Reflections on my tour of the Soteria Project at St Hedwig Hospital, Berlin

A fabulous, enlightened experiment in Berlin with humane treatment of patients suffering severe mental disorder that we cannot reproduce in the United States.

 

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A fabulous, enlightened experiment in Berlin with humane treatment of patients suffering severe mental disorder that we cannot reproduce in the United States.

soteria doorI 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.

outside SoteriaI 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.

Professor Heinz and I became friends when I critiqued his study of open versus locked inpatient psychiatric wards, Why Lancet Psychiatry study didn’t show locked inpatient wards ineffective in reducing suicide   . We can still agree to disagree about the interpretation of complex observational/administrative data, but we came to appreciate differences in our sociocultural perspectives.

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.

group meetingWith Professor Heinz’s permission, here is a refined Google translation of the Project website.

See also  an excellent discussion of the thinking that went into the architecture of Soteria, aimed at maximizing its potential as a therapeutic environment.

around the hearth

Special thanks also to Psychiatrists Dr med Felix Bermpohl and Dr med Martin Voss Oberarzt.

SOTERIA

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.

He is the author of the just released A New Understanding of Mental Disorders: Computational Models for Dimensional Psychiatry, MIT Press, 2017.

 

 

Talking back to “Talking Therapy Can Literally Rewire the Brain”

This edition of Mind the Brain was prompted by an article in Huffington Post, Talking Therapy Can Literally Rewire the Brain.

The title is lame on two counts: “literally” and any suggestion that psychotherapy does something distinctive to the brain, much less “rewiring” it.

I gave the journalist the benefit of a doubt and assumed that the editor applied the title to the article without having the journalist’s permission. I know from talking to journalists, that’s a source of enormous frustration when it happens. But in this instance, the odd title came directly from a press release from King’s College London  (Study reveals for first time that talking therapy changes the brain’s wiring)which concerned an article published in the  Nature Publishing journal, Translational Psychiatry 

Hmm, authors from King’s College and published in a Nature journal suggest this might be a serious piece of science worth giving a closer look. In the end, I was reminded not to make too much of authors’ affiliation and where they publish.

I poked fun on Twitter at the title of the Huffington Post article.

literally twitter postThe retweets and likes drifted into a discussion of neuroscientists saying they really didn’t know much about the brain. Somebody threw in a link to an excellent short YouTube video by NeuroSkeptic on that topic that I highly recommend.

Anyway, I found serious problems with the Huffington Post article that should have been sufficient to stop with it.  Nonetheless, I proceeded and the problems got compounded when I turned to the press release with its direct quotes from the author. I wasn’t long into the Translational Psychiatry article before I appreciated that its abstract was misleading in claiming that there were 22 patients in the study. That is a small number, but if the abstract had stated the actual number, which was 15 patients, readers would have been warned not to take too seriously complicated multivariate statistics that were coming up.

How did a prestigious journal like Translational Psychiatry allow authors to misrepresent their sample size? I would shortly be even more puzzled about why the article was even published in Translational Psychiatry, although I formed unflattering some hypotheses about that journal. I’ll end with those hypotheses.

Talking To A Therapist Can Literally Rewire Your Brain (Huffington Post)

The opening sentence would raise the skepticism of informed reader:

If you can change the way you think, you can change your brain.

If I accept that statement, it’s going be with a broad stretching of it to meaninglessness. “If you can change the way you think..” covers lots of territory. If the statement  is going to remain the correct, then the phrase “change your brain” is going to have to be similarly broad. If the journalist wants to make a big deal of this claim, she would have to concede that reading my blog changes her brain.

That’s the conclusion of a new study, which finds that challenging unhealthy thought patterns with the help of a therapist can lead to measurable changes in brain activity.

Okay, we now know that at least a specific study with brain measurements is being discussed.

But then

In the study, psychologists at King’s College London show that Cognitive Behavioral Therapy strengthens certain healthy brain connections in patients with psychosis. This heightened connectivity was associated with long-term reductions in psychotic symptoms and recovery eight years later, according to the findings, which were published online Tuesday in the journal Translational Psychiatry.

“Over six months of therapy, we found that connections between certain key brain regions became stronger,” Dr. Liam Mason, a clinical psychologist at King’s College and the study’s lead author, told The Huffington Post in an email. “What we are really excited about here is that these stronger connections lead to long-term improvements in people’s symptoms and overall recovery across the eight years that we followed them up.”

A lot of skepticism is being raised. The article seems to be claiming that changes in brain function observed in the short term with cognitive behavior therapy for psychosis [CBTp] were associated with long-term changes over the extraordinary eight years.

The problems with this? First CBTp is not known to be particularly effective, even in the short term. Second, this a lot heterogeneity under the umbrella of “psychosis,” but in eight years, a person who has had that label appropriately applied will have a lot of experiences: recovery and relapse, and certainly other mental health treatments. How in all that noise and confusion can a signal detected that a psychotherapy that isn’t particularly effective explains any long-term improvement?

[Skeptical about my claim that CBTp is ineffective? See Effect of a missing clinical trial on what cochrane-slide-2we think about cognitive behavior therapy  and the slides about Cochrane reviews from a longer Powerpoint presentation.]

Any discussion of how CBT works and what long-term improvements it predicts has get past considerable evidence CBT doesn’t work any better than nonspecific supportive treatments. Without short-term effects, how can have long-term effects?

cbt cochrane 1

 

 

 

There is no acknowledgment in the Huffington Post article of the lack of efficacy of CBTp. Instead, we have a strong assumption that CBTp works and that the scientific paper under discussion is important because it shows that CBTp strongly works, with observable long-term effects.

The journalist claims that the present scientific paper builds on earlier one:

In the original study, patients with psychosis underwent brain imaging both before and after three months of CBT. The patients’ brains were scanned while they looked at images of faces expressing different emotions. After undergoing CBT, the patients showed marked increases in brain activity. Specifically, the brain scans showed heightened connections between the amygdala, the brain region involved in fear and threat processing, and the prefrontal cortex, which is responsible for reasoning and thinking rationally ― suggesting that the patients had an improved ability to accurately perceive social threats.

“We think that this change may be important in allowing people to consciously re-think immediate emotional reactions,” Mason said.

Readers can click back to my earlier blog post, Sex and the single amygdala: A tale almost saved by a peek at the data. The same experimental paradigms was being used to study the amygdala in terms of activity predicted changes in the number of sexual partners over time. In that particular study, p-hacking, and significance chasing and selective reporting were used by the authors to create the illusion of important findings. If you visit my blog post, check out the comments that ridiculed the study, including from two very bright undergraduates.

We don’t need to deter into a technical discussion of functional magnetic resonance imaging (fMRI) data to make a couple of points. The authors of the present study used a rather standard experimental paradigm and the focus on amygdala concerned some quite nonspecific psychological processes.

The authors of the present study soon concede this:

There’s a good chance that similar brain changes also occur in CBT patients being treated for anxiety and depression, Mason said.

“There is research showing that some of the same connections may also be strengthened by CBT for anxiety disorders,” he explained.

But wait: isn’t the lead author also saying in the Huffington Post article and the title of the press release as well that this is a first-time study ever?

For the present purposes, we need only to dispense with any notion that we’re talking about a rewiring of the brain known to be specifically associated with psychosis or even that there is reason to expect that such “rewiring” could be expected to predict long-term outcome of psychosis.

Reading further, we find that the study only involved following 15 patients from a larger study, un like the misleading abstract that claims 22.

Seriously, are we being asked to get worked up about a fMRI study with only 15 patients? Yup.

The researchers found that heightened connectivity between the amygdala and prefrontal cortex was associated with long-term recovery from psychosis. The exciting finding marks the first time scientists have been able to demonstrate that brain changes resulting from psychotherapy may be responsible for long-term recovery from mental illness.

What is going on here? The journalist next gives free reign to the lead author to climb up on a soap box and proclaim his agenda behind all of these claim:

The findings challenge the “brain bias” in psychiatry, an institutional focus on physical brain differences over psychological factors in mental illness. Thanks to this common bias, many psychiatrists are prone to recommending medication to their clients rather than psychological treatments such as CBT.

But medication has been proved to be effective with psychosis, CBTp has not.

“Psychological therapy can lead to changes in the mechanics of the brain,” Mason said. “This is especially important for conditions like psychosis which have traditionally been viewed as ‘brain diseases’ that require medication or even surgery.”

“Mechanics of the brain”?  Now we have escalated from ‘literally rewiring’ to “changes in the mechanics.” Dude, we are talking about a fMRI study. Do you think we have been transported to an auto repair shop?

“This research challenges the notion that the existence of physical brain differences in mental health disorders somehow makes psychological factors or treatments less important,” Mason added in a statement.

Clicking on the link takes one to Science Daily article which churnals (plagiarizes) a press release from Kings College,  London.

The Press Release: Study reveals for first time that talking therapy changes the brain’s wiring

There is not much in this press release that is not been regurgitated in the Huffington Post article except for some more soapbox preaching:

Unfortunately, previous research has shown that this ‘brain bias’ can make clinicians more likely to recommend medication but not psychological therapies. This is especially important in psychosis, where only one in ten people who could benefit from psychological therapies are offered them.”

But CBT, the most evaluated psychotherapy for psychosis has not been shown to be effective, by itself. Sure, patients suffering from psychosis need a lot of support, efforts to maintain positive expectations, and opportunities to talk about their experience. But in direct comparisons between such support provided by professionals or by peers, CBT has not been shown to be more effective.

The researchers now hope to confirm the results in a larger sample, and to identify the changes in the brain that differentiate people who experience improvements with CBT from those who do not. Ultimately, the results could lead to better, and more tailored, treatments for psychosis, by allowing researchers to understand what determines whether psychological therapies are effective.

Sure, we are to give a high priority to examining the mechanism by which CBT, which has not been proven effective, works its magic.

Translational Psychiatry: Brain connectivity changes occurring following cognitive behavioural therapy for psychosis predict long-term recovery

[This will be a quick tour, only highlighting some of the many problems that I found. I welcome readers probing the open access article and posting what they find.]

The Abstract misrepresents the study as having 22 patients, when it actually only had data from 15.

The Introduction largely focuses on previous work of the author group. If you bothered to check, none of it involves randomized trials, despite making claims of efficacy for CBTp. No reference is made to a large body of literature finding a lack of effectiveness for CBTp. In particular, there is no mention of the Cochrane reviews.

A close reading of the Methods indicates that what are claimed to be “objective clinical outcomes” are actually unblinded, retrospective ratings of case notes by the two raters including the first author. Unblinded ratings, particularly by an investigator, are an important source of bias in studies of CBTp and lead to exaggerated estimates of outcome.

An additional measure with inadequate validation was obtained at 7 to 8 year follow-up:

Questionnaire about the Process of Recovery (QPR,31), a service-user led instrument that follows theoretical models of recovery and provides a measure of constructs such as hope, empowerment, confidence, connectedness to others.

All patients came from clinical studies conducted by the author group that did not involve randomization. Rather, assignment to CBTp was based on provider identifying patients “deemed as suitable for CBTp.“ There is considerable risk of bias if it patient data is treated if it arose in a randomized trial. I previously raised issues about the inadequacy of routine care provided to psychotic patients both in terms of its clinical adequacy and an meaningfulness as a control/comparison group because of its lack of nonspecific factors.

All patients assigned to CBTp were receiving medication and other services. A table revealed that receipt of other services was strongly correlated with recovery status. Yet the authors are attempting to attribute any recovery across the eight years to the brief course of CBTp at the beginning. Obviously, the study is hopelessly confounded and no valid inferences possible. This alone should have gotten this study rejected.

There were data available from control subjects at follow-up, including fMRI data, but they were excluded from the present report. That is unfortunate, because these data would allow at least minimal evaluation of whether CBTp versus remaining in routine care had any difference in outcomes and – importantly – if the fMRI data similarly predicted the outcomes of patients not receiving CBTp.

Data Analysis indicates one tailed, multivariate statistical tests that are quite inappropriate and essentially meaningless with such a small data set. Bonferonni corrections, which were inconsistently applied, offer no salvation.

With such small samples and multivariate statistics, a focus on p-values is inappropriate, but the authors do just that and report p<.04 and p<.06, the latter being treated as significant. The hypothesis that this might represent significance chasing is supported when supplementary data tables are examined. When I showed them to a neuroscientist, his first response was that they were painful to look at.

longitudinalI could go on but…

Why did the authors bother with this study? Why did King’s College London publicize the study with a press release? Why was it published in Nature’s Translational Psychiatry without the editor or the reviewers catching obvious flaws?

The authors had some data lying around and selected out post-hoc a subset of patients and applied retrospective ratings and inappropriate statistics. There is no evidence of a protocol for a priority hypothesis being pursued, but strong circumstantial of p-hacking, significance chasing and selective reporting. This is not a valid study, not even an experimerciasl, it is a political, public relations effort.

soao box 2Statements in the King’s College press release echoed in the Huffington Post indicate a clear ideological agenda. Anyone who knows anything about psychiatry, neuroscience, cognitive behavior therapy for psychosis is unlikely to be persuaded. Anyone who examines the supplementary statistical tables armed with minimal statistical sophistication will be unimpressed, if not shocked. We can assume that as a group, these people would quickly leave the conversation about cognitive behavior therapy for psychosis literally rewiring the brain, if they ever got engaged.

The authors were not engaging relevant audiences in intelligent conversation. I can only presume that they were targeting naive vulnerable patients and their families having to make difficult decisions about treatment for psychosis. And the authors were preaching to the anti-psychiatry crowd. One of the authors also appears as an author of Understanding Psychosis, a strongly non-evidence-based advocacy of cognitive behavior therapy for psychosis, delivered with a hostility towards medication and psychiatrists (See my critique.) I did know that about this author until I read the materials I’ve been reviewing. It is an important bit of information and speaks to the author’s objectivity and credibility.

Obviously, the press office of King’s College London depends a lot, maybe almost entirely, on the credibility of authors associated with that institution. Maybe next time, they should seek an independent evaluation. Or maybe they are  just interested in publicity about research of any kind.

But why was this article published in the seemingly prestigious Nature journal, Translational Psychiatry? It should be noted that this journal is open access, but with exceptionally pricey Article Processing Costs (APCs) of £2,400/$3,900/€2,800. Apparently adequate screening and appropriate peer review are not including in these costs. These authors have purchased a lot of prestige. Moreover, if you want to complain about their work in a letter to the editor, you have to pay $900. So the authors have effectively insulated themselves from critics. Of course, is always blogging, PubMed Commons and PubPeer for post-publication peer review.

I previously blogged about another underpowered, misreported study claiming to have identified a biomarker blood test for depression. The authors were explicitly advertising that they were seeking commercial backers for their blood test. They published in Translational Psychiatry. Maybe that’s the place to go for placing outlandish claims into open access – where anybody can be reached – with a false assurance of a prestige protected by rigorous peer review.

 

Why Lancet Psychiatry study didn’t show locked inpatient wards ineffective in reducing suicide

  • 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.
king of heratrs poster
As seen in the popularity of this movie, many of us had romanticized views of emancipating psychiatric inpatients in the 60s – 70s. De-institutionalization and neglect of huge numbers of homeless persons with psychosis was the unanticipated result.

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

This press release, Psychiatry on closed and open wards: The suicide risk remains the same  provided limited details of the study, but misrepresented the study’s finding of risk for suicide as being based on 350,000 patients.

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.

as Alabama cuts

Alabama sheriff
Just one of numerous results of a movement of resources away from mental health services for the severely impaired and vulnerable.

 

 

 

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: Locked wards vs open wards: does control = safety?

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.

another without a parachuteI 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.

models lockedPresumably, 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:

Glynn RJ, Schneeweiss S, Stürmer T. Indications for propensity scores and review of their use in pharmacoepidemiology. Basic & Clinical Pharmacology & Toxicology. 2006 Mar 1;98(3):253-9.

It states:

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.

And

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.

full clinical characteristicsLet’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.

Postscript

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.

Note

*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.

 

 

Effect of a missing clinical trial on what we think about cognitive behavior therapy

  • Data collection for a large, well-resourced study of cognitive behavior therapy (CBT) for psychosis was completed years ago, but the study remains unpublished.
  • Its results could influence the overall evaluation of CBT versus alternative treatments if integrated with what is already known.
  • Political considerations can determine whether completed psychotherapy studies get published or remain lost.
  • This rich example demonstrates the strong influence of publication bias on how we assess psychotherapies.
  • What can be done to reduce the impact of this particular study having gone missing?

A few years ago Ben Goldacre suggested that we do a study of the registration of clinical trials.

lets'collaborate

I can’t remember the circumstances, but Goldacre and I did not pursue the idea further. I was already committed to studying psychological interventions, in which Goldacre was much less interested. Having battled to get American Psychological Association to fully accept and implement CONSORT in its journals, I was well aware how difficult it was getting the professional organizations offering the prime outlets for psychotherapy studies to accept needed reform. I wanted to stay focused on that.

I continue to follow Goldacre’s work closely and cite him often. I also pay particular attention to John Ioannidis’ follow up of his documentation that much of what we found in the biomedical literature is false or exaggerated, like:

Ioannidis JP. Clinical trials: what a waste. BMJ. 2014 Dec 10;349:g7089

Many trials are entirely lost, as they are not even registered. Substantial diversity probably exists across specialties, countries, and settings. Overall, in a survey conducted in 2012, only 30% of journal editors requested or encouraged trial registration.

In a seeming parallel world, I keep showing that in psychology the situation is worse. I had a simple explanation why that I now recognize was naïve: Needed reforms enforced by regulatory bodies like the US Food and Drug Administration (FDA) take longer to influence the psychotherapy literature, where there are no such pressures.

I think we now know that in both biomedicine and, again, psychology, that broad declarations of government and funding bodies and even journals’ of a commitment to disclose a conflict of interest, registering trials, sharing data, are insufficient to ensure that the literature gets cleaned up.

Statements were published across 14 major medical journals endorsing routine data sharing]. Editors of some of the top journals immediately took steps to undermine the implementation in their particular journals. Think of the specter of “research parasites, raised by the editors of New England Journal of Medicine (NEJM).

Another effort at reform

Following each demonstration that reforms are not being implemented, we get more pressures to do better. For instance, the 2015 World Health Organization (WHO) position paper:

Rationale for WHO’s New Position Calling for Prompt Reporting and Public Disclosure of Interventional Clinical Trial Results

WHO’s 2005 statement called for all interventional clinical trials to be registered. Subsequently, there has been an increase in clinical trial registration prior to the start of trials. This has enabled tracking of the completion and timeliness of clinical trial reporting. There is now a strong body of evidence showing failure to comply with results-reporting requirements across intervention classes, even in the case of large, randomised trials [37]. This applies to both industry and investigator-driven trials. In a study that analysed reporting from large clinical trials (over 500 participants) registered on clinicaltrials.gov and completed by 2009, 23% had no results reported even after a median of 60 months following trial completion; unpublished trials included nearly 300,000 participants [3]. Among randomised clinical trials (RCTs) of vaccines against five diseases registered in a variety of databases between 2006–2012, only 29% had been published in a peer-reviewed journal by 24 months following study completion [4]. At 48 months after completion, 18% of trials were not reported at all, which included over 24,000 participants. In another study, among 400 randomly selected clinical trials, nearly 30% did not publish the primary outcomes in a journal or post results to a clinical trial registry within four years of completion [5].

Why is this a problem?

  • It affects understanding of the scientific state of the art.

  • It leads to inefficiencies in resource allocation for both research and development and financing of health interventions.

  • It creates indirect costs for public and private entities, including patients themselves, who pay for suboptimal or harmful treatments.

  • It potentially distorts regulatory and public health decision making.

Furthermore, it is unethical to conduct human research without publication and dissemination of the results of that research. In particular, withholding results may subject future volunteers to unnecessary risk.

How the psychotherapy literature is different from a medical literature.

Unfortunately for the trustworthiness of the psychotherapy literature, the WHO statement is limited to medical interventions. We probably won’t see any direct effects on the psychotherapy literature anytime soon.

The psychotherapy literature has all the problems in implementing reforms that we see in biomedicine – and more. Professional organizations like the American Psychological Association and British Psychological Society publishing psychotherapy research have the other important function of ensuring their clinical membership developer’s employment opportunities. More opportunities for employment show the organizations are meeting their members’ needs this results in more dues-paying members.

The organizations don’t want to facilitate third-party payers citing research that particular interventions that their membership is already practicing are inferior and need to be abandoned. They want the branding of members practicing “evidence-based treatment” but not the burden of members having to make decisions based on what is evidence-based. More basically, psychologists’ professional organizations are cognizant of the need to demonstrate a place in providing services that are reimbursed because they improve mental and physical health. In this respect, they are competing with biomedical interventions for the same pot of money.

So, journals published by psychological organizations have vested interests and not stringently enforcing standards. The well-known questionable research practices of investigators are strengthened by questionable publication practices, like confirmation bias, that are tied to the organizations’ institutional agenda.

And the lower status journals that are not published by professional organizations may compromise their standards for publishing psychotherapy trials because of the status that having these articles confers.

Increasingly, medical journals like The Lancet and The Lancet Psychiatry are seen as more prestigious for publishing psychotherapy trials, but they take less seriously the need to enforce standards for psychotherapy studies the regulatory agencies require for biomedical interventions. Example: The Lancet violated its own policies and accepted publication Tony Morrison’s CBT for psychosis study  for publication when it wasn’t registered until after the trial and started. The declared outcomes were vague enough so they could be re-specified after results were known .

Bottom line, in the case of publishing all psychotherapy trials consistent with published protocols: the problem is taken less seriously than if it were a medical trial.

Overall, there is less requirement for psychotherapy trials be registered and less attention paid by editors and reviewers as to whether trials were registered, and whether outcomes are analytic plans were consistent between the registration in the published study.

In a recent blog post, I identified results of a trial that had been published with switched outcomes and then re-published in another paper with different outcomes, without the registration even being noted.

But for all the same reasons cited by the recent WHO statement, publication of all psychotherapy trials matters.

archaeologist digging for goldRecovering an important CBT trial gone missing

I am now going to review the impact of a large, well resourced study of CBT for psychosis remaining on published. I identified the study by a search of the ISRCTN:

The ISRCTN registry is a primary clinical trial registry recognised by WHO and ICMJE that accepts all clinical research studies (whether proposed, ongoing or completed), providing content validation and curation and the unique identification number necessary for publication. All study records in the database are freely accessible and searchable.

I then went back to the literature to see what it happened with it. Keep in mind that this step is not even possible for the many psychotherapy trials that are simply not registered at all.

Many trials are not registered because they are considered pilot and feasibility studies and therefore not suitable for entering effect sizes into the literature. Yet, if significant results are found, they will be exaggerated because they come from an underpowered study. And such results become the basis for entering results into the literature as if it were a planned clinical trial, with considerable likelihood of not being able to be replicated.

There are whole classes of clinical and health psychology interventions that are dominated by underpowered, poor quality studies that should have been flagged as for evidence or excluded altogether. So, in centering on this trial, I’m picking an important example because it was available to be discovered, but there is much of their there is not available to be discovered, because it was not registered.

CBT versus supportive therapy for persistent positive symptoms in psychotic disorders

The trial registration is:

Cognitive behavioural treatment for persistent positive symptoms in psychotic disorders SRCTN29242879DOI 10.1186/ISRCTN29242879

The trial registration indicates that recruitment started on January 1, 2007 and ended on December 31, 2008.

No publications are listed. I and others have sent repeated emails to the principal investigator inquiring about any publications and have failed to get a response. I even sent a German colleague to visit him and all he would say was that results were being written up. That was two years ago.

Google Scholar indicates the principal investigator continues to publish, but not the results of this trial.

A study to die for

The study protocol is available as a PDF

Klingberg S, Wittorf A, Meisner C, Wölwer W, Wiedemann G, Herrlich J, Bechdolf A, Müller BW, Sartory G, Wagner M, Kircher T. Cognitive behavioural therapy versus supportive therapy for persistent positive symptoms in psychotic disorders: The POSITIVE Study, a multicenter, prospective, single-blind, randomised controlled clinical trial. Trials. 2010 Dec 29;11(1):123.

The methods section makes it sound like a dream study with resources beyond what is usually encountered for psychotherapy research. If the protocol is followed, the study would be an innovative, large, methodologically superior study.

Methods/Design: The POSITIVE study is a multicenter, prospective, single-blind, parallel group, randomised clinical trial, comparing CBT and ST with respect to the efficacy in reducing positive symptoms in psychotic disorders. CBT as well as ST consist of 20 sessions altogether, 165 participants receiving CBT and 165 participants receiving ST. Major methodological aspects of the study are systematic recruitment, explicit inclusion criteria, reliability checks of assessments with control for rater shift, analysis by intention to treat, data management using remote data entry, measures of quality assurance (e.g. on-site monitoring with source data verification, regular query process), advanced statistical analysis, manualized treatment, checks of adherence and competence of therapists.

The study was one of the rare ones providing for systematic assessments of adverse events and any harm to patients. Preumably if CBT is powerful enough to affect positive change, it can have negative effects as well. But these remain entirely a matter of speculation.

Ratings of outcome were blinded and steps were taken to preserve the blinding even if an adverse event occurred. This is important because blinded trials are less susceptible to investigator bias.

Another unusual feature is the use of a supportive therapy (ST) credible, but nonspecific condition as a control/comparison.

ST is thought as an active treatment with respect to the patient-therapist relationship and with respect to therapeutic commitment [21]. In the treatment of patients suffering from psychotic disorders these ingredients are viewed to be essential as it has been shown consistently that the social network of these patients is limited. To have at least one trustworthy person to talk to may be the most important ingredient in any kind of treatment. However, with respect to specific processes related to modification of psychotic beliefs, ST is not an active treatment. Strategies specifically designed to change misperceptions or reasoning biases are not part of ST.

Use of this control condition allows evaluation of the important question of whether any apparent effects of CBT are due to the active ingredients of that approach or to the supportive therapeutic relationship within which the active ingredients are delivered.

Being able to rule out the effects of CBT are due to nonspecific effects justifies the extra resources needed to provide specialized training in CBT, if equivalent effects are obtained in the ST group, it suggests that equivalent outcomes can be achieved simply by providing more support to patients, presumably by less trained and maybe even lay personnel.

It is a notorious feature of studies of CBT for psychosis that they lack comparison/control groups in any way equivalent to the CBT in terms of nonspecific intensity, support, encouragement, and positive expectations. Too often, the control group are ill-defined treatment as usual (TAU) that lacks regular contact and inspires any positive expectations. Basically CBT is being compared to inadequate treatment and sometimes no treatment and so any apparent effects that are observed are due to correcting these inadequacies, not any active ingredient.

The protocol hints in passing at the investigators’ agenda.

This clinical trial is part of efforts to intensify psychotherapy research in the field of psychosis in Germany, to contribute to the international discussion on psychotherapy in psychotic disorders, and to help implement psychotherapy in routine care.

Here we see an aim to justify implementation of CBT for psychosis in routine care in Germany. We have seen something similar with repeated efforts of German to demonstrate that long-term psychodynamic psychotherapy is more effective than shorter, less expensive treatments, despite the lack of credible data [ ].

And so, if the results would not contribute to getting psychotherapy implemented in routine care in Germany, do they get buried?

Science & Politics of CBT for Psychosis

A rollout of a CBT study for psychosis published in Lancet made strong claims in a BBC article and audiotape promotion.

morroson slide-page-0

 

 

 

The attention attracted critical scrutiny that these claims couldn’t sustain. After controversy on Twitter, the BBC headline was changed to a more modest claim.

Criticism mounted:

  • The study retained fewer participants receiving CBT at the end of the study than authors.
  • The comparison treatment was ill-defined, but for some patients meant no treatment because they were kicked out of routine care for refusing medication.
  • A substantial proportion of patients assigned to CBT began taking antipsychotic medication by the end of the study.
  • There was no evidence that the response to CBT was comparable to that achieved with antipsychotic medication alone in clinical trials.
  • No evidence that less intensive, nonspecific supportive therapy would not have achieved the same results as CBT.

And the authors ended up conceding in a letter to the editor that their trial had been registered after data collection had started and it did not produce evidence of equivalence to antipsychotic medication.

In a blog post containing the actual video of the presentation before his British Psychological Society, Keith Laws declares

Politics have overcome the science in CBT for psychosis

Recently the British Psychological Society invited me to give a public talk entitled CBT: The Science & Politics behind CBT for Psychosis. In this talk, which was filmed…, I highlight the unquestionable bias shown by the National Institute of Clinical Excellence (NICE) committee  (CG178) in their advocacy of CBT for psychosis.

The bias is not concealed, but unashamedly served-up by NICE as a dish that is high in ‘evidence-substitute’, uses data that are past their sell-by-date and is topped-off with some nicely picked cherries. I raise the question of whether committees – with such obvious vested interests – should be advocating on mental health interventions.

I present findings from our own recent meta-analysis (Jauhar et al 2014) showing that three-quarters of all RCTs have failed to find any reduction in the symptoms of psychosis following CBT. I also outline how trials which have used non-blind assessment of outcomes have inflated effect sizes by up to 600%. Finally, I give examples where CBT may have adverse consequences – both for the negative symptoms of psychosis and for relapse rates.

A pair of well-conducted and transparently reported Cochrane reviews suggest there is little evidence for the efficacy of CBT for psychosis (*)

cochrane slide-page-0                          cochrane2-page-0

 

These and other slides are available in a slideshow presentation of a talk I gave at the Edinburgh Royal  Infirmary.

Yet, even after having to be tempered in the face of criticism, the original claims of the Morrison study get echoed in the antipsychiatry Understanding Psychosis:

“Other forms of therapy can also be helpful, but so far it is CBTp that has been most intensively researched. There have now been several meta-analyses (studies using a statistical technique that allows findings from various trials to be averaged out) looking at its effectiveness. Although they each yield slightly different estimates, there is general consensus that on average, people gain around as much benefit from CBT as they do from taking psychiatric medication.”

Such misinformation can confuse patients making difficult decisions about whether to accept antipsychotic medication.

go on without mejpgIf the results from the missing CBT for psychosis study became available…

If the Klingberg study were available and integrated with existing data, it would be one of the largest and highest quality studies and it would provide insight into any advantage of CBT for psychosis. For those who can be convinced by data, a null finding from a large studythat added to mostly small and methodologically unsophisticated studies could be decisive.

A recent meta-analysis of CBT for prevention of psychosis by Hutton and Taylor includes six studies and mentions the trial protocol in passing:

Two recent trials of CBT for established psychosis provide examples of good practice for reporting harms (Klingberg et al. 20102012) and CONSORT (Consolidated Standards of Reporting Trials) provide a sensible set of recommendations (Ioannidis et al. 2004).

Yet, it does not provide indicate why it is missing and is not included in a list of completed but unpublished studies. Yet, the protocol indicates a study considerably larger than any of the studies that were included.

To communicate a better sense of the potential importance of this missing study and perhaps place more pressures on the investigators to release its results, I would suggest that future meta-analyses state:

The protocol for Klingberg et al. Cognitive behavioural treatment for persistent positive symptoms in psychotic disorders indicates that recruitment was completed in 2008. No publications have resulted. Emails to Professor Klingberg about the status of the study failed to get a response. If the study were completed consistent with its protocol, it would represent one of the largest studies of CBT for psychosis ever and one of the few with a fair comparison between CBT and supportive therapy. Inclusion of the results could potentially substantially modify the conclusions of the current meta-analysis.

 

The Holocaust intrudes into conversations about psychiatric diagnosis: Godwin’s rule confirmed

peter_kinderman_140x140The President-elect of the British Psychological Association drops the N word and invokes the Holocaust in denouncing mental health professionals who embrace the biomedical model.

The conversation concerning Understanding Psychosis and Schizophrenia  (hereafter UPS) took another wrong turn with extended references to Nazism and the Holocaust in a blog post by Peter Kinderman, Me, my brain and baked beans. Goodwin’s rule is once again confirmed.

please removePeter Kinderman is one of the main spokespersons for the British Psychological Society UPS document. The blog further identifies him as a Professor at University of Liverpool, and the President-elect of the British Psychological Society.

Godwin’s Rule or Godwin’s Rule of Nazi Analogies is “As an online discussion grows longer, the probability of a comparison involving Nazis or Hitler approaches 1.“ Michael Godwin elaborates on it in I Seem To Be A Verb: 18 Years of Godwin’s Law:

I created Godwin’s Law and began to repeat it in online forums whenever I encountered a silly comparison of someone or something to Hitler or to the Nazis…. My feeling is that “Never Again” loses its meaning if we don’t regularly remind ourselves of the terrible inflection point marked in human culture by the Holocaust. Sure, there has been genocide before that point and genocide after it, but to see an advanced, highly civilized nation warp itself into something capable of creating such a horror—well, I think Nazi Germany does count as a first in that regard. And to a great extent, our challenge as human beings who live in the period after that inflection point is that we no longer can be passive about history—we have a moral obligation to do what we can to prevent such events from ever happening again. Key to that obligation is remembering, which is what Godwin’s Law is all about.

Those horrified by the Holocaust as a unique historical event see invoking it casually in political or professional rivalries as a “gross misappropriation of the past and an obscene misuse of history.”

The continued misuse  and trivialization of the word prompted Elie Wiesel, Nobel laureate and chronicler of the Holocaust, to discontinue using it. “Whatever mishap occurs now, they call it ‘holocaust,'” Wiesel said. “I have seen it myself in television in the country in which I live. A commentator describing the defeat of a sports team, somewhere, called it a ‘holocaust.'”

This will be a long read edition of PLOS Mind the Brain because of extensive direct quotes from BPS President-elect Kinderman. His statements strain all credibility. I don’t want any ambiguity as to whether I made them up.

Readers are encouraged to retrieve Kinderman’s blog post and see for themselves. It is posted at the anti-psychiatry blog, Mad in America.

A résumé of what his blog reveals

  1. President-elect Kinderman has unusual psychological experiences which he traces to growing up in a family environment with a harsh, unloving mother.
  2. In ways that frighten him, he fantasizes about winning Nobel or Pulitzer prizes and being awarded knighthood. And “I lurch forwards and jump to conclusions in my mental logic.” He is prone to tangential connectivity and abstract, ‘clang’ associations.
  3. He believes that these experiences would have caused him to be castrated if the Nazis had won World War II.
  4. He believes that those who adhere to what he terms a disease model of psychological disorder are essentially following the Nazis.
  5. He believes the connection is obvious to friends and colleagues, who consider him brave in making it public.
  6. He makes extensive references to the Holocaust in developing his argument.
  7. Kinderman is particularly frightened by advocates of this disease model because of the rise of right-wing political parties in Europe.
  8. He ends with a plea “don’t use the ‘disease-model’ as a framework.”

A résumé of my commentary

  1. Kinderman sees his unusual experiences as giving him privileged status to condemn those who accept the biomedical model of psychopathology.
  2. He invokes the Holocaust and Nazi analogy to bolster his argument in what he sees as a turf war between his supporters and psychiatrists. Actually, the overwhelming majority of academic mental health professionals accept some version of a biomedical model.
  3. He has long been caricaturing psychiatric diagnosis in reductionist terms,  referring to the biomedical model as a “genetic disease” model. But by invoking the Holocaust and the Nazis, he is excluding himself from participation in any subsequent conversation.
  4. Until President-elect Kinderman apologizes to the larger community which accepts the need to protect the memory of Holocaust from such desecration, the credibility of the British Psychological Society remains damaged. The BPS Board of Trustees should condemn him or accept responsibility for having such a spokesperson.
  5. Kinderman indicates that his blog is “a slightly longer version” of an article published elsewhere. The earlier article lacked any reference to the Holocaust or Nazis and he expresses appreciation to Anne Cooke for editing the transition. She therefore shares responsibility with Kinderman for the references to the Holocaust and Nazis. She is similarly disqualified as a participant in any conversation in the social media until she apologizes.
  6. In place of scientific evidence, Kinderman’ frequently claimed the authority of personal eminence associated with his professorship. This is disallowed by his references to the Holocaust and Nazism, which place him outside of academic discourse.
  7. UPS was explicitly aimed at influencing mental health service users and policymakers. Vigorous debate should continue, but critics should not require the authors to engage them. After all, what do you expect from somebody who considers you a Nazi? And to get back into the conversation, the authors of Understanding Psychosis have to address Kinderman putting the Holocaust and Nazism on the table.

I hope that these résumés will inform, but do not satiate you. I  hope they encourage you to read further in what will prove a fascinating discussion. But regardless, begin asking yourself what responsibility the trustees of the British Psychological Society have in dealing with the situation that Kinderman has now created. Or does it really matter that the President-elect of this organization has written such things?

Kinderman’s Me, My Brain, and Baked Beans

beans_on_toast430x300Kinderman starts off with a statement of annoyance but gives no indication where he is going.

In mental health, resolving the relative contributions of our biology and genetics and how these interact with social and environmental factors (our parenting, peer-relationships, learning, and experiences of both abuse and nurturing) is more than an intellectual puzzle. I’m occasionally annoyed by what appears to be a rather simplistic suggestion that, if there’s a biological, even heritable, element, to a psychological phenomenon, then we’re inevitably discussing an illness, a disease.

A Difficult Childhood

He soon gets to depicting his early family environment and readers can again ponder ‘where is this taking us?’

After my mother’s death, we discovered that, when she had confessed to a religious mentor that she was in danger of loving her children more than God, there was a subsequent process of re-adjustment … she was encouraged to practice loving her children less. My parents rejected the material world as merely a stepping-stone to heaven (or hell) and paid little attention to worldly pursuits. I remember opening a letter from Cambridge University confirming an offer of a place as an undergraduate. I told my mother, whose reply was; “Very nice dear, now, do you want baked beans on toast for breakfast?”

Kinderman’s point seems to be that he and his siblings were not reared in a loving and accepting environment. His mother’s religiosity was pivotal. Kinderman discourages us from having any sympathy for the mother. But now that he has brought her up, we can nonetheless wonder about how she might have been suffering.

An astute reader with a sense of history might also wonder if we are being set up for a simplistic refrigerator mother explanation of psychological problems in offspring.

In the 1990s, Irish motivational speaker Tony Humphreys  drew upon his own adverse childhood experiences to extend a discredited theory of the refrigerator mothers of children with autism to explain schizophrenia and diabetes. He was subsequently censured by the Irish Psychological Society.

Humphreys was following up on the 1940s work of Leo Kanner  who coined the phrase in describing mothers of autistic children as “just happening to defrost enough to produce a child.”

refrigerator motherAs an antidote to this nasty mother bashing, I strongly recommend Refrigerator Mothers,  an hour-long movie freely available on the Internet. It provided an opportunity for mothers with autistic children to talk back against the stereotype of them.

 

Once isolated and unheard, these mothers have emerged with strong, resilient voices to share the details of their personal journeys. Through their poignant stories, Refrigerator Mothers puts a human face on what can happen when authority goes unquestioned and humanity is removed from the search for scientific answers.

Kinderman claims to be an expert by experience

Kinderman then describes his unusual psychological experiences and behavior.

So I am emotionally labile; my self-esteem and emotions are very fragile and very much dependent on what I imagine other people are thinking. Or, at least, I think I am; my observations of my own behaviour are themselves subjective, and it’s possible that others do these things as much as I do. I frighten myself (given my relative’s experiences) by fantasising about… winning Nobel prizes, winning Pulitzer prizes, being elected to this and that, being awarded knighthoods… and that’s frightening because I’ve seen self-referent fantasies ruin other people’s lives.

…And, perhaps most saliently, I lurch forwards and jump to conclusions in my mental logic. So, if you give me the sequence “A, B, C” and ask me to complete the sequence, I’ll say Z. Maybe that’s a bit of a joke (a pun on ‘complete’), and it’s unequivocally good for me in my academic career. A creative professor is a good professor. I also and simultaneously make abstract and surreal connections. It’s a recognised part of my teaching style – I’ll veer off on a tangent. Again, perhaps useful in an academic and possibly engaging or at least entertaining for students (if they can keep up…). But jumping to conclusions, tangential connectivity and abstract, ‘clang’ associations all have very interesting connotations in the field of mental health.

Too much information. What shall we to make of these deeply personal and out-of-place disclosures from the President-elect of the British Psychological Society? Kinderman claims benefit from it these experiences and does not want to discredit himself. Yet he is giving live ammunition to critics who have long been frustrated with his distinctive torrents of scrambled anecdata and pomposity. No worry, Kinderman is about to discredit himself more thoroughly.

But for a bit, Kinderman continues quite reasonably:

So I am very interested (and, I hope, open-minded) about what it is, if anything, that we inherit. How do I differ from other people? What proportion of the variance in these traits can be accounted for by genetic differences? What proportion of the variance in these traits comes from being brought up by repressed religious extremists? What proportion comes from being reinforced, through my childhood, for being academic? Which elements of my upbringing were different other people’s anyway?

Kinderman brings in the Nazis

Out of context, this appears a reconciliatory statement that invites agreement from critics. But there is a disaster ahead. Kinderman’s train of thought transports unknowing readers to the death camps of the Holocaust with contemporary psychiatrists branded Nazis. Kinderman apparently thinks his friends and colleagues will consider him brave for exposing this obvious connection.

…I think it’s perfectly possible to be intelligent and open-minded about the contribution of genetic and environmental factors in our mental health. We can intelligently and respectfully discuss how experiences and heritable traits can interact to produce the wonderful variety of human experience. This, I think, is a much more accurate and helpful way to conceptualise what’s going on than to say that some of us – but only some of us – have ‘mental illnesses’. Labels such as ‘schizophrenia’ not only suffer from the validity problems that we’ve discussed elsewhere, but also obfuscate these important considerations. I don’t think it’s helpful to consider how I have managed to avoid developing ‘schizophrenia’, or whether I have ‘attenuated psychosis syndrome’. To do that, to reduce these discussions to binary considerations of the presence or absence of disorders, necessarily constrains the scientific debate. It can also sometimes have frightening consequences in the real world. When I’ve mentioned some of these issues before in less public settings, friends and colleagues have often told me that I’m being brave, and that it’s a potentially risky topic of conversation. So why might that be?

The eradication of undesirable genetic traits

Part of the reason that people might be reluctant to talk about such issues is that we have a very poor track record in this area. This is a difficult topic, but I think it is important to remember the infamous 1933 Nazi Law for the Prevention of Genetically Diseased Offspring (Gesetz zur Verhütung erbkranken Nachwuchses). Arguments of genetic science not only led to the drafting of this law (which permitted the compulsory sterilisation of any citizens who were judged to possess a ‘genetic disorder’ which could be passed onto their children) but indeed led German-American psychiatrist Franz Kallmann to argue that such a policy of sterilisation should be extended to the relatives of people with mental health problems (in order to eradicate the genes supposedly responsible). The notorious Action T4 ‘eradication’ programme was the logical extension of these policies.

From Kinderman’s Me, my brain and baked beans.

Adolf Hitler’s order for the Action T4 programme
Adolf Hitler’s order for the Action T4 programme.
Reich Law Gazette on 25 July 1933: Law for the Prevention of Genetically Diseased Offspring

 

 

 

 

 

 

 

 

 

 

 

 

Kinderman accuses Franz Kallmann of being a war criminal. Kinderman should have spent more time at Google University learning about Kallmann who fled the Nazis in the 1936.

Considered a Jew by the Nazis although not by himself, he could not publish his work, and had to rely on friends at Munich to read his papers for him. He could only get his statistics into print by quotation in papers of others’ authorship.

… Despite of all obstacles, he succeeded in organizing the first research department in psychiatric genetics in the United States at the New York State Psychiatric Institute. This department became the main source of intellectual support of psychiatric genetic research in the U.S. for a generation.

Kinderman’s description of Kallmann as a “German-American psychiatrist” is used to smear all of contemporary psychiatry with the taint of Nazism.

At the Bath Conference on Understanding Psychosis, Kinderman refused to engage other members of the panel. It is too bad that the event was not recorded and that the BPS insisting on editing a journalist’s account. But those who were there will recall Kinderman closed with a rambling, incoherent rant about the horrors of mental health professionals telling psychiatric patients that they had a genetic disease.

Perhaps uncomfortable with having invoked the Nazis, in his blog he tries to shift to fascism. He introduces a non sequitur in claiming that if schizophrenia represents “a biological problem, we can dismiss any further troubling considerations.” Then he insists in a most extraordinary way on his privileged status talk of the Holocaust because of its personal relevance and threat.

Of course, a focus on biological aspects of mental health problems is not in any sense necessarily synonymous with fascism. But for many of us, there are echoes of blame, of stigma, when we identify the pathology within the genetic substrate of the person. I’m reminded of Eric Pickles’ notorious throw-away comment to a voter campaigning about the abuse she’d experienced that she should “adjust her medication”. If the pathology lies in the person, and particularly if it is a biological problem, we can dismiss any further troubling considerations.

So one way to understand these kinds of experiences is to diagnose some form of ‘subclinical’ syndrome, perhaps attenuated psychosis. If the Nazis had won the second world war, I would have been castrated as a first-degree relative of a ‘schizophrenic’. Disease-model, eugenic, thinking is a direct threat to me personally, especially given the recent rise of UKIP and other far-right parties in Europe. I am interested in whether the traits that make me a good professor may also be related to the traits I listed earlier, and on their impact on my emotions. I am interested in whether they may have emerged from a similar mix of genes and environment that led my relative to experience psychosis. I am very interested in the practical implications; I have always, for example, avoided certain classes of street drugs. It is absolutely possible to discuss gene × environment interactions, but – please – don’t use the ‘disease-model’ as a framework.

Why Peter Kinderman and Anne Cooke are excluded from further discussions of Understanding Psychosis until they publicly apologize.

“A good rule in most discussions is that the first person to call the other a Nazi automatically loses the argument.”  This has been elaborated in Godwin’s Law FAQ:

godwin faq

Nonetheless, gratuitous references to the Holocaust in Nazis regularly occur around the world, highlighting all the more the need to insist on them being obscene.

The memory of six million Jews and the eleven million other human beings who died in the Holocaust is too sacred for calculating politicians and their paranoid cheerleaders to be turned into a semantic missile.

Republican presidential candidate Mike Huckabee is incorrigible. In 2014 he said

 

If you felt something incredibly powerful at Auschwitz and Birkenau over the 11 million killed worldwide and the 1.5 million killed on those grounds, cannot we feel something extraordinary about 55 million murdered in our own country in the wombs of their mothers? Does that not speak to us?

Now Huckabee is being condemned by Israel for saying the Iran nuclear deal is “marching the Israelis to the door of the oven.”  Israel does not need that kind of support.

Why did Kinderman destroy his credibility by publishing this?

For the same reason that Mike Huckabee made the comparison between abortion and the Holocaust. He believes these things, he has bad judgment, and he thought he wouldn’t be caught.

Huckabee speech was captured on a videotape in 2014 and subsequently distributed by Right Wing Watch, a non-profit working to expose the Far-Right’s extreme and intolerant agenda. Otherwise most of us would not have learned of his statements.

Kinderman similarly may have thought that he was in a closed environment where he could express views that would resonate with an important part of his constituency. He surely would not have made them at an international scientific psychology gathering.

The long thread of comments Kinderman elicited at the blog site showed little indignation and tacit acceptance that psychiatrists are Nazis. He seems to have only tweeted once about this blog post and probably didn’t think it would come to the attention of the larger community.

He may be a professor at University of Liverpool and President-elect of the British Psychological Society, but he plays to a constituency that is neither academic nor professional.

Dealing with the offense to all comes first

Even before the references to the Holocaust and Nazis aside, there there have been many reasons be offended by Kinderman’s promotion of the BPS UPS.

  • Serious academics have been outraged by Kinderman’s arguments without evidence against diagnosis, his claim that antipsychotic medication is toxic and ineffective, his crass emotional appeals, and his slandering of the large other side on an important issue. UPS simply not does not adhere to academic standards in terms of logic and reference to evidence and would not pass independent peer review.
  • Mental health service consumers and their family members have been upset that issues that concern them are being framed in such a misleading and irrational way by a professional. They are unrepresented and silenced by the carefully selected clinical examples in the UPS. Treatment options have been misrepresented in ways intended to frighten them. They have legitimate concerns about having to be diagnosed or treated by psychologists who hold such warped views.
  • Many members of the British Psychological Society are embarrassed by the organization sinking to this level. They would not want to be asked in a public gathering if UPS represents solid science. Many UK psychologists who are not members of BPS are upset that the organization that supposedly speaks for them is associated with such ridiculous statements.

All who are offended should feel free to speak out. But the preemptive issue is before the larger community is that Kinderman has behaved in an unacceptable manner. Kinderman is out of the discussion. His license is revoked and he needs to reapply.

If Kinderman or Anne Cooke pop up in these discussions, they should simply be asked “Don’t you have a problem with desecrating the memory of the Holocaust?” and then ignored.

The dilemma facing the British Psychological Society

Kinderman blurs any distinction between his personal views and those of the organization with which he incessantly claims to speak, often in forums only available because he represents BPS. It’s incumbent upon the BPS to clarify where they stand on what is now a game-stopping issue. Do they condemn Kinderman or are they left implicitly condoning him?

Here is a list of members of the Board of Trustees and some of their email addresses I was able to obtain from the internet. Readers might want to individually and collectively inquire about where the board stands about Kinderman casually invoking the Holocaust and Nazism in a context where references to these historical events have no place.

  • President Professor Jamie Hacker Hughes CPsychol CSci FBPsS profjamiehh@gmail.com
  • Vice President Professor Dorothy Miell CPsychol FBPsS d.e.miell@ed.ac.uk
  • Honorary General Secretary Dr Carole Allan CPsychol Csci FBPsS Carole.Allan@glasgow.ac.uk
  • Honorary Treasurer Professor Ray Miller CPsychol FBPsS
  • Chair Education and Public Engagement Board Professor Catriona Morrison CPsychol AFBPsS c.morrison@hw.ac.uk
  • Chair Research Board Professor Daryl B O’Connor CPsychol AFBPsS D.B.O’Connor@leeds.ac.uk
  • Chair Professional Practice Board Dr Ian Gargan CPsychol AFBPsS
  • Chair Membership Standards Board Dr Mark Forshaw CPsychol CSci FBPsS FIHPE

It is fair game to raise the issue of Kinderman’s transgression when members of the BPS Board of Trustees appear at public gatherings. I intend to do so when Daryl B O’Connor shows up at the European Health Psychology Conference in Cyprus and encourage others to do so as well. “Hey Daryl, about Kinderman’s references to the Holocaust and Nazis…”

BPS President Jamie Hacker Hughes announced the launch of Understanding Psychosis on Twitter and then unsuccessfully tried to squelch discussion when it turned negative.

hacker huges exchangeIt was foolish for the BPS President to insist that conversation about a document that could not conceivably pass independent peer review be confined to venues gated by peer review. It would be a disaster for him to adopt this strategy in trying to squelch the conversation about what Kinderman has done.

The other authors of UPS and Kinderman’s bringing in the Holocaust and the Nazis

Anne Cooke is given credit for the transition for an earlier blog post by Kinderman that lack references to the Holocaust and the Nazis to the present one.

Acknowledgement: Thanks to Anne Cooke for helpful comments and advice on earlier drafts.

She also edited UPS. Some of the contributors  have expressed previously extreme anti-psychiatry sentiments in public. Now that Kinderman’s blog post is distributed, they need to get clear on where they stand on desecrating the memory of the Holocaust.

UPS Contributers

The conversation about Understanding Psychosis and Schizophrenia

From its launch, critics of Understanding Psychosis and Schizophrenia lots of abuse. Their own blog posts have been spammed with threats and demands the blog posts be taken. There have been hit and run attacks on blog comment threats and Twitter by pseudonymous commentators who morph and disappear from the internet. Often, outrageous comments are left and elicit responses, only to later be removed,leaving whole threads incoherence.

The day of the official launch of Understanding Psychosis and Schizophrenia, Keith Laws, Alex Langford, and Samei Huda posted a detailed critique that became one of the most viewed posts at Mental Elf ever. Angela Wilson Ursery posted a comment attacking the three as engaging in mutual masturbation and bragged about it on Twitter. The moderator at Mental Elf quickly edited her comment, but Kinderman retweeted her announcement and Anne Cooke favored it.

welcome circle jerk full

So, Kinderman has now gone from endorsing the views of UPS critics as masturbating each other, to expressing worries about being castrated, and now tying in the Holocaust and Nazis. Very strange for a President-elect of the BPS

At 1Boring Old Man  psychiatrist Mickey Nardo unflinchingly takes aim at NIMH Director Thomas Insel and American Psychiatric Association President Jeffrey Lieberman. Mickey approvingly quotes long statements from the Critical Psychiatry Network and engaging its representatives in long threads of comments on his blog posts. But he has grown frustrated trying to deal with the authors of UPS and their followers.

I’ve sort of stopped responding to comments myself because they focus on anything I say as evidence of my being some insensitive psychiatrist who holds people back and snows them with medication. I’m not that…The cases of psychotic illness I followed in my practice were treated much in the same way as the BPS Report suggests, though my attitude about medications changed over time because of frequent relapses.

But I don’t think the responders want to know what my objections really are, and would prefer to keep me in the bad guy role. I’m not interested in being defensive. If my writings about this aren’t clear, ask me a question. If you prefer to see me as some doom-sayer, that’s your call…

Well, now you know, Mickey, some of them think you are a Nazi.

The conversation about UPS must continue, without Kinderman and Cooke

BPS offered UPS as

A resource for people who work in mental health services, people who use them and their friends and relatives, to help ensure that their conversations are as well informed and as useful as possible. It also contains vital information for those responsible for commissioning and designing both services and professional training, as well as for journalists and policy-makers”.

UPS is chock-full of posturing in what its authors see as a turf war, misinformation, and simple nonsense. We should continue to provide mental health service uses, policymakers, and other professionals with evidence-based alternative information. From the first day of its launch, the UPS authors have not been keen on sustained evidence-based exchanges. We should continue without them, despite Kinderman having seriously damaged the debate.

 

DISCLAIMER: I am grateful for PLOS blogs providing me the space for free expression. However, the views I present here are not necessarily those of PLOS nor of any of my institutional affiliations.

 

Barney Carroll on domesticating psychosis

Although posted only a couple of days ago, my presentation from Royal Edinburgh Infirmary, Division of Psychiatry, University of Edinburgh is now passing the benchmark of over 1000 views.

chrys
Chrys Muirhead

You can also find an interesting Storify of my lecture by a mental health activist and correspondent for the Critical Psychiatry Network, Chrys Muirhead. I’m sure she’ll also be presenting an alternative view of my lecture at her blog.

In one of my introductory slides , I acknowledge a number of go-to’s to whom I am indebted. I actively engage with the go-to’s through social media with questions and requests for feedback. They have kept me from what would have been embarrassing gaffes.  They allow me to present and write smarter than I am, when I let them. However any excesses or inaccuracies in my work are entirely my own.

One of these go-to’s is Bernard “Barney” Carroll. In future blogs I will be saying a lot about his influence on me, although we have never actually met. In hindsight, it’s too bad that my decade at the University of Michigan Mood Disorders Program that he developed started only after he had left.

Barney has

made major contributions to research on the biology and treatment of depression. He is best known as a pioneer of the neuroendocrine research strategy for depression, and as developer of the field of laboratory markers in psychiatry.

Barney often says profound things with a relaxed elegance, particularly when engaging in debate. Long before Kris Kristofferson, I’m sure those with whom he disagreed saw him as the original silver tongued devil.

I realize this comment dates me, because few of my younger readers even know Kris Kristofferson is, not even that he wrote Me and My Bobbie McKee that Janis Joplin made famous. So, here, distract yourself with some 70s music.

 

domesticating-page-0Anyway, on slide 37 of my presentation, I used Barney’s term domesticating psychosis as a heading for some direct quotes from Understanding Psychosis and Schizophrenia, the British Psychological Society Division of Clinical Psychology document that I  critiqued in coming slides. Here is the elaboration on that graphic phrase that Barney provided on my Facebook wall July 27, 2015.

Barney Carroll, in his own words:

I guess I am the person who gets the credit for characterizing the BPS report Understanding Psychosis and Schizophrenia as domesticating psychosis. Ronald Pies called it romanticizing psychosis and Joseph Pierre termed it trivializing psychosis.
The BPS folks, and Lucy Johnstone in particular, deserve all the frowns and brickbats that are coming their way for this misstep. It is an appalling document: Self-neglect due to impaired frontal executive function is niced down to “When people are in a state of distress and confusion they can sometimes need help to maintain an adequate diet, or look after their home.” That does not begin to capture the clinical reality of decompensating psychotic patients smashing furniture to stop the voices, smearing faeces, living in filth, going to the streets, eating out of dumpsters…. The report’s pervasive focus on just hearing voices as emblematic of psychosis is a domesticating strategy: One hallucination does not a schizophrenia make. This domestication distracts attention from the more serious features of psychosis such as negative symptoms, social and occupational decline, first rank positive psychotic symptoms, formal thought disorder, formal language disorder, catatonia, cognitive impairment, affective lability, delusions, and loss of ego boundaries in psychotic decompensations. These get short shrift in the terminal niceness of the BPS report.

fear my squirreley wrathI can only agree with James Coyne that the BPS folks, and Lucy Johnstone in particular, have been squirrelly in their responses to challenges. We saw that earlier this year. Look at the threads linked here on the 1Boringoldman blog: http://tinyurl.com/q7lw8md; and http://tinyurl.com/nq4ws5b. They are especially reckless in their glossing over of completed suicide in psychotic states. I discussed that on Joseph Pierre’s blog earlier in the year: see the several comments on this thread – http://tinyurl.com/ofcsr4j.

1 Boring Old Man » which side of the street?…

You can read Barney’s set of comments at Mickey Nardo’s 1 Boring Old Man website, along with Barney’s engagement with critics. But here’s an excerpt

… This approach is what I call domesticating psychosis. The BPS document fails adequately to convey the range of symptoms and associated behaviors in psychosis/schizophrenia. Even when these are mentioned, they are not addressed in a way that matches their clinical salience. Thus, decompensating psychotic crises are discussed unhelpfully in the framework of poor sleep habits. Acute inpatient psychiatric units are discussed in a patronizing way and are faulted as being unhelpful for some patients – never mind their rescue function. Catatonia as a common feature is not acknowledged. Psychotic terror and panic are not acknowledged. Formal thought disorder with truly crazy speech is not acknowledged. The 10% lifetime incidence of suicide among schizophrenic patients is not acknowledged. Core negative symptoms are brushed away as demoralization or as neuroleptic drug side effects. All of the recommendations made in the BPS document for improvement of psychological and social services are admirable but none are really new – they all fall within the traditional biopsychosocial model of psychiatry. We can all agree that psychiatry has not implemented that model consistently, in large measure because of underfunding, but that does not invalidate the model.

Their intellectual bias is further evidenced by their halfhearted endorsement of the need for antipsychotic drugs. They go out of their way to emphasize that, even though these are sometimes helpful, “… there is no evidence that (the drugs correct) an underlying biological abnormality.” Well, bless my heart, we can say the same of most drugs used in medicine: steroids for autoimmune diseases; bronchodilators for respiratory diseases; anticonvulsant drugs for seizure disorders … So, what is their point here, exactly, beyond gratuitous negative innuendo? It seems to me that the BPS document is a manifesto in the professional turf wars, heavily slanted towards gaining funds from the U.K regulators, rather than driven by an understanding of the classic psychotic disorders

Well said.

From Where's NAMI?
From Where’s NAMI?

Consistently poor coverage of mental health issues in The Guardian

Issuing a readers’ advisory: The Guardian provides misleading, badly skewed coverage of mental health issues vitally important to mental health service users.

Guardian PulitzerStories in The Guardian can confuse and disempower mental health service users seeking information for difficult decisions about choosing and sticking to treatments. Articles labeled Psychology and Health and sometimes Science don’t adhere to the quality that earned The Guardian a Pulitzer Prize.

In this issue of Mind the Brain, I show why there should be a formal readers advisory for mental health information appearing in The Guardian. The excellent watchdog of faulty health coverage in the media, NIH Choices: Behind the Headlines  should routinely monitor stories appearing in The Guardian and provide more balanced analyses.

NHS choices

 

 

 

 

You can compare my assessments to your own evaluation with the links I provide to the stories in The Guardian.

Some recent examples:

At last, a promising alternative to antipsychotics for schizophrenia

Imagine that, after feeling unwell for a while, you visit your GP. “Ah,” says the doctor decisively, “what you need is medication X. It’s often pretty effective, though there can be side-effects. You may gain weight. Or feel drowsy. And you may develop tremors reminiscent of Parkinson’s disease.” Warily, you glance at the prescription on the doctor’s desk, but she hasn’t finished. “Some patients find that sex becomes a problem. Diabetes and heart problems are a risk. And in the long term the drug may actually shrink your brain.”

It is insulting to those who suffer from schizophrenia to have their life-altering experience trivialized and domesticated as simply “feeling unwell for a while.”

The article provides a fright-mongering depiction of the difficult choice that patients with schizophrenia face. Let’s give a critical look at the authors’ claim about drugs shrinking the brain. The sole citation is a PLOS One article. Authors of that article provided a carefully worded press release:

A study published today has confirmed a link between antipsychotic medication and a slight, but measureable, decrease in brain volume in patients with schizophrenia. For the first time, researchers have been able to examine whether this decrease is harmful for patients’ cognitive function and symptoms, and noted that over a nine year follow-up, this decrease did not appear to have any effect.

The UK senior author of the study further clarified:

doesn't appear

 

 

 

 

The study is not a randomized trial in which the amount of antipsychotic medication that patients received was manipulated. It is a small observational study comparing 33 patients with schizophrenia to 71 controls. Causal interpretation depends on statistical manipulation of correlational data. Yet a group of only 33 (!) patients with schizophrenia does not allow reliable multivariate analysis to explore alternative interpretations of the data. One plausible interpretation is that the amount of medication particular patients received is tied to severity of course of their schizophrenia. This would be a classic example of confounding by indication. The authors acknowledge this possibility:

It is conceivable that patients with the most severe illness lose more brain volume over time, reflecting intrinsic aspects of the pathology of schizophrenia, and the fact that severely ill patients receive higher doses of medication.

They further note:

Whilst it is extremely important to determine the causes of loss of brain volume in schizophrenia, an equally important question concerns its clinical significance. Loss of brain volume occurs throughout the majority of adult life in the healthy population, and whilst it might seem trivial that this would be disadvantageous, in some periods of development loss of brain tissue appears to be potentially beneficial [43]*.

Yes, antipsychotic medication poses serious side effects, doesn’t cure schizophrenia, and there are problems with adherence. But The Guardian article fails to note that the longer an episode of schizophrenia goes untreated, the less likelihood that a patient will ever resume a semblance of a normal life. And schizophrenia is associated with a 10% rate of suicide. What alternative does The Guardian article suggest?

A team led by Professor Anthony Morrison at the University of Manchester randomly assigned a group of patients, all of whom had opted not to take antipsychotics, to treatment as usual (involving a range of non-pharmaceutical care) or to treatment as usual plus a course of cognitive therapy (CT). Drop-out rates for the cognitive therapy were low, while its efficacy in reducing the symptoms of psychosis was comparable to what medication can achieve.

You can compare this summary to my critiques [1,2].

  • “Drop out rates..,were low?” The study retained fewer participants receiving cognitive therapy at the end of the study than there were authors.
  • The comparison treatment was ill-defined, but for some patients meant no treatment because they were kicked out of routine care for refusing medication.
  • A substantial proportion of patients assigned to cognitive therapy began taking antipsychotic medication by the end of the study.
  • There was no evidence that the response to cognitive therapy was comparable to that achieved with antipsychotic medication alone in clinical trials.

The authors of the study backed down from this last claim in an exchange of letters [1 and 2] at the Lancet with myself and others. BBC News dropped that claim after initially making it in coverage of the study.

as effective

 

 

Became

moderately effective

 

 

Don’t settle for my interpretation of the literature concerning cognitive therapy for psychosis (CBTp), go to a summary of available evidence in a blog post by Clive Adams, Chair of Mental Health Services Research and Co-Ordinating Editor of the Cochrane Schizophrenia Group at the University of Nottingham.

Adams wraps up with

Where does this leave CBTp?

In the opinion of this writer, having read and thought about the reviews (and others in some detail) it is time to move on.

It is great that there are data for questions around this potentially potent intervention for people with schizophrenia (for many treatments there are no data at all). I just cannot see that this approach (CBTp), on average, is reaping enough benefits for people.

Adams cites

Jones C, Hacker D, Cormac I, Meaden A, Irving CB. Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.: CD008712.

Which concludes

Trial-based evidence suggests no clear and convincing advantage for cognitive behavioural therapy over other – and sometime much less sophisticated – therapies for people with schizophrenia.

Mark Taylor chaired the Scottish Intercollegiate Guidelines Network (SIGN) committee that produced the Scottish Guidelines for the Management of Schizophrenia. SIGN is the equivalent to the British National Initiative for Clinical Excellence (NICE). In an editorial in British Journal of Psychiatry he commented on the NICE guidelines’ favoring of cognitive behavioral therapy:

NICE has also taken the bold step of recommending CBT and family therapy alone for people with first-episode psychosis who wish it. The guideline acknowledges that psychosocial interventions are more effective in conjunction with antipsychotic medication, but still suggests this intervention alone for one month or less. This is controversial in view of the lack of robust supportive evidence and could potentially worsen outcomes. A related point is that in the guideline NICE seem oblivious to the fact that many patients with acute schizophrenia have impaired insight into their illness and health needs,5 and thus may not have capacity to consent to their treatment.

And finally, there is a Keith Laws’ carefully documented Science & Politics of CBT for Psychosis.

A Guardian story on mindfulness: New study shows mindfulness therapy can be as effective as antidepressants

Glass half-full readers, of course, will see that the trial results demonstrate that we actually have two similarly effective treatment options for recurrent depression: one involves eight weeks of a psychological therapy, the other relies on taking medication for two years. The challenge now is to make both equally available in treatment services.

I provided a detailed critique of this study. You would never guess from The Guardian article that mindfulness therapy used in this study was not designed to treat depression, only to prevent relapse in patients who had recovered in treatment by other means. And there was no assessment of whether patients assigned maintenance antidepressants were actually adhering to them or receiving adequate, guideline congruent care. You can see my comments on this study at PubMed Commons and leave your own as well.

The lead author of the study who is a colleague of the author of The Guardian went to the trouble of modifying the study registration to clarify that the trial was not designed to compare mindfulness therapy antidepressants for depression.

Feeling paranoid? Your worries are justified but can be helped

In this article The Guardian authors present as mainstream their unconventional views of what “feeling paranoid” represents. One of the authors promotes his own treatment for which he conducts workshops tied to his self-help books about worrying.

The fog machine gets going when the authors merge colloquial use of paranoid with the psychotic symptom. Many people, especially the young use “paranoid” in every speech in a way far removed from professionals discussing the psychotic symptom. Most endorsements of “feeling paranoid” on a checklist would not represent a psychiatric symptom. Even when present, the psychiatric symptom of paranoid is neither necessary nor sufficient for a diagnosis of schizophrenia.

When occurring in the context of a diagnosis of schizophrenia, however, paranoid delusions can be strongly held convictions accompanied by other lack of insight and thought disorder. I know of no evidence that everyday suspiciousness turns into psychotic persecutory delusions in persons who are not otherwise at risk for psychosis.

Think of someone insisting on shifting a conversation about skin cancer to talking about moles. Dropping lung cancer and chronic obstructive pulmonary disease for a more inclusive, but nonspecific “cough.” These are silly moves in a language game that prevent evaluation of health problems in terms of available evidence of necessity tied to more precise language.

The Guardian authors propose:

As we’ve noted previously on Guardian Science, anti-psychotics don’t work for everyone. And their side effects can be so unpleasant that many people refuse to take them. Moreover, there’s compelling evidence to suggest that the concept of “schizophrenia” doesn’t stand up scientifically, operating instead as a catch-all for a variety of distinct and frequently unrelated experiences.

What compelling evidence? Says who? I doubt that the one of these authors who is in the Psychology at Oxford would make such a statement in a formal presentation to his colleagues. But apparently it suffices for a lay audience including mental health services users seeking information about their condition and available treatments.

In general, readers should beware of authors making such sweeping statements in the media without identifying specific sources, degree of scientific consensus, or grade of evidence. The Guardian authors require readers to turn off critical skills and trust them.

This is why scientists have increasingly focused on understanding and treating those experiences in their own right, rather than assuming they’re simply symptoms of some single (albeit nebulous) underlying illness. So what have we discovered by applying this approach to paranoia?

Which “scientists”? Where? Readers are again left trusting the expertise of The Guardian authors.

The authors are getting set to promote the treatment developed by one them for “worry” in patients with paranoid delusions, which is marketed in his workshops, using his self-help book. I previously reviewed this study in detail.

I concluded

  • The treatment was a low intensity variation of a self-help exercise using excerpts from The Guardian authors’ book.
  • The treatment of the control group was ill-defined routine care. Relying on this control group as the only comparison precluded evaluating whether the intervention was any better than a non-branded similar amount of attention and support.
  • The primary outcome was hopelessly confounded with nonspecific worrying or anxiety and inadequate to assess clinically significant changes in psychotic symptoms of paranoid delusions.

I could go on with examples from other articles in The Guardian. But I think these suffice to establish that mental health service users seeking reliable information can find themselves misled by stories in The Guardian. Readers who don’t have the time or feel up to the task of checking out what they read against what is available in the literature would do well to simply ignore what is said in The Guardian about serious mental disorder and its treatment.

insect parts-page-0Readers advisory

Despite The Guardian having won the Pulitzer Prize for science reporting, readers may find stories about mental health that are seriously misleading and of little use in making choices about mental health problems and treatments. Information about these issues are not responsibly vetted or fact checked.

Whatever happened to responsible journalism at The Guardian?

in April 2015,The Guardian announced a Live Question and Answer Session.

How can academics help science reporters get their facts straight?

Academics have never been under more pressure to engage with the public and show the impact of their work. But there’s a problem. The media, one of the key channels for communicating with people outside academia, has a reputation for skewing or clumsily confusing scientific reports.

The session was in response to larger concerns about the accuracy of health and science journalism. With serious cutbacks in funding and layoffs of experienced professional journalists, the media increasingly rely upon copy/pasting exaggerated and inaccurate press releases generated by self-promoting researchers in the universities. What has been lost is the important filter function by which journalists offer independent evaluation of what they are fed by researchers’ public relations machines.

Many readers of The Guardian probably did notice a profound shift from reliance on professional journalists to to blogging provided free by academics. Accessing a link to The Guardian provided by a Google Search or Twitter, readers are given no indication that they will be reading a blog.

A blog post last year by Alastair Taylor identified the dilemma –

Media outlets, such as the Guardian Science Blogs, can present the science direct (and without paying for it) from the experts themselves. Blogging also opens up the potential for the democratisation of science through online debates, and challenges established hierarchies through open access and public peer review. At the same time, can scientists themselves offer the needed reflection on their research that an investigative journalist might do?

In the case of these  authors appearing in The Guardian, apparently not.

The new system has obvious strengths. I look forward to reading regular blog posts by academic sources who have proved trustworthy such as Suzi Gage, Chris Chambers, or many others. They have earned my trust sufficiently for me to recommend them. But unfortunately, appearing in The Guardian no longer necessarily indicates that stories are scientificially accurate and helpful to consumers. We must suspend our trust in The Guardian and be skeptical when encountering stories there about mental health.

I sincerely hope that this situation changes.

NOTE

*The authors of the PLOS One article cite a Nature article for this point, which states

More intelligent children demonstrate a particularly plastic cortex, with an initial accelerated and prolonged phase of cortical increase, which yields to equally vigorous cortical thinning by early adolescence. This study indicates that the neuroanatomical expression of intelligence in children is dynamic [bolding added].