Compulsory treatment – a life saver?
Patients with first-episode psychosis who go untreated pose a disproportionate threat to themselves and others, according to psychiatrists in Australia. Matthew Large, an independent clinician, and Olav Nielssen at St Vincent’s Hospital in Sydney, say that a more widespread adoption of the UK’s policy on compulsory treatments could save a significant number of lives.
Writing in the journal Social Psychiatry and Psychiatric Epidemiology, Large and Nielssen estimate that the risk of murder by patients diagnosed with psychosis is 20 times higher before they have received treatment compared with afterwards (tinyurl.com/3yu3ga). Yet the present situation in many countries, including the USA, France, and five states in Australia, requires that a patient with psychosis be proven dangerous before treatment can be administered without their consent. By contrast, in the UK and Finland, for example, psychiatrists are able to compel patients to receive treatment without proving their dangerousness, so long as it can be demonstrated that the patient is
incapable of giving informed consent.
Comparing data across eight countries including the UK, Australia and the USA, Large and Nielssen found that the proportion of those with first-episode psychosis who commit murder is much higher in countries where the average delay before treatment is longer.
‘I do think untreated initial psychosis is a singularly dangerous condition,’ Large told The Psychologist. ‘First-episode patients are not well known to services and nor is the effect of their illness on their behaviour, hence the risk is greatest but our ability to predict it lowest. I advocate that there be no legal test for the proof of dangerousness for unconsented treatment in first-episode psychosis.’
The context for this debate is that the overwhelming majority of murders and violent acts are committed by people without mental illness. Yet rare, high-profile cases of people with a mental illness committing violent acts inevitably lead to questions over whether more could be done to prevent similar tragedies occurring in the future.
Matthew Huss of Creighton University in Nebraska has conducted research showing how poor mental health professionals are at predicting who will be violent. He told us compulsory treatment without need to prove dangerousness would significantly intrude on the rights of the mentally ill, lead to a potentially dramatic rise in the need for psychiatric beds, and cause a resulting decrease in the standard of care for an already overly taxed mental health care system. Moreover, he said calls for policy changes regarding compulsory treatment are usually based on this mistaken assumption that mental illness dramatically increases the risk for violence.
‘A colleague of mine is about to submit a manuscript for publication that suggests it is not mental illness per se, but factors associated with those who are mentally ill (e.g. low socio-economic status, unemployment) that are related to increased risk of violence,’ Huss said.
‘A better strategy may be to target prevention efforts at those variables that are more causally related to increased risk for violence, instead of increasing the risk to the civil liberties of the mentally ill and overburdening an already limited mental health care system.’
Elsewhere there are further signs that experts are far from reaching a consensus on whether mental illness is associated with increased risk of violence. The February issue of Psychiatric Services is a special issue in which E. Fuller Torrey, founder of the Treatment Advocacy Centre in Virginia, and Jonathan Stanley, debate with the authors of the 1998 MacArthur Study – a classic paper often cited as showing that mentally ill patients are no more dangerous than the general public (tinyurl.com/3al7uo).
Crucially, the MacArthur study does not speak to the issues raised by Large and Nielssen as it did not feature any first-episode patients. ‘I agree treated patients are, on average, not much more dangerous than the general community,’ Large said. ‘In New South Wales, the community risk of murder is 1 in 50,000. Previously treated patients may have a risk of 1 in 10,000 – only a small increase really as rates are so low. By contrast, first-episode patients have a risk in the order of one in 500 prior to treatment.’ Responding to Huss’s concerns, Large said: ‘Mental health systems are underresourced in the USA – no doubt – it takes an average of a year and half to get treatment in the USA; in the UK it is only 30 weeks. This is my point.’ CJ
Launched in March, an innovative scheme will match-make UK scientists with communities in the developing world facing particular problems .
Established as a not-for-profit organisation, ‘Science for Humanity’ will bring together scientists, international development agencies like Practical Action, and local social enterprises to develop workable and sustainable science-based solutions to specific problems in developing world communities.
The idea for Science for Humanity was originally conceived by Baroness Susan Greenfield while researching her latest book. She said: ‘I was inspired by how the innovative use of science could help people in poverty and wanted to ensure that scientists could meaningfully engage with the right people and organisations to make that happen.’
Scientists who would like to get involved or who think their research could have broader applications in the developing world are encouraged to sign up at www.scienceforhumanity.net
The angry elephant in the room
Dr Andrew McCulloch, Chief Executive of the Mental Health Foundation (MHF), has dubbed problem anger ‘the elephant in the room in mental health’. His comments came as the MHF published a report, Boiling Point, calling for a meta-analysis of anger interventions, and a comprehensive evaluation of local anger management resources.
Published in March, the report argues that anger is linked with poor health and can devastate relationships. New survey data reportedly show that nearly two thirds of those interviewed believe people are ‘getting angrier’, almost a third know someone with an anger problem, and one in ten say they have trouble controlling their own anger. Meanwhile GPs interviewed for the report said they had few options for helping patients within the NHS and lacked confidence referring people to voluntary organisations.
An NHS anger management service in Swindon, overseen by Society member Annette Law, was among those existing projects highlighted by the report as an example of good practice. ‘We describe them as evening classes rather than therapy groups. The content is largely anger control, and it’s primarily for
people who operate at a short fuse and get themselves into explosive interactions. It looks at recognising the build-up of anger, and there is some emphasis on relaxation techniques and getting in there early to stop anger reaching exploding point,’ Law says in the report.
Matt Fossey, Deputy Director of Improving Access to Psychological Therapies (IAPS; access their online anger questionnaire at tinyurl.com/3adl97) is also interviewed, and says: ‘Anger is something we looked at when defining anxiety disorders, so if people have an elevated level of anxiety around anger, we will look at that within the clinical set-up.’ However, the Boiling Point report calls on IAPS to go further, stating that ‘Problem anger should not be tackled only as a subset of depression or anxiety.’ CJ
I See www.yourboilingpoint.org.uk. For a self-help guide to controlling anger, see tinyurl.com/2lp4xb
Is happiness overrated?
As the UK government prepares to pump millions of pounds into the treatment of anxiety and depression, the Institute of Psychiatry’s 35th Maudsley Debate, held in March, asked ‘Is Happiness Overrated?’ Christian Jarret reports
Paul Ormerod, an economist, argued that happiness is indeed overrated by pointing to the longitudinal data showing happiness has flat-lined over the decades while income and public expenditure have risen dramatically. It seems that being better off isn’t making us any happier. And rising inequality, as observed in America, apparently isn’t making us any less happy either. ‘These
data series have no meaning whatsoever,’ Ormerod said. ‘It’s very dangerous to base policy on data that seems to contradict common sense.’
Ormerod said we shouldn’t just take his word for it. A new comprehensive review published in the Journal of Economic Psychology concluded recently, on the basis of more than 10,000 studies, that the existing evidence base on well-being is not as strong as some people make out, and certainly not a suitable basis for policy decisions.
Opposing the motion, the ubiquitous economist Lord Layard retorted that Ormerod’s argument was reminiscent of the man who looks for his missing keys under a street lamp, because he says can see more easily there. ‘We shouldn’t decide what we care about based on what is easy to measure,’ Layard explained.
‘My argument is simple,’ Layard continued – ‘happiness matters because most people want to be happy, and most parents want their children to be happy. It’s self-evident that feeling good is important.’ Mental illness is the biggest contributor to misery, Layard argued, and that is why he has campaigned for an expansion of psychological services. And as for the notion that misery has some intrinsic value, Layard said such a view is ‘morally abhorrent’.
Next up, clinical psychologist Rachel Perkins, who has herself been diagnosed with bipolar disorder, seconded the motion by explaining her concerns about a one-size-fits-all approach to mental well-being. ‘We need people who climb mountains, who sail single-handedly across oceans,’ she said. ‘We need people whose anger drives them in their quest for social justice.’
Unbowed by Layard’s views, Perkins then highlighted the link between bipolar disorder and creativity, arguing that the world would be a poorer place without those who have battled depression: Virginia Woolf, Wittgenstein, Robbie Williams, to name but
a few. Feeling depressed is awful, Perkins said, but having been through the experience can make people all the richer for it.
According to Perkins, another psychologist diagnosed with bipolar disorder, Kate Jamison, has said that given the choice, she too would keep her bipolar condition, and that she feels more deeply for having been depressed, and has laughed more for having cried more. ‘Yes, we all need happiness in our lives,’ Perkins concluded, ‘but we need more than that.’
The final speaker, psychiatrist Carmine Pariante, opposed the motion (that happiness is overrated), explaining it was important to draw a distinction between the sadness that we all experience at various times, and the chronic debilitating nature of clinical depression.
Pariante also took the opportunity to slam the recent claims that antidepressant drugs are no more effective than placebo (see the April issue News). He said the widely publicised meta-analysis had found a big difference between drug and placebo effects, it’s just that the authors had judged the difference to be clinically insignificant. ‘But what if that small improvement allows me to get back to work?’ he asked. ‘What if it gives me the energy to wash myself for the first time in two weeks. Is that not clinically significant?’ In conclusion, Pariante said: ‘Happiness is not overrated, depression is underrated… please show you care for people with depression and vote against
Before the arguments were heard, the audience voted against the motion by 145 votes to 84, with 13 abstentions. Ormerod and Perkins persuaded some to change their mind, but not many, with the final votes being 120 against the motion, and 94 for the motion, with 7 abstentions.
The dilemmas of economics, cooperation and punishment
Cooperation in human societies has proved to be something of an evolutionary mystery because of the benefits to be gained by a selfish individual who betrays the group. Threat of punishment has been mooted as one means by which such selfishness can be avoided. But now Martin Nowak at Harvard University and colleagues have used an economic game to show that although the option to punish does increase cooperation, it actually damages profits. This undermines the idea that retribution has evolved to promote group cooperation, and points to instead to reciprocity as the real driver of cooperative behaviour.
Participants played several rounds of The Prisoner’s Dilemma in pairs (see box for details), with the option to cooperate or defect. When a third option to punish was also made available, cooperation increased, yet profits usually suffered. ‘Punishment therefore has no benefit for the group, which makes it hard to argue that punishment might have evolved by group selection,’ the researchers said.
In fact, those players who never punished their partner were the most successful, whereas those players who punished most ended up with the lowest profits. Instead of dishing out punishment, the most successful players dealt with a partner who defected by defecting back, using a tit-for-tat strategy.
Co-author David Rand told The Psychologist that their finding has lessons for real-life situations involving cooperation and collaboration: ‘Say you are working with a colleague on a project, and you feel that this team-mate is not contributing as much as he or she should. Our study suggests that you should also stop contributing, withdraw from the project, and find another partner to work with, as opposed to attacking or threatening your partner in an attempt to get him or her to contribute more. Winners are those who can stay even-headed and not escalate conflicts.’
Writing in the journal Nature (tinyurl.com/2mfell), the researchers said their findings also show that punishment, as a social tool, has evolved for some other purpose than fostering cooperation – perhaps for coercion or establishing dominance hierarchies. They argue it is reciprocity that has driven human cooperation.
David Rand explained: ‘Direct reciprocity involves
my behaviour towards you depending on what you have done to me. If there is a sufficiently high chance of another interaction – which there certainly was in small ancestral communities – then cooperative tit-for-tat strategies are favoured by evolution. Indirect reciprocity involves players having reputations, and my behaviour towards you depends on what you have done to others. If the chance of me knowing how you behaved in the past was high enough (again, which it certainly was in our evolutionary past), then cooperation again is favoured by evolution.’
Coincidentally, researchers based in the UK have also published new findings on the role of punishment in cooperative games. Benedikt Herrmann, at the University of Nottingham, and colleagues, identified striking cultural differences in the way university students played The Public Goods Game (see box).
Across 16 nations, when players had the option to punish, the groups tended to cooperate more, consistent with past research showing that the ability to punish can help foster altruistic behaviour. However, in some countries, such as Saudi Arabia, Oman and Belarus, ‘selfish’ players also showed a tendency to punish cooperative players, perhaps as a means of revenge for punishments they had suffered, or maybe as a way of punishing do-gooders for showing them up. The researchers called this ‘antisocial punishment’, and the groups where this occurred more tended to cooperate less.
Prior research has shown that people in those countries where antisocial punishment occurred more tend to have less faith in the rule of law and less belief in civic cooperation. Writing in the journal Science (tinyurl.com/3488qe), the researchers concluded: ‘The detrimental effects of antisocial punishment on cooperation (and efficiency)…provide a further rationale why modern societies shun revenge and centralise punishment in the hands of the state.’ CJ
Economic games are used by social scientists to investigate how humans interact. ‘Game theoretic models abstract out the essence of very complicated real-life decisions,’ David Rand told us. ‘The Prisoner’s Dilemma captures the conflict between the interests of the individual and the group which runs through all of our social interactions. The simplicity of such games is in fact their main strength.’
The Prisoner’s Dilemma
In the traditional version of the game, two players choose on each round whether to cooperate or defect. If both players cooperate, they each gain. If one player defects and the other cooperates, then only the defector gains. If both players defect, no one gets anything. Martin Nowak and colleagues introduced a third option to punish, which meant that for the cost of one unit to the punisher, the punished lost four units. Nowak’s team found that the most successful players dealt with defectors by defecting back – a tit-for-tat strategy – rather than by punishing.
The Public Goods Game
Anonymous players in groups of four choose how many of their 20 tokens to contribute to the group kitty. The kitty is multiplied by a fixed amount before being distributed equally to all players regardless of how much they contributed. If all players cooperate, for example by contributing the maximum amount, then everyone gains. However, the most lucrative option is to be selfish and freeload on others’ contributions. In some countries, the introduction of the ability to punish drove up cooperation, but in others, players punished the cooperative not just the selfish, which harmed cooperation.
The Ultimatum Game
Played in pairs, the proposer offers a share of a sum to a recipient who must decide whether to accept the offer. If the recipient accepts, the sum is split as proposed; if they reject the offer then neither party gets anything. Many players choose to reject low offers, showing we are willing to punish unfair behaviour even at a cost to ourselves.
Identifying the cuteness response
Researchers have identified a neural correlate of parental instinct. A region in the front of the brain – the medial orbitofrontal cortex (OFC) – responds rapidly to the sight of unfamiliar baby faces but not adult faces. It’s hoped the finding, published in PLoS One, could help detect risk for postnatal depression (tinyurl.com/2p9gha).
Twelve participants were presented with images of baby and adult faces, matched for attractiveness, luminosity and size, for 300ms at a time. To ensure processing of the faces was as automatic as possible, the participants’ actual task was to spot when an on-screen cross changed colour. Meanwhile, Morten Kringelbach and Alan Stein at the University of Oxford and colleagues scanned the participants’ brains using magneto-encephalography, a technique favoured for its high temporal resolution.
Within 130ms of the presentation of a baby face, activity increased in the medial OFC relative to the brain response to an adult face. This was true for both parents and non-parents. The researchers believe this may represent part of the brain basis for what Charles Darwin and Konrad Lorenz recognised as an evolutionary mechanism by which adults are prompted to care for infants.
Kringelbach told us his team hope their finding will offer a way to identify women who are at risk of developing postnatal depression. ‘Our results do not suggest any potential treatment but do suggest that activity in the medial OFC might be used as a potential early marker for those vulnerable to anxiety and postnatal depression. We are currently testing this hypothesis.’
He added: ‘Overall, our findings complement and may potentially enrich our understanding of the functions of the OFC, which is emerging as one of the pivotal brain regions involved in human pleasure and emotion.’
There is a possibility that the OFC response observed here is not specific to baby faces, but related to cuteness in general. For that reason, Kringelbach’s team are also planning a repeat of this study with baby animals versus adult animals. ‘Interestingly, this issue may be linked to why Mickey Mouse has evolved
to become more baby-like as suggested by the late, great evolutionary biologist Steven Jay Gould,’ Kringelbach said.
In a separate but related development, Madoka Noriuchi and colleagues at Tokyo Metropolitan University have used fMRI to identify a swathe of brain areas, including the OFC, that are activated more when mothers look at videos of their own baby versus other people’s babies. John Krystal, Editor of Biological Psychiatry, where the findings are published (tinyurl.com/2mmlcx) said: ‘This type of knowledge provides the beginnings of a scientific understanding
of human maternal behaviour. This could be helpful some day in developing treatments for the many problems and diseases that may adversely affect the mother–infant relationship.’ CJ
OUT NOW in BPS journals
Jon Sutton selects from this month’s offerings
- A desire for fame among the UK public is driven by largely negative factors – a meaning derived through comparison with others in life, a reflection of a vulnerable state, attention seeking or conceitedness. Two other more ambiguous factors, ‘glamour’ and ‘social access’, are described as theoretically and empirically weaker. That’s according to studies by John Maltby (University of Leicester) and his team, who say that as some teenagers are prepared to abandon formal education in pursuit of fame, the development of such a scale among children is important. (BJP)
- A client with schizophrenia is more likely to form a strong group alliance in therapy when there is a high average level of insight within the group, and when the individual has lower autistic preoccupation and social functioning. The authors (David Johnson and colleagues at the University of North Carolina) say there are implications for determining group composition and identifying clients low in therapeutic engagement. (BJCP)
- According to the Common Sense Model of self-regulation, illness generates both cognitive and emotional representations of the nature of the threat, each generating its own behavioural attempts at regulation. In a special issue, various authors use the model to address health problems such as diabetes, asthma and chronic fatigue syndrome (CFS). For example, Vincent Deary (Newcastle University) explains how people with CFS attempt to regulate the threat by operating within a narrow ‘energy budget’, which ultimately becomes self-defeating. He advocates a more explicit switch from avoidance to mindfulness and acceptance of symptoms and distress. (BJHP)
Schools get mental health guidance
New guidance published by the National Institute for Health and Clinical Excellence (NICE) has called on schools to adopt a comprehensive approach to children’s social and emotional well-being. Among its recommendations, the guidance states that ‘schools and local authority children’s services should work closely with child and adolescent mental health and other services to develop and agree local protocols’.
Mental health professionals, including primary mental health workers, are called on to train teachers in how to develop children’s psychological well-being, and how to recognise when children are experiencing anxiety, emotional distress or behavioural problems. Interventions using a stepped-care approach should then be made available to children showing persistent signs of emotional or social difficulties, the guidance states. These should include problem-focused group sessions for the children and their parents, delivered by specialists such as educational psychologists.
The guidance also outlines research questions that need to be addressed, including establishing how social and emotional well-being should be measured, and identifying the most cost-effective interventions for improving the social and emotional well-being of children.
Health psychologist professor Susan Michie, of the BPS Centre for Outcomes Research & Effectiveness at University College London, was among the experts advising NICE on this new guidance. CJ
- See tinyurl.com/2sp9o7
From the Research Digest…
Blobs on the brain
The media love those colourful brain images – the ones adorned by blobs purportedly showing which areas are most active when the experimental participant is thinking about something specific like cheese on toast. Now researchers in America have shown just how persuasive these images can be.
David McCabe at Colorado State University and Alan Castel at the University of California presented university students with 300-word news stories about fictional cognitive research findings that were based on flawed scientific reasoning. For example, one story claimed that watching TV was linked to maths ability, based on the fact that both TV viewing and maths activate the temporal lobe. Crucially, students rated these stories to be more scientifically sound when they were accompanied by a brain image, compared with when the equivalent data were presented in a bar chart, or when there was no graphical illustration at all.
McCabe and Castel also repeated the experiment with a control condition featuring a topographical activation map – it's just as visually complex as a brain image but it doesn't look like a brain. These stories were rated as more credible when accompanied by a brain image compared with a topographical map, showing that the allure of brain images is not merely down to their complexity.
A final study used a real-life news story taken from the BBC: ‘Brain scans can detect criminals’. This time the students were more likely to agree with the conclusions of the news report when it was accompanied by a picture of the brain. Writing in the journal Cognition (tinyurl.com/5z3xoe), McCabe and Castel said their results show people have a ‘natural affinity for reductionistic explanations of cognitive phenomena, such that physical representations of cognitive processes, like brain images, are more satisfying, or more credible, than more abstract representations, like tables or bar graphs.’
The new findings follow earlier research showing that the mere mention of cognitive neuroscience data leads people to judge scientific findings to be of higher quality (see News, August 2007, and tinyurl.com/6qhonw).
This item originally appeared in the Society’s free Research Digest.
For more and to sign up, see www.researchdigest.org.uk/blog
Making the mind up
Artificial simulation of the human mind has come a step closer with reports that a computer character has been programmed that is capable of passing the classic false belief task of developmental psychology. While the MIT-built robot Leonardo achieved the feat last year, this is reportedly the first time that a computer character has demonstrated the skill.
The false belief test is designed to reveal whether children have developed the ability to represent the perspective of others – what psychologists call having a theory of mind. Selmer Bringsjord and colleagues at the Rensselaer Polytechnic Institute say they have programmed the character ‘Eddie’ to pass the test. ‘Our aim is not to construct a computational theory that explains and predicts actual human behaviour,’ says Bringsjord, ‘but rather to build artificial agents made more interesting and useful by their ability to ascribe mental states to other agents… Applications include entertainment and gaming, but also education and homeland defence.’
The development was announced at the First Conference on Artificial General Intelligence held at the University of Memphis in March. A video of Eddie passing the test is available online at tinyurl.com/3yzl39 (.mov format). CJ
You and I have memories
A new study about memory and the Beatles could help psychologists learn more about how the brain functions and the way we relate to our memories.
Magical Memory Tour is a collaboration between the British Association for the Advancement of Science and Professor Martin Conway and Dr Catriona Morrison of the University of Leeds, with support from the ESRC and the Dana Alliance for Brain Initiatives, along with the Beatles Story.
The researchers’ interactive website, at www.magicalmemorytour.com, says that the study will investigate ‘How have the Beatles shaped people’s lives?’ and ‘What kind of role do the Beatles and their music play in our personal histories and can this help increase our understanding of human memory?’. JS
Work is where the heart is
Homeworkers are just as committed as their office-based colleagues, but less stressed. That’s according to research presented by Professor Tom Redman to the British Institute of Facilities Management conference, held in March. Redman, of Durham Business School, and co-workers, studied 749 staff in British-based knowledge-intensive industries such as consulting, media and financial services. Professor Redman said: ‘Employers were worried that staff who worked from home would not be as committed to those extra duties where employees
go above and beyond the call of duty for their company. However we found that working from home did not undermine this behaviour.’ There was a downside to homeworking – many remote staff worried that their absence from the office could be detrimental to their career advancement. CJ
RESEARCH FUNDING NEWS
Following the comprehensive spending review £12m has been made available to the Research Councils for Science Bridge activities with the US, China and India (£4m per country) over the period 2008/9 to 2010/11. Details of the funding process to be used and eligibility are being finalised and it is anticipated that a call will be made in the near future. Advance notice is being given to enable possible UK applicants to begin discussions with possible partner institutions. For further information contact Randal W. Richards at RCUK [email protected] or see the website.
The Higher Education Academy Psychology Network has two funding opportunities to help support learning and teaching within higher education. The Departmen
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