by Sharifi V, Eaton WW, Wu LT, Roth KB, Burchett BM, and Mojtabai R.British Journal of Psychiatry. 2015 May 7 [Epub ahead of print].[First received 10 Dec 2013, final revision 24 Nov 2014, accepted 24 Nov 2014, Published online 1 July 2015.]
Background: Psychotic experiences are common in the general population and are associated with adverse psychiatric and social outcomes, even in the absence of a psychotic disorder.Aims: To examine the association between psychotic experiences and mortality over a 24-27 year period.Method: We used data on 15,049 adult participants from four sites of the Epidemiologic Catchment Area baseline survey in the USA in the early 1980s, linked to the National Death Index and other sources of vital status up until 2007. Psychotic experiences were assessed by the Diagnostic Interview Schedule.Results: Lifetime psychotic experiences at baseline [n = 855; weighted prevalence, 5.5%] were significantly associated with all-cause mortality at follow-up after adjustment for sociodemographic characteristics and psychiatric diagnoses, including schizophrenia spectrum disorders [P<0.05]. Baseline psychotic experiences were associated with over 5 years’ shorter median survival time. Among the underlying causes of death, suicide had a particularly high hazard ratio [9.16, 95% CI 3.19-26.29].Conclusions: Future research needs to explore the association of psychotic experiences with physical health and lifestyle factors that may mediate the relationship of psychotic experiences with mortality.
Earlier this year when the British Psychological Society released their Understanding Psychosis and Schizophrenia, Dr. Jeffrey Lieberman unleashed an ad hominem attack that a lot of us felt was way out of bounds [even for him] [see which side of the street?…] similar to another a bit later against Robert Whitaker [just stop…]. But calling out Dr. Lieberman for conduct unbecoming didn’t necessarily signal support for the BPS Report. It really was a hard report to even discuss because it was presented more as an emotional polemic than a scientific report. If you haven’t read it, please do. It isn’t something that can be easily summarized. But there are only two possible responses: Psychiatry pathologizes normality or The BPS normalizes pathology. Here were some of my reactions at the time it came out : <to be continued>…, back to the drawing board…, impossibility…, jettison schizophrenia?…, and jettison schizophrenia? no thanks…. In this study, beside the loss of 6+ years from the lifespan [survival curve above], the other data of note in this paper is in Table 2 [abbreviated below]:
[truncated for simplicity]
In both the Cox and the Generalized Gamma Models, the shortened lifespan was significant for the overall group reporting psychotic experiences [p<0.001]. And when the analysis was repeated with the covariates separated out [formal psychotic disorders like Schizophrenia, Bipolar Disorder, etc], the significance remained [p<0.05]. In the overall group with psychotic experiences, suicide was a particularly prominent cause of death [Cox Model 9.16(3.19–26.29) p<0.001], but not in the psychotic experience without psychotic disorder group [Cox Model 2.28 (0.36–14.41) p>0.05].
This was a population study with information limited to the recorded parameters without specific subject narratives. But the difference, over a six year shortening of lifespan, is impressive. The contrast between the pictures painted by the British Psychological Society’s Understanding Psychosis and Schizophrenia and an article like this one is dramatic. The BPS Report would characterize the psychotic experience without psychotic disorder group as a benign variant of normal, not something that would be expected to be associated with morbidity or shortened life.
I find the controversies that swirl around these differences difficult. In their recent book, Psychiatry Under the Influence, Whitaker and Cosgrove make much of the guild interests that have driven a lot of the psychiatric literature in the recent decades, and they are justified – as am I when I make similar complaints. But I can’t read that BPS Report or many of the like-minded blog posts without seeing the guild interests of those authors front and center as an equally prominent force. I expect there will come a time when all of this is will be clear, but I’m not sure this is it. It feels like it’s a yes/no argument that needs a large [non-binary] study that reframes the issue into one with many answers done by impartial people, and there aren’t many in sight. Guild wars appear to be the currency of the day.
“But I can’t read that BPS Report or many of the like-minded blog posts without seeing the guild interests of those authors front and center as an equally prominent force”
People can certainly make it seem like this is a guild issue. Obviously some of the people you reference have made a career out of it. As as mental health “guilds” go the psychiatric guild has been the least active – by far.
But the bottom line is that people with psychotic disorders aren’t being brought into hospitals by the thousands just so psychiatrists can have careers or to legitimize psychiatry. The idea that we now have “proof” that psychotic disorders have a high morbidity and can be lethal requires that one actively ignore all the literature and clinical experience of the past century.
Many of these critics who lack that basic knowledge base have an easy time doing that. People who actually practice psychiatry can’t.
I just watched Eleanor Longden’s course:
http://madinamericacontinuinged.org/ (free to watch, pay to get CME).
I used to think (as I think is implied above) that it was a distinction between people who had mild kinds of experiences or who romanticized psychosis vs. those who were more severely impaired.
But now I think it is a distinction in how we try to engage with people. I think I know something about how dangerous and debilitating psychosis can be. I also think the brain is involved (albeit in a multiplicity of ways only few of which – if any – are as yet understood). But I am no longer sure that it is best to only engage people with the so-called brain disease narrative especially when it tends to shut down other kinds of conversations. I also think it depends on the person and Dr. Longden agrees that what was most helpful to her may not be helpful to everyone. But the initial care she received – which was not at all helpful for her – is the standard of care for most everyone who makes their way to our offices (and as for guild, I think most psychologists these days would refer a person experiencing psychosis to a psychiatrist).
I have started a hearing voices group. Although in the room we do not focus much on the brain or discussions of brain abnormalities, our group is not in any way anti-psychiatry. But the people who come seem to derive some benefit (albeit it is not in any way quantified), just talking about their experiences – really their relationship to their voices – and in that space, there is much that I, a non-voice hearer – can understand not because I am a psychiatrist but because I am human being.
After reading your blog for awhile, I find it hard to believe you would find what I write controversial or even surprising or “new” so I am left wondering wherein lies the controversy.
With respect, Mickey, I have to challenge your interpretation of this study. One of the points made in the BPS report – and in fact in a good many other places, particularly since DSM5 – is that we cannot reliably distinguish between ‘psychotic experiences’ and ‘psychotic disorders’ (not terms that I would use, but that is a separate issue); or indeed between these conditions and ‘normality.’ In fact, you make this point yourself at the end of your post. Therefore the dichotomy on which the study is based is not, I suggest, valid.
You say:’ The BPS Report would characterize the psychotic experience without psychotic disorder group as a benign variant of normal, not something that would be expected to be associated with morbidity or shortened life.’ I respond: Not at all. The BPS report would challenge these terms and their underlying assumptions, both in general and as a basis for selecting the groups in this study.
(The authors admit to an additional layer of subjectivity introduced by their assessment: experiences were classed as ‘psychotic’ if they were judged to be ‘without plausible explanations.’ How could they possibly know?)
There are (at least) 2 other possibilities for the association between a large, poorly-defined, heterogenous group of ‘psychotic experiences’ and mortality: 1. Via the link with social stress and adversity, as the authors acknowledge. (A trauma-informed perspective would see these factors as causal in ‘psychosis’, but this aside, there are very well-established links between adversities and physical health problems, as the ACE studies show.) 2. Via damage from psychiatric medications. It is not clear how many of the people in the ‘psychotic experiences’ group had been given formal psychiatric diagnoses and treatment, but it is implied that at least some of them had.
If these two possibilities are at work, it is not surprising that both groups in this study had a raised risk of mortality, since both are likely to have contained people with a background of adversities and/or psychiatric interventions that made physical illhealth more likely. This doesn’t mean that the BPS report was wrong in contending that some experiences that are captured by the loose and amorphous term ‘psychotic’ are harmless, or even valued. Equally, it doesn’t mean that there is something intrinsically damaging to mental or physical health about such experiences. Further research is needed!
I’m also unhappy with your allegations about ‘guild interests.’ No profession is free from these; you have been relentless in exposing them as they apply to psychiatry, and clinical psychologists have often turned a critical eye on their own profession as well. But is every action of a profession – specifically, in this case, the BPS report – to be dismissed in this way? If so, it is interesting that many UK psychiatrists don’t see it like that. In fact the BPS report was formally launched and strongly endorsed by Dr Geraldine Strathdee, psychiatrist and National Clinical Director for Mental Health in England, along with other senior UK psychiatrists.
And I think your reading of the report is too narrow. It is not obvious to me that arguing for a much greater role for self-help and social/political interventions, which could put us all out of business, is driven mainly by professional interests. You find yourself unable to read some material ‘without seeing the guild interests of those authors first and center.’ I feel exactly the same about much (not all) of the criticism of the BPS report – but that kind of allegation isn’t a helpful way forward. Much better to engage with the arguments.
Thanks for your post, and I will be interested in your response.
“I’m also unhappy with your allegations about ‘guild interests.’ No profession is free from these; you have been relentless in exposing them as they apply to psychiatry, and clinical psychologists have often turned a critical eye on their own profession as well. But is every action of a profession – specifically, in this case, the BPS report – to be dismissed in this way?”
I think I responded already to that. In writing this post, I reread the BPS report and rethought about it. I wish you would spread the sentiment you express here [But is every action of a profession – specifically, in this case, the BPS report – to be dismissed in this way?] around some, for example here, there, and everywhere…
“I find the controversies that swirl around these differences difficult. In their recent book, Psychiatry Under the Influence, Whitaker and Cosgrove make much of the guild interests that have driven a lot of the psychiatric literature in the recent decades, and they are justified – as am I when I make similar complaints. But I can’t read that BPS Report or many of the like-minded blog posts without seeing the guild interests of those authors front and center as an equally prominent force. I expect there will come a time when all of this is will be clear, but I’m not sure this is it. It feels like it’s a yes/no argument that needs a large [non-binary] study that reframes the issue into one with many answers done by impartial people, and there aren’t many in sight. Guild wars appear to be the currency of the day.”
As you probably recall, I “dropped out” of the repartee about that report in our earlier private emails because it felt like it was turning into another tit-for-tat kind of dialog. And likewise, I started my response to the Report with calling out Jeffrey Lieberman for his inappropriate response both in the past and this post. In the interim, I’ve looked at the CBT papers by Tony Morrison [a pilot…, slim pickings…]. If you didn’t see that, it’s the best I could do with that data and I would also recommend the comments to those posts that were quite good. I certainly stand by “Guild wars appear to be the currency of the day.”
Finally, I still think the BPS Report is a polemic. Of course, many of the humanistic recommendations are things I’ve always advocated. In fact, I tried to have the “no meds” stance, but over a career, learned to be very careful with that. If my post seems dismissive, I’d reread it.
Your tweet, “More doubts raised about #understandingpsychosis by @1boringoldman – but are they valid?” is an invitation to enter a dialogue about this Report. As you point out, I have been a “relentless” critic of psychiatry’s guild conflicts of interest. You’re asking me not to see the other side of that – in the Report, in Bob’s new book, on MIA. But I do see it, and there’s not much more to say than that. I’ve been fairly soft-spoken about that, but I’m unlikely to “unsee it”…
One can only wish that Lucy Johnstone did some fact checking before opining airily about “damage from psychotropic medications.” In fact, a recent overview reported that ” Long-term cumulative exposure (7–11 years) to any antipsychotic treatment was associated with lower mortality than was no drug use (0·81, 0·77–0·84)” in patients with schizophrenia.
The link I just gave doesn’t seem to be working, so here is another from the same investigators.
In my estimation “guild interests” are a significant source of bias in many papers that are critical of psychiatry and should be considered as important as who pays for the research.
And is the same true of articles supportive of psychiatry? Or are they to be deemed magically free from all possible bias?
Lucy, bias is one thing… ignorance is something else.
“I still think the BPS Report is a polemic. Of course, many of the humanistic recommendations are things I’ve always advocated. In fact, I tried to have the “no meds” stance, but over a career, learned to be very careful with that. If my post seems dismissive, I’d reread it.”
I think I finally figured out why I find so much of what is posted here about severe psychotic illness so distressing. .
My personal experience with the mental health system was devastating. I am beginning to think from your comments (and please correct me if I am wrong) that you and others believe that the ‘humanistic recommendations and the attempt to be ‘no med'” is wide spread in mainstream psychiatry. This was certainly not our experience.. Nor was there any humility or uncertainty expressed about treatments given.
I am grateful for this site in terms of parsing studies, including the CBT studies cited in the BPS report. This is important information. However, in other posts I do not feel that the similar lack of evidence about drug treatment and whether it improves or hinders lasting functional recovery, generated the ‘moral outrage’ I would have expected given that drug treatment in the absence of informed consent happens regularly.
“Fools rush in where angels fear to tread” is a quote that pops up in my head when I think about that expedient, inpatient experience we had that prioritized “diagnosis” over care, prompt ‘medical management’ and what can only be called ‘pop’ or ‘surface’ psychological practices. How different is the approach taken by some of the alternative open dialogue or ‘sanctuary type’ model. There is no reason why their approaches should be considered less valid. These people often have years of experience with someone’s distress and many successful stories.
Is the PBS polemic? -maybe it is, and maybe it even needs to be if my experience is as widespread as I suspect – but this is not what dominates my thinking when I read the report – What I am always wondering about is if and how these types of documents could improve overall patient care. Dr. Pat Bracken, a critical psychiatrist and philosopher who does believe that psychiatry has a future, has commented that the most exciting thing to happen in psychiatry is the rise of the ‘user’ movement. He says that information from ;’survivors and consumers’ just wasn’t available 25 years ago. The BPS report does an amazing job, in my opinion of embodying that voice. The authors have said they welcome feedback to the report – they ask for that – and yet it does not seem that they are considered worthy of being given constructive criticism to make the report better. I When I think of it like that, it does seem that they are treated in a dismissive way particularly by the critiques you linked to.
I think I deleted my final paragraph so I will add it here…..
I believe that if we had been in contact with professionals (from the beginning) that embodied the principals of the BPS report we would not have had to deal with layers of distress that were in addition to the distress of having a loved one with a serious illness. I believe psychiatry does need a very strong humanistic document to guide practice that takes into account the experiences of survivors and families, that acknowledges how much uncertainty there is in the field, that stresses collaboration and choice, and informs people of the variety of different approaches taken not only by different psychiatrists, but by others who also have a wealth of experience in the area.
sorry again ….I meant “The treatment of psychosis needs” not `Psychiatry needs’