specific location, there was no chance of higher-risk patients being allocated to hospitals with locked wards. This reduced the risk of bias.
This is also not true. An unknown proportion of the hospitals, probably most, had both locked and unlocked wards. There could easily have been strong selection bias by which patients was referred to a locked ward. We are not told whether patients could be referred into other catchment areas, but this information would be useful in interpreting the authors’ claims.
The authors warn that an open door strategy might not be appropriate everywhere, as mental health care provision differs in other ways, too, for example, how many beds are available, the percentage of acutely ill patients, and how long they are treated for.
Germany has around 1.1 psychiatric care beds for every 1,000 people, compared with 0.5 beds per 1,000 in the United Kingdom and 0.3 in the United States. Where there are fewer beds, patients who receive treatment are more likely to be severely ill and more at risk.
So, Germany has more than 3 times the beds/100 people than the USA and more than the twice the availability of beds in the UK. We can learn from other sources:
Germany is one of the countries with highest expenditure for mental health care in the world. However, in contrast to other western European countries, psychiatric treatment in Germany is still mainly provided by psychiatric hospitals, outpatient clinics and office based psychiatrists and only rarely by community mental health teams. As mental health policy, except the provision of pharmaceutical treatment, is the responsibility of the federal states, no national mental health plan exists. Therefore, community mental health care systems vary widely with regard to conceptual, organisational and economic conditions across the country. Moreover, the fact that different components of community mental health care are funded by different payers (and on different legal bases) hampers coordination and integration of services.
Studies largely conducted in other countries with organizations of care different than in Germany have consistently concluded that Assertive Community Treatment (ACT) programs are effective in reducing the need for inpatient treatment.
In order to keep the level of psychiatric inpatient treatment and institutional care as low as possible these services should be provided by multi-professional community mental health teams organized according to the principles of Assertive Community Treatment (ACT).
ACT programs keep persons with psychosis from being placed in psychiatric inpatient units like those studied in the Lancet Psychiatry and they lead to shorter hospital stays.
The Lancet Psychiatry article makes no mention of ACT in Germany. My inference is that implementation was not widespread during the study. If there are ACT programs in Germany, their influence on this data set is through an invisible hand.
Inpatient psychiatric beds are quite scarce in the US, even for patients and families willing to pay out of pocket. To deal with demand that is not met by psychiatric facilities, the Los Angeles jail has become the largest locked facility. Whether it not it was the intention of the Lancet Psychiatry, the ideology with which it is infused has served to make inpatient beds less available in the United States and greater reliance on jails instead of least restrictive, and more supportive settings for protecting persons with psychosis.
Inpatient hospitalizations in the United States are much shorter than in Germany. In some states, the mean length of stay is five days. Hospitalization has different goals in the US- only stabilization of the patient’s condition.
The means of killing oneself are also different between the US and Germany. Firearms are much more readily available in the US than in Germany, suggesting different means-restriction strategies for reducing suicide.
So, I cannot see the generalizability of the findings from the Lancet Psychiatry study to the US – or the UK, for that matter. Can you?
The Mental Elf advertises itself as offering “no bias, no misinformation, just what you need.” Its coverage of the study occurred the same day the embargo was lifted. Its coverage uncritically echoed what was in the press releases, adding some emotional and ideologically-driven amplification.
The reason usually given for wards being locked is that the people within them need to be kept safe; safe from harming themselves and safe from committing harm to others. Of course these are very real fears, but they are often wrongly magnified by a still sadly stigmatising media and public perception of severe mental illness.
There is certainly an uneasy tension between the Mental Health Act Code of Practice and the reality of locking up severely ill mental health patients, which is brought into sharp focus when we consider the lack of evidence for locked wards. The literature is primarily made up of expert opinion that insists safety is paramount, but fails to provide any compelling evidence that locking people up actually increases safety.
Let’s examine Mental Elf’s claim of the lack of “any compelling evidence that locking people up actually increases safety.” Presumably, he is referring to the lack of RCTs.
I have been a scientific advisor to experimental studies like the US PROSPECT study and quasi-experimental European studies attempting to test whether suicidality could be reduced. Any such studies suffer from the serious practical limitation that suicide is an infrequent event. But to say there is no compelling evidence for restricting opportunities for acutely suicidal persons to hurt themselves is akin to BMJ’s spoof systematic review finding no evidence from RCTs that parachutes reduce deaths when jumping of planes.
Neither RCTs nor the propensity analyses of administrative data that Mental Elf favors can produce “compelling data.” As I will soon show, this study displays the pitfalls of propensity analyses.
We can systematically examine the contextual circumstances of particular deaths by suicide when they do occur, and make suggestions whether some sort of means restriction, including access to a locked inpatient unit would have made a difference. We can also hold professionals in a decision making capacity legally responsible when they fail to avail themselves of such facilities, and we should.
The Mental Elf wrapped on a rousing, uncritical, and ultimately nonsensical note:
This is a novel and compelling study, conducted in Germany, but very relevant to any Western country that has a secure system for mentally ill inpatients.
Our obsession with security and safety in an ever more dangerous world is justified if you watch the TV news channels for any prolonged period of time. The world is after all full of war, terrorism, violent crime, child abuse; or so we’re led to believe.
I spent a very enjoyable day at City University last week, participating in the #COCAPPimpact discussions, which included some rich and very constructive conversations about therapeutic relationships. It doesn’t take much to appreciate that relationships (therapeutic or otherwise) are stronger and more equitable on open wards.
The Mental Elf website claims (8/5/20016) 215 responses to this post. All but a very few were approving tweets that did not depend on the tweeter having read the study.
The reference to TV news channels is at the level of evidence of a Donald Trump tweet in which he refers to something he saw on TV.
Taking a look at the actual article and its supplementary information.
Christian G. Huber, Andres R. Schneeberger, Eva Kowalinski, Daniela Fröhlich, Stefanie von Felten, Marc Walter, Martin Zinkler, Karl Beine, Andreas Heinz, Stefan Borgwardt, and Undine E. Lang. Suicide Risk and Absconding in Psychiatric Hospitals with and without Open Door Policies: A 15-year Naturalistic Observational Study. The Lancet Psychiatry, 2016 DOI: 10.1016/S2215-0366(16)30168-7
At the time of the media campaign, most people who wanted to access the article could only obtain its abstract, which you can click here .
Why were there only 75 suicides being explained?
Much ado is being made of 75 suicides that occurred over a 15 year period across 21 hospitals. Suicides are an infrequent event, even in high risk populations. But why were only 75 available for analysis from a sample that initially consisted of 350,000 in this amount of time?
Let’s start with the 350,000 admissions that are misrepresented as “cases” in the official press releases. The article states:
The resulting dataset contained 349 574 hospital admissions from 177 295 patients.
Presumably, a considerable proportion of these patients had multiple admissions over the 15 years. Suicides were probably concentrated in the group with multiple admissions. But some patients had only one admission. Moreover, some patients may have been admitted to different types of facilities – locked versus unlocked – on different occasions. Confusion is being generated, bias is being introduced, and valuable information is being lost about the non-independence of observations – i.e., admissions.
How many suicides occurred among these 349 574 hospital admissions? Readers cannot tell from the article. Table 4 states that multivariate analyses were based on predicting 79 suicides. Yet, going to supplementary materials, Table S1 indicates that the analyses were done without the matching requirements imposed by propensity analyses, there were 174 suicides to it explain. The authors aren’t particularly clear, but it appears that in order to meet the requirements of their propensity analysis, they threw away data on most of the suicides.
The exaggerated power of propensity analyses
The authors extol the virtues of propensity analyses:
We used propensity score matching and generalised linear mixed-eﬀects models to achieve the strongest causal inference possible without an experimental design. Since patients were not randomly allocated to the diﬀerent hospital types, causal inference between hospital type and outcomes might be biased—potential confounders could aﬀect both the probability of relevant outcomes and the probability of a case having been admitted to a speciﬁc hospital type. The propensity score of patients reﬂects their probability of having been admitted to a hospital with an open-door policy rather than one with a locked-door policy.15 By matching cases from both hospital types based on their propensity score, datasets with similar distributions of confounders can be generated. These allow stronger causal inference when analysed.15
A full discussion of propensity analyses is beyond the scope of this blog post. I worry that I would lose a lot of readers here if I attempted one. But here is a very readable, accessible source:
It remains unclear whether, and if so when, use of propensity scores provides estimates of drug effects that are less biased than those obtained from conventional multivariate models. In the great majority of published studies that have used both approaches, estimated effects from propensity score and regression methods have been similar.
Use of propensity scores will not correct biases from unmeasured confounders, but can aid in understanding determinants of drug use and lead to improved estimates of drug effects in some settings.
One problem with applying analysis of propensity scores to the data set used in the Lancet Psychiatry is that there was a great deal of difficulty matching the admissions to different settings. Moreover, because it was an administrative data set, there are numerous unmeasured, but particularly crucial confounds that could not be included in the propensity matching or in the generalised linear mixed-eﬀects model analyses thereafter. So, in using propensity analysis, the authors threw way most of their data without been able to achieve adequate statistical control for confounds.
We calculated propensity scores for all cases based on a model that included all clinical characteristics before admission as exploratory variables (age, sex, marital status, housing situation, living together with others, employment situation, main diagnosis, comorbid substance use disorder, comorbid personality disorder, comorbid mental retardation, self-injuring behaviour before admission, suicidal ideation before admission, suicide attempt before admission, type of admission, and voluntary admission). These calculations were done on a complete case basis, therefore 36 300 (10·4%) cases with missing covariate were excluded.
There is the temptation to ask “what is the harm in adjustments that involve the loss of only 10.4% of cases, particularly if better statistical control is achieved?” Well,
Overall, 72,869 pairs of matched cases could be created, resulting in a total matched set consisting of 145,738 cases from 87,640 individual patients for the analyses themselves.
So, the authors have lost a nonrandom selection of more than half the admissions with which they started, and they’ve lost the nonindependence of observations in this shrunken data set. Just look at the ratio of 145,738 “cases” to the 87,640 individual patients from which they came. There is a lot of valuable data being suppressed concerning the fate of individual patients when hospitalized in different settings.
How complete is the data available for matching and control of statistical confounds?
We calculated propensity scores for all cases based on a model that included all clinical characteristics before admission as exploratory variables (age, sex, marital status, housing situation, living together with others, employment situation, main diagnosis, comorbid substance use disorder, comorbid personality disorder, comorbid mental retardation, self-injuring behaviour before admission, suicidal ideation before admission, suicide attempt before admission, type of admission, and voluntary admission.
Let’s look at baseline characteristics in Table 1 of the Lancet Psychiatry article. These are the only variables that are available for matching or controlling for statistical confounds.
Recall that the effectiveness statistical controls assumes that all relevant variables have been measured with perfect precision. Statistical control is supposed to eliminate crucial differences among patients so they can be assumed to be otherwise equivalent in likelihood of being admitted to a locked or unlocked ward for the basis of analysis and interpretation. Statistical control is supposed to equip us to make “all-other-things-being equal” judgments about the effects of being in a locked or unlocked ward.
Zero in on main and comorbid diagnoses. What kind of statistical voodoo can possibly be expected to level other differences between patients at higher risk for suicide like the 49% minority with schizophrenia spectrum or affective of disorder versus the others at considerably lower risk? How does it help that this large minority of higher risk patient is thrown in with lower risk patients with organic mental disorder (dementia or mental retardation) and “neurotic, stress-related and somatoform disorders”?*
If there’s any rationality to the German system of care (and I assume there is), at least some crude risk assessment would guide patients with lower risk into less restrictive settings.
And then there is the question of substance use disorder, which was the primary diagnosis for 67,811 (25·5%) of the patients going into locked facilities and 14,621 (18·7%);
Substance use disorder was the comorbidity for another 100 128 (36·9%) going into locked facilities and 28 363 (36·2%) going into unlocked facilities. Issues for substance use disorder and exit security on psychiatric wards are very different than for patients without such disorders. These issues in relationship to absconding or dying by suicide are not going to be sorted by entering diagnosis into a propensity analysis or generalised linear mixed-eﬀects model analyses of a data set shrunken by matching in a propensity analysis.
I conclude that the data set is much less impressive and relevant than it first appears. There are not a lot of suicides. They occur in a heterogeneous population in a length of time in which the patterning of circumstances associated with these characteristics likely changed. Because it was the administrative data set, there were restricted opportunities for matching of patients or control of confounds. Any substantive interpretation of multivariate results requires dubious, unsubstantiated assumptions.
But more importantly, the data set does not provide much evidence for the ideologically saturated claims of the authors or their promoter, Mental Elf. They can pound their drums, but it is not evidence that they are announcing. And patients and their families in both Germany and elsewhere could suffer if the recommendations are taking seriously.
*The “neurotic, stress-related and somatoform disorders” admissions to inpatient units are a distinctly German phenomenon. Persons from the community claiming “burnout” can be admitted to facilities overseen by departments of psychotherapy and psychosomatics. There is ample insurance coverage for what can be a spa-like experience with massage and integrative medicine approaches.
Reviews important barriers to effective approaches to reducing suicide, as cited in the editorial.
Discusses editorials in general as a form of privileged access publishing by which non-peer-reviewed material makes its way into ostensibly peer reviewed journals.
Identifies the self-promotional and personal agendas of the authors reflected in the editorial.
Notes that the leading means of death by suicide in the United States is not even mentioned, much less addressed in this editorial. I’ll discuss the politics behind this and why its absence reduces this editorial to a venture in triviality, except that it is a call for the waste of millions of dollars.
Barriers to reducing mortality by suicide
Prevention of death by suicide becomes an important public health and clinical goal because of suicide’s contribution to overall mortality, the seeming senselessness of suicide, and its costs at a personal and social level. Yet as a relatively infrequent event, death by suicide resists prediction and effective preventive intervention.
Evidence concerning the formidable barriers to reducing death by suicide inevitably clashes with the strong emotional appeals and political agendas of those demanding suicide intervention programs.
Skeptics encounter stiff resistance and even vilification when they insist that clinical and social policy concerning suicide should be based on evidence.
A skeptic soon finds that trying to contest emotional and political appeals quickly becomes like trying to counter Ted Cruz or Donald Trump with evidence contradicting their proposals for dealing with terrorism or immigration. This is particularly likely after suicides by celebrities or a cluster of suicides by teenagers in a community. Who wants to pay attention to evidence when emotions are high and tears are flowing?
The JAMA: Psychiatry article’s identification of barriers
The JAMA: Psychiatry article identifies some key barriers to progress in reducing deaths due to suicide [bullet points added to direct quotes]:
Suicide rates in most Western countries have not decreased in the last decade, a finding that compares unfavorably with the progress made in other areas, such as breast and skin cancers, human immunodeficiency virus, and automobile accidents, for which the rates have decreased by 40% to 80%.
Preventing suicide is not easy. The base rate of suicide is low, making it hard to determine which individuals are at risk.
Our current approach to the epidemiologic risk factors has failed because prediction studies have no clinical utility—even the highest odds ratio is not informative at the individual level.
Decades of research on predicting suicides failed to identify any new predictors, despite the large numbers of studies.
A previous suicide attempt is our best marker of a future attempt, but 60% of suicides are by persons who had made no previous attempts.
Although recent studies in cognitive neuroscience have shed light on the cognitive “lesions” that underlie suicide risk, especially deficits in executive functioning, we have no biological markers of suicide risk, or indeed of any mental illness.
People at risk of suicide do not seek help. Eighty percent of people at risk have been in contact with health services prior to their attempts, but they do not identify themselves, largely because they do not think that they need help.
As clinicians, we know something about the long-term risk factors for suicide, but we are much less able to disambiguate short-term risk or high-risk factors from the background of long-term risk factors.
How do editorials come about? Not peer review!
Among the many privileges of being editor-in-chief or associate editors of journals is the opportunity to commission articles that do not undergo peer review. Editors and their friends are among the regular recipients of these gifts that largely escape scrutiny.
Editorials often provide a free opportunity for self-citation and promotion of agenda. Over the years, I’ve noticed that editorials are frequently used to increase the likelihood that particular research topics will become a priority for funding for the particular ideas will be given advantage in competition for funding.
Editorials of great opportunities for self citation. If an editorial in a prestigious journal cites articles published in less prestigious places, readers will often cite the article, without bothering to examine the original source. This is a way of providing false authority to poor quality or irrelevant evidence.
Not only do authors of commissioned articles get to say what they wish without peer review, they can restrict what can be said in reply. Journals are less willing to publish letters to the editor about editorials rather than empirical papers. They often give the writers of the editorial veto power over what criticism is published. Journals always give the writers of the editorial last word in any exchange.
So, editorials and commentaries can be free sweet plums if you know how to use them strategically.
Helen Christensen, PhD Black Dog Institute, University of New South Wales, Randwick, New South Wales, Australia.
Pim Cuijpers, PhD Department of Clinical, Neuro, and Developmental Psychology, Vrije Universiteit Amsterdam, the Netherlands
Charles F. Reynolds III, MD Department of Psychiatry and Neurology, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Our unique approach incorporates clinical services with our cutting-edge research, our health professional training and community education programs. We combine expertise in clinical management with innovative research to develop new, and more effective, strategies for people living with mental illness. We also place emphasis on teaching people to recognise the symptom of poor mental health in themselves and others, as well as providing them with the right psychological tools to hold the black dog at bay.
A key passage in the JAMA: Psychiatry editorial references her work.
Modeling studies have shown that if all evidence-based suicide prevention strategies were integrated into 1 multifaceted systems approach, about 20% to 25% of all suicides might be prevented.
Here is the figure from the editorial:
The paper that is cited would be better characterized as an advocacy piece, rather than a balanced systematic review.
Most fundamentally, Christiansen makes the mistake of summing attributable risk factors to obtain a grand total of what would be accomplished if all of a set of risk factors were addressed.
The problem is that attributable risk factors are dubious estimates derived from correlational analyses which assume that the entire correlation coefficient represents a modifiable risk. Such estimates ignore confounding. If one adds together attributable risk factors calculated in this manner, one gets a grossly inflated view of how much a phenomenon can be controlled. The attributable risk factors are themselves correlated and they share common confounds. That’s why it is bad science to combine them.
Christiansen identifies the top three modifiable risk for suicide as (1) training general practitioners in detection and treatment of suicidal risk, and notably depression; (2) training of gatekeepers such as school personnel, police, (and in some contexts, clergy) who might have contact with persons on the verge of dying by suicide; and (3) psychosocial treatments, namely psychotherapy.
Training of general practitioners and gatekeepers has not been shown to be an effective way of reducing rates of suicide. #Evidenceplease. I’ve been an external scientific advisor to over a decade of programs in Europe which emphasized these strategies. We will soon be publishing the last of our disappointing results.
Think of it: in order to be effective in averting death by suicide, training of police requires that police be on the scene in circumstances where they could use that training to prevent someone from dying by suicide, say, by jumping from a bridge or self-inflicted gun wounds. The likelihood is low that it would be a police officer with sufficient training being in the right place at the right time, with sufficient time and control of the situation to prevent a death. A police officer who had received training would unlikely encounter only a few, if any situations in an entire career.
The problem of death by suicide being an infrequent event that is poorly predicted again rears its ugly head.
Christiansen also makes a dubious assumption that more readily availability of psychotherapy will substantially reduce the risk of suicide. The problem is that persons who die by suicide are often in contact with professionals, but they either break the contact shortly before death or never disclose their intentions.
Christiansen provides a sizable estimate for the reduction in risk for suicide by means restriction.
]. Yet, I suspect that she underestimates the influence of this potentially modifiable factor.
She focuses on restricting access to prescription medications used in suicides by overdose. I don’t know if death-by-overdose data holds for even Australia, but the relevant means needing restriction in the United States is access to firearms. I will say more about that later.
So, Christiansen makes use of the editorial to sell her pet ideas and her institute markets training.
Pim Cuijpers doesn’t cite himself and doesn’t need to. He is rapidly accumulating a phenomenal record of publications and citations. But he is an advocate for large-scale programs incorporating technology, and notably the Internet to reduce suicide. His interests are reflected in passages like
Large-scale trials are also needed. Even if we did all of these things, large-scale research programs with millions of people are required, and technology by itself will not be enough. Although new large trials show that the effects of community programs can be effective,1,6 studies need to be bigger, combining all evidence-based medical and community strategies, using technology effectively to reduce costs of identification and treatment.
Help-seeking may well be assisted by using social media. Online social networks such as Facebook can be used to provide peer support and to change community attitudes in the ways already used by marketing industries. We can use the networks of “influencers” to modify attitudes and behavior in specific high-risk groups, such as the military, where suicide rates are high, or “captive audiences” in schools.
Disseminating effective programs is no longer difficult using online mental health programs. Although some early suicide apps and websites have been tested, better online interventions are needed that can respond to temporal fluctuations in suicide risk. The power of short-term prediction tools should be combined with the timely delivery of unobtrusive online or app personalized programs. However, if these development are not supported by government or industry and implemented at a population level, they will remain missed opportunities.
Pim Cuijpers is based the Netherlands and writing at a time when enthusiasm of the European Research Council is waning in funding large-scale suicide prevention programs, especially expensive ones requiring millions of participants. Such studies have been going on for over a decade and the yield is not impressive.
The projects on which I consulted adopted the reasonable assumption that because suicide is a rare event, a population of 500,000 would not be sufficient to detect a statistically significant reduction in suicide rates of less than 30%. Consider all the extraneous events that can impinge on comparisons between intervention and control sites in the time period in which the intervention could conceivably be influential. this is too low an estimate of the sample that would be needed.
The larger the sample, the greater the likelihood of extraneous influences, the greater the likelihood that the intervention wouldn’t prove effective at key moments when it was needed to avert a death by suicide, and the greater the cost. See more about this here.
Pim Cuijpers has been quite influential in developing in evaluating web-based and app-based interventions. But after initial enthusiasm, the field is learning that such resources are not effective if left unattended without users being provided with a sense that they are in some sort of a human relationship within which they are consistent use of this technology is being monitored and appreciated, as seen in appropriate feedback. Pim Cuijpers has contributed the valuable concept of supportive accountability. I have borrowed it to explain what is missing when primary care physicians simply give depressed patients a password to an Internet program and leave it at that, expecting they will get any benefit.
Evaluations of such technology have been limited to whether they reduce depressive symptoms. There is as much a leap from evidence of such reductions, when they occur, claims about preventing suicide, as there is from leaping from evidence that psychotherapy reduces the depressive symptoms to a case that psychotherapy prevents suicide.
Enlisting users of Facebook to monitor and report expressions of suicidality is not evidence based, It is evaluated by some as a disaster and a consumer group is circulating a petition demanding that such practices stop. A critical incident was
Charles F. Reynolds
Although Charles Reynolds does not reference his paper in the text of the editorial, but nonetheless cites it.
I have critiqued the study elsewhere. It was funded in a special review only because of political pressure from Senator Harry Reid. The senator’s father had died by suicide shortly after a visit to a primary care physician. Harry Reid required that Congress fund a study showing that improving the detection and treatment of suicidality in the elderly by primary care physicians would reduce suicide.
I was called by an NIMH program officer when I failed to submit a letter of intent concerning applying for that initiative. I told her it was a boondoggle because no one could show a reduction in suicides by targeting physician behavior. She didn’t disagree, but said a project would have to funded. She ended up a co-author on the PROSPECT paper. You don’t often see program officers getting authorship on papers from projects they fund.
The resulting PROSPECT study involved 20 primary care practices in three regions of the Northeastern United States. In the course of the intervention study, one patient in the intervention group died by suicide and two patients, one in each of the intervention and control group, made serious attempts. A multimillion dollar study confronted the low incidence of suicide, even among the elderly. Furthermore, the substantial baseline differences among the practices dwarfed any differences in suicidal ideation in the intervention versus control group. And has of discussed elsewhere [ ], suicidal ideation is a surrogate end point that can be changed by factors that do not alter risk for suicide. No one advocating more money for these kind of studies would want to get into the details of this one.
So, the editorial acknowledges the difficulties studying and preventing suicide as a public health issue. It suggests that an unprecedented large study costing millions of dollars would be necessary if progress is to be made. There are formidable barriers to implementing an intervention in a large population of the complexity of the editorial suggests is necessary. Just look at the problems that PROSPECT encountered.
Who will set the direction of suicide prevention research?
The editorial opens with a citation of a blog by the then Director of NIMH
Insel T. Director’s Blog: Targeting suicide. National Institutes of Health website. Posted April 2, 2015.
The blog calls for a large increase in funding for the research concerning suicide and its prevention. The definition of the problem is shaped by politics more than evidence. But at least the blog post is more candid than the editorial in making a passing reference to the leading means of suicide in the United States, firearms.
51 percent of suicide deaths in the U.S. were by firearms. Research has already demonstrated that reducing access to lethal means (including gun locks and barriers on bridges) can reduce death rates.
Great, but surely death by firearms deserves more mentioned than a passing reference to locks on guns if the Director of NIMH is serious about asking Congress for a massive increase in funding for suicide research. Or is he being smart in avoiding the issue and even brave in the passing reference that he makes to firearms?
Firearms deserve not only mention, but thoughtful analysis. But in the United States, it is politically dangerous and could threaten future funding. So we talk about other things.
Banning research on the role of firearms in suicide
In the spring of 1996, the National Rifle Association and its allies set their sights on the Centers for Disease Control and Prevention for funding increasingly assertive studies on firearms ownership and the effects on public health. The gun rights advocates claimed the research veered toward advocacy and covered such logical ground as to be effectively useless.
At first, the House tried to close down the CDC’s entire, $46 million National Center for Injury Prevention. When that failed, [Congressman Jay Dickey to whom the Dickey amendment is named] Dickey stepped in with an alternative: strip $2.6 million that the agency had spent on gun studies that year. The money would eventually be re-appropriated for studies unrelated to guns. But the far more damaging inclusion was language that stated, “None of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.”
Dickey proclaimed victory — an end, he said at the time, to the CDC’s attempts “to raise emotional sympathy” around gun violence. But the agency spent the subsequent years petrified of doing any research on gun violence, making the costs of the amendment clear even to Dickey himself.
He said the law was over-interpreted. Now, he looks at simple advances in highway safety — safety barriers, for example — and wonders what could have been done for guns.
The Dickey amendment does not specifically ban NIMH from investigating the role of firearms in suicide, but I think Tom Insel and all NIMH directors before and after him get the message.
“Gun violence is probably the only thing in this country that kills so many people, injures so many people, that we are not actually doing sufficient research on,” Dr. Alice Chen, the executive director of Doctors for America, told The Huffington Post.
Well over half a million people have died by firearms since 1996, when the ban on gun violence research was enacted, according to a HuffPost calculation of data through 2013 from Centers for Disease Control and Prevention. According to its sponsors, the Dickey Amendment was supposed to tamp down funding for what the National Rifle Association and other critics claimed was anti-gun advocacy research by the CDC’s National Center for Injury Prevention. In effect, it stopped federal gun violence research almost entirely.
So, why didn’t the Associate Editor of the JAMA: Psychiatry, Charles Reynolds exercise his editorial prerogative and support this effort to repeal the Dickey amendment, rather than lining up with his co-authors in a call for more wasteful research that avoids this important issue?