The Rosenhan experiment examined

The ‘Rosenhan experiment’ is a well known experiment examining the validity of psychiatric diagnosis.  It was published in 1975 by David Rosenhan in a paper entitled ‘On being sane in insane places’

The study consisted of two parts.  The first involved ‘pseudopatients’ – people who had never had symptoms of serious mental disorder – who, as part of the study, briefly reported auditory hallucinations in order to gain admission to psychiatric hospitals across the United States.

After admission, the pseudopatients no longer reported hallucinations and behaved as they ‘normally’ would.  Despite this many were confined as inpatients for substantial periods of time and all were discharged with the diagnosis of a psychiatric disorder.

For the second part of the experiment staff at a teaching hospital, whose staff had learned of Rosenhan’s above results, were informed that one or more pseudopatients would attempt to be admitted to their hospital over an ensuing three month period.  Many patients were subsequently identified as likely pseudopatients but in fact no pseudopatient had been sent.

‘On being sane…’ also examines, though the experience of the pseudopatients, the patient experience of psychiatric inpatient wards.  This part of the paper is discussed often only in passing.

Rosenhan’s conclusion was stark:  A psychiatric diagnosis is more a function of the situation in which the observer finds a patient and reveals little about a patient themselves.

“It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals“

Despite being over thirty years old the Rosenhan experiment remains well known and is often cited.  Accounts of the experiment are widespread on the internet, but critiques are rarer and many people accept the study’s conclusions at face value.

This was an audacious experiment and the subsequent paper had an extremely good title, but was Rosenhan justified in his conclusion?  Anthony Clare, amongst others, wrote that Rosenhan was ‘theorising in the absence of sufficient data’.  But if Rosenhan was correct then his experiment remains extremely important; as if diagnoses are in ‘the mind of the observer’ and do not reflect a quality inherent a patient, they are of little use.

If you wish to read the original paper it can be found here.

Spitzer’s 1975 critique is:  Spitzer, Robert L More on pseudoscience in science and the case for psychiatric diagnosis Arch Gen Psychiatry Vol 33 April 1976

Davis’s critique here.  Davis, Douglas A. On being detectably sane in insane places: Base rates and psychodiagnosis. Journal of Abnormal Psychology, Vol 85(4), Aug 1976, 416-422

Clare’s ‘Psychiatry in dissent’ is available in preview here.

Circumstances of diagnosis and the detecting of sanity.

In the experiment eight pseudopatients presented at psychiatric hospitals complaining of hearing a voice.  Asked what the voices said, they replied that the voices were often unclear, but as far as they could tell, said “empty,” “hollow,” and “thud.”  Beyond alleging this symptom, and falsifying their names and vocations, no other falsehoods were told.  Upon admission to the ward the pseudopatients are reported to have ceased to claim symptoms and behaved as they ‘normally’ would.

Length of hospitalization was an average of 19 days during which time no pseudopatients were identified as fraudulent. All pseudopatients except one (diagnosed with bipolar disorder) were discharged with a diagnosis of ‘schizophrenia in remission’.  In light of this Rosenhan regards there to have been ‘uniform failure to recognise sanity’.  Rosenhan refused to identify the hospitals used on the grounds of his concern for confidentiality.  This is laudable in some respects, but it makes it impossible for anyone at the hospitals in question to corroborate or refute this account of how the pseudopatients acted or were perceived.

It is a difficulty that Rosenhan seeks to answer whether patients can be identified as ‘sane’ or ‘insane’, whilst psychiatrists, whose practice he wishes to scrutinize, do not make such distinctions in their practice but instead aim to identify and treat what they view as psychiatric disorders.  This objection aside, and working within this terminology, in his 1975 critique Spitzer identifies three possible meanings for ‘detecting of sanity’.

  1. Recognition, when he is first seen, that the pseudopatient is feigning insanity as he attempts to gain admission to the hospital. This would be detecting sanity in a sane person simulating insanity.
  2. Recognition, after having observed him acting normally during his hospitalization, that the pseudopatient was initially feigning insanity. This would be detecting that the currently sane person never was insane.
  3. Recognition, during hospitalization, that the pseudopatient, though initially appearing to be ‘insane’ was no longer showing signs of psychiatric disturbance.

Only the first two involve identifying a pseudopatient as a fraud and Spitzer feels that it is these that Rosenhan implies are all that are relevant to the central research question.  He disagrees, writing that when the third definition of detecting of sanity is considered Rosenhan’s conclusions cannot be sustained.

This assertion hinges on Rosenhan’s report that all the pseudopatients were diagnosed as being ‘in remission’, that is recognised as being, currently, without signs of mental disorder or ‘sane’.  By this view the data as reported by Rosenhan contradicts Rosenhan’s own conclusion.  Spitzer also writes that ‘schizophrenia in remission’ was a diagnosis rarely used by psychiatrists at the time of the experiment, and as such this indicates that the diagnoses given were a function of the patients’ behaviours and not simply of the environment in which they were made.

Should a psychiatrist be able to able to detect that a patient is a fraud?  That is, should a psychiatrist be able to detect that, after observing a patient acting normally, that they were initially feigning insanity?  Rosenhan reports that this possibility was considered by the pseudopatients’ fellow patients but by no clinical staff:

“It was quite common for the patients to “detect” the pseudopatient’s sanity.  During the first three hospitalizations, when accurate counts were kept, 35 of a total of 118 patients on the admissions ward voiced their suspicions, some vigorously.  “You’re not crazy.  You’re a journalist, or a professor (referring to the continual note-taking).  You’re checking up on the hospital.” …. The fact that the patients often recognized normality when staff did not raises important questions.”

Rosenhan reports that the psychiatrists did not spend much time with the pseudopatients.  Other patients of course had ample time to formulate their own theories.  Whilst the medical staff’s lack of engagement with the pseudopatients is regrettable, it does point towards poor clinical skills rather than an indictment of psychiatric classification.  Clare again:

“Rosenhan and those many critics of psychiatry who have greeted his paper with enthusiasm seem in fact to be saying that, since the doctors did not appear to have the faintest idea as to what constitutes the operational concept of ‘schizophrenia’ and yet applied it with haste to people showing virtually no signs or symptoms whatsoever, the whole diagnostic approach should be scrapped!”

Rosenhan later wrote that he considered the patients apparent insight over that of the psychiatrists as due to the ‘experimenter effect’ or ‘expectation bias’.  The professionals expected to see a patient with a mental illness, so they looked for reasons to believe it, and eventually they convinced themselves that the pseudopatients were actually suffering from schizophrenia.

People do sometimes simulate mental illness for their own ends and this is a genuine diagnostic problem.  It is a situation not unique to psychiatry and how easily a disorder psychiatric or otherwise can be feigned tells us little about the worth of the psychiatric classification system.  Kety has something to say on this.

“If I were to drink a quart of blood and, concealing what I had done, come to the emergency room of any hospital vomiting blood, the behavior of the staff would be quite predictable. If they labeled and treated me as having a bleeding peptic ulcer, I doubt that I could argue convincingly that medical science does not know how to diagnose that condition”

Clare makes a similar point using the example that the signs and symptoms of diabetes exist independently of whether they are correctly elicited or not.

Rosenhan does consider in his paper that that a mental illness is a life sentence:

“A broken leg is something one recovers from, but mental illness allegedly endures forever”

If a disorder was known to be always chronic and unremitting, it would illogical not to question the original diagnosis if the patient was later found to be asymptomatic and it is at this that Rosenhan is presumably driving.  If the pseudopatients ‘recovered’ from an incurable illness whilst under the gaze of their psychiatrists and this did not alter the diagnosis then this would be an example, just as Rosenhan says, of the hospital environment influencing diagnostic decision making.  But in stating that mental illness is something that endures forever Rosenhan is taking a very selective view of the wide range of presentations all of which come under the umbrella of ‘schizophrenia’.  Schizophrenia has acute subtypes from which full recovery is possible and can also relapse and remit.

As for the non-existent impostor experiment it is surprising that it was agreed to by the teaching hospital in question.  The poor reliability of psychiatric diagnoses means that the design of the experiment could only produce an outcome where actual patients were incorrectly identified as pseudopatients.

Conditions on the ward

All of the pseudopatients took extensive notes.  Rosenhan makes much of this writing being “seen as an aspect of their pathological behaviour” on the grounds of the nursing entry that read “engages in writing behaviour”.  Spitzer argues that was routine for nursing staff to frequently and intentionally comment on non-pathological activities in which a patient engages to enable other staff members to have knowledge of how the patient spends his time.  As such, a comment about note taking is therefore inevitable and unremarkable.  He is struck by what he sees as Rosenhan’s actual failure to provide data demonstrating where normal hospital experiences were categorized as pathological.

Rosenhan’s account of the conditions on the psychiatric wards is, for me, the most interesting part of the paper.  The staff and patients were strictly segregated, the professional staff and especially the psychiatrists being rarely seen and having little patient contact.

“Staff and patients are strictly segregated. Staff have their own living space, including their dining facilities, bathrooms, and assembly places. The glassed quarters that contain the professional staff, which the pseudopatients came to call “the cage,” sit out on every dayroom. The staff emerge primarily for care-taking purposes – to give medication, to conduct therapy or group meeting, to instruct or reprimand a patient. Otherwise, staff keep to themselves, almost as if the disorder that afflicts their charges is somehow catching.”

This description bears resemblance to modern UK psychiatric wards.  Psychiatrists spend little time with the patients in their care and nurses are occupied for a great deal of their time sitting in a locked room doing paperwork.  The healthcare staff members with the most patient contact are the least qualified.  This is far from ideal, and a target for improvement, but it should be noted that within healthcare this distance between staff and patients is not restricted to psychiatric wards and the pressures on staff due to the number of patients in their care means that a more desirable personal service is something with which the NHS struggles in all its domains.

Rosenhan’s description of the depersonalising effect of a long stay on the wards is also powerful.  Despite their commitment to the experiment in which they are taking part, their wish to resist the powerlessness they experience leads several of them to jeopardise the study.

“The patient is deprived of many of his legal rights by dint of his psychiatric commitment. He is shorn of credibility by virtue of his psychiatric label. His freedom of movement is restricted. He cannot initiate contact with the staff, but may only respond to such overtures as they make. Personal privacy is minimal. Patient quarters and possessions can be entered and examined by any staff member, for whatever reason. His personal history and anguish is available to any staff member (often including the “grey lady” and “candy striper” volunteer) who chooses to read his folder, regardless of their therapeutic relationship to him. His personal hygiene and waste evacuation are often monitored. The water closets have no doors.”

Attendants were reported to deliver verbal and occasional physical abuse to patients, something that can in no way be justified.  Rosenhan’s report of this leads to an interesting inconsistency.  Despite initial descriptions of abusive staff behaviour, in his conclusion Rosenhan describes the staff as overwhelmingly ‘committed and … uncommonly intelligent’.  Spitzer considers that this is because of Rosenhan does not wish to direct attention toward shortcomings of the staff, rather wishing to concentrate on diagnostic labels.

Validity of diagnosis.

There are two issues here.  Where the psychiatrists who met his pseudopatients wrong to make a diagnosis of schizophrenia within the DSM II diagnostic framework? And are psychiatric diagnoses of use or should they be replaced by an alternative?

The ease with which the pseudopatients gained admission on the basis of what are reported to be mild symptoms was remarked upon by Anthony Clare in Psychiatry in Dissent.

“It is a matter of some interest that a solitary complaint of a hallucinatory voice in the absence of any other unusual experience or personal discomfort should actually persuade certain American hospitals to open their doors.  Such is the current demand for a psychiatric bed within the National Health Service and the prevailing emphasis on treating patients outside hospitals and in the community that the average admitting doctor in Britain is likely to find himself under strict instructions to avoid admitting any patient who can see, speak, and do all of these things without bothering himself or others to an significant extent.  On suspects that, in Britain, Professor Rosenhan might well be advised to go home like a good man, get a decent night’s rest and come back again in the morning.”

And many people have been critical of the way the pseudopatients were diagnosed with schizophrenia on the basis of hallucinations – a single symptom and not even essential for the diagnosis.  Anthony Clare again:

“…the doctors did not appear to have the faintest idea as to what constitutes the operational concept of ‘schizophrenia’ and yet applied it with haste to people showing virtually no signs or symptoms whatsoever…”

Spitzer remarks that the doctors should have been wary of making a diagnosis of schizophrenia in a previously unknown patient presenting without any history of insidious onset.  However he is more lenient toward the pseudopatients’ psychiatrists, writing that, given the information available, schizophrenia was the most reasonable diagnosis.  Davis and Weiner agree, respectively arguing from statistical and attribution theory standpoints that schizophrenia was the most likely diagnosis.  Rosenhan himself presents no differential diagnosis.

Hunter takes exception to Rosenhan’s assertion that the pseudopatients acted ‘normally’ in the hospital:

“The pseudopatients did not behave normally in the hospital.  Had their behaviour been normal, they would have talked to the nurses’ station and said “Look, I am a normal person who tried to see if I could get into the hospital by behaving in a crazy way or saying crazy things.  It worked and I was admitted to the hospital but now I would like to be discharged from the hospital”.

We in fact learn very little about the diagnostic process beyond the initial presentations of the pseudopatients.  It should be noted that the pseudopatients would likely not have been, unlike Rosenhan’s assertion, admitted on the basis of their hallucinations solely.  Their presentation to hospital and request for admission may also have carried diagnostic weight as it suggested much greater distress.  However, whatever the fine detail, throughout their stay, the pseudopatients do not appear to have been assessed in detail.

The poor diagnostic skills and apparent lack of curiosity of the psychiatrists that the pseudopatients met is not an indictment of the classification per se, rather its application.   The Rosenhan paper offers no insight as to why psychiatric classification had developed into the shape that he found it in 1973.

The purpose of a disease classification system is that it allows healthcare professionals to:

  • Communicate with each other about the subject of their concern
  • Avoid unacceptable variations in diagnostic practice
  • Predict their outcome disorders and suggest a treatment.
  • Conduct research

Amongst others Richard Bentall has made a career out of pointing out that psychiatric diagnosis is neither particularly valid nor reliable.  However in Spitzer’s view the historical precedent is that classification in medicine has always been preceded by clinicians using imperfect systems.  These have then improved on the basis of clinical and research experience.  The clinician is forced to do the best he/she can until something better comes along.

In contrast to psychiatric disorders, the diagnosing of physical medical conditions is often portrayed as being solid and dependable.  This does not bear close inspection, as many medical conditions are at least as vaguely described as psychiatric disorders.  Although it is true that by-and-large a physical illnesses diagnosis rests on biological ‘facts’, the accompanying negative impact on person is the most important factor and this is highly subjective.  For instance we all have bacteria in the back of our throats, but do not consider ourselves to have an infection.

In light of his experiment, rather than the syndromal classification system, Rosenhan would favour a classification system based on behaviours:

“It seems more useful … to limit our discussions to behaviours, the stimuli that provoke them, and their correlates”

Yet despite this early on in the paper he writes that “Anxiety and depression exist”, suggesting he favours an ad-hoc classification system at least.


Rosenhan concludes:

“It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals. The hospital itself imposes a special environment in which the meaning of behavior can easily be misunderstood. The consequences to patients hospitalized in such an environment – the powerlessness, depersonalization, segregation, mortification, and self-labeling – seem undoubtedly counter-therapeutic.”

There are sufficient objections to the design of Rosenhan’s experiment – not least that his study consisted of only eight subjects- to doubt whether he is justified in writing his initial sentence.  Rosenhan’s observational study of conditions on psychiatric wards – to which the rest of the above paragraph alludes – still has relevance today and remains a note of caution for anyone who works in mental health.


Mind changers 27 July 2009 Radio 4: The pseudopatient study

“Who wants to be a psychiatrist?” London Division academic day May 20 2010

“Who wants to be a psychiatrist?” a London Division academic day, was an interesting day of talks, workshops and discussion examining reasons and solutions for the current problems of UK psychiatric recruitment.

Prof Robert Howard, Dean of the Royal College of Psychiatrists, perhaps summed the current situation the most baldly.  “The recruitment crisis is the biggest challenge psychiatry faces”.  Concerning, he also said that this is leading to an “unacceptable variation in quality amongst trainees and consultants”.

The situation does indeed appear to be dire.  This year the London Deanery received 250 applications for core training posts, down from 400 in previous years.  In the country as a whole the competition ratio of applicants to psychiatric training to jobs available is 1:1.  The result, as Michael Maier, head of the London Specialty School of Psychiatry put it, is that “psychiatry is a recruiting, not a selecting specialty”.

Yet despite this, a recent Royal Society of Medicine study found that, alongside general practice, it was doctors who worked in psychiatry who found their lives the most satisfying.  The popularity of the study of psychology suggests that, amongst school leavers, a general lack of interest in the mind and its problems is not a problem; however again and again, upon leaving foundation jobs, doctors in training choose other specialities for a career.

How could this have come about?  Prof Ania Korszun from Barts and the London suggested three culprits: psychiatry is seen as not ‘medical’ or ‘scientific’ enough; psychiatry recruitment suffers by association with the widespread popular stigma surrounding mental disorder; and medical students are discouraged from psychiatric careers by the negative views held by doctors working in other specialities with whom they spend much of their training.

This relentless disparagement directed towards the ears of impressionable medical students appears to be particularly potent.  Dr Gianetta Rands, who talked about psychiatry as a part of foundation training, told us that the longer medical students spend in non-psychiatric specialities the less likely they are to choose a career in psychiatry.  The split between acute trusts and mental health trusts also means that psychiatrists are rarely present – be it at grand rounds or in the canteen – to put forward an alternative viewpoint.  It has been recognised that more psychiatry foundation year placements are required, especially in year one.  There are currently 500 placements over both years, but 2000 are needed.

Psychiatry undoubtedly has an image problem and Dr Peter Byrne, chairman of the Royal College of Psychiatry’s public education committee, presented a fascinating talk about the profile that psychiatrists have in the media and also our role as ‘evidence based public educators’.  An interesting insight was that whilst newspaper stories about physical health most often concerned the stereotype of ‘bad patient’, those concerning mental health focus on that of the ‘bad doctor’.  The recent BBC programme Mental: A history of the madhouse is an example of this.  Dr Byrne encouraged media engagement by psychiatrists and this theme was further examined in a workshop run by Dr Mark Salter, the event’s organiser.  Other workshops tackled writing skills, running student psychiatric societies and making a psychiatric documentary.

Given the current situation, it might have been possible to find some of the messages of the day dispiriting.  Fortunately there were many moments of levity and an overall note of optimism.  Dr Chris Manning, a GP with experience of mental health services from both sides, praised psychiatrists and delivered an enthusiastic panegyric: “Minding the brain – the best job in the world”.  Dr Kate Stein, a foundation doctor, was equally enthusiastic when she told us about her plans for a psychiatric career.  The active role of medical students present as delegates was also welcome and encouraging.

Of course it is not simply enough to identify a problem and there is a plan of action, in which – amongst others – Prof Howard, Dean of the College, is taking a special interest.  He wishes to raise the profile of psychiatry, especially with medical students, and to make medicine in general ‘more psychiatric’.

The day closed with a rabble rousing talk from Prof Simon Wessely “Why psychiatrists still need to be doctors”.  Prof Wessely convincingly argued that patients both want and need their mental health disorders to be treated by psychiatrists who are also doctors.  He spoke of the value of our ability to make a diagnosis and in our use of the biomedical model.  Psychiatrists’ ability to distinguish physical from psychiatric disease makes us indispensible to our physical medicine colleagues.

Psychiatry has in fact never recruited as many UK trained doctors as it needs to fill its posts and in seeking to reverse this phenomenon we seek to overturn a historical precedent.  Improving the situation requires action on many fronts.  It particularly concerns me that we may be recruiting the wrong mix of students to medical school, as current science focused selection criteria favours technical knowledge over a candidate’s potential to flourish into the practitioner of holistic medicine that psychiatric practice requires and may preclude those who will eventually wish to take the path required by psychiatric practice.  A central message of “Who wants to be a psychiatrist?” is that we can all become involved in this debate and every day should regard ourselves as “walking, talking adverts for psychiatry”.


Originally published in the June 2010 newsletter of the RCPsych London Division


Image credit Wikipedia

Web 2.0 and evidence based health and mental health

wenb 2.0

I’ve been writing an article on Web 2.0 and evidence based medicine, which will appear on this site once it is published.

In the meantime here are the resources I came across, should anyone be interested:


Evidence based medicine: what it is and what it isn’t BMJ 1996;312:71-72 (13 January)

How web 2.0 is changing medicine BMJ  2006;333:1283-1284 (23 December)

The effect of web 2.0 on the future of medical practice and education: darwikinian evolution or folksonomic revolution?

Wikis, blogs and podcasts: a new generation of web-based tools for virtual collaborative clinical practice and education


How and why junior physicians use web 2.0

The web 2.0-EBM medicine split [1] introduction to a short series

Wishful thinking in medical education

Image source: Wikipedia

Frontier Psychiatrist Election Special: “Another bad election for bald people”


A time of writing the early results suggest that the May 6th UK general election will produce a slim Conservative victory. Time then to address an issue that has rarely been touched upon in the mainstream election run up: bald men have an unfortunate record in British politics. Indeed, if one thing unites the three candidates for Prime Minister it’s that none appear to have any hair loss. Granted Brown does wears his fringe long which raises the possibility that he is wearing a toupee. If this is the case, I suggest that he remove it.

The last bald Prime Minister of the UK was Jim Callaghan, beaten by Margaret Thatcher in 1979. Since then we’ve John Major (full head of hair), Blair (thinning yes, but not actually bald) and Brown (full head of hair). In elections the bald man consistently loses – Hague and Howard were seen off comprehensively by Blair. Hague in particular was pilloried for his appearance, regularly being compared to a Mekon – the bad guys in Dan Dare, pilot of the future. Iain Duncan Smith was never even allowed to contest an election.

Leaders aside, if the Conservatives do form the next government then William Hague could hope to become Foreign Secretary.  An achievement indeed, but considering that 25% of men are balding by the age of 30, bald men are still poorly represented in both the current (probably) outgoing Labour cabinet and Conversative shadow cabinet. The Labour cabinet has 3 (out of 22, 3 women) the Conservatives 4 (out of 32, 7 ladies). Bald men have as poor a representation in the higher echelons of power as women. Quite an achievement.

It’s worse for bald Americans.  It was during the 2004 election the Democrat Candidate John Kerry was quoted as saying “We’ve got better vision, better ideas, real plans. We’ve got a better sense of what’s happening to America and we’ve got better hair”. “There goes the bald vote,” Teresa Heinz Kerry told her husband. Kerry lost the election and may still be reflecting on his insensitive comments.

It’s difficult to place the last bald President of the United States. It was actually Gerald Ford, who was never actually elected as either a President or Vice President. He ran for President in 1976 and lost to Jimmy Carter (full head of hair) and only one bald man has run for president since. Carter lost to Reagan (full head of hair) in 1980. Reagan vs Mondale (full head of hair) in 1984. Bush Senior (full head of hair) vs. Dukakis (full head of hair) 1988. The Bush Senior vs Clinton (full head of hair). Then Clinton vs. Dole (full head of hair), Gore vs Bush Jr (full head of hair), Bush Jr vs Kerry (full head of hair), and most recently Obama (full head of hair) vs. McCain. McCain was balding and lost.

It’s Russia, a country otherwise untouched by sense, were that a more enlightened approach prevails when it comes to recognising the virtues of bald men. Very fairly the bald and non-bald take it turn about: Putin (baldish), Yeltsin (hair), Gorbachev (no hair), Chernenko (hair), Andropov (no hair), Brezhnev (hair), Khrushchev (no hair), Stalin (hair), Lenin (no hair).

And does anyone think that, on the BBC coverage, Andrew Neil’s thatch was somewhat unlikely…..


Bald truth about attracting voters
Can bald men win elections

Addendum 7 May 1415hrs.  Tories may form a minority government with Lib Dems.  I’ve received no reponse from those in politics to the above.

A trainee on Triage: a brave new paradigm for acute inpatient units?


Here is a piece I wrote for the RCPsych London division December Newsletter.  It’s about Triage ward on the Ladywell unit in Lewisham.


Triage ward is one of five general adult wards serving the inpatient psychiatric needs of the Lewisham area.  It is based in Lewisham hospital and is part of the Ladywell Unit which in turn is part of the South London and Maudsley NHS Trust (SLAM).  Judging by the number of visitors we have had to the ward whilst I have been working here, there is a great deal of interest in the way we do things. 

Triage ward is part of an unusual model for managing psychiatric admissions, and one that is soon to be implemented across SLAM.  As a ward it acts as a single point of admission for all patients who enter the Ladywell unit.  It is aimed that patients will stay for a maximum of two weeks, whilst their needs are considered.  If, after this time, they need to continue as an inpatient for a further spell, they are then transferred to a longer stay ward.   This model contrasts to the established paradigm whereby ward allocation is sectorized, where patients are on admission immediately assigned to wards depending on their postcode or the location of their general practitioner and there is no envisaged limit on admission duration.  The impetus for establishing Triage was a desire to address common problems found within psychiatric in-patient units where wards are busy and overcrowded, leading to patient overspill into the private sector and a high staff turnover.  It was established in 2003 by Dr Martin Baggaley, who is now medical director of SLAM.

Triage is a mixed ward and its maximum capacity is 16 patients.  Asides having an airlock and being more secure, it looks much like any other inpatient psychiatric ward, although newer than some.  The provision of staff is generous compared to other sites and asides a contingent of skilled nursing staff, there are two CT1-3s doctors, a ST4 doctor, two part time consultants (full time equivalent), and a social worker. 

Triage’s aim is that, after admission, patients should have their needs met and be discharged to the community or another ward as quickly as possible and much of what we do has this goal in mind.  The turnover of patients is extremely high and amounts to 920 patients per year.  There can be as many as four new patients in a day across a wide ethnic mix.  Some patients seem to go before one has even met them and after a returning from a week’s annual leave the ward’s inpatients will have almost completely changed.  This constant flux means it’s difficult to form a rapport with any of the patients.   The life of a junior doctor is very busy and a recent new duty is a completion of an OPCRIT computer based diagnostic assessment for each patient.  Unlike other SHO jobs, time constraints mean that we don’t complete the patient discharge summaries and this responsibility is passed onto the ST4 trainees.  Fellow CT trainees on other wards are jealous of this concession!

A lot of my work is administrative, which can be dull but in compensation there is plenty of opportunity to learn at the consultant lead ward round, which is held daily to ensure swift patient movement through the system.  Here my role is to make interview and management plan notes and this is done on a computer terminal which is projected for all to read.  With two different consultants it is possible to observe different interviewing styles.  I have found interviewing more difficult than I expected and my ability to undertake a mental state examination has much improved.  The presentations of our patients are very varied and sometimes the ward rounds can be quite dramatic.  About half of our patients are under section at any one time and, much is as one might expect, depressive, psychotic and personality disordered presentations predominate.  We work closely with the local crisis resolution service and a member of their team is often present.  The downside of such regular ward rounds is that with senior doctors so regularly available, there’s little latitude for independent thought. 

Triage might perhaps appear foreboding to the uninitiated.  The ward and staff base can feel as busy and noisy as general medical wards post take, but there are plenty of calm periods too.  The staff base is shared between doctors and nurses.  This makes for good multi-disciplinary communication and although we’re short of computer terminals this is never a cause of friction.  I have however become resigned to our second printer being permanently broken.  There can be an air of unpredictability and the ward panic alarm is activated a lot.  I’ve never felt personally threatened, although it’s not unheard of for a member of the nursing staff to be assaulted.    

Patient treatment is predominantly medication based and I think it’s a shame that there are no psychologists on the ward, but there is a social worker available to address social needs, which oftentimes is the most important thing.    The air conditioning we have is a mixed blessing as patients often complain of being cold in bed at night.  The ward environment is rather boring for the patients, although there is a daily newspaper and a table tennis table; the nature of the disorders with which we deal means that some patients, who might wish for peace and quiet, are disturbed by other more vociferous residents. 

Overall my experience of working on Triage ward has been very positive.  On other wards on which I have been employed patients can sometimes be admitted for several days before they are seen by a consultant, an experience that can be very frustrating.  However on Triage ward, with its daily ward round, things move much more quickly and it is also hard not be impressed by the financial savings Triage has bought to the SLAM trust, as it is now almost unheard of for a Ladywell patient to be accommodated in the private sector.

The state we’re in: London cycling


Perhaps it’s the congestion charge or the increased provision of cycling lanes, or maybe we’re inspired by high profile cyclists Boris Johnson and David Cameron, but cycling in London has risen by a staggering 70 per cent since the year 2000. Corresponding with this newfound popularity, the profile of London cycling has risen dramatically and, previously, a pursuit for the foolhardy, the joys and tribulations of a daily bicycle commute are now a favorite dinner party conversation topics for the chattering classes.

One feels that the British capital’s roads would sport even more cyclists were it not for lingering concerns over safety. There has been a recent upsurge in cycle related injuries as well as collisions with pedestrians.  Stark reminders of the vulnerability of cyclists are the ‘ghost bikes’ which can be seen chained to railings at several major junctions across the city. If the amount of copy in national newspapers such as the Guardian is anything to go by, the lobbying power of cyclists is increasing and most of this is focussed on increasing safety. The majority of concerns are about careless driving and cycling organizations such as the CTC, the organisation formerly known by the rather quaint name of the Cyclists’ Touring Club, like to paint a picture of cyclists as a saintly breed, innocent victims of the negligence of others.  A website has recently been launched to address this issue, its title drawn from the allegedly popular excuse for a near miss: “Sorry mate I didn’t see you”.

Users of the site are invited to document instances of bad driving. And yet, individual cases aside, anyone who uses London’s roads knows that this vision of cyclists as entirely innocent does not bear scrutiny. Occupying as they do a dim and ill-defined hinterland somewhere between motorised vehicles and pedestrians, strict adherence to the Highway Code seems not to have caught on.  High visibility clothing and lights at night are eschewed. The conscience of the average London cyclist appears untroubled by flouting traffic lights and any visiting pedestrian will quickly learn, as residents already have, that many cyclists have no intention of stopping for crossings. One feels that the true motivation for some bike commuters are not those of pursuing alternative modes of transport, but rather that they could no longer go sufficiently fast in their cars.

The current distain shown by four wheels for two and two wheels for two legs can perhaps best be understood in two ways. Firstly as a competition between different groups for road space and speed, both scarce resources in an ancient and ‘un-designed’ cities like London and Dublin. It is a neat coincidence that when sociologists talk of the propensity of a societal group to mistreat those directly below it on the social ladder they talk of the ‘bicycling reaction’, so named as just like a cyclist the group bows to those in before it and kicks those below.  The treatment of pedestrians by London cyclists is not so dissimilar. Secondly, some of the quasi-conflict appears to have its roots in class. Cyclists are predominantly from higher socio-economic groups who can afford to live within cycling distance of work. Conflict, then, as much about people seeking to demonstrate their difference from – and superiority to – others as it is to getting anywhere quickly.

It would be nice to see people improving their behaviour without police crackdowns or yet more Government leglisation – and before the current cycling paradigm becomes so engrained that it is part of the Londoner’s character. Cyclists will certainly get no encouragement to change from the CTC, which has written in support of cycling on pavements.   Many seem to think that, simply by virtue of their being likely to come off worse from collision with a motorised vehicle, cyclists occupy the moral high ground. They do not. Cycling should be encouraged, but a sober reassessment of the behaviour of cyclists rather than blind support of their rights on the road would be the most appropriate.

Cycling has much in its favour: it is quick, cheap and increases fitness. As a result there are plans for a massive increase in cycling provision across Britain, but this will only work if cyclists begin to play by the rules.  Boring, I know.

Also published on

Photograph credit

US healthcare reform in turmoil

I was out for dinner with a New Yorker friend of mine recently. She’s British, but she’d brought along an American friend and I happened to mention to him how much I was digging President Obama. Things deteriorated from there. “Obama is a socialist!” the heads of the rest of the table turned, as the conversation up until that point had been about interior furnishings.

“I don’t think that you appreciate what a socialist is” I replied. “You should try living in France; America doesn’t have a party of the left. All you’ve got is centre and right”. The conversation then moved onto healthcare, which was proposed as an example of where liberal economic theory fails to deliver. Our American friend was undeterred by this argument.

“It’s possible to get free healthcare in the United States” he opined. “People come into a hospital sick and get treatment, and once they’re in, the hospital can’t throw them out”

I’ve been thinking about this curry-fuelled conversation over the past few days whilst reading about Obama’s troubles in pushing healthcare reform, something he considers to be the most important aim of his presidency. To the European bystander, US healthcare would seem to be in desperate need of attention. Despite the United States being the world’s richest country, millions of its people do not have healthcare cover and anyone who’s seen Michael Moore’s film Sicko will know that even those with cover can find themselves severely financially compromised by the payments they are forced to make. The system costs more per head than anywhere else in the world, but yet is only rated 37th in comparison to other countries. The effects have been felt beyond that simply of the individual; the struggling General Motors sites the healthcare costs of its staff as a significant contribution toward its instability (link to Washington Post but no longer available).

Why then are some American right so vociferous in their opposition of reform? Meetings of members of Congress who are trying to promote Obama’s plans are frequently being disrupted and Congressman David Scott had a swastika painted outside his office. It seems that healthcare reform is being equated with increased state invention in the lives of citizens something that is, in the minds of some, directly comparable to fascism. Former Vice-Presidential candidate Sarah Palin – whom, for what it’s worth, I entirely loathe – is not shy of this imagery. She wrote on her blog, in a gross characterisation of the Obama proposals:

…the America I know and love is not one in which my parents or my baby with Down’s syndrome will have to stand in front of Obama’s ‘death panel’ so his bureaucrats can decide, based on a subjective judgment of their ‘level of productivity in society’, whether they are worthy of healthcare. Such a system is downright evil.

Here and elsewhere the NHS has been getting caught in the crossfire.   Palin is presumably referring to NICE’s attempts to decide whether expensive drugs provide value for money.  Republican senator Chuck Grassley has also confidently said that, under the NHS, Senator Edward Kennedy would be left to die untreated for his brain tumour.

Misinformation must be blamed for the violent reaction to the possiblity of health care reform, but if I was an American I would be more concerned about the wider issues. If the society that the Americans have built is simply not coherent enough for people to wish to contribute toward the health of their fellow humans then it is in urgent need of reevaluation. Those without healthcare should not simply be the disparaged “them” of my dinner companion’s discourse. For universal healthcare to work “us” is the most important word.


I should point out that I do not consider myself to be “anti-American”.  An interesting read on the subject is The Eagle’s shadow: Why America fascinates and infuriates the world by Mark Hertsgaard.  Also BBC North American correspondent Justin Webb wrote this interesting piece for Radio 4’s From our own correspondent recently.

Independent: Is US healthcare so bad that it needs a lesson from Britain? – Q&A
Guardian: US Healthcare
Guardian: Debate over US healthcare reform takes an ugly turn
Guardian: ‘Evil and Orwellian’ – America’s right turns its fire on NHS
Guardian: This NHS row is paralysing progress – if you only read one of these links make is this one

BMJ Blogs: Is it unpatriotic to criticise the NHS?


Addendum Mark Mardell on From our own correspondent

Reader, I went to a complementary therapy debate and had these thoughts

I went to a debate on complementary medicine recently, hosted by the KCL Social Medicine Society.  Despite being held on Guy’s Hospital Campus, a supposed stronghold of conventional medicine, the lecture theatre was awash with complementary therapists and when the pre-debate votes were taken the numbers were two to one against critics – like me – of complementary practice.

The speeches for and against the motion, although equally disadvantaged by the lack of anticipated audiovisuals, were, by and large, as I had expected as they rehearsed well known arguments on medical evidence and the primacy of double blind randomized control trials.  What I hadn’t been expecting was the degree of tension between the two viewpoints; for instance several audience members felt regularly moved to heckle Simon Singh, co-author of Trick or Treatment – a paean to evidence based medicine, not content that he is already subject to a libel lawsuit from the British College of Chiropractors.

After the addresses, relations deteriorated further when participation was invited from the floor.  It wasn’t just that some of the points made were verbose and closer to statements than actual questions, the vehemence of the complementary therapy supporters disagreement with a conventional medical approach was striking.  It was almost as if they felt that those opposing their view not only disagreed with them, but did so malignly with murderous intent.

Of course the sample of people I saw was self-selecting, but why would people feel so strongly that conventional medicine, and by extension doctors, wished them ill?  A partial answer as to the schism between complementary and conventional medicine is provided by Bad Science guru Ben Goldacre, who in his recent book lists reasons why ‘clever people believe stupid things’.  His argument is psychologically based: people are biased; see patterns where there is only random noise; see causal relations where there are none and overvalue and seek out confirmatory information.  From these beans a beanstalk grows all the way up to Matthias Rath.

I don’t doubt Goldacre’s assessment, but it cannot wholly account for the hostility which I witnessed.  The supporters of complementary medicine at the debate seemed to feel entirely disenfranchised by conventional medicine, and alienated even from cordial debate.  The root of this emotional intensity may be that although the majority of people tolerate the NHS’s faults and are basically satisfied with the service they receive, some people’s experience of conventional medicine can be poor.  Consider the people who feel unheeded by their doctor who can only allot them seven minutes, or those upset and resentful about their parent who died from the effects of chemotherapy; or those suffering from medicine side effects or whose operations lead to complications. For some, it won’t just be the message, but the messenger too: doctors nearly all come from a privileged swathe of society and our relative erudition and advantage will make some patients, whose achievements may on the face of it seem more humble, feel unpleasantly diffident.

Other factors against doctors are wired in from our training.  Despite modern efforts, it all too rarely leads us to heed that a patient’s experience of receiving their healthcare can be even more important than the healthcare itself and we still tend to see people in terms of aggregations of symptoms, ignoring that most of our patients come to see us for reasons only partially related to an identifiable disorder.  Although improvements have been made and medical schools have pulled up their socks, the MRCPsych and other membership exams give pitiful consideration to the cultural forces behind poor health.    Overall, and especially post graduation, our manner with our patients and our ability to help them in any way beyond a narrow biomedical confine it is not treated as central to what we do but rather something we are expected to pick up as we go along.

Could complementary therapy for its staunch adherents be then one in the eye to all the people like doctors who ‘think they’re clever’ and fail to adequately assess or understand patient difficulties?  Is it an inevitable outcome as the result of some people wishing for a more equal partnership for healing? For the disenfranchised, complementary medicine may be something that they can own, and a haven from the people whose education unfortunately makes them seem intimidating and unapproachable.

Addendum 4 June 2009:  In an earlier version of this email I used the spelling complimentary as in ‘to offer praise’ rather than the correct complementary as in ‘to act as an accompanyment’.  Gradually chipping away at my ignorance….  Indebted to TimA for his wise counsel.

Guardian A sceptical inquiry 9 March 2009

The Velvet Underground at the NY society for clinical psychiatry

John Cale, Welshman, and former member of seminal rock band the Velvet Underground was interviewed in the Guardian this week.

… what about the night Andy Warhol got the Velvet Underground to play a convention of psychiatrists at Delominco’s steak house? The psychiatrists were appalled. “That was revenge – Lou’s revenge,” Cale says, “and I was all for it.” As a teenager, Reed had been given electric shock treatment to “cure” him of homosexuality. “Lou and I were going to put out a record with his psychiatrist’s letter on one side and my arrest record* on the other,”

The Velvet Underground were a band formed in the mid-1960s by Lou Reed and John Cale together with Mo Tucker and Stirling Morrison.  Although their lifespan was brief they combined the energy of rock with the sonic adverturism of the avant-garde.   Pop artist Andy Warhol was their manager and their first album famously featured a large yellow banana sticker and the instructions ‘peel slowly and see’.  Andy Warhol had been invited to speak at the annual banquet of the New York Society for Clinical Psychiatry and he decided to take the the band along with him as ‘a kind of community action-underground-look-at-your-self-film project’

The psychiatrists who turned out in droves for the dinner, were there to be entertained – but also, in a way, to study Andy. “Creativity and the artist have always held a fascination for the serous student of human behavior,” said Dr. Robert Campbell, the program chairman. “And we’re fascinated by the mass communications activities of Warhol and his group.

“I suppose you could call this gathering a spontaneous eruption of the id,” said Dr. Alfred Lilienthal. “Warhol’s message is one of super-reality,” said another, “a repetition of the concrete quite akin to the L.S.D. experience.” “Why are they exposing us to these nuts?” a third asked. “But don’t quote me.” source

I really wish I could have been there.

The second the main course was served, the Velvets started to blast and Nico started to wail. Gerard and Edie jumped up on the stage and started dancing, and the doors flew open and Jonas Mekas and Barbara Rubin with her crew of people with camera and bright lights came storming into the room and rushing over to all the psychiatrists asking them things like:

What does her vagina feel like?
Is his penis big enough? Do you eat her out?
Why are you getting embarrassed? You’re a psychiatrist; you’re not supposed to get embarrassed…. source

The New York Times reported on the event the next day under the heading, ‘Shock Treatment for Psychiatrists’

Excerpt of the performance

Addendum 17 May 2009:

I found a further account of this in the book Women’s Experimental Cinema by Robin Blaetz.  She’s talking about Barbara Rubin, an underground film maker and a player in Warhol’s factory:

On January 13 1966, Warhol was invited to be the evening’s entertainment at the NY society for Clinical Psychiatry’s forty thir- annual dinner, held at Delmonico’s Hotel. Bursting into the room with a camera, as the Velvet Underground acoustically tortured the guests and Gerard Malanga and Edie Sedgwick performed the ‘whip dance’ in the background, Rubin taunted the attending psychiatrists. Casting blinding lights in their faces, Rubin hurled derogatory questions at the esteemed members of the medical profession, including: ‘What does her vagina feel like? Is his penis big enough? Do you eat her out? As the horrified guests began to leave Rubin continued her interrogation: ‘Why are you getting embarrassed? You’re a psychiatrist; you’re not supposed to get embarrassed. The following day the NY Times reported on the event; their chosen headline, ‘Shock treatment for psychiatrists’, reveals the extent to which Rubin’s guerrilla tactics had inverted the sanctioned relationship between patient and doctor expert and amateur.

Addendum 18 May 2009: Mindhacks has featured this also

*Cale had been previously arrested for possessing chemical substances.

Urban living, migration and mental health

The history of the last two hundred years of humankind is the history of the city. In the world there are now more than 90 cities with populations in excess of 3 million people and 19 megacities with populations over 10 million. By contrast two thousand years ago, when the world population was approx 200 million, there were only 40 cities with more than 50 000 inhabitants. The population density of central London is now in excess of 10 000 people per square kilometre.

Their invention is relatively recent. Initially we, humans, lived our lives as hunter gatherers, living off nuts and berries with a population density a roomy one person per square kilometre. Then, seventy thousand years ago we began migrate from the African plains and ten thousand years ago nomadic societies began to give way to those which were settled and agricultural. These pastoralists were advantaged in that they could feed greater numbers of people and support a higher density of population. The downside was that their diet was less varied and that they were a sickly bunch, as with people now living in close proximity to their domesticated animals many diseases like influenza jumped the species barrier.

Cities have provided their inhabitants with an enormous number of benefits. There are improved opportunities for jobs, education, housing, and transportation. Universities have been founded and specialised health centres are possible. The breath of entertainments can satisfy every whim. Urban areas can also have much more diverse social communities allowing others to find people to whom they relate whom they might not be able to meet in rural areas. In fact it’s hard to imagine that many of the things we regard as everyday parts of modern life if people had not been able to live in the close proximity that city life makes a possibility.

But, the story of cities is not only the story of the people they serve ably. Life in a shanty town on the edges of a Sal Paulo or on a on the outskirts of Manchester sink estate is unlikely to offer any of these advantages. For many people, especially those in less developed countries, greater urbanization is likely to bring only poverty and disease. Even for people not so far down Maslow’s hierarchy, problems can abound as social bonds are often much looser and more fluid in cities than in smaller rural communities and rather than fit into those prexisting, city dwellers are forced to build their own social networks. Furthermore, modern social forces, mostly city based, have lead to an increasingly flexible employment market with more reliance on short term contracts and part time positions. This breeds uncertainty, stress, fuels competition and encourages us to see our colleagues as rivals and potential threats.

Thus, for almost anyone, cities place complex demands with concomitant stress. These circumstances appear to affect the proportion of the population suffering from mental illness. This urban settings effect is most acutely observed for schizophrenia, a disorder which occurs more commonly in cities. There are two competing hypotheses as to why this should be so. The ‘drift’ hypothesis suggests that urban environments attract selective migration of preschizophrenia individuals. On the other hand the ‘breeder’ hypothesis suggests that cities precipitate psychosis in genetically vulnerable people by the stress of social isolation and complex cognitive demands that characterise inner city life. Ultimately both are likely to contribute, and mental illness may be a cause or consequence of social isolation. A 2004 survey of all Swedes between ages 25 and 64 revealed that people living in the most densely populated had almost twice the rate of psychosis of those in the least populated areas.

Cities also tend be the home of migrants. In 2001 4.9 million people in the UK were born overseas, twice 2.1 million in 1951. Decade 1991 to 2001 saw the biggest leap in immigration to the UK – 1.1 million – since before the second world war. Migrants suffer the travails of city living, only more so; the upheaval of being uprooted from their homeland, having to cope with a strange new culture, learning a new language. Studies in London, Nottingham and Bristol found that schizophrenia is nine time as common in African Caribbean people and six times as prevalent in black Africans as in the white British population. Non migrant Afro-Carribeans and Africans do not have similar rates of illness; misdiagnosis by racist doctors has mostly been discounted as the cause for this difference. Soberingly the UN Global commission on international migration notes that:

Migrants are often viewed with suspicion by other members of society. In parts of the world certain politicians and media outlets have found it easy to mobilize support by means of populist and xenophobic campaigns that project systemically negative images of migrants…first generation migrants suffer disproportionately from physical, mental and reproductive health problems…they have lower educational attainments than nationals and generally live in poorer quality accommodation. Migrants also tend to occupy low-wage and low-status jobs and are more likely to suffer from long-term unemployment than other members of society (chapter 4)

Our species, homo sapiens, is thought to have originated 200 000 years ago. Full behavioural modernity, including language and music is thought to have emerged 50 000 years ago. Thus, compared to the age of our species, the city as a place to live is a relative new comer and it is perhaps small wonder that organise city living to everyone’s benefit, and that the project as a whole is still causing problems. The connection of mental illness to city dwelling suggests that we will be unable to fully address the problems of this problem until we have address wider issues of poverty.


An interesting fact (gleaned from a Robin Murray lecture): The incidence of schizophrenia in a particular area is predicted by the proportion of the population who vote in a General Election. The thinking is that If you live in an area where there is a sense of community and cohesiveness, then there is generally a higher percentage of people who vote, and lower incidences of schizophrenia. In a disorganised area, where nobody votes, and nobody knows their neighbours, there is lower ‘social capital’, and higher rates of schizophrenia. (see comment below for clarification on this)

Jared Diamond The rise and fall of the third chimpanzee is informative about hunter gatherers and is a generally excellent book

Paranoia: a 21st century disease is informative about urban living and its effect on mental health