Royal College Press Office: Do they read or understand their own papers?

There's a retrospective study in this month's issue of The Psychiatrist titled: "Use of anti-dementia drugs and delayed care home placement: an observational study". It's not the best study in the world but the authors appropriately acknowledge the limitations, explicitly stating in the abstract that: "However, based on purely observational data, no conclusion can be made as to whether such association is causal."

It was a retrospective study which means that it couldn't compensate for all sorts of factors that may have confounded the finding that, "...there was a delay in care home placement by a median of 12 months in those who took ChEIs compared with those who did not." This is not the first study to suggest that anti-dementia drugs may delay admission to care homes, and many other studies were much better designed and prospective. Importantly, the authors state: "...at the end of the follow-up there was no significant reduction in the probability of being in a care home setting between those who had taken ChEIs compared with those who had not." So, the drugs didn't prevent care home admission, only that those that took drugs were admitted to care homes later than those that didn't. The authors mention that the groups weren't matched and only suggest that there weren't differences. However, no comparisons are reported and the authors don't provide detail on the factors that they themselves report as potential confounders.

It's not possible to know, for example, if those that took anti-dementia drugs were of a less-advanced stage or if they had less comorbidity - neither of these things appear to have been corrected for. This means that more unwell patients might have been considered unsuitable for the drugs and their course of illness would mean that they were already closer to admission. Since the two groups (receiving drug and control) weren't described in detail (in terms of age, diagnosis, severity of illness, medical illness) we can't be sure if the drugs had anything to do with it.

You might hope that such limitations would be taken into account. But the RCPsych press office announce that:

Anti-dementia drugs may help delay people’s admission to care homes

This is precisely what the study didn't say and what the authors were careful to caution against concluding. Still, it seems that the scientific credibility of the RCPsych is less important than getting 'good news' headlines.

Meaningless nonsense

There's a really odd letter in this month's The Psychiatrist. You can read it online here (if you have access), or download the PDF (without restriction).

It's odd because it seems to have no grounding in old-fashioned ideas about falsifiability; the concept proposed by Karl Popper which basically suggests that a statement can be falsified by an observation (typically experimental) that contradicts it. A classic example would be the statement "all swans are white" can be falsified by the observation of a single black swan. In many ways, it's what scientific method is based on.

You can be pretty sure that when someone starts going on about "mental - symbolic - membranes...[which] secures its architectural codes in a semantic link with external signs and objects" they are proposing things which cannot be contradicted in any meaningful way; in the same way that Freudian psychoanalysis can't be falsified. One cannot prove the non-existence of the 'Id'. Indeed, the whole 'unconscious' becomes unavailable to scientific exploration.

Further, when an author starts quoting 'studies' from 1929 which are meant to be applicable to modern understanding of mental disorder, it's highly likely that all such ideas have limited currency. If you type in 'cassirer "psychopathology of symbolic consciousness"' to Google, you get 4 hits; all of which refer to the letters in The Psychiatrist. When you remember that Google indexes billions of websites, to only get 4 hits is indicative of a somewhat limited impact of this particular work.

Finally, the author suggests that "Mental illness is the inability to (stabilize and/or) integrate own pattern of behaviour into a social framework, leading to a breakdown of (different & multiple) layers of ‘symbolic formation’". This is, of course, alien to any diagnostic classification in the last 20-30 years, which have (rightly so) separated themselves from assertions about aetiology, mainly because anyone who suggests that they know what causes (all) mental illness is probably wired to the moon...

What's the Royal College of Psychiatrists really about?

The British Medical Journal this week (8 October 2011) includes advertisements from most Royal Colleges and Deaneries advertising recruitment into their specialty. Many include a brief description of the specialty. This is what the Royal College of Psychiatrists (RCPsych) says:

"Whether you are interested in hard-core neuroscience, the interface between science and the arts or simply want to know more about what makes people tick, training in psychiatry will take you into intellectual and personal places that no other specialty can."

It might seem worrying that the RCPsych is training people so that they can can better understand artistic representation of 'science', rather than focusing on the diagnosis, treatment, and management of mental illness. Similarly, the idea that training in psychiatry is about understanding "what makes people tick" is a bit like saying that cardiology is all about that thumpy-thumpy thing in peoples' chests. It's a glib simplification of the complexity of mental illness.

Perhaps, however, this is what the RCPsych sees itself doing. Not treating mental illness but ensuring that psychiatrists get to the cinema enough and taking them to all sorts of "personal places"; whatever that means. It certainly sees neuroscience as being "hard-core" rather than the substrate and mediator of all mental symptoms. The College has always been keen to hang on to 'good old' Cartesian dualism - it seems to shy away from the idea that psychiatrists might be treating brain disorders rather than 'getting to the root of the problem' or understanding "what makes people tick".

Unfortunately, in my experience many psychiatrists appear to lack both an understanding of neuroscience, psychopharmacology, and what 'makes people tick'.

If the College was really serious about recruiting the best candidates into a 21st Century specialty where the frontiers are about genetics, neurocircuitry, and modern imaging, it would embrace the concept that the brain is where it's at; rather than promoting a soft, fuzzy specialty which really wants people who like the cinema and have always wondered if Bollywood films are depicting mental illness accurately...