Issuing a readers’ advisory: The Guardian provides misleading, badly skewed coverage of mental health issues vitally important to mental health service users.
Stories in The Guardian can confuse and disempower mental health service users seeking information for difficult decisions about choosing and sticking to treatments. Articles labeled Psychology and Health and sometimes Science don’t adhere to the quality that earned The Guardian a Pulitzer Prize.
In this issue of Mind the Brain, I show why there should be a formal readers advisory for mental health information appearing in The Guardian. The excellent watchdog of faulty health coverage in the media, NIH Choices: Behind the Headlines should routinely monitor stories appearing in The Guardian and provide more balanced analyses.
You can compare my assessments to your own evaluation with the links I provide to the stories in The Guardian.
Some recent examples:
At last, a promising alternative to antipsychotics for schizophrenia
Imagine that, after feeling unwell for a while, you visit your GP. “Ah,” says the doctor decisively, “what you need is medication X. It’s often pretty effective, though there can be side-effects. You may gain weight. Or feel drowsy. And you may develop tremors reminiscent of Parkinson’s disease.” Warily, you glance at the prescription on the doctor’s desk, but she hasn’t finished. “Some patients find that sex becomes a problem. Diabetes and heart problems are a risk. And in the long term the drug may actually shrink your brain.”
It is insulting to those who suffer from schizophrenia to have their life-altering experience trivialized and domesticated as simply “feeling unwell for a while.”
The article provides a fright-mongering depiction of the difficult choice that patients with schizophrenia face. Let’s give a critical look at the authors’ claim about drugs shrinking the brain. The sole citation is a PLOS One article. Authors of that article provided a carefully worded press release:
A study published today has confirmed a link between antipsychotic medication and a slight, but measureable, decrease in brain volume in patients with schizophrenia. For the first time, researchers have been able to examine whether this decrease is harmful for patients’ cognitive function and symptoms, and noted that over a nine year follow-up, this decrease did not appear to have any effect.
The UK senior author of the study further clarified:
The study is not a randomized trial in which the amount of antipsychotic medication that patients received was manipulated. It is a small observational study comparing 33 patients with schizophrenia to 71 controls. Causal interpretation depends on statistical manipulation of correlational data. Yet a group of only 33 (!) patients with schizophrenia does not allow reliable multivariate analysis to explore alternative interpretations of the data. One plausible interpretation is that the amount of medication particular patients received is tied to severity of course of their schizophrenia. This would be a classic example of confounding by indication. The authors acknowledge this possibility:
It is conceivable that patients with the most severe illness lose more brain volume over time, reflecting intrinsic aspects of the pathology of schizophrenia, and the fact that severely ill patients receive higher doses of medication.
They further note:
Whilst it is extremely important to determine the causes of loss of brain volume in schizophrenia, an equally important question concerns its clinical significance. Loss of brain volume occurs throughout the majority of adult life in the healthy population, and whilst it might seem trivial that this would be disadvantageous, in some periods of development loss of brain tissue appears to be potentially beneficial *.
Yes, antipsychotic medication poses serious side effects, doesn’t cure schizophrenia, and there are problems with adherence. But The Guardian article fails to note that the longer an episode of schizophrenia goes untreated, the less likelihood that a patient will ever resume a semblance of a normal life. And schizophrenia is associated with a 10% rate of suicide. What alternative does The Guardian article suggest?
A team led by Professor Anthony Morrison at the University of Manchester randomly assigned a group of patients, all of whom had opted not to take antipsychotics, to treatment as usual (involving a range of non-pharmaceutical care) or to treatment as usual plus a course of cognitive therapy (CT). Drop-out rates for the cognitive therapy were low, while its efficacy in reducing the symptoms of psychosis was comparable to what medication can achieve.
You can compare this summary to my critiques [1,2].
- “Drop out rates..,were low?” The study retained fewer participants receiving cognitive therapy at the end of the study than there were authors.
- The comparison treatment was ill-defined, but for some patients meant no treatment because they were kicked out of routine care for refusing medication.
- A substantial proportion of patients assigned to cognitive therapy began taking antipsychotic medication by the end of the study.
- There was no evidence that the response to cognitive therapy was comparable to that achieved with antipsychotic medication alone in clinical trials.
The authors of the study backed down from this last claim in an exchange of letters [1 and 2] at the Lancet with myself and others. BBC News dropped that claim after initially making it in coverage of the study.
Don’t settle for my interpretation of the literature concerning cognitive therapy for psychosis (CBTp), go to a summary of available evidence in a blog post by Clive Adams, Chair of Mental Health Services Research and Co-Ordinating Editor of the Cochrane Schizophrenia Group at the University of Nottingham.
Adams wraps up with
Where does this leave CBTp?
In the opinion of this writer, having read and thought about the reviews (and others in some detail) it is time to move on.
It is great that there are data for questions around this potentially potent intervention for people with schizophrenia (for many treatments there are no data at all). I just cannot see that this approach (CBTp), on average, is reaping enough benefits for people.
Jones C, Hacker D, Cormac I, Meaden A, Irving CB. Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.: CD008712.
Trial-based evidence suggests no clear and convincing advantage for cognitive behavioural therapy over other – and sometime much less sophisticated – therapies for people with schizophrenia.
Mark Taylor chaired the Scottish Intercollegiate Guidelines Network (SIGN) committee that produced the Scottish Guidelines for the Management of Schizophrenia. SIGN is the equivalent to the British National Initiative for Clinical Excellence (NICE). In an editorial in British Journal of Psychiatry he commented on the NICE guidelines’ favoring of cognitive behavioral therapy:
NICE has also taken the bold step of recommending CBT and family therapy alone for people with first-episode psychosis who wish it. The guideline acknowledges that psychosocial interventions are more effective in conjunction with antipsychotic medication, but still suggests this intervention alone for one month or less. This is controversial in view of the lack of robust supportive evidence and could potentially worsen outcomes. A related point is that in the guideline NICE seem oblivious to the fact that many patients with acute schizophrenia have impaired insight into their illness and health needs,5 and thus may not have capacity to consent to their treatment.
And finally, there is a Keith Laws’ carefully documented Science & Politics of CBT for Psychosis.
A Guardian story on mindfulness: New study shows mindfulness therapy can be as effective as antidepressants
Glass half-full readers, of course, will see that the trial results demonstrate that we actually have two similarly effective treatment options for recurrent depression: one involves eight weeks of a psychological therapy, the other relies on taking medication for two years. The challenge now is to make both equally available in treatment services.
I provided a detailed critique of this study. You would never guess from The Guardian article that mindfulness therapy used in this study was not designed to treat depression, only to prevent relapse in patients who had recovered in treatment by other means. And there was no assessment of whether patients assigned maintenance antidepressants were actually adhering to them or receiving adequate, guideline congruent care. You can see my comments on this study at PubMed Commons and leave your own as well.
The lead author of the study who is a colleague of the author of The Guardian went to the trouble of modifying the study registration to clarify that the trial was not designed to compare mindfulness therapy antidepressants for depression.
Feeling paranoid? Your worries are justified but can be helped
In this article The Guardian authors present as mainstream their unconventional views of what “feeling paranoid” represents. One of the authors promotes his own treatment for which he conducts workshops tied to his self-help books about worrying.
The fog machine gets going when the authors merge colloquial use of paranoid with the psychotic symptom. Many people, especially the young use “paranoid” in every speech in a way far removed from professionals discussing the psychotic symptom. Most endorsements of “feeling paranoid” on a checklist would not represent a psychiatric symptom. Even when present, the psychiatric symptom of paranoid is neither necessary nor sufficient for a diagnosis of schizophrenia.
When occurring in the context of a diagnosis of schizophrenia, however, paranoid delusions can be strongly held convictions accompanied by other lack of insight and thought disorder. I know of no evidence that everyday suspiciousness turns into psychotic persecutory delusions in persons who are not otherwise at risk for psychosis.
Think of someone insisting on shifting a conversation about skin cancer to talking about moles. Dropping lung cancer and chronic obstructive pulmonary disease for a more inclusive, but nonspecific “cough.” These are silly moves in a language game that prevent evaluation of health problems in terms of available evidence of necessity tied to more precise language.
The Guardian authors propose:
As we’ve noted previously on Guardian Science, anti-psychotics don’t work for everyone. And their side effects can be so unpleasant that many people refuse to take them. Moreover, there’s compelling evidence to suggest that the concept of “schizophrenia” doesn’t stand up scientifically, operating instead as a catch-all for a variety of distinct and frequently unrelated experiences.
What compelling evidence? Says who? I doubt that the one of these authors who is in the Psychology at Oxford would make such a statement in a formal presentation to his colleagues. But apparently it suffices for a lay audience including mental health services users seeking information about their condition and available treatments.
In general, readers should beware of authors making such sweeping statements in the media without identifying specific sources, degree of scientific consensus, or grade of evidence. The Guardian authors require readers to turn off critical skills and trust them.
This is why scientists have increasingly focused on understanding and treating those experiences in their own right, rather than assuming they’re simply symptoms of some single (albeit nebulous) underlying illness. So what have we discovered by applying this approach to paranoia?
Which “scientists”? Where? Readers are again left trusting the expertise of The Guardian authors.
The authors are getting set to promote the treatment developed by one them for “worry” in patients with paranoid delusions, which is marketed in his workshops, using his self-help book. I previously reviewed this study in detail.
- The treatment was a low intensity variation of a self-help exercise using excerpts from The Guardian authors’ book.
- The treatment of the control group was ill-defined routine care. Relying on this control group as the only comparison precluded evaluating whether the intervention was any better than a non-branded similar amount of attention and support.
- The primary outcome was hopelessly confounded with nonspecific worrying or anxiety and inadequate to assess clinically significant changes in psychotic symptoms of paranoid delusions.
I could go on with examples from other articles in The Guardian. But I think these suffice to establish that mental health service users seeking reliable information can find themselves misled by stories in The Guardian. Readers who don’t have the time or feel up to the task of checking out what they read against what is available in the literature would do well to simply ignore what is said in The Guardian about serious mental disorder and its treatment.
Despite The Guardian having won the Pulitzer Prize for science reporting, readers may find stories about mental health that are seriously misleading and of little use in making choices about mental health problems and treatments. Information about these issues are not responsibly vetted or fact checked.
Whatever happened to responsible journalism at The Guardian?
in April 2015,The Guardian announced a Live Question and Answer Session.
How can academics help science reporters get their facts straight?
Academics have never been under more pressure to engage with the public and show the impact of their work. But there’s a problem. The media, one of the key channels for communicating with people outside academia, has a reputation for skewing or clumsily confusing scientific reports.
The session was in response to larger concerns about the accuracy of health and science journalism. With serious cutbacks in funding and layoffs of experienced professional journalists, the media increasingly rely upon copy/pasting exaggerated and inaccurate press releases generated by self-promoting researchers in the universities. What has been lost is the important filter function by which journalists offer independent evaluation of what they are fed by researchers’ public relations machines.
Many readers of The Guardian probably did notice a profound shift from reliance on professional journalists to to blogging provided free by academics. Accessing a link to The Guardian provided by a Google Search or Twitter, readers are given no indication that they will be reading a blog.
A blog post last year by Alastair Taylor identified the dilemma –
Media outlets, such as the Guardian Science Blogs, can present the science direct (and without paying for it) from the experts themselves. Blogging also opens up the potential for the democratisation of science through online debates, and challenges established hierarchies through open access and public peer review. At the same time, can scientists themselves offer the needed reflection on their research that an investigative journalist might do?
In the case of these authors appearing in The Guardian, apparently not.
The new system has obvious strengths. I look forward to reading regular blog posts by academic sources who have proved trustworthy such as Suzi Gage, Chris Chambers, or many others. They have earned my trust sufficiently for me to recommend them. But unfortunately, appearing in The Guardian no longer necessarily indicates that stories are scientificially accurate and helpful to consumers. We must suspend our trust in The Guardian and be skeptical when encountering stories there about mental health.
I sincerely hope that this situation changes.
*The authors of the PLOS One article cite a Nature article for this point, which states
More intelligent children demonstrate a particularly plastic cortex, with an initial accelerated and prolonged phase of cortical increase, which yields to equally vigorous cortical thinning by early adolescence. This study indicates that the neuroanatomical expression of intelligence in children is dynamic [bolding added].