Trust ’sorry’ for murders by patients in its care

• Reports criticise Humber mental health trust for failure of care
• Mother of five and elderly woman died in separate incidents

* Sam Jones
* guardian.co.uk, Wednesday 6 May 2009 00.30 BST

A mental health trust has apologised to the family of a pregnant woman who was killed by a paranoid schizophrenic man, and to the relatives of an 82-year-old woman who died at the hands of her mentally ill son.

New reports into both cases have criticised Humber mental health teaching NHS trust for failing to provide better care for the two men.

Tina Stevenson, a 31-year-old mother of five, was on her way home from an ante-natal class in Hull on 5 January 2005 when she passed Benjamin Holiday. The 25-year-old man, who had missed his medication the day before, stabbed Stevenson in the back. Neither she nor her unborn twin boys could be saved.

Holiday admitted manslaughter during his trial in May 2006 and was ordered to be detained indefinitely at a secure mental hospital.

An independent report into his care and treatment published by NHS Yorkshire and Humber concluded he had been “under-treated” by the trust.

Holiday, who had been suffering mental health problems since 2001, spent a fortnight in a secure unit in 2004 but was later discharged and treated in the community. The report admitted that Holiday, whom it referred to as “B”, was a difficult patient to engage with and was skilled at masking his symptoms.

It concluded: “The root cause contributing to B’s continuing severe mental disorder was that of ‘under treatment’. B’s situation and condition could and should have been more assertively managed.”

The chief executive of the Humber trust, David Snowden, apologised to those affected by the case and promised lessons would be learnt. He said his trust “fully accepted the recommendations, which we are taking very seriously”.

The trust also apologised to the family of Ivy Torrie, 82, who was killed by her mentally ill son, Michael, in Pocklington, East Yorkshire, in 2003.

A separate report attributed Michael Torrie’s actions to the “rapid reduction of medication and the way this was managed in the absence of a risk assessment”.

Marjorie Wallace, chief executive of the mental health charity Sane, said that although such events were rare, they did not “come out of the blue”.

“It is not an expensive revolution in care we need but common sense,” she said. “You do not leave an 82-year-old mother alone to care for her mentally ill son whose medication has been radically changed, with no support.

“Nor do you allow someone who may be becoming severely disturbed to dictate their own care and treatment without rigorous assessment of the risk they may pose to themselves or others.

“We have had 15 years of independent inquiries all exposing the same fault lines in the care and treatment of people with serious mental illness.”

Filed under: Other Mental Health, Violence, psychosis , healthcare, mental health, Schizophrenia, Violence

Mental health and offending: One man’s prison experience

A new report today by Lord Keith Bradley says offenders with mental health problems are being failed by the criminal justice system. David Smith, who suffers from schizoaffective disorder, explains why prison wasn’t the right place for him

* Mary O’Hara
* guardian.co.uk, Thursday 30 April 2009 16.47 BST

Like many people who run up against the criminal justice system while dealing with a serious mental health condition, David Smith [not his real name] felt that neither the police nor the prison service were equipped to deal with him. Smith has schizoaffective disorder. He manages his condition with fortnightly injections but in early 2008 he missed a series of appointments for medication, and became unwell.

By April his symptoms returned. These included hearing voices. David went to speak to his mother, with whom he had a fraught relationship, about his problems but the encounter turned into a confrontation that frightened her. At 2am the police arrested him on suspicion of common assault. He was locked in police cells for four days.

When he finally went to court they asked for a psychiatric report. The judge recommended that Smith receive hospital treatment but in the absence of a bed in a secure mental health unit Smith was instead sent to Wormwood Scrubs prison and spent a total of four months there.

“I have difficulty remembering my appointments; I never intend to miss any, I just find it difficult to remember when they are,” David says, explaining his state of mind at the time of his arrest. “My regular CPN [community psychiatric nurse] understands this and she gives me a ring the day before to remind me. When she went on leave I got a new CPN. He knew I couldn’t remember my appointments but he wouldn’t ring me with a reminder.

“I must have missed more than one injection,” he concludes. “My friends tell me there’s a pattern when I’m getting unwell. My symptoms came back and when I was at home one day I heard my mum screaming, ‘I’m going to kill myself’. I went to speak to her. I tried to talk to her. Mum just got frightened. I didn’t get anywhere with her so I went home.”

When he was arrested, Smith says, he did his best to explain himself to police officers but what happened was unsettling and frustrating. He recalls: “At the station another police officer asked me exactly the same questions; they didn’t look at any of the notes that had been taken. The policeman was trying to wind me up. I was so pissed off, I just said ‘yeah, whatever’ and sat down. They knew I had a mental illness as my mum phoned the hospital before she phoned the police. I was interviewed and put in a cell for four days. When I went to court the solicitor explained about my condition. One of the first things they said was that they needed a psychiatric report. Then the judge said I should be in hospital but there weren’t any secure beds so I went straight to Scrubs.

“When I got there I was very unwell but I didn’t know I was so I told them I didn’t have a mental illness and they put me on a general prison wing. They did put me in a single cell so I guess they had my [medical] notes. On my first day someone took the TV out of my cell. I thought to myself they’ll take anything, so I sat in my cell for two weeks. For those two weeks I was probably getting worse, more unwell. No one noticed, they [the prison] haven’t got the staff to notice.”

After throwing a chair and wardens intervening because his behaviour became so erratic, Smith was put in the hospital wing of the prison but was soon transferred back into the general prison population.

He reacted by throwing a chair.

“I spent the last two months in the general wing. I was well then. I talked to staff a lot. They were good to me. When I’m well I’m very polite so I was no trouble.”

Smith says that most of all he felt unlistened to, as if what he was going through was misinterpreted and that the prison wasn’t equipped to deal with his problems. He decided to write to a judge to see if he could get his point of view across.

“I wanted the judge to know what happened from my point of view. I felt I hadn’t been heard in court,” he explains. “Everyone talked about me and not to me. I wanted to say I was sorry. My case came up again and the judge said that I had clearly stabilised, I understood what had happened and that I had already served the time I would have done on a guilty plea while waiting for a bed in a secure hospital so I could go.”

Prison life is simply not the right environment for people like himself, Smith believes.

“If you can handle yourself when in prison you’re OK, if not it’s all over,” he says. “I managed but I met guys who came in after me and they tried to commit suicide or burn down their cells. It’s a 23-hour lock down. I spent most of my time pacing in my cell. I can still remember the pattern my pacing took, the same one over and over again. I never want to go back. I’m doing everything in my power not to go back. I’m keeping myself busy.”

Filed under: Other Mental Health, Violence, psychosis , mental health, prisons, schizoaffective disorder

Adolescents At Risk Of Developing Psychosis Benefit From Early And Network-Oriented Care

Date: 15 May 2009 – 3:00

Family and network oriented, stress-reducing care improves level of overall functioning and mental health in adolescents at risk of developing psychosis, suggests a recent Finnish study. Jorvi Early psychosis Recognition and Intervention (JERI) project at Helsinki University Central Hospital (HUCH), Jorvi Hospital, Finland, is a project with an early intervention team for adolescents at risk of developing first-episode psychosis. As developing psychosis has been suggested to be a result of a combination of acute life stressors and trait-like vulnerability to psychosis, the intervention is based on the idea of multiprofessional, need-adapted, community-, family- and network-oriented, stress-reducing, overall functioning supporting and low-threshold care. The JERI team meets with adolescents at ages 12-20 in their natural surroundings, e.g. at school or at home, together with their parents and community co-worker, who has originally contacted the JERI team because of unclear mental health problems. The aim of the team is to recognize potential risk cases and reduce the stress level by family and network intervention. A follow-up study was performed to test how presented intervention will help adolescents at risk. Data was collected between January 2007 and May 2008. During the intervention, mean scores rose statistically significantly on overall functioning and scores on quality of life, depression, anxiety and pre-psychotic symptoms decreased statistically significantly, showing an improvement in overall functioning and mental health in adolescents at risk of developing first-episode psychosis. Adolescents did not receive other therapy or any antipsychotic medication. “JERI- intervention seems to improve level of overall functioning and support mental health in adolescents at risk of developing first-episode psychosis, even though further study with larger number of subjects, with a proper control group and with a longer follow-up time is needed”, says Dr. Niklas Granö, the leader of the research.

Results are published in the journal Early Intervention in Psychiatry. Reference: Niklas Granö, Marjaana Karjalainen, Jukka Anto, Arja Itkonen,Virve Edlund and Mikko Roine: An intervention to improve level of overall functioning and mental condition of adolescents at high risk of developing first-episode psychosis in Finland. Early Intervention in Psychiatry (2009; 3: 94-98) Source: Niklas Grano, Ph.D. University of Helsinki

Filed under: Other Mental Health, psychosis , early intervention, family, psychosis, stress, young people

Hollow Mask Illusion Fails To Fool Schizophrenia Patients

ScienceDaily (Apr. 17, 2009) — Patients with schizophrenia are able to correctly see through an illusion known as the ‘hollow mask’ illusion, probably because their brain disconnects ‘what the eyes see’ from what ‘the brain thinks it is seeing’, according to a joint UK and German study published in the journal NeuroImage. The findings shed light on why cannabis users may also be less deceived by the illusion whilst on the drug.
People with schizophrenia, a mental illness affecting about one per cent of the population, are known to be immune to certain vision illusions. The latest study confirms that patients with schizophrenia are not fooled by the ‘hollow mask’ illusion, and that this may relate to a difference in the way two parts of their brains communicate with each other – the ‘bottom-up’ process of collecting incoming visual information from the eyes, and the ‘top-down’ process of interpreting this information.

Illusions occur when the brain interprets incoming sensory information on the basis of its context and a person’s previous experience, so called top-down processing. Sometimes this process can mean that people’s perception of an object is quite different to reality – a phenomenon often exploited by magicians. The new study, by scientists at the Hannover Medical School in Germany and UCL Institute of Cognitive Neuroscience in the UK, suggests that patients with schizophrenia rely considerably less on top-down processing during perception.

The study used a variation on the three-dimensional ‘hollow mask’ illusion. In this illusion, a hollow mask of a face (pointing inwards, or concave) appears as a normal face (pointing outwards, or convex). During the experiment, 3D normal faces and hollow faces were shown to patients with schizophrenia and control volunteers while they lay inside an fMRI brain scanner, which monitored their brain responses.

As expected, all 16 control volunteers perceived the hollow mask as a normal face – mis-categorising the illusion faces 99 percent of the time. By contrast, all 13 patients with schizophrenia could routinely distinguish between hollow and normal faces, with an average of only six percent mis-categorisation errors for illusion faces.

The results of the brain imaging analysis suggested that in the healthy volunteers, connectivity between two parts of the brain, the parietal cortex involved in top-down control, particularly spatial attention, and the lateral occipital cortex involved in bottom-up processing of visual information, increased when the hollow faces were presented. In the patients with schizophrenia, this connectivity change did not occur. These results suggest that patients with schizophrenia have difficulty coordinating responses between different brain areas, also known as ‘dysconnectivity’, and that this may contribute to their immunity to visual illusions. The research group is now investigating dysconnectivity in schizophrenia further, which will hopefully advance our understanding of this disorder.

Danai Dima, Hannover Medical School, says: “The term ‘schizophrenia’ was coined almost a century ago to mean the splitting of different mental domains, but the idea has now shifted more towards connectivity between brain areas. The prevailing theory is that perception principally comprises three components: firstly, sensory input (bottom-up); secondly, the internal production of concepts (top-down); and thirdly, a control (a ‘censor’ component), which covers interaction between the two first components. Our study provides further evidence of ‘dysconnectivity’ between these components in the brains of people with schizophrenia.”

Dr Jonathan Roiser, UCL Institute of Cognitive Neuroscience, says: “Our findings also shed light on studies of visual illusions which have used psychomimetics – drugs that mimic the symptoms of psychosis. Studies using natural or synthetic tetrahydrocannabinol (THC), the ingredient of cannabis resin responsible for its psychotic-like effects, have found that people under the influence of cannabis are also less deceived by the hollow mask illusion. It may be that THC causes a temporary “disconnection” between brain areas, similar to that seen in patients with schizophrenia, though this hypothesis needs to be tested in further research.”

Journal reference:

1. Dima et al. Understanding why patients with schizophrenia do not perceive the hollow-mask illusion using dynamic causal modelling. NeuroImage, 2009; DOI: 10.1016/j.neuroimage.2009.03.033

Adapted from materials provided by University College London.

Filed under: Other Mental Health, psychosis , Schizophrenia, illusion, perception, top-down, bottom-up, cannabis

Prozac, used by 40m people, does not work say scientists

I am posting this because on a recent course on responding to suicidal behaviour, I suggested that fluoxetine (Prozac), paroxetine (Seroxat), venlafaxine (Effexor) and nefazodone (Serzone) were far less effective than previously thought. One participant asked about the evidence, so here it is. happy reading! Iain Bourne

Analysis of unseen trials and other data concludes it is no better than placebo

Prozac, the bestselling antidepressant taken by 40 million people worldwide, does not work and nor do similar drugs in the same class, according to a major review released today.

The study examined all available data on the drugs, including results from clinical trials that the manufacturers chose not to publish at the time. The trials compared the effect on patients taking the drugs with those given a placebo or sugar pill.

When all the data was pulled together, it appeared that patients had improved – but those on placebo improved just as much as those on the drugs.

The only exception is in the most severely depressed patients, according to the authors – Prof Irving Kirsch from the department of psychology at Hull University and colleagues in the US and Canada. But that is probably because the placebo stopped working so well, they say, rather than the drugs having worked better.

“Given these results, there seems little reason to prescribe antidepressant medication to any but the most severely depressed patients, unless alternative treatments have failed,” says Kirsch. “This study raises serious issues that need to be addressed surrounding drug licensing and how drug trial data is reported.”

The paper, published today in the journal PLoS (Public Library of Science) Medicine, is likely to have a significant impact on the prescribing of the drugs. The National Institute for Health and Clinical Excellence (Nice) already recommends that counselling should be tried before doctors prescribe antidepressants. Kirsch, who was one of the consultants for the guidelines, says the new analysis “would suggest that the prescription of antidepressant medications might be restricted even more”.

The review breaks new ground because Kirsch and his colleagues have obtained for the first time what they believe is a full set of trial data for four antidepressants.

They requested the full data under freedom of information rules from the Food and Drug Administration, which licenses medicines in the US and requires all data when it makes a decision.

The pattern they saw from the trial results of fluoxetine (Prozac), paroxetine (Seroxat), venlafaxine (Effexor) and nefazodone (Serzone) was consistent. “Using complete data sets (including unpublished data) and a substantially larger data set of this type than has been previously reported, we find the overall effect of new-generation antidepressant medication is below recommended criteria for clinical significance,” they write.

Two more frequently prescribed antidepressants were omitted from the study because scientists were unable to obtain all the data.

Concerns have been raised in recent years about the side-effects of this class of antidepressant. Evidence that they could prompt some young people to consider suicide led to a warning to doctors not to prescribe them for the under-18s – with the exception of Prozac, which was considered more effective than the rest.

In adults, however, the depression-beating benefits were thought to outweigh the risks. Since its launch in the US in 1988, some 40 million people have taken Prozac, earning tens of billions of dollars for the manufacturer, Eli Lilly. Although the patent lapsed in 2001, fluoxetine continues to make the company money – it is now the active ingredient in Sarafem, a pill sold by Lilly for premenstrual syndrome.

Eli Lilly was defiant last night. “Extensive scientific and medical experience has demonstrated that fluoxetine is an effective antidepressant,” it said in a statement. “Since its discovery in 1972, fluoxetine has become one of the world’s most-studied medicines. Lilly is proud of the difference fluoxetine has made to millions of people living with depression.”

A spokesman for GlaxoSmithKline, which makes Seroxat, said the authors had failed to acknowledge the “very positive” benefits of the treatment and their conclusions were “at odds with what has been seen in actual clinical practice”.

He added: “This analysis has only examined a small subset of the total data available while regulatory bodies around the world have conducted extensive reviews and evaluations of all the data available, and this one study should not be used to cause unnecessary alarm and concern for patients.”

Filed under: Impact Training, Other Mental Health, Suicide, psychosis , anti-depressants, fluxetine, prozac

New Imaging Research Reveals Dysfunction In The Brain’s “Hub” In The Earliest Stages Of Schizophrenia

Although the following article is not new, I’m putting it up in response to some enquiries relating to the thalamus and hallucinations. Happy reading! Iain Bourne

ScienceDaily (Jan. 1, 2001) — A new brain imaging study from the Institute of Psychiatry shows for the first time that the thalamus, the brain’s main sensory filter or ‘hub’, is smaller than normal from the earliest stages of schizophrenia. The findings, published in the American Journal of Psychiatry in January, may explain why people with schizophrenia experience confusion during their illness. The thalamus is the area where information is received and relayed to other areas of the brain. It is of particular interest in schizophrenia because of the role it plays in processing information. The thalamus receives information via the senses, which is then filtered and passed to the correct regions of the brain for processing. People with schizophrenia often have difficulties in processing information properly and as a result may end up with an information overload in some areas of the brain. This study, led by Dr Tonmoy Sharma, involved 67 participants: 38 were experiencing their first episode of psychosis and 29 were healthy volunteers. In contrast to other studies, thirteen of the people with schizophrenia had no or little experience of antipsychotic medication. Magnetic resonance imaging (MRI) scans identified differences in the thalamus between the two groups. Previous MRI studies have identified several brain regions affected by schizophrenia, but the results in the thalamus have been inconclusive. This study finds that even in the earliest stages of schizophrenia the thalamus is smaller than in healthy people. Dr Tonmoy Sharma said: “This study reveals that there is a fundamental problem in the hub of the brain. If you think of the brain in terms of networks, it is like making a phone call when the line is not connected properly, the call can’t be made, or you may get through to the wrong person. It is the same in the brain. If there are problems with the connections, information will not be passed to the correct regions. The ability to filter and process information is vital for leading a normal life.” These findings, along with a recent study from Dr Sharma’s team that showed people with schizophrenia have decreased grey matter at the earliest stages of the illness suggest a role for brain imaging in pinpointing warning signs of the illness and even preventing its development.

Filed under: Impact Training, Other Mental Health, Violence, psychosis

I talk back to the voices in my head

* Dean Smith * The Guardian, Saturday 4 April 2009

Dean Smith Dean Smith of Stockport who has suffered from schizophrenia.

I was working as a holiday rep in Brittany 15 years ago when I started hearing voices. I was in my mid-20s and thought it was my mates mucking about. I looked inside and outside the flat to see where they were. It felt really scary, because the voices were saying stuff like, “Right, you’re having it” and, “We’ll get you in the end.” Over the next four days, the voices taunted me more and more, and I became depressed and paranoid. I had a strong desire to be with my family – I had no money, but I got back to my mum and dad’s house in Stockport by hitchhiking and dodging fares. The train journey was particularly harrowing: the voices convinced me everyone was talking about me. My family were brilliant. My mum used to care for my auntie, who had mental health issues, so she had some insight, and my dad was very patient with me. My visits to the GP were less successful – I was put on antidepressants and, when they didn’t work, antipsychotics. They didn’t work either, and by now I was regularly hearing three, one laughing in a wicked kind of way, the other two using abusive and threatening language. The voices got me down so much that I started self-harming. I wound up getting sectioned several times. I was put on heavy medication and encouraged to spend my days playing games with the other patients – anything to distract the voices. Each time, I’d come out being a fantastic Scrabble or blackjack player, but none the wiser about the voices. Ten years ago, at 29, I was told I had paranoid schizophrenia. Friends – well, people I thought were friends – immediately associated the diagnosis with knife-wielding murderers. A lot of them stopped having anything to do with me. I realised I’d been given a label that comes with a huge stigma and a prescription of potent, but in my case useless, medication. I remained keen to find out about innovative treatments, and finally, at a mental health seminar, I heard a speaker talk about an approach advocated by growing numbers of mental health professionals that involves people engaging with the voices inside their head. He was from the Hearing Voices Network and I agreed to visit him. He said I should be frank and uncompromising with the voices. If they told me to self-harm, I should just say no. “If anyone else told you to put your finger in the fire, you wouldn’t, so why act on what they say?” he said. He added that if I wanted to know why they were there, I should ask them, and if I wanted them to go away, I should tell them. It was so simple, but it made so much sense. I took his advice, questioning them, challenging them and even cutting them off if I didn’t have time to talk to them. I’d say things like, “I’m watching TV now, I’ll talk to you later” or “Why exactly do you think I deserve it when bad things happen to me? You can’t answer that, can you?” Sometimes I’d do it in my head; other times out loud. I began to recognise the voices as representing the negative feelings I had about myself, and that alone helped me feel less frightened of them. It’s not that they aren’t real, but they ceased to have the power over me they did. I began to realise they couldn’t carry out their threats. Now they bother me a lot less and, when they do, I’m in control of the conversations. I’ll still talk out loud to them if I feel like it, even if I’m on the bus or in the street. I get some funny looks, but I don’t mind. Recently another voice appeared, but this one is positive and happy, sounding like me as a young teenager. He’s mischievous, but funny, and I quite enjoy chatting with him. I’m off medication now and have been discharged from mental health services. I’ve got my own place and have a girlfriend, and I train nurses and mental health staff in helping others to engage with their voices. The fact that I can speak with genuine understanding means I usually have a captive audience. I also work with people who hear voices, getting them to understand the benefits of talking back. I’ve learned that my voices themselves are not a problem. It’s my relationship with them that’s important. Facing them and working with them has changed my life and made me feel optimistic about it instead of scared. • Do you have an experience to share? Email experience@guardian.co.uk

Filed under: Other Mental Health, psychosis , hallucinations, Hearing Voices Network, Schizophrenia, voices

Mental illness alone is no trigger for violence

Mental illness alone is no trigger for violence
- February 02, 2009

CHICAGO – A new large study challenges the idea that mental illness alone is a leading cause of violence. Researchers instead blame a combination of factors, specifically substance abuse and a history of violent acts, that drives up the danger when combined with mental illness in what they call an “intricate link.”

People with serious mental illness, without other big risk factors, are no more violent than most people, according to the study of more than 34,000 U.S. adults. The research was released Monday in Archives of General Psychiatry.

“Mental illness can provide the knee-jerk explanation for the Virginia Tech shootings,” but it’s not a strong predictor of violence by itself, said lead author Eric Elbogen of the University of North Carolina at Chapel Hill School of Medicine.

Elbogen compiled a “top 10″ list of things that predict violent behavior, based on the analysis.

Younger age topped the list. History of violence came next, followed by male gender, history of juvenile detention, divorce or separation in the past year, history of physical abuse, parental criminal history and unemployment in the past year. Rounding out the list were severe mental illness with substance abuse and being a crime victim in the past year.

After the 2007 Virginia Tech killings by a student ordered to get psychiatric treatment, some states considered laws adding mental health questions to background checks for gun buyers or denying weapons to people who’ve been involuntarily committed for mental health treatment.

The new research, which bolsters other similar findings, raises questions about such laws, experts said. Such legislation may be both ineffective and discourage people who need help from getting treatment.

“We are being misled by our own fears,” said Columbia University psychiatry professor Dr. Paul Appelbaum, who wasn’t involved in the new study. “We ought to be concerned about providing good treatment and helping people lead fulfilling lives, not obsessed with protecting ourselves from phantom threats that appear to be unrelated to mental illness.”

U.S. systems to treat mental illness and substance abuse are separate, uncoordinated and could do a better job treating people with both problems, Appelbaum said.

For the new study, the researchers analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions. The original survey in 2001-2002 involved more than 43,000 face-to-face interviews with a representative sample of American adults. Three years later, many of the same people, more than 34,000, were interviewed again.

Questions about violence in both interviews included:

-”Ever use a weapon like a stick, knife or gun in a fight?”

-”Ever hit someone so hard that you injured them or they had to see a doctor?”

-”Ever start a fire on purpose to destroy someone’s property or just to see it burn?”

-”Ever force someone to have sex with you against their will?”

From the responses, the researchers determined what elements raised the risk of violent behavior.

There were 3,089 people deemed to have severe mental illness – schizophrenia, bipolar disorder and major depression – but no history of either violence or substance abuse. They reported very few violent acts, about 50, between interviews.

But when mental illness was combined with a history of violence and a history of substance abuse, as in about 1,600 people, the risk of future violence increased by a factor of 10.

The relationship between mental illness and violence is there, “but it’s not as strong as people think,” Elbogen said.

Predicting who will act violently is complex, said John Monahan, a psychologist at University of Virginia’s law school, who has done similar research but was not involved in the new study.

“It is true that our crystal balls are very murky,” Monahan said. “The vast majority of violence that occurs in American society has absolutely nothing to do with mental illness.”

The large national survey, conducted by the National Institute on Alcohol Abuse and Alcoholism, included people living in shelters, hotels and group homes, as well as houses and apartments, but it didn’t include people living in hospitals, jails or prisons.

Rosanna Esposito of the nonprofit Treatment Advocacy Center in Arlington, Va., applauded the study but pointed out the researchers weren’t able to analyze whether the subjects were in psychiatric treatment or not. Medication for serious mental illness can reduce the risk of violence, she said.

On the Net:

Archives of General Psychiatry: http://www.archgenpsychiatry.com

Copyright 2009 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

Filed under: Violence, psychosis

Schizophrenia is the modern leprosy

Sathnam Sanghera Three charities have teamed up to tackle what they call “the social justice issue of the 21st century” – mental illness. About time too.Some might sneer at the multimillion-pound Time to Change campaign for using celebrities – such as Stephen Fry, who was diagnosed with bipolar disorder at 37, but in my view anything, up to and including the use of Alastair Campbell in advertising material (“I said to Tony Blair, you do know about my breakdown, don’t you?”), is welcome if it encourages more open discussion of mental ill health.

However, as someone with a parent and sibling who suffer from schizophrenia, the most severe of all psychiatric illnesses, I am concerned about the campaign. In its glitzy efforts to show that mental illness need be no bar to becoming rich and famous, and in its enthusiasm to tackle some of the myths surrounding the subject, it glosses over the harrowing effects of more serious psychiatric conditions and creates a myth of its own – that all mental illness is the same.

At the heart of this problem lies the claim that “mental health problems affect one in four people”, a statistic that encompasses conditions ranging from anxiety to depression and schizophrenia. Each of these conditions can, of course, destroy lives. But what do anxiety or mild depression have in common with schizophrenia? Not much, I would argue. Three of the six generalisations in Time to Change’s “myth-busting” Tube adverts don’t apply to schizophrenia.

The campaign, for instance, claims it is a “fact” that “people with mental illness can and do recover”, which may be true of types of depression but isn’t necessarily the case with severe mental illnesses. What happens to people with schizophrenia varies greatly according to sex, age at its onset, the speed of onset, awareness of the illness and initial response to medication. But basically it is a lifelong condition with no cure. Only a tiny number of people have a single episode and then live their lives without medication.

The campaign also claims as a myth that “people with mental illness are violent and unpredictable” and that “people with mental illness are more likely to be a victim of violence”. Again, this is true for depression, but one of the many tragedies of schizophrenia is that sufferers are as much a risk to themselves as to others: between 10 and 15 per cent of sufferers take their own lives.

As E. Fuller Torrey, a leading US psychiatrist, has explained in The Wall Street Journal: “To be precise, mentally ill individuals who are taking medication to control the symptoms of their illness are not more dangerous. But on any given day, approximately half of severely mentally ill individuals are not taking medication. The evidence is clear that a portion of these individuals are significantly more dangerous.”

Then there is the assertion that people are wrong if they think they don’t “know anyone with a mental illness” and that “someone you know or love has experienced mental illness”. In this case, my objection is not that the generalisation doesn’t apply to schizophrenia, which affects 1 in 100 people, but that the silence surrounding the disease is much more profound and intense.

In my reading on the subject, I have been struck by how commonly friends and family members abandon sufferers because the symptoms – which can include hearing voices, feeling that your thoughts are being broadcast to the outside world, feeling that things are crawling beneath the skin, and believing an alien force is directing you – are so terrifying that people don’t know what to do and end up running away. Indeed, it was not until my mid-twenties that I confronted the reality of my father’s and sister’s schizophrenia.

Schizophrenia really is the modern equivalent of leprosy. I have counselled friends through depression and, as shattering as the effects have been on them, they do not compare to what schizophrenia has done to my family. My father is a gentle and kind man and has been stable for a long time. But he had to live through decades of violent breakdowns, suicidal episodes, a period of imprisonment, endless firings from jobs due to erratic behaviour, and unexplained domestic violence before he got there. And this is what accounts of family lives blighted by schizophrenia are like: the painful narrative keeps lurching forward bleakly until the medication starts working or someone – usually the sufferer – dies.

Pain isn’t relative, of course, but, frankly, even Stephen Fry’s difficult experience of manic depression doesn’t compare. He at least has had the choice of not taking medication, whereas sufferers of schizophrenia don’t, and his symptoms have been such that he has managed to garner the nation’s sympathy, whereas I can’t recall the last time anyone stood up to defend someone with schizophrenia in public, if, as a result of involuntary symptoms, they committed an act of violence.

The Time To Change campaign is doing something noble in pointing out that mental illness needn’t be a bar to personal achievement. But in its implication that all mental illness can be overcome, it trivialises more severe diseases and diminishes the harrowing experiences of sufferers.

Smoking and Schizophrenia: Self-medication?

Recently on a Difficult, Disturbing and Dangerous Behaviour course I was asked about a comment I made regarding the self-medicating aspects of smoking among patients suffering from schizophrenia. I thought that the following from:

http://www.mentalhealthcare.org.uk/research/expanded/index.php?id=21

may be of interest.

Happy reading

Iain Bourne (impact@dangerousbehaviour.com)

www.dangerousbehaiour.com

Smoking in schizophrenia – an attempt to self medicate?

3rd November 2005 | schizophrenia and psychosis

Just over one quarter of the UK population are smokers. In people with schizophrenia the rate of smoking is thought to be between two and four times higher. In addition, smokers with schizophrenia smoke more cigarettes per day and smoke stronger brands than other smokers.

Various theories have been put forward as to why so many people with schizophrenia smoke. It is thought that nicotine acts as a form of ‘self-medication’ for people with schizophrenia, producing a number of beneficial effects despite the negative impact of smoking on long term health.

Dr Veena Kumari and colleagues from the Institute of Psychiatry investigated the self-medication theory, examining evidence from previous research studies. Their findings are described below.

Symptom reduction

Many smokers with schizophrenia report that smoking helps to reduce their symptoms. This has been confirmed by studies showing that smoking is related to a reduction in the negative symptoms of schizophrenia, such as lack of motivation and social withdrawal. It is thought that this effect is caused by nicotine’s ability to raise dopamine levels in areas of the brain involved in attention and engaging with one’s surroundings. Atypical antipsychotic drugs that produce a reduction in negative symptoms, including Clozapine, are thought to act in a similar way.

However, there is no evidence that nicotine has any effect on the positive symptoms of schizophrenia such as hallucinations and delusions and if nicotine is withdrawn from smokers with schizophrenia there is no increase in these symptoms.

Reduction of medication side effects

There is also evidence that smoking may reduce the unpleasant side effects of antipsychotic medication including stiffness and rigidity of movement. Again, this effect is though to be produced by the action of nicotine stimulating dopamine release in the brain.

Nicotine has also been found to counteract the adverse side-effects of certain antipsychotics on some kinds of mental function. A study of patients taking the drug haloperidol who were given nicotine skin patches found them to be less affected by side effects such as the slowing of thought and reduction of attention span.

Improvements in attention and working memory

The areas of the brain thought to be involved in working memory, attention span and motivation have large numbers of receptors for the nicotine molecule. Experiments have shown that nicotine improves these functions both in smokers with schizophrenia and non smoking people with no mental illness. However, in general, people with schizophrenia show greater improvements than the general population. This suggests that there may be genetic differences that determine the extent to which a person will be affected by the effects of nicotine.

Given the negative effects of smoking on health, including greatly increased risk of heart disease and cancer, Dr Kumari believes there is an urgent need for treatments that provide the benefits of nicotine without the risks to long term health. Drugs are being developed that have a similar action to nicotine but these have not yet been tested on people with schizophrenia. Dr Kumari predicts that when these new treatments are available they will not only provide a valuable new way of treating the illness but also offer an alternative for the many people with schizophrenia who put their health at risk by smoking.

Filed under: Impact Training, psychosis , Schizophrenia, self-medication, smoking