The other day I happened upon a 2008 paper by Large, Nielssen, Ryan, and Hayes, entitled “The danger of dangerousness: why we must remove the dangerousness criterion from our mental health acts.” (J Med Ethics 2008;34:877-881). I won’t link to it, as it’s not freely available. However, I will summarise the main arguments as best I can, and then discuss both my agreement and concerns.

The authors’ point is that dangerousness is not a logical, useful, or ethically-sound, criterion on which to base involuntary psychiatric treatment. They then suggest a person’s capacity to consent as a better replacement.

They start with some historical background on the Obligatory Dangerousness Criterion (i.e. not simply that dangerousness can justify involuntary detention and treatment, but that only dangerousness (to self or others, generally) can do so). They then present arguments against the validity and value of an ODC: that the reasoning behind it is flawed, and its effects unhelpful and possibly even harmful.

First they argue that an ODC is unnecessary as a justification for overriding a mentally ill person’s autonomy, because their illness has already robbed them of their autonomy. This is the point at which I began annotating my PDF… it seems to me to be a rather sweeping generalisation to write, as they do:

“In most cases mentally ill people who refuse treatment do so because their mental illness has robbed them of their capacity to consent to that treatment.”

O rly? “most cases”? That’s definitely a statement I would have liked to have seen backed up by a slew of references – especially as it forms the basis of their later suggestion.

Anyway…

They go on to make I think more cogent arguments against an ODC. First they draw a comparison with non-psychiatric situations where a person might be unable to consent to treatment, and make the point that dangerousness is not a part of the decision-making about their treatment.

Second (and deserving its own paragraph), they discuss our inability to be clear about dangerousness in any really reliable way. Even using the best available actuarial tools, in controlled research settings, you see unsupportably-large amounts of misclassification of risk (they cite particularly the MacArthur Study of Mental Disorder and Violence, in which – despite a higher baseline prevalence of risk than one would usually be dealing with, which increases one’s positive predictive value – 29% of the study subjects were misclassified).

And that’s the best case scenario. By a long way. Most studies agree that a psychiatrist has no better ability to predict who will or won’t kill themselves or someone else, than flipping a coin.

So, I agree with these authors: that seriously undermines the justification for an ODC.

Next they take on the utility of an ODC. One might argue on utilitarian grounds that if an ODC is useful, then let’s go with it even if it’s not logically or clinically justified. I wouldn’t, but one might…. However, they discuss some evidence showing that the Duration of Untreated Psychosis is longer (by 5 months) in countries with an ODC compared to countries without – and they say that was not able to be explained by clinical characteristics of the patients, or by the funding or delivery of psychiatric services. The longer the DUP, essentially the worse the clinical outcome for the ill person. They then cite studies showing a statistical correlation between longer DUP and greater risk of violence, suggesting (in an indirect manner, it should be said) that the adverse effects of an ODC (assuming that is in fact what is causing the problems) are not just limited to the person themselves, but also may involve harm to others.

So, an ODC doesn’t make sense, and isn’t useful. But no-one wants to return to just locking up psychiatrically ill people because they’re psychiatrically ill, so what do we use instead? These authors suggest an assessment of capacity:

“Mental health acts should be redrafted so that treatment without consent can be provided to a mentally ill person if and only if:
1. It can be reasonably held by an independent authority that the mentally ill person lacks the capacity to consent to the proposed treatment.
2. It can be reasonably held by an independent authority that the mentally ill person will gain substantial benefit from the proposed treatment, or alternatively, if a proxy decision maker believes that the mentally ill person would have consented to the treatment had he or she the calacrity to do so.
3. The treatment is provided in the least restrictive environment practicable.”

They go on to say that such a change in criteria:

“…would return the fulcrum for compulsion to its proper place. That is, that the mentally ill person has, usually by virtue of their illness, lost the capacity to see themselves as ill, and as in need of treatment.”

And that, I have a problem with. While I agree with the argument against an ODC, I have serious reservations about the use of capacity as a replacement. In practice I think it would mean people would be detained simply for refusing treatment – with their lack of capacity to consent to treatment being assumed, tautologically, by virtue of their refusal of treatment.

Taking a step back from the practical reality, this also requires a substantial value judgement about both mental illness and the available treatments, and an assumption that the ill person must necessarily share our adjudged values – or that if they don’t, it must be a reflection of their illness, and warrant involuntary treatment.

I accept that there are established methods for the assessment of capacity, and their (mandatory) use might address my first reservation; however, I’m left with the second, and I’m not sure how to surmount it.

In addition, if we were to allow involuntary treatment of someone who lacks the capacity to consent, then why only in psychiatric illness? Why even specifically in psychiatric illness? Shouldn’t this argument then just represent a call for a “Health Act” allowing involuntary treatment of anyone who lacks capacity to consent to treatment of whatever ailment they have?

Cat … pigeons….

And are we talking passive assent or real informed consent? – And how would we monitor the consent processes in relation to such a “Health Act”?

Sadly, I don’t have any answers. I do think the ODC should go. It’s senseless, and probably either useless or actually harmful. However, I’m unconvinced that capacity to consent is a reasonable replacement, and I can’t think offhand of anything else.

Not an easy thing, figuring out what might constitute a reasonable justification for removing a person’s basic human rights …

According to Dr McFerran, teenagers who listen to heavy metal might be placing themselves at risk for depression, anxiety, and suicide:

“Examples of this are when someone listens to the same song or album of heavy metal music over and over again and doesn’t listen to anything else. They do this to isolate themselves or escape from reality.

“If this behavior continues over a period of time then it might indicate that this young person is suffering from depression or anxiety, and at worst, might suggest suicidal tendencies.”

Ummm… Haven’t we been here before?

Oh noes! The metal brootalz! Won’t someone think of the children?!

Ok, having convincingly declared my bias…

In none of the “articles” about this (all of which – other than the above-linked from Guitar World – are essentially reprinting the press release, so I won’t even bother linking to them) is there any link to, or even mention of, a paper – published, in press, or even submitted. So, in similar fashion to the moronic “study” about caffeine-induced hallucinations that, incidentally, also came from a university in Melbourne, I cannot look at the actual methods, results, or analysis engaged in by Dr McFerran.

The lack of logic, and the alarmist tone, displayed in the press release however, do not give me cause to think the study would be particularly rigorous, or itself logical.

“The mp3 revolution means that young people are accessing music more than ever before and it’s not uncommon for some to listen to music for seven or eight hours a day,” she said.

… She said. She did. She said.

Let’s deconstruct this and see if it means anything. “Not uncommon” for “some”… to me is saying that “some” people (however many that is) but not others, will “not uncommon”ly (however often that is) listen to music for 7-8 hours a day. It doesn’t tell me who make up that “some”, or what music they’re listening to, or why, or the context … Or indeed anything useful.

And really, what it is designed to say, is not what I take from it; what it is meant to do is create the image of the children (“won’t someone please think of the children?!”) spending too much time listening to music (which is after all the devil’s pastime – unless it’s whatever music Dr McFerran is keen on in the Melbourne Conservatory of Music.

Probably not the metal brootalz.

“Most young people listen to a range of music in positive ways; to block out crowds, to lift their mood or to give them energy when exercising, but young people at risk of depression are more likely to be listening to music, particularly heavy metal music, in a negative way.”

So … Hang on. Back up the metal-bashing bus just a minute.

You’ve just suggested, have you not, that the arrow of causation is the other way? That depressed/anxious/suicidal kids might listen to metal more than do the non-depressed/anxious/suicidal kids? … not that the heavy metal is what’s making them depressed, anxious, and suicidal. They are perhaps seeking solace, support, expression, whatever, in that music.

But that’s a bad thing if it’s heavy metal.

Because, y’know … the brootalz.

Or perhaps it’s just a spurious association. I wonder, how did Dr McFerran arrive at her startling conclusions? Why, by:

“…conducting in-depth interviews with 50 young people aged between 13 and 18, along with a national survey of 1000 young people”

Well hold the phone. That’ll do it for me. Especially without any substantive details (who they selected, how they selected, how they controlled, what they asked…); they might just spoil a good story.

You know, I’m almost surprised there was no mention of satanism and back-masked messages.

I hate, hate, hate this sort of crap: putting out melodramatic press releases with no data, no mention of evidence to back up the sensationalist claims made – and then dutiful churnalists just regurgitate it without a scrap of critical thought.

So. Unless Dr McFerran does produce a good-quality peer-reviewed paper that shows solid evidence to back up what she says, I say: enjoy your metal brootalz. \m/

Crazydelusionalinsanelooneymadman!!!!11!11!eleven!

It was bad enough when people (even PZ Myers, who ought to know better, being a level 20 sceptic with a +10 amulet of rationality) pronounced Breivik “delusional and insane” and a “lunatic” – without any good evidence that is the case. It is both a symptom and cause of the stigma and discrimination the psychiatrically ill face every day, that whenever someone does something appalling that (by its appalling nature) is beyond the comprehension of the rest of us, people start saying “he must be crazy” and variations.

Now, while I am not saying he is definitely not psychiatrically ill, I am saying there is nothing so far evident in his actions or his “manifesto” that really indicates him to be so. He might yet turn out to be psychotic, but at this point we have no evidence to say so.

Particularly, there is no apparent formal thought disorder in what I’ve read of his manifesto. Thought disorder is generally more apparent in writing than speech, and given that English is apparently his second language, any thought disorder ought to be screamingly apparent in his written English. So I think we can say he’s probably not thought disordered.

Is he deluded? Nothing in what he’s written indicates clearly that to be the case. They’re awful ideas, yes, but seriously, if they – by their content, which is all we have to go on – are delusions, then the US Tea Party are all deluded …

… ‘k … Moving on …

Is he hallucinated? I’ve seen no mention of anything to suggest so. No communication from God or Satan or anyone else for example, which you might expect if this were psychotically-driven.

Is he insane? That’s perhaps easier to make an armchair comment on. Most definitions of insanity (a legal term, not a psychiatric one any more) are based on the McNaughton rules, which basically require that the person, to be found insane, be unable – through mental illness, sometimes mental retardation – to understand the nature or moral wrongfulness of their actions. It appears pretty clear that Breivik knew exactly the nature of his actions. Moral wrongfulness? Ok, that’s arguable, but unless his moral compass is askew because of psychosis, it doesn’t make him legally insane; a psychopathic nationalistic hate-filled horror yes … but not insane.

Just a psychopathic nationalistic hate-filled horror.

DOUBLETHINK

Anyway … Then we get the doublethink starting, and while the “crazy” talk bugs me deeply on a professional level, it’s this doublethink that really boggles my mind. I mean really, how do these people walk without falling down?

A good piece in Salon captures a lot of the idiocy. Even though Breivik explicitly espoused the nationalistic, racist, white-supremacist, anti-Islam sentiments of the far right, they have divined, using their amazing powers of divination, that in fact the “problems” that created him and caused this tragedy were… wait for it … Multiculturalism and Islam and such. Even abortion, would you believe?

And people are saying Breivik’s insane?

George Orwell invented a term for this amazing capacity to believe totally contradictory things (such as Glenn Beck saying that a youth politics camp “sounds a little like the Hitler Youth” – despite running a political youth camp himself: DOUBLETHINK – and that’s exactly what these rightwing whackos are displaying: super-Orwellian degrees of doublethink.

Scary as hell. Orwell had it sussed, ladies and germs. This is, indeed, the world of 1984.

Update: Andrew Bolt has actually managed to cram in both of these positions in one post for the Herald-Sun. Wow.

Pleh, I say. And also bah.

First red flag: this is not yet published, but Professor Crowe is giving press releases and interviews to the general media. Not an especially auspicious sign.

So, I can’t check out the details of what was done, including any statistics. I can however comment on what they’ve said in their press release about the experiment:

“The participants were assigned to either a high or a low stress condition and a high or a low caffeine condition on the basis of self-report.”

It gets worse. They didn’t administer caffeine, or even measure intake or serum caffeine levels. Perhaps they asked how many coffees the participants drank, but different types of coffee (brewed, espresso, instant…) differ in their caffeine content, and even with the same sort of coffee, different baristas will give different results (for example, I’d lay good odds there’s a lot more caffeine in one shot from me than in a double shot from almost any cafe in which I’ve observed the barista). There are no details about how they determined whether the person was subject to a high or low stress condition – so we can basically almost discount the stated difference between the groups in the “study”, before we even really begin.

“The participants were then asked to listen to white noise and to report each time they heard Bing Crosby’s rendition of “White Christmas” during the white noise. The song was never played. The results indicated that the interaction of stress and caffeine had a significant effect on the reported frequency of hearing “White Christmas”. The participants with high levels of stress or consumed high levels of caffeine were more likely to hear the song.”

So. Maybe interesting. Not hallucinations though. Not without a lot more detail. At most I suppose we could call them secondary hallucinations (an hallucination triggered by a real perception), but my money’s on illusions/misperceptions. This was done under the guise of a hearing test, and the subjects were led to think White Christmas would be played. Therefore they were listening for it. It is perhaps interesting that (possibly) more highly stressed or caffeinated individuals were more likely to think they heard something, but it expressly does not mean…

“This study also helped to explain the mechanism by which stress may facilitate the symptoms of schizophrenia in non-clinical samples. Caffeine has only recently been reported to increase proneness to hallucinate. ‘The results also support both the diathesis-stress model and the continuum theory of schizophrenia in that stress plays a role in the symptoms of schizophrenia and that everyone, to some degree, can experience these symptoms. This was demonstrated by a significant effect of stress on the occurrence of hallucinatory experiences, or hearing the song.”

Absolute. Rot.

There is no basis – from what has been reported (and only in their press release and news media) – on which to extrapolate illusions when primed to expect a particular experience, to schizophrenia. None. Zip. Nada.

Certainly, stress plays a part in psychotic illness. Certainly it’s plausible to think stimulating the brain might not be the best thing in the world to do, especially if that brain is vulnerable. This wretched (or at best, wretchedly reported) excuse for a study takes us no further than those two basically common-sense statements.

So, go forth and sup your coffee.

I’m disappointed. I’m not surprised, but I’m disappointed. I’m disappointed that in a “mental health package” of 2.2 billion over five years, there is almost nothing aimed at those most in need. In fact I’ll go further: there is absolutely nothing aimed at those most in need, and I’m more than disappointed; while I am remaining calm (because of the lack of surprise, primarily), my feelings about this are pretty much unprintable.

So I’d better stick with my thoughts.

The main thought is quite simple: this will not help. This will not help the most severely ill. This will not help those who do not fall within a particular age band. Thus will not help those who do not have a particular type of disorder.

The bulk of the money (at least of that going into actual clinical service) as I understand is earmarked for the creation of more Headspace, and Early Psychosis Prevention and Intervention Centres (EPPIC). As I have remarked on previously, these services serve only a narrow age band, and the majority of the psychiatrically ill thereby miss out on any increase in resources. Headspace is expressly not set up to treat serious psychiatric illness, so even young people will not be helped by that money if they have a serious illness. EPPIC are aimed, as the name suggests, at psychotic disorders. So young people with a serious but non-psychotic psychiatric illness will not be helped by this extra money.

An abiding characteristic of boutique services like Headspace, and (I admit this is an assumption) EPPIC, is that they are not geared up to treat really acute illness. If someone requires daily input, if they have strong thoughts of suicide or harm to themselves – or others – they will be referred to the acute service of the general mental health service.

People like me.

Working in teams that are chronically under-funded and under-resourced.

Teams that see people of any age, with any disorder, when they are most severely and acutely ill.

Teams that don’t have the luxury of saying no on the basis of age, lack of psychosis – or simply being too sick or too “risky”.

Teams that will see not a red cent from this budget.

Professor Alan Rosen from the Brain Mind Research Institute at Sydney University has written criticising the allocation of this extra funding. He has made similar points, but more gently, and without calling anyone an idiot. So I shall do that:

This. Is. Complete. Idiocy.

There was mention of not putting more money into old systems – that are not working. Fair enough on the face of it. However, allow me to illustrate some of what I face every day. I work in one of the largest and fastest-growing Local Government Areas in the country. It has large amounts of poverty, of alcohol and other drug abuse, and of disability – both medical and psychiatric. Our outpatient psychiatric services however, at half the national average, receive the lowest level of resources, in terms both of dollars and staffing, in the country. If you do that to a service, I can guarantee that no matter your model of service, it will not function well.

We are the ambulance at the bottom of the cliff. And indeed we are the ambulance, despite a huge throng of people milling around at the top and falling off. So unsurprisingly we don’t do as well as we need to. These services like Headspace and EPPIC will contend they are like a fence at the top of the cliff; build a proper fence and you won’t need more ambulances.

Admirable, but bollocks. Actually they just pick out a few of the people farthest away from the cliff and make them a really swish fence – but if they start to get too close to the cliff’s edge, will just tell them to be sure to look for the ambulance at the bottom.

Maybe they’ll call to give the ambulance a heads-up, but that’s about it.

Now I realize that people far more eminent than I (Professor Ian Hickie and Professor Patrick McGorry) have spoken lovingly about this budget and the wondrous things it will do for mental health care in this country. Well … they would, wouldn’t they? Headspace is Prof Hickie’s baby, and EPPIC Prof McGorry’s. Colour me cynical, but I don’t think that’s coincidental.

Severe and Debilitating

Ok, there’s something in the budget for those with severe and debilitating illness. Not acute care though. Look, I don’t take issue with enhancing the recovery care we provide. In fact that’s the whole damn point, but the first step in recovery for many is acute treatment of terrible illness. If you don’t do that right, the rest is most unlikely to succeed; at best it will provide less benefit than it could have.

The stuff about “increasing economic and social participation for people with mental illness” is the same: excellent and necessary, but needs to be able to build on the results of good acute care of serious psychiatric illness. That acute care is under-resources and poorly structured, and this budget will do nothing to change that.

I agree that simply pouring money in is unlikely to give great results. I also agree with Professor Rosen when he notes that:

“… provision of well tested 7 day and night mobile mental health teams, with adaptations for regional populations, has not yet been tried consistently and equitably across this country. One state, Victoria, is an exception, and even the resourcing there is now fraying.

These teams only don’t work where they have never been tried. Or when their resources are withdrawn due to managerial expediency or loss of a clinically informed culture. However, there is little encouragement for public mental health services in this budget, except a pious hope that at the next CoAG meeting, the Commonwealth will be able to convince the states to match this investment.”

The evidence is there, for Assertive Community Treatment teams, for acute care home-based treatment teams, for models of care that would make a very real difference to the lives of those with severe psychiatric illness. This budget commitment is idiotic and superficial, and will do damn-all for the people who really needed more.

Disappointed. Frustrated. Angry.

And really sad.