I need to congratulate Roychowdhury & Adshead[1][1] on a thought-provoking critique. Their arguments struck a chord in exposing the flaws in risk assessment tools and their unjust application in preventative detention; however, I was disappointed that they did not go further. All of these tools,
{"title":"Overselling risk assessment.","authors":"Trevor D Broughton","doi":"10.1192/pb.38.4.195a","DOIUrl":"https://doi.org/10.1192/pb.38.4.195a","url":null,"abstract":"I need to congratulate Roychowdhury & Adshead[1][1] on a thought-provoking critique. Their arguments struck a chord in exposing the flaws in risk assessment tools and their unjust application in preventative detention; however, I was disappointed that they did not go further. All of these tools,","PeriodicalId":90710,"journal":{"name":"Psychiatric bulletin (2014)","volume":"38 4","pages":"195"},"PeriodicalIF":0.0,"publicationDate":"2014-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1192/pb.38.4.195a","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"32680923","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Anyone working in an insulin unit in the 1950s would not recognise Dr Pimm’s account of the results of their treatment,1 or details of what it involved. The patients received daily and increasing doses of insulin, rising to many hundreds of units, for a 6-week period. The depth of the resulting hypoglycaemic coma was determined by the patient demonstrating a Babinski response over a period of 15 min. They were then revived by ingesting glucose. I worked in the insulin unit at Newcastle General Hospital from 1956 to 1959, when I was senior registrar to Sir Martin Roth. Insulin treatment was reserved for people experiencing their first attack of schizophrenia, and from memory I would say half made a complete remission and another 25% improved. Nobody thought that we were effecting a cure, but remissions lasted about 2 years. One woman relapsed 9 years after her treatment. Of course there were dangers, but in those days the alternative was incarceration in a locked ward in a Victorian asylum, with little hope of rehabilitation or discharge. Martin Roth was an intellectual giant, but also a man who was perspicacious and compassionate, and who would not have contemplated using such a treatment if he did not think it effective. The depth of the coma seemed to me to be critical in terms of remission. A few patients did not regain consciousness when given glucose, but usually ‘came out of it’ after some hours, although there was the occasional death. Very occasionally, a patient who was clearly psychotic who had an ‘irreversible coma’ on recovery was greatly mentally improved. These days, people find this difficult to believe, but I witnessed it on one occasion. I find it inconceivable that a multitude of psychiatrists, working in Europe and North America over 25 years, would not have noticed that the treatment they were giving was having no effect, when it clearly was, if only for a limited period. The real question was not whether insulin worked but how did insulin work. I have no wish to minimise the success of Dr Bourne’s crusade, but what made insulin units redundant was the realisation that the new antipsychotic drugs actually worked, and at last, we had an effective, cheap and long-lasting method of managing a seemingly incurable disease. This was generally accepted by 1960.
{"title":"Insulin coma therapy.","authors":"Alan Gibson","doi":"10.1192/pb.38.4.198","DOIUrl":"https://doi.org/10.1192/pb.38.4.198","url":null,"abstract":"Anyone working in an insulin unit in the 1950s would not recognise Dr Pimm’s account of the results of their treatment,1 or details of what it involved. The patients received daily and increasing doses of insulin, rising to many hundreds of units, for a 6-week period. The depth of the resulting hypoglycaemic coma was determined by the patient demonstrating a Babinski response over a period of 15 min. They were then revived by ingesting glucose. \u0000 \u0000I worked in the insulin unit at Newcastle General Hospital from 1956 to 1959, when I was senior registrar to Sir Martin Roth. Insulin treatment was reserved for people experiencing their first attack of schizophrenia, and from memory I would say half made a complete remission and another 25% improved. Nobody thought that we were effecting a cure, but remissions lasted about 2 years. One woman relapsed 9 years after her treatment. Of course there were dangers, but in those days the alternative was incarceration in a locked ward in a Victorian asylum, with little hope of rehabilitation or discharge. \u0000 \u0000Martin Roth was an intellectual giant, but also a man who was perspicacious and compassionate, and who would not have contemplated using such a treatment if he did not think it effective. The depth of the coma seemed to me to be critical in terms of remission. A few patients did not regain consciousness when given glucose, but usually ‘came out of it’ after some hours, although there was the occasional death. Very occasionally, a patient who was clearly psychotic who had an ‘irreversible coma’ on recovery was greatly mentally improved. These days, people find this difficult to believe, but I witnessed it on one occasion. I find it inconceivable that a multitude of psychiatrists, working in Europe and North America over 25 years, would not have noticed that the treatment they were giving was having no effect, when it clearly was, if only for a limited period. The real question was not whether insulin worked but how did insulin work. \u0000 \u0000I have no wish to minimise the success of Dr Bourne’s crusade, but what made insulin units redundant was the realisation that the new antipsychotic drugs actually worked, and at last, we had an effective, cheap and long-lasting method of managing a seemingly incurable disease. This was generally accepted by 1960.","PeriodicalId":90710,"journal":{"name":"Psychiatric bulletin (2014)","volume":"38 4","pages":"198"},"PeriodicalIF":0.0,"publicationDate":"2014-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1192/pb.38.4.198","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"32680930","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
In her editorial, Rebecca McGuire-Snieckus warns clinicians against promoting optimism in their clients, since this can lead to unmet expectations and negative reactions when such expectations are not realised.1 In his commentary on the editorial, Femi Oyebode criticises Martin Seligman for exaggerating the importance of happiness at all costs as a goal of existence, and quotes Aristotle as stating that it is the mark of a courageous man to face things that are terrible to a human being.2 I wish to illustrate this in the context of family carers of relatives with schizophrenia. In particular, I focus on the overinvolved carer who is unable to relinquish her/his hopes and expectations for the affected relative. They are readily recognised by habitually referring to their relative in the past tense, for example, ‘she was such a beautiful girl’ or ‘he was such a good student’. This form of speech reveals the fact that the carer is living in the past and has not come to terms with the reality of their relative’s illness. This is particularly hard on the patient, who then feels driven to attempt to satisfy the carer’s need for their success, and fails again and again. The remedy is to offer the carer grief work to mourn their losses and to accept the reality of their relative’s disability and release both parties from this impasse, enabling them to develop a more realistic view. The patient will also benefit from grief work, administered separately from the carer.
{"title":"Hope and hopelessness in carers of a relative with schizophrenia.","authors":"Julian Leff","doi":"10.1192/pb.38.4.198a","DOIUrl":"https://doi.org/10.1192/pb.38.4.198a","url":null,"abstract":"In her editorial, Rebecca McGuire-Snieckus warns clinicians against promoting optimism in their clients, since this can lead to unmet expectations and negative reactions when such expectations are not realised.1 In his commentary on the editorial, Femi Oyebode criticises Martin Seligman for exaggerating the importance of happiness at all costs as a goal of existence, and quotes Aristotle as stating that it is the mark of a courageous man to face things that are terrible to a human being.2 I wish to illustrate this in the context of family carers of relatives with schizophrenia. In particular, I focus on the overinvolved carer who is unable to relinquish her/his hopes and expectations for the affected relative. They are readily recognised by habitually referring to their relative in the past tense, for example, ‘she was such a beautiful girl’ or ‘he was such a good student’. This form of speech reveals the fact that the carer is living in the past and has not come to terms with the reality of their relative’s illness. This is particularly hard on the patient, who then feels driven to attempt to satisfy the carer’s need for their success, and fails again and again. The remedy is to offer the carer grief work to mourn their losses and to accept the reality of their relative’s disability and release both parties from this impasse, enabling them to develop a more realistic view. The patient will also benefit from grief work, administered separately from the carer.","PeriodicalId":90710,"journal":{"name":"Psychiatric bulletin (2014)","volume":"38 4","pages":"198"},"PeriodicalIF":0.0,"publicationDate":"2014-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1192/pb.38.4.198a","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"32680931","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The article by Roychowdhury & Adshead starts to place violence risk assessment in the context of medical care.1 Although this is welcome, their partial defence of risk assessment in general, and of structured professional judgement in particular, is based on some significant distortions. The first distortion is the gross overestimation of the power of risk assessment to discriminate between low-risk and high-risk people. The authors present a contingency table that they imagine shows the ‘potential’ outcomes of a violence risk assessment (Table 2). Using their tabulated data, a diagnostic odds ratio for risk assessment can be calculated to be 81, indicating that the risk of violence in the high-risk group (50%) is hugely higher than in the low-risk group (1.2%). These figures are totally unrealistic. In fact, the diagnostic odds ratio of violence risk assessment in replication studies was recently estimated by meta-analysis2 to be 3. Roychowdhury & Adshead overestimate the discriminating power of risk assessment by 27 times. Moreover, even an unrealistically powerful risk assessment with diagnostic odds of 16 is of little or no value because of failure to detect potential violence in the low-risk group and the large proportion of false positives in the high-risk group.3 The second distortion relates to the underestimation of the precision of medical tests. In fact, the authors seem to have had difficulty finding any medical test with diagnostic odds that they could compare to a violence risk assessment. Instead they chose to compare two medical treatments. They argue that the high number-needed-to-treat as a result of a violence risk assessment is acceptable in psychiatry because in cardiology the number of bypass grafts needed to prevent one fatal outcome has been calculated to be 53.3 However, the meta-analysis they derived this figure from compared coronary bypass surgery to angioplasty - both of which are highly efficacious treatments for angina.3 In reality, medical tests that are used to diagnose conditions with serious implications for the patient are very accurate - biopsy is an excellent indicator of cancer and an angiogram a good indicator of coronary heart disease. Despite these limitations, I support the authors’ general idea of viewing risk assessment as a medical procedure. I would go further: surely violence risk assessment should be judged by the standards of evidence-based medicine. The real questions then become: (1) are there any rational interventions that can be justified in terms of cost and benefit that might reduce violence among high-risk patients (many of whom will not be violent) and yet should not be offered to low-risk patients (who commit as many or even the majority of acts of violence); and (2) is there evidence that shifting treatment resources from low-risk to high-risk people can, in any way, reduce overall levels of harm? The answer to both these questions is no.4,5 There is no doubt that medical di
{"title":"Risk assessment and evidence-based medicine.","authors":"Matthew Large","doi":"10.1192/pb.38.4.196","DOIUrl":"https://doi.org/10.1192/pb.38.4.196","url":null,"abstract":"The article by Roychowdhury & Adshead starts to place violence risk assessment in the context of medical care.1 Although this is welcome, their partial defence of risk assessment in general, and of structured professional judgement in particular, is based on some significant distortions. \u0000 \u0000The first distortion is the gross overestimation of the power of risk assessment to discriminate between low-risk and high-risk people. The authors present a contingency table that they imagine shows the ‘potential’ outcomes of a violence risk assessment (Table 2). Using their tabulated data, a diagnostic odds ratio for risk assessment can be calculated to be 81, indicating that the risk of violence in the high-risk group (50%) is hugely higher than in the low-risk group (1.2%). These figures are totally unrealistic. In fact, the diagnostic odds ratio of violence risk assessment in replication studies was recently estimated by meta-analysis2 to be 3. Roychowdhury & Adshead overestimate the discriminating power of risk assessment by 27 times. Moreover, even an unrealistically powerful risk assessment with diagnostic odds of 16 is of little or no value because of failure to detect potential violence in the low-risk group and the large proportion of false positives in the high-risk group.3 \u0000 \u0000The second distortion relates to the underestimation of the precision of medical tests. In fact, the authors seem to have had difficulty finding any medical test with diagnostic odds that they could compare to a violence risk assessment. Instead they chose to compare two medical treatments. They argue that the high number-needed-to-treat as a result of a violence risk assessment is acceptable in psychiatry because in cardiology the number of bypass grafts needed to prevent one fatal outcome has been calculated to be 53.3 However, the meta-analysis they derived this figure from compared coronary bypass surgery to angioplasty - both of which are highly efficacious treatments for angina.3 In reality, medical tests that are used to diagnose conditions with serious implications for the patient are very accurate - biopsy is an excellent indicator of cancer and an angiogram a good indicator of coronary heart disease. \u0000 \u0000Despite these limitations, I support the authors’ general idea of viewing risk assessment as a medical procedure. I would go further: surely violence risk assessment should be judged by the standards of evidence-based medicine. The real questions then become: (1) are there any rational interventions that can be justified in terms of cost and benefit that might reduce violence among high-risk patients (many of whom will not be violent) and yet should not be offered to low-risk patients (who commit as many or even the majority of acts of violence); and (2) is there evidence that shifting treatment resources from low-risk to high-risk people can, in any way, reduce overall levels of harm? \u0000 \u0000The answer to both these questions is no.4,5 There is no doubt that medical di","PeriodicalId":90710,"journal":{"name":"Psychiatric bulletin (2014)","volume":"38 4","pages":"196"},"PeriodicalIF":0.0,"publicationDate":"2014-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1192/pb.38.4.196","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"32680925","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-08-01DOI: 10.1192/pb.bp.114.048520
Julia Bland
{"title":"Profile: Stigma and the psychiatrist - Julia Bland talks to Dinesh Bhugra.","authors":"Julia Bland","doi":"10.1192/pb.bp.114.048520","DOIUrl":"https://doi.org/10.1192/pb.bp.114.048520","url":null,"abstract":"","PeriodicalId":90710,"journal":{"name":"Psychiatric bulletin (2014)","volume":"38 4","pages":"180-2"},"PeriodicalIF":0.0,"publicationDate":"2014-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1192/pb.bp.114.048520","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"32680916","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-08-01DOI: 10.1192/pb.bp.113.044693
Tania Louise Gergel
Challenges to psychiatric stigma fall between a rock and a hard place. Decreasing one prejudice may inadvertently increase another. Emphasising similarities between mental illness and 'ordinary' experience to escape the fear-related prejudices associated with the imagined 'otherness' of persons with mental illness risks conclusions that mental illness indicates moral weakness and the loss of any benefits of a medical model. An emphasis on illness and difference from normal experience risks a response of fear of the alien. Thus, a 'likeness-based' and 'unlikeness-based' conception of psychiatric stigma can lead to prejudices stemming from paradoxically opposing assumptions about mental illness. This may create a troubling impasse for anti-stigma campaigns.
{"title":"Too similar, too different: the paradoxical dualism of psychiatric stigma.","authors":"Tania Louise Gergel","doi":"10.1192/pb.bp.113.044693","DOIUrl":"https://doi.org/10.1192/pb.bp.113.044693","url":null,"abstract":"<p><p>Challenges to psychiatric stigma fall between a rock and a hard place. Decreasing one prejudice may inadvertently increase another. Emphasising similarities between mental illness and 'ordinary' experience to escape the fear-related prejudices associated with the imagined 'otherness' of persons with mental illness risks conclusions that mental illness indicates moral weakness and the loss of any benefits of a medical model. An emphasis on illness and difference from normal experience risks a response of fear of the alien. Thus, a 'likeness-based' and 'unlikeness-based' conception of psychiatric stigma can lead to prejudices stemming from paradoxically opposing assumptions about mental illness. This may create a troubling impasse for anti-stigma campaigns. </p>","PeriodicalId":90710,"journal":{"name":"Psychiatric bulletin (2014)","volume":"38 4","pages":"148-51"},"PeriodicalIF":0.0,"publicationDate":"2014-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1192/pb.bp.113.044693","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"32679953","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-08-01DOI: 10.1192/pb.bp.112.041723
Catriona Mellor
Aims and method To systematically review the published literature on the effectiveness of classroom-based interventions to tackle the stigma of mental illness in young people, and to identify any consistent elements within successful programmes. Results Seventeen studies were included in the analysis. A minority of studies reported a positive impact on stigma or knowledge outcomes at follow-up and there were considerable methodological shortcomings in the studies reviewed. These interventions varied substanitally in content and delivery. It was not possible to use this data to draw out what aspects make a successful intervention. There is currently no strong evidence to support previous conclusions that these types of intervention work for children and adolescents. Clinical implications When anti-stigma interventions for young people are rolled out in the future, it is important that the programme design and method of delivery have evidence to prove their effectiveness, and that the audience and setting are the most appropriate to target. There is a current lack of strong evidence to inform this.
{"title":"School-based interventions targeting stigma of mental illness: systematic review.","authors":"Catriona Mellor","doi":"10.1192/pb.bp.112.041723","DOIUrl":"https://doi.org/10.1192/pb.bp.112.041723","url":null,"abstract":"<p><p>Aims and method To systematically review the published literature on the effectiveness of classroom-based interventions to tackle the stigma of mental illness in young people, and to identify any consistent elements within successful programmes. Results Seventeen studies were included in the analysis. A minority of studies reported a positive impact on stigma or knowledge outcomes at follow-up and there were considerable methodological shortcomings in the studies reviewed. These interventions varied substanitally in content and delivery. It was not possible to use this data to draw out what aspects make a successful intervention. There is currently no strong evidence to support previous conclusions that these types of intervention work for children and adolescents. Clinical implications When anti-stigma interventions for young people are rolled out in the future, it is important that the programme design and method of delivery have evidence to prove their effectiveness, and that the audience and setting are the most appropriate to target. There is a current lack of strong evidence to inform this. </p>","PeriodicalId":90710,"journal":{"name":"Psychiatric bulletin (2014)","volume":"38 4","pages":"164-71"},"PeriodicalIF":0.0,"publicationDate":"2014-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1192/pb.bp.112.041723","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"32680912","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Roychowdhury & Adshead should be thanked for raising the issue of the ethics of the use of actuarial risk assessment in psychiatry.1 These ethics might at first appear obvious: medical practitioners must have an overriding duty to protect the public from serious crime. It follows that they must do everything possible to accurately assess the risk of such crime, including the use of these assessment instruments. However, as Roychowdhury & Adshead point out, these instruments will produce misleading results if the prevalence of the serious crime being considered in the relevant population is low or unknown. Indeed, they point out: ‘A key challenge in psychiatry is that base rates [of the prevalence of serious crime] are often not known, are low and vary for different types of violence.’ So if doctors use these assessments they risk wrongly identifying their patient as at high risk of committing a serious crime, and then act in a way that is not in the best interests of that patient. Such an act would of course be inconsistent with the duties of a doctor as set out by the General Medical Council (GMC) in Good Medical Practice.2 It follows that while the prevalence of particular serious crimes in various patient populations is unknown or is known to be low, the use of these actuarial risk assessments will remain unethical. As Roychowdhury & Ashhead conclude: ‘[structured professional judgement] tools used as checklists of risk factors without construction of risk scenarios or a risk management plan remains harmful and unethical practice.’ In my opinion psychiatrists would value guidance on this issue from the GMC.
{"title":"GMC guidance needed.","authors":"Keith E Dudleston","doi":"10.1192/pb.38.4.195b","DOIUrl":"https://doi.org/10.1192/pb.38.4.195b","url":null,"abstract":"Roychowdhury & Adshead should be thanked for raising the issue of the ethics of the use of actuarial risk assessment in psychiatry.1 These ethics might at first appear obvious: medical practitioners must have an overriding duty to protect the public from serious crime. It follows that they must do everything possible to accurately assess the risk of such crime, including the use of these assessment instruments. However, as Roychowdhury & Adshead point out, these instruments will produce misleading results if the prevalence of the serious crime being considered in the relevant population is low or unknown. Indeed, they point out: ‘A key challenge in psychiatry is that base rates [of the prevalence of serious crime] are often not known, are low and vary for different types of violence.’ So if doctors use these assessments they risk wrongly identifying their patient as at high risk of committing a serious crime, and then act in a way that is not in the best interests of that patient. Such an act would of course be inconsistent with the duties of a doctor as set out by the General Medical Council (GMC) in Good Medical Practice.2 It follows that while the prevalence of particular serious crimes in various patient populations is unknown or is known to be low, the use of these actuarial risk assessments will remain unethical. As Roychowdhury & Ashhead conclude: ‘[structured professional judgement] tools used as checklists of risk factors without construction of risk scenarios or a risk management plan remains harmful and unethical practice.’ In my opinion psychiatrists would value guidance on this issue from the GMC.","PeriodicalId":90710,"journal":{"name":"Psychiatric bulletin (2014)","volume":"38 4","pages":"195-6"},"PeriodicalIF":0.0,"publicationDate":"2014-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1192/pb.38.4.195b","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"32680924","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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