Tag Archives: Mental health

Modern Chemotherapy for Severe Mental Disorders in a Prayer Camp

I thank Prof Swaran Singh for drawing my attention to a randomised trial of traditional faith healing with chemotherapy versus traditional faith healing alone for patients with serious psychiatric disorders.[1] The study took place in a faith-based healing centre. Belief in spiritual origins for mental illness is common in many countries. A randomised trial was conducted to evaluate the additional benefits of pharmacotherapy for patients with a range of psychotic conditions. The outcome of the trial was based on the brief psychiatric rating scale. Patients in the intervention group had much better outcomes than patients in the control group over the first six weeks following randomisation. That is to say, adding chemotherapy to faith healing produced a marked improvement in outcome.

The interesting feature of this trial was that it combined modern medical treatment with traditional healing methods. Thus it is not a head-to-head of the two different approaches; rather it is a trial of both methods compared with traditional methods alone.

Although the study produces interesting findings, the traditional methods did not sit comfortably with the medical approach; for instance patients were often put in chains so that they could not escape or harm themselves or others. This invokes the deeper question about whether the two methods (allopathic and traditional) can really exist side-by-side on a routine basis. Many providers of psychiatric services would find it difficult to live with a situation in which patients for whom they felt responsible were also subjected to practices that they consider degrading, if not outright harmful. The question can be fairly asked as to whether medical practitioners in the study were endorsing or even colluding in these practices. I tackled the moral and epistemological Implications of trying to integrate enlightenment science and spiritual practices within the same system of care, in a recent news blog.[2] The above research paper seems to reinforce my opinion that integration of modern medicine and traditional practices is much more than simply a technical issue. While clinical trials such as the one cited above can produce useful information, they cannot, by themselves, resolve the deeper issues.

— Richard Lilford, CLAHRC WM Director


  1. Ofori-Atta A, Attafuah J, Jack H, et al. Joining Psychiatric Care and Faith Healing in a Prayer Camp in Ghana: Randomised trial. Br J Psychiatry. 2018; 212: 34-41.
  2. Lilford RJ. Traditional Healers and Mental Health. NIHR CLAHRC West Midlands News Blog. 12 January 2018.

Traditional Healers and Mental Health

The case for traditional healers in mental health

There are two arguments for traditional healer involvement in mental health provision; one pragmatic and one theoretical. The pragmatic argument turns on the huge shortfall in human resources to deal with mental health problems in low- and middle-income countries (LMICs).[1] Traditional healers could make up for this shortage in human resources in the formal sector. A theoretical argument for the role of traditional healers turns on cultural factors. The argument here is that traditional healers are ideally placed to intervene in conditions with social origins, or when symptoms are coloured by cultural assumptions. Traditional healers, one might suppose, can tap into the beliefs and expectation of local people to reach parts of the mind that are simply inaccessible under a ‘medical model’. According to this argument modern medicine is the appropriate vehicle for the diagnosis and management for the conditions that are mainly of the body. It would be unwise, for example, to rely on traditional healers for the treatment of an acutely febrile child, or for provision of contraceptive advice. However, the traditional healer might be the appropriate first port of call for people with conditions of the mind.

The case against traditional healers in mental health

An argument against the above position is that the most serious types of mental health condition, psychotic illnesses, require modern pharmacotherapy, at least to stabilise patients. While all psychiatric conditions are of both brain and mind, psychotic conditions can be closer in form to those of standard medical diseases and the effects of properly targeted chemotherapy can be dramatic. There are many well documented cases where access to appropriate pharmacological therapy was denied or cruelly delayed while patients were treated unsuccessfully by traditional healers. From this perspective one should no more consult a traditional healer for a mental illness than for suspected malaria.

Reconciling the case for and against: a topic for investigation and research

On the one hand, traditional healers can offer culturally sensitive treatment for non-psychotic conditions, while on the other hand, severe mental illness requires medical services. It could be argued that traditional and modern medical services should be integrated so that traditional healers could treat the majority of patients, i.e. those with non-psychotic diseases, while allopathic clinicians treat the more severe cases. Moreover, different people have different preferences, and individuals may wish to receive care from both types of providers, even for the same illness. These would seem to be further arguments to integrate traditional and allopathic services within the same system and, indeed, in an integrated reimbursement system. Before implementing such a system it would surely be sensible to evaluate the effectiveness of traditional healers in the treatment of various psychiatric conditions and to ensure that, with the appropriate education, they would be able to refer cases that need medical treatment.

Philosophical problems in collaboration between traditional healing and modern medicine

The CLAHRC WM Director is keen to explore the relative effectiveness of traditional and allopathic treatments for non-psychotic mental illness but he is concerned that there may be irreconcilable philosophical differences in the traditional versus allopathic approach. This concern arises from different ontologies that underpin the different kinds of service. That is to say these traditions have different views on what counts as truth. Modern medical practice is very much a product of what might be called ‘enlightenment thinking’; practice built on an understanding of biological mechanisms / scientific explanations.[2] Such a world view is a far cry from the assumptions that underpin traditional healing, and which are guided by a set of traditional beliefs, often of a religious nature. So the question is whether it is possible to truly integrate systems with such different sets of underpinning assumptions? This is partly an empirical question – different systems could be examined to understand how well they can work together. The CLAHRC WM Director understands that moves are afoot to integrate allopathic medicine with traditional Chinese medicine in China, and in Ayurvedic medicine in India. It would be interesting to make independent studies of these systems. But in the meantime I would suggest a thought experiment. Let us imagine a proposed trial of rose-hip water vs. anti-depressant medication taking place in an integrated hospital. The allopathic practitioners present this as a placebo-controlled trial, while the traditional healers present this as a trail of two effective alternatives – the underlying belief systems determine how the treatments are presented. The CLAHRC WM Director suspects that it is very difficult to really integrate two systems based on very different philosophical premises. It is one thing to make irenic statements about mutual respect and so on, but another to supress tensions that seem likely to arise from fundamentally irreconcilable philosophical assumptions.

Living with contradictions

The question of integrating these different systems of thought is, perhaps, unresolvable. The systems have existed side by side for a hundred years or more. In high-income countries there is a thriving industry in complementary therapies and the list of alternative methods is almost too long to recite. Likewise traditional medicine and modern medicine have existed side by side quite happily in Africa, South Asia and China for many years. The populations in all these countries seem, on the whole, pretty savvy at working out which method is more appropriate for them in which condition. I have never heard of anyone going to a homeopath for their family planning needs. But systems co-existing in society is one thing, integrating them in common administrative and reimbursement systems is another. Every now and then there is an attempt to unite religion and science around a common purpose – the Lancet commission is currently involved in such a process.[3] [4] However, it may be the case that like religion and science; traditional and allopathic medicine can live happily side by side within the same community and within the same individual. Whether and how they can really be brought together in a structural / organisational sense, for example in the same institution or within the same reimbursement system, is a matter for analysis and exploration. One thing I am sure of is that policy should not be made as though this were a technical issue and without considering the very different world views that lie behind each type of provision. Maybe the best that can be accomplished is for the systems to become more aware of each other and cross-refer when necessary, but to continue to make their own independent contributions?

— Richard Lilford, CLAHRC WM Director


  1. Rathod S, Pinninti N, Irfan M, Gorczynski P, Rathod P, Gega L, Naeem F. Mental Health Service Provision in Low- and Middle-Income Countries. Health Serv Insights. 2017; 10:
  2. Spray EC. Health and Medicine in the Enlightenment. Jackon M (ed). The Oxford Handbook of the History of Medicine. 2011.
  3. Horton R. When The Lancet went to the Vatican. Lancet. 2017; 389: 1500.
  4. Lee N, Remuzzi G, Horton R. The Vatican-Mario Negri-Lancet Commission on the value of life. Lancet. 2017; 390: 1573.

Cognitive Behavioural Therapy vs. Mindfulness Therapy

It is known that mindfulness therapy is effective in improving depression and, in many circumstances, in improving chronic pain (see later in News Blog). What is not so clear is whether it is better than the more standard therapy of cognitive behavioural therapy (CBT).

Cognitive behavioural therapy aims to abolish or reduce painful and harmful thoughts. Mindfulness therapy on the other hand does not seek to extirpate the depressing thoughts, but rather to help the person disassociate themselves from the harmful consequences of these thoughts. It often involves an element of meditation.

We have found three recent studies which compare CBT and mindfulness therapy head-to-head for depression.[1-3] In all three RCTs the two therapies were a dead heat. In short, both methods seem equally effective and certainly they are both better than nothing. But does this mean that they are equal; that the choice does not matter one way or the other?

In this article I argue that the fact that the two therapies all equally effective in improving mood, does not mean that they are equivalent. This is because they are designed to have different effects – abolition of harmful thoughts in one case, learning to live with them in the other. So it is reasonable to ask which one would prefer, abolishing the painful thoughts or simply learning not to be affected by them.

Philosophically, the argument behind CBT is that thoughts, at least at a certain level, are a kind of behaviour. They are a behaviour in the sense that they can be changed under conscious control. Mindfulness therapy does not attempt to ‘over-write’ thoughts. This means that the two therapies, in so far as they achieve their objectives, are not philosophically equivalent. Moreover, there are arguments in favour of removing the harmful thoughts, even if this does not result in any greater improvement in mood than the counter-factural. Consider a man whose wife is annoyed by certain movements that he is unable to control. It is surely much better, both from her point of view and from the point of view of the husband, that these painful thoughts should be removed altogether, rather than just tolerated. Alternatively, consider a person who is chronically distressed by a recurring memory of the painful death of a parent. Again, it is surely better that this person trains himself to think of another aspect of the parent’s life whenever the troubling thoughts recur, than to simply continue to remember the death, but not get upset by it.

So, I think that CBT is philosophically preferable to mindfulness therapy, even if it is no more effective in improving mood. From a philosophical point of view, it is important to develop a high rectitude way of thinking. When negative or morally questionable thoughts pop into the brain, as they do from time to time, these should be suppressed. A racist thought, for example, should be replaced with thoughts of higher rectitude. It is the purpose of the examined life to be able to control negative or bigoted thoughts and supplant them with more positive thoughts under conscious control. From this philosophical perspective CBT can be seen as an extension of the human ability to supplant negative or reprehensible thoughts with ones that are more positive or of higher rectitude. I choose CBT over mindfulness; for all that they might be equally effective in elevating mood, psychiatric treatments have implications that go beyond purely clinical outcomes – since they affect the mind there is always a philosophical dimension.

— Richard Lilford, CLAHRC WM Director


  1. Manicavasagar V, Perich T, Parker G. Cognitive Predicators of Change in Cognitive Behaviour Therapy and Mindfulness-Based Cognitive Therapy for Depression. Behav Cogn Psychother. 2012; 40: 227-32.
  2. Omidi A, Mohammadkhani P, Mohammadi A, Zargar F. Comparing Mindfulness Based Cognitive Therapy and Traditional Cognitive Behavior Therapy With Treatments as Usual on Reduction of Major Depressive Symptoms. Iran Red Crescent Med J. 2013; 15(2): 142-6.
  3. Sundquist J, Lilja A, Palmér K, et al. Mindfulness group therapy in primary care patients with depression, anxiety and stress and adjustment disorders: randomised controlled trial. Br J Psychiatry. 2015; 206(2): 128-35.

The New and Growing Interest in Mental Health: Where Should it Be Directed?

Mental health provision and mental health research are undergoing something of a renaissance. The subject has been the priority of successive governments, more people are entering mental health professions, and mental health attracts a financial premium under the Research Evaluation Framework, through which universities receive care funding. The biological basis of many mental health diseases has recently been unravelled – see for instance past News Blogs on the molecular biology of schizophrenia, and Alzheimer’s disease.[1] [2] From a philosophical standpoint the mind is now seen as a function of the brain, just as circulating the blood is a function of the heart. The interaction between the brain and the rest of the body, first discovered by observations on Alexis St. Martin in 1822, and later seen in ‘Tom’ in 1947,[3] is now a major source of investigation (see another article in this News Blog on a part of the brain called the amygdala).

>Much of this renewed attention on mental illness carries the, often implicit, implication that mental health treatment should improve. This is undoubtedly the case for many diseases at the severe end of the psychiatric spectrum. One does, however, have to wonder whether the traditional medical model that serves us well in diseases such as schizophrenia and autism, is really the right way to go for other conditions such as depression and anxiety, especially in their milder forms. Depression, one often reads, affects 30% of the population. But 30% represents a choice of threshold, since the definition of ‘caseness’ turns on where the line is drawn. If set at roughly one-third of the population one has to wonder about the logistics of supplying sufficient treatment. And even if the logistics can be managed, it still seems wrong to make ‘cases’ of fully a third of the human race. To put this another way, common problems, such as depression and obesity are best tackled at the societal level. Therapeutic services can then deal with the most serious end of the spectrum – people who really should be given a diagnostic label. This would seem to be the way to go for (at least) two reasons. First, many people (especially at the milder end of the spectrum, where normality elides into diseases) do not present to health services. Their mental health is important. Second, the brain is a ‘learning machine’ and it is hard to reverse harmful behaviours, such as eating disorders, once they have been firmly encoded in neural circuits. Mental health practitioners therefore have a preventive / public health responsibility to intervene by encouraging a wider ‘psycho-prophylactic’ approach. And this topic needs research support every bit as much as therapy. A population level approach would seem to have two broad components – a supportive environment, and encouraging resilience in the population.

Let us consider a supportive environment. Reducing bullying in schools is an archetypal example of an intervention to create a psychotropic environment. There is clear and present evidence that the victim (but not the perpetrator) is harmed by bullying, and there is also good evidence that the problem can be prevented.[4] How a psycho-therapeutic environment may look in other respects is less clear-cut. Workplace culture is likely to be important. The Whitehall studies show that a feeling of powerlessness is associated with stress and illness,[5] but putting this right is not a simple manner. For example, it is widely believed that an optimistic, or so-called ‘positive’, outlook is helpful in the workplace, but the experimental evidence actually points the other way. Being realistic about difficulties ahead and (often low) chances of success, is more helpful than a culture of poorly titrated optimism.[6]

There are many specific groups that are at risk of mental suffering and where environmental modification may help. While the workplace is stressful and a source of anxiety and depression, it has its antithesis in the loneliness that often accompanies old age. There is a fashion to try to keep everyone living independently in their homes for as long as possible. However, such an environment is likely to lead to increasing isolation. I think that communal living should be encouraged in the declining years between retirement and death.[7]

What about resilience in the population? To a degree, the workplace will always be stressful since competing interests and time pressures are inevitable. How can we increase resilience? Taking part in guides and scouts is associated with better mental health outcomes in young people.[8] Exercise has positive benefits on mental health across the age spectrum,[9] and team sports seem particularly beneficial. It is possible that we can encourage ‘mental hygiene’ by talking about it and encouraging healthy mental behaviours. I have a tendency to self-pity and so practice a kind of cognitive behavioural therapy on myself – I think of role models and count my blessings. Others practice ‘mindfulness’. We need to learn more about how to build resilience through experience. Where lies the balance between a bland life devoid of competition, and a ruthless environment creating ingrained winners and losers? I hypothesise that an environment where people are encouraged to have a go, but where coercion is avoided and failure is seen as par for the course, will prepare children for life’s vicissitudes. However, I suspect we are in the foothills of discovery in this regard.

There is always a temptation to screen for illness when it cannot be fully prevented, but the screening can often do more harm than good, and this is true in mental health as well as a physical context. Certainly, routine debriefing after a major incident or difficult childbirth appears to be at best unhelpful. CLAHRC WM collaborator Swaran Singh and colleagues showed that screening for the prodromal symptoms of schizophrenia is also unhelpful as it produces an extremely high false positive rate.[10] Again, working out when screening is of net benefit is an important task for the future.

In conclusion, none of what I have written should be seen as a criticism of therapeutic research and practice. Rather, I argue for a broadening of scope, not only to find things that are predictive of poor mental health, but to find workable methods to improve mental health at a population level. Public mental health is an enduring topic in CLAHRC WM.

— Richard Lilford, CLAHRC WM Director


  1. Lilford RJ. Psychiatry Comes of Age. NIHR CLAHRC West Midlands News Blog. 11 March 2016.
  2. Lilford RJ. A Fascinating Account of the Opening up of an Area of Scientific Enquiry. NIHR CLAHRC West Midlands News Blog. 11 November 2016.
  3. Wolf S. Stress and the Gut. Gastroenterol. 1967. 52(2):288-9.
  4. Menesini E & Salmivalli C. Bullying in schools: the state of knowledge and effective interventions. Psychol Health Med. 2017; 22(s1): 240-53.
  5. Bell R, Britton A, Brunner E, et al. Work Stress and Health: the Whitehall II study. London: Council of Civil Service Unions / Cabinet Office; 2004.
  6. Lilford RJ. Managing Staff: A Role for Tough Love? NIHR CLAHRC West Midlands News Blog. 2 September 2016.
  7. Lilford RJ. Encouraging Elderly People to Live Independent Lives: Bad Idea? NIHR CLAHRC West Midlands News Blog. 16 April 2014.
  8. Lilford RJ. Does Being a Guide or Scout as a Child Promote Mental Health in Adulthood?. NIHR CLAHRC West Midlands News Blog. 25 November 2016.
  9. Lilford RJ. On the High Prevalence of Mental Disorders. NIHR CLAHRC West Midlands News Blog. 7 March 2014.
  10. Perry BI, McIntosh G, Welch S, Singh S, Rees K. The association between first-episode psychosis and abnormal glycaemic control: systematic review and meta-analysis. Lancet Psychiatry. 2016; 3(11): 1049-58.

It’s Never Too Early: Policy Implications From Early Intervention in Youth Mental Health

Two pieces of news may have escaped your attention in recent months: the first was that in the post-Brexit cabinet re-organisations, the Secretary of State for Health, Jeremy Hunt, picked up the responsibility for mental health, which had previously been separated from the health portfolio. This resulted in barely a mention in the mainstream media and has not resulted in any perceptible changes in policy… yet.

The second piece of news was last week, and featured prominently in the Health Services Journal, but to my surprise seemed to make very little impact in the national news. Jeremy Hunt described children’s mental health services as “the biggest single area of weakness in NHS provision at present”. When you stop to consider the breadth and depth of challenges facing the NHS at present, to single out this oft overlooked area so starkly came as a surprise, albeit a welcome one.

Of course, bold statements are one thing and actions another, but there seemed to already be early seeds of policy initiatives creeping in to the detail of the statement, along with the suggestion that this was a particular area of concern for the Prime Minister Theresa May. The statement highlighted the need for early intervention for children with mental health problems and suggested closer working between Child and Adolescent Mental Health Services (CAMHS) and schools, as well as the challenges that exist within the 16-24 year old age group and the need to address this gap in service for particular conditions. Interestingly, some of these issues have also been brought to the fore in policy documents issued by the Clinton Presidential campaign in the United States.

All this bodes well for the Youth Mental Health theme of CLAHRC West Midlands. CLAHRC researchers though both this CLAHRC and the previous incarnation of CLAHRC Birmingham and Black Country have worked on a variety of projects whose research could help provide an evidence base for policy formulation. These include the redesign of youth mental health services to improve access; early intervention in first episode psychosis; the impact of schools on mental health (see also youthspace.me), and interventions within the 0-25 age range.

Professor Max Birchwood, Theme lead for the Youth Mental Health theme commented “It’s great to see this important area of health receiving national attention and mirroring many elements of the research undertaken by CLAHRC BBC and now CLAHRC WM. We look forward to playing an active role in contributing to the discussion and helping to shape future guidance and policy in this area”.

— Paul Bird, CLAHRC WM Head of Programme Delivery (Engagement)

From Global to Local: How Patient and Public Involvement is Shaping Mental Health Services in CLAHRC West Midlands

Each year, World Mental Health day draws attention to the many issues people with mental health issues need to overcome on a daily basis. Although there are effective treatments for mental health disorders, such as medication and therapies, it is important that people can access the right care at the right time.

There are many stigmas associated with having a mental health disorder, which impact on people disclosing that they have a problem in the first place and then accessing the right treatment as early as possible. In the UK, NICE quality guidelines, which were informed by research undertaken by CLAHRC WM, recommend that 50% of people of all ages who experience psychotic symptoms for the first time should be treated with a NICE approved care package within two weeks of a referral. However, researchers in CLAHRC WM’s Prevention and Early Intervention in Youth Mental Health theme found that young people were not always accessing the services they needed, particularly as they were making the transition from child to adult mental health services. This was due to a number of reasons, including poor help-seeking behaviour, and bottlenecks in specialist mental health services. You can read more about this research here.

Having identified a need to improve access for mental health services for young people in the region, CLAHRC WM researchers work in partnership with patient and public advisers to deliver research that is both meaningful and accessible to them. In particular, CLAHRC WM researchers work with existing patient and public groups in the region to co-design and develop services that are appropriate for the young people that will use them. These groups included the Young Person’s Advisory Group, facilitated by the Clinical Research Network, and the Youth Board (recently renamed Ripple), a group of people aged 16-25 years old, some of whom have lived experiences of mental health issues.

As with all projects within CLAHRC WM, patients and the public can work with researchers in all stages of the research cycle: from coming up with ideas of what research to do, right through to making sense of research findings and sharing these with relevant networks. Readers of the News Blog will have read about how researchers and young people worked with primary care and Child and Adolescent Mental Health Services (CAMHS) to create an effective and appropriate youth clinical service to meet local needs, reduce delays, improve transitions between services, and adopt a preventative triaged intervention model. This new service is delivered by the Forward Thinking Birmingham Partnership.

Young people working in partnership with CLAHRC WM are essential to ensuring that the services both meet the needs of the people who will use them, and are also designed in the right way. Some examples of how CLAHRC WM has involved patients and the public are:

  • Designing and developing www.youthspace.me, an online resource that offers relevant, up-to-date information and advice for young people and their families on all aspects of mental health. Young people helped to design the pages, write content and ensure that the language is accessible.
  • Helping to raise awareness of mental health issues through designing materials for public campaigns such as ‘Don’t Stay Silent’ and ‘Don’t turn your back on the symptoms of psychosis’.
  • Celebrating the successes of the new care pathway through ‘Shout Out for Youth Mental Health’, an event held in Birmingham on 7 June 2016. Young people had an active role in planning the day and facilitating the sessions. Challenges of living with mental health disorders were brought to life through dance and poetry performances by young people, and young people’s willingness to share their experiences emphasised the need to ensure mental health services are accessible and acceptable. You can read more about the event here.
  • Participating in an educational randomised controlled trial in secondary schools across Birmingham to reduce stigma and increase mental health literacy in young people.

Researchers in CLAHRC WM’s Youth Mental Health theme work with Patient and Public Advisers, Barry Clark, Keith Elder and Richard Grant, to ensure that benefits of working with patients and the public in research are maximised. Bringing a wealth of experience and knowledge, our Advisers have not only helped to shape PPI strategies within the theme, but have engaged local networks and communities about the research undertaken by CLAHRC WM in youth mental health. Working in partnership with patient and public advisers ensures that key findings from research are accessible and have impact.

One of the current projects underway in the Youth Mental Health theme is SchoolSpace, a partnership with CLAHRC WM researchers and schools to understand the factors which precede the onset of eating disorders. With growing need for schools to concern themselves with the well-being of their students, researchers in CLAHRC WM are working with schools to design effective screening tools and interventions for teachers and those who work with young people. Our PPI Advisers have worked closely with researchers to help ensure the successful development and implementation of SchoolSpace.

On World Mental Health day, some of the twitter hashtags were #timetotalk and #timetochange. CLAHRC WM researchers are doing their bit by talking and listening to people that use the services and working in partnership with them to deliver change. By working ‘with’ young people, patients and the public, rather than ‘to’ or ‘for’ them, CLAHRC WM has demonstrated the value of meaningful patient and public involvement. Not only is the research undertaken relevant: people using the service have had a key input into the way research is shaped and delivered. Involving people at every stage at the research cycle has benefits including healthy participation rates and widespread dissemination. Most importantly, partnership with patients and the public has led to outcomes that are suitable and of benefit to people using the service, resulting in better care. CLAHRC WM is doing its utmost to ensure that we are removing stigmas to mental health and enabling people to access the right treatments and therapies as soon as possible.

Do Refugees Have a Higher Incidence of Schizophrenia than Immigrants?

Yes, at least according to a recent data linkage study of 1,191,004 Swedes, 24,123 refugees and 132,663 migrants arriving in Sweden.[1] While immigrants had an adjusted increase risk of 1.7, the increase was three-fold for refugees. The study was based on over 8.9 million person years of follow-up. Among refugees from sub-Saharan Africa the gradient between refugees and immigrants was not apparent, but the overall risk was higher. This finding is compatible with a more psychogenic provenance across both refugees and migrants in Africa and/or greater discrimination on arrival. Schizophrenia is a rare disease – the overall incidence was well under one in 1,000 in the above study, but the CLAHRC WM Director thinks it may be a bell-weather for higher population risk of other mental illness. Refugees are at risk of post-traumatic stress disorder.

— Richard Lilford, CLAHRC WM Director


  1. Hollander AC, Dal H, Lewis G, et al. Refugee migration and risk of schizophrenia and other non-affective psychoses: cohort study of 1.3 million people in Sweden. BMJ. 2016; 352: i1030.

Psychiatric Diagnosis: In the Eye of the Beholder?

The incidence of autism has risen fourfold over the last few decades. Scientists have sought the cause in physical, chemical and biological agents, including, notoriously, vaccines. But many have suspected that the whole thing is an artefact of labelling – labelling cases that would otherwise not have receive a label, or re-labelling other conditions as autism. It turns out that approximately two-thirds of the increase can be accounted for by re-labelling alone.[1] In an ingenious study, investigators analysed all American children enrolled in special educational programmes, all of whom are recorded (as required by law) on a national database. An increase in ‘autism’ was largely offset by a corresponding decline in other stated categories of disability. I am afraid that psychiatric diagnoses will be dominated by ephemeral factors until it is based on underlying biology. Reductionism has a bad name in some circles, but the search for deterministic explanations of human mental diseases is the remaining frontier for medical discovery. Will molecular genetics and functional MRI get us there, or do we need another fundamental breakthrough, as suggested in a previous post?

— Richard Lilford, CLAHRC WM Director


  1. Polyak A, Kubina RM, Girirajan S. Comorbidity of intellectual disability confounds ascertainment of autism: implications for genetic diagnosis. Am J Med Genet B Neuropsychiatr Genet. 2015. [ePub].


School-based suicide prevention – prepare to be impressed

A recent cluster trial [1] covered over 11,000 pupils in 168 schools randomised to three different types of intervention or control. The interventions were:

  1. Educating teachers to spot children at risk;
  2. A programme delivered by outside instructors, which included role play and other measures aimed at enhancing resilience and reducing negative thoughts;
  3. A screening service.

All interventions were associated with a reduced risk of attempted suicide, but this was substantial and statistically significant only for the second intervention targeting adolescents directly. CLAHRC WM has programmes of youth psycho-prophylaxis and the Director was mega-impressed by this study.

— Richard Lilford, CLAHRC WM Director


  1. Wasserman D, Hoven C, Wasserman C, et al. School-based suicide prevention programmes: the SEYLE cluster-randomised, controlled trial. Lancet. 2015; 385; 1536-44.

Radical or what?

As far as the CLAHRC WM Director can discern, the massive closure of in-patient psychiatric beds in the 1970s was not evidence based. It was driven by all sorts of social forces and ideology. That does not mean it was necessarily a bad thing – and of course some psychiatric beds remain. So the real question is “what is the optimal provision for severe mental illness?” According to Sisti et al.[1] current provision is far too low. Some who need beds end up in prison services. Many others may also benefit from inpatient care. Careful comparison between community and hospital care among equipoised patients [2] (i.e. those with no real preference) would go a long way to identifying optimal provision. In the meantime, the CLAHRC WM Director and his colleague Celia Taylor are collaborating with RAND Europe on the evaluation of Liaison and Diversion services, so that people with severe mental illness are diverted to mental health services when they have been arrested. Some of these diverted patients will need inpatient care.

— Richard Lilford, CLAHRC WM Director


  1. Sisti DA, Segal AG, Emmauel EJ. Improving Long-term Psychiatric Care: Bring Back the Asylum. JAMA. 2015; 313(3): 243-4.
  2. Lilford RJ, Jackson J. Equipoise and the ethics of randomization. J R Soc Med. 1995; 88(10): 552-9.