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Schizophrenia and the Art of War

2 Sep, 09 | by Steven Reid, Evidence-Based Mental Health

We have had a War on Terror, a War on Drugs, a War on Cancer, and a War on Poverty. We do have a mental health czar – it seems a czar is essential when forces need to be mobilized – but no War on Mental Illness as yet. Maybe we should…Mark Salter sees parallels in our responses to war and schizophrenia in his trenchant critique of the updated NICE guidance on the management of schizophrenia. You can find it on the EBMH homepage. The parallels are not especially favourable although he doesn’t mention lions or donkeys. Maybe he should…

Clozapine: first-line treatment for schizophrenia?

24 Jul, 09 | by Steven Reid, Evidence-Based Mental Health

Long considered the Heineken of antipsychotic drugs (refreshing the parts of the brain other drugs cannot reach…sorry), clozapine also comes with more restrictions and health warnings than a pack of cigarettes in California. That might change following this study from the Lancet showing that people with schizophrenia prescribed clozapine had a lower mortality rate than those taking any other antipsychotic or on no treatment at all.

Clozapine has been around since the 1960s and when it was introduced offered the distinct advantage of an extremely low incidence of the motor side effects – stiffness, abnormal movements – that beset other antipsychotics at the time. That was until 1975 when it was withdrawn after a case series was reported of 16 patients on clozapine developing agranulocytosis (a severe deficiency of white blood cells), half of them going on to die.

The drug disappeared for 10 years or so until in 1988 it was rehabilitated following a classic study that demonstrated its superior efficacy in treatment-resistant schizophrenia, where other drugs had little or no effect. It was invited back into the formulary but this time with compulsory blood count monitoring and the proviso that at least two other antipsychotics should be tried first

For this new study Jari Tiihonen and colleagues were looking at the gap in mortality between people with schizophrenia and the general population in Finland over 11 years. They had access to data on 67000 individuals with schizophrenia – that’s right 67000. You can do research like that when you have ‘socialized’ medicine. First, they found that over the duration of the study the 25 year gap in life expectancy remained unchanged, despite the introduction of newer treatments. In what may come as a surprise to some, given the notoriety of antipsychotics and their side effects, those taking antipsychotics over the course of the study had a lower mortality rate than those who were drug-free. But by far the drug with the lowest risk of death (due to any cause) was clozapine. Quetiapine, haloperidol and risperidone increased that risk by 41 per cent, 37 per cent and 34 per cent respectively when compared to an older drug, perphenazine. In contrast use of clozapine was associated with a 26 per cent reduction in mortality. Clozapine was also associated with a lower risk of suicide than any other drug.

The NICE guidance for schizophrenia (in England and Wales) updated in March this year had this to say about clozapine: Offer clozapine to people with schizophrenia whose illness has not responded adequately to treatment despite the sequential use of adequate doses of at least two different antipsychotic drugs. At least one of the drugs should be a non-clozapine second-generation antipsychotic.

Time for a rethink perhaps as not only is clozapine the most effective antipsychotic we have; it may also be the safest.

Madness at the Movies

27 May, 09 | by Steven Reid, Evidence-Based Mental Health

“Explaining madness is the most limiting and generally least convincing thing a movie can do.” That was the view of the critic Pauline Kael, and despite mental illness and its treatment remaining an ever-popular source for film-makers it is an opinion that I think still holds true. Psycho-killers, maniacs, hysterics, and the ubiquitous manipulative, deviant psychiatrist: stereotypes and clichés abound.

I recently watched Clint Eastwood’s film Changeling, a drama set in Depression-era Los Angeles ostensibly based on real events involving a missing child. A major theme is the role of psychiatry as a means for the social control of women. A subject worthy of exploration certainly, but we could do without the almost inevitable addition of the ‘Cuckoo’s Nest’ scenes: the barbaric use of involuntary electroconvulsive therapy. ECT certainly makes for melodramatic viewing, but it was introduced as a treatment in 1936 and wasn’t being used in 1928 when the film is set.

Last month saw the US release of The Soloist, a film ‘based’ on a book telling the story of Nathaniel Ayers, a musician with schizophrenia. I can’t comment as it hasn’t reached the UK, but typically it has received contrasting reviews for its depiction of psychosis: a sentimental cheapening, or a triumph. Your views would be welcome on this or other films that you believe provide a persuasive and truthful account of living with mental illness.

Coincidentally one of The Soloist’s lead characters is played by Robert Downey Jr. – an actor who provoked outrage in the scabrous Tropic Thunder for satirizing Hollywood’s ham-fisted approach to mental illness and learning disabilities. If you want to win an Oscar: “Never go full retard. You don’t buy that? Ask Sean Penn, 2001, “I Am Sam.” Remember? Went full retard, went home empty handed…”

Offensive? Certainly, but as honest an appraisal of the portrayal of mental disorder in film as you’ll find anywhere.

Do we need yet another homicide inquiry?

17 May, 09 | by Steven Reid, Evidence-Based Mental Health

Last week NHS Yorkshire and Humber released the findings of an external investigation into the care and treatment of Benjamin Holiday. You can find the report here. In January 2005 Holiday, a young man with schizophrenia, killed a pregnant woman, Tina Stevenson, stabbing her in the street close to her home. He was under the care of a community mental health team and living at home with his mother. Having no recollection of the attack he pleaded guilty to manslaughter with diminished responsibility and has been detained indefinitely in a special hospital.

Department of Health guidelines (shouldn’t that be directives?) call for a series of reviews when a homicide has been committed by a person who has been in contact with mental health services:
1) A fast-track (72 hours) investigation to identify any necessary immediate action
2) An internal mental health trust investigation (within 3 months)
3) And finally, an independent investigation commissioned by the Strategic Health Authority.

The reasons for an external investigation are obvious: lessons must be learned to prevent such events happening again. But do they work? They certainly provide a revealing insight into the day to day care of someone living with a severe mental illness, affording a degree of transparency for relatives and carers that is rarely available elsewhere. And outcomes? There have been at least 400 homicide inquiries in the last 15 years yet the rates of homicide by people with mental disorder remains unchanged: 30-50 from 800 homicides annually, with fewer than 10 committed by people with a psychotic illness (the remainder largely related to personality disorder and drug misuse). The recommendations have become familiar too: improved risk assessment, better communication and better record-keeping. Another report isn’t needed to tell us that. The Holiday Inquiry illustrates their inefficiency. Tina Stevenson was killed in 2005; the inquiry reports four years later in which time things have changed. We have a new Mental Health Act, community treatment orders, crisis resolution teams and I’m sure that like elsewhere, services in Hull have been completely reorganised. The authors acknowledge that much of what they say was reported in 2006 by the mental health trust’s internal review.

Much has been made of bringing an end to the ‘blame culture’ in the NHS which encourages staff to cover up errors for fear of retribution. The new focus is on systematic factors that allow such errors to be made. It is human nature, however, to search for a scapegoat and in this inquiry: “…if we are allowed to indulge in one piece of viewing this investigation through a ‘retrospective-scope’ we would conclude this was a missed opportunity to possibly break into the cycle”. What they are referring to here is the decision by a social worker not to complete an application to detain Holiday under Section 3 of the Mental Health Act two months before the homicide. At the time however, he was agreeing to an informal admission, and following his discharge one month later he was seen by a nurse on two occasions and given his depot antipsychotic injection. It is just as plausible that by detaining him at that time he may have become less cooperative with treatment and disengaged completely – a classic example of hindsight bias.

Of course these points have been made before. In 1999 the DoH’s Safer Services report recommended that homicide inquiries be scrapped but they keep on coming. Clearly they fulfil a social need. The Department of Health guidelines state that mental health services must ‘be seen to investigate’ any serious incident and though not explicit, the allaying of the publics’ anxiety about the mentally ill is key. We used to have asylums to contain the mad, but now we have community care – an idea that now attracts as much vilification as political correctness. The fear of mental illness is as potent as ever and homicide inquiries serve to remind us that whilst they may live among us, they remain alien and dangerous – as illustrated by headlines such as this: Crazed Killers – trust’s failings exposed.

The End of Kraepelin’s Dichotomy

23 Jan, 09 | by Steven Reid, Evidence-Based Mental Health

No, don’t worry; this isn’t a blog about metaphysics. It was over 100 years ago that Emil Kraepelin, widely considered the father of contemporary psychiatry, divided psychosis into two discrete disorders: dementia praecox (schizophrenia) and manic-depressive insanity (bipolar disorder). Hence the dichotomy, which remains a hallmark of the classification of mental illness.


This categorical approach to diagnosis has plenty of critics but the divide remains firmly in place. Why? Partly because making a psychiatric diagnosis is often an uncertain business. It’s inherently appealing to have just two options to choose from when trying to make sense of a complex clinical picture. Plus the textbooks tell you it’s straightforward: schizophrenia means an enduring illness, with a flat, unreactive mood, and inevitably a poor outcome, in contrast to bipolar illness which is episodic with dramatic changes in mood, and of course that flair for creativity. Well life’s not actually like that. In clinical practice it’s often difficult to discriminate between the two. Take a look at the casenotes of a person with schizophrenia and at some point it’s likely someone will have made a diagnosis of bipolar disorder, and vice versa. In fact we’ve even had to invent a new diagnosis – schizoaffective disorder – for those cases when you just can’t make up your mind. So there has been disquiet about Kraepelin’s dichotomy for some time and now we have a behemoth of a study which may well prove to be the final nail in its coffin.


Published in the Lancet this is a population-based study including over nine million Swedes, that teases apart the genetic and environmental contributions to both schizophrenia and bipolar disorder. Previous genetic studies have been nowhere near as big so the findings are compelling. We know that genes are important in both schizophrenia and bipolar disorder but here it’s demonstrated that they share a common genetic cause. First-degree relatives of people with bipolar illness had an increased risk for schizophrenia, including adopted children to biological parents with bipolar disorder. Similarly, relatives of those with schizophrenia were at increased risk of bipolar disorder.


So what next? Out with the old diagnostic criteria? Perhaps…it certainly gives the committees debating the next version of the psychiatrists’ diagnostic manual (DSM-V) plenty to think about. Maybe it’s time we moved toward a psychosis-spectrum disorder with a renewed emphasis on symptoms. After all, it’s the symptoms that predict response to a specific treatment, not the diagnosis. And what of Kraepelin, would he approve? Well he was having doubts about his own dichotomy back in 1920, “No experienced psychiatrist will deny that there is an alarmingly large number of cases in which it seems impossible, in spite of the most careful observation, to make a firm diagnosis…. It is becoming increasingly clear that we cannot distinguish satisfactorily between these two illnesses and this brings home the suspicion that our formulation of the problem may be incorrect”.

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