Pigeons, meet cat: "The Hans Eysenck affair: Time to correct the scientific record"

I'm heading off-piste with my musings today, drawing your attention to a paper by Anthony Pelosi [1] and an accompanying editorial by David Marks [2] (both open-access) that are likely to 'put the cat among the pigeons' in some quarters (with thanks to Matthew Dalby for bringing the Pelosi study to my Twitter attention). Indeed, the publishing journal - The Journal of Health Psychology - is no stranger to 'cat among the pigeons' discussions, as per their 2017 special edition [3] on the PACE trial "for patients with myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS)." Perhaps interestingly, there is a 'psychosomatic' connection between the topic covered in the Pelosi paper and those critical musings on how to (or perhaps how not to) treat ME/CFS...

The person at the centre of the Pelosi paper is the late Prof. Hans Eysenck; a figure who anyone with the slightest interest in the discipline called psychology would probably have heard of. Personality was one of the major research interests for Eysenck, and in particular, the proposal of dimensions to personality: extroversion/introversion, neuroticism/stability, psychoticism/socialisation. Perhaps not as famously known about, but still influential, were Eysenck's views relating to "his persistent denial of the carcinogenic effects of tobacco." Indeed, his 'alternative view' that "certain personality traits that lead to smoking also increase the risk of developing cancer" is starting to look decidedly 'shaky' in modern times. More so when there is talk of 'funding' and 'sources of funding' potentially complicating the issue.

Pelosi (and Marks) make a case that the time is right for psychology and various other interconnected disciplines to start looking more critically at the collected published work of Eysenck and some of his colleagues. They argue that claims "about the alleged effectiveness of psychotherapy in preventing cancer" or that "behaviour therapy may be useful in prolonging life, as well as in preventing disease" have little place in modern, evidence-based, science and medicine. Pelosi - who has some important history of being slightly critical of some of Eysenck's findings alongside other notable names - also goes one stage further in suggesting that some of the "widely cited studies" published with Eysenck's name attached "have had direct and indirect influences on some people’s smoking and lifestyle choices." Further: "This means that for an unknown and unknowable number of individual men and women, this programme of research has been a contributory factor in premature illness and death." Strong words indeed.

Marks ends his editorial with open letters to the President and Principal of King's College London and the Chief Executive of the British Psychological Society (BPS) calling for further investigation of the points highlighted in the Pelosi paper. Pelosi has seemingly approached the BPS previously on this matter but apparently did not receive a particularly warm reception to his then request for further investigation of some of the science and conclusions made in this area (see here). Whether such a second request - made in the era of social media - will be acted upon differently this time is a 'wait and see' question. All of this taking into account the moves being made to make psychology a more credible science these days...

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[1] Pelosi AJ. Personality and fatal diseases: Revisiting a scientific scandal. Journal of Health Psychology. 2019. Feb 23.

[2] Marks DF. The Hans Eysenck affair: Time to correct the scientific record. Journal of Health Psychology. 2019. Feb 23.

[3] Marks DF. Special issue on the PACE Trial. Journal of Health Psychology. 2017. July 31..

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Early mortality in mums of children with autism or intellectual disability

I know the paper by Jenny Fairthorne and colleagues [1] (open-access) is probably not the happiest thing to read with their conclusion that: "During the study period, mothers of children with intellectual disability or ASD [autism spectrum disorder] had more than twice the risk of death" but their message is nonetheless an important one.

Based on data derived from "state-wide databases" covering women living in Western Australia who gave birth between 1983 and 2005, researchers detected mums with a child diagnosed with autism and/or intellectual disability (learning disability if you prefer) and cross-referenced findings with "the state mortality registry" providing information on "dates and cause of death by ICD-9 or 10 codes". Various study (case) groups were formed on the basis of offspring diagnosis - intellectual disability (ID) of unknown cause (further separated based on levels of ID), ID of known cause (specifically Down syndrome or other) and a diagnosis of autism spectrum disorder (ASD) with and without ID - and aided analyses.

After some correction for various confounders including maternal age and socio-economic status (SES), from a starting population of some 300,000 mothers, approximately 1% had died before 2011 (the longer follow-up period). To quote: "Twenty-five years after the birth of their index child, the survival rates of mothers of children with no intellectual disability and no ASD were about 98%, followed by 96% for mothers of children with ASD and 95% for mothers of children with intellectual disability." These group difference were significant and led researchers to draw the conclusion: "Mothers from all case groups had an increased risk of death during the study period."

A few other details are also recorded in the Fairthorne study. "Mothers with both a psychiatric disorder and a child with intellectual disability or ASD had about six and a half times the risk of death" was an important finding reported by the authors. When it came to the cause of death, various factors were over-reported in case group mums including cancers, cardiovascular disease and death by misadventure (death due to an unintentional accident, homicide or suicide according to the authors' criteria).

Reiterating that the Fairthorne paper makes for quite uncomfortable reading, there are some potentially important lessons to be learned from the collected data. First and foremost I should stress that the excess percentages of deaths reported during the study period were overall, quite small for the case groups. Whilst there was an excess of deaths over and above that seen in the asymptomatic control group, the data do not suggest that mothers of children with autism or Down syndrome for example, are facing a gigantic excess risk. Risk is risk and influenced by lots of different variables. I say all that with my cold, dispassionate science goggles on, recognising that each death is a mother lost.

That being said, one might make a case for further inspection of maternal (and paternal) health and wellbeing as and when a diagnosis of autism and/or ID is received in one or more offspring. I've covered the topic of parental stress and autism before on this blog (see here) and the [evidence-based] ways and means it might be reduced. Stress is mentioned in the Fairthorne paper as potentially being one factor linking parenting and early mortality although I'd also suggest the concepts of resilience and coping might also require investigation.

Maternal health issues such as a history of psychiatric issues and/or more somatic diagnoses like diabetes and obesity are also covered in the discussion on possible reasons for the added risk in case groups. As per the research suggesting that some of these factors alone or in combination might increase the risk of offspring autism for example (see here), management of said issues should also rank high on the list of monitoring parental wellbeing. Lifestyle issues such as tobacco smoking and poor exercise regimes can also be mitigated if and when required.

Finally, I want to make one further point specifically related to the idea that cancer may feature as one reason for the excess mortality noted in the current study. Late last year (2014) I covered the complicated issue of cancer risk and autism (see here) on the basis of some further 'big data' derived from the Taiwan National Health Insurance database [2]. In amongst the discussions on that post was some mention of a familial history of certain cancers potentially being heightened in cases of autism on the basis of data from Ingudomnukul and colleagues [3]. The Fairthorne data corroborates this view, and further implies screening should perhaps be preferentially extended to mums of children with ID and/or autism. Early detection can save lives.

Mortality and autism is never going to be a great topic to discuss whether based on personal experience or the peer-reviewed evidence base. Linked to the suggestion that a diagnosis of autism - or at least some of the comorbidities which it can carry - for example, might also elevate the risk of early mortality (see here), I believe that it is time to start bigger conversations on how science and society can go about reducing such risk and reducing health inequality. Mothers, like their children, are precious things...

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[1] Fairthorne J. et al. Early Mortality and Primary Causes of Death in Mothers of Children with Intellectual Disability or Autism Spectrum Disorder: A Retrospective Cohort Study. PLoS ONE. 2014; 9(12): e113430.

[2] Chiang H-L. et al. Risk of Cancer in Children, Adolescents, and Young Adults with Autistic Disorder. J Pediatrics. 2014. 18 November.

[3] Ingudomnukul E. et al. Elevated rates of testosterone-related disorders in women with autism spectrum conditions. Horm Behav. 2007 May;51(5):597-604.

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Fairthorne J, Hammond G, Bourke J, Jacoby P, & Leonard H (2014). Early Mortality and Primary Causes of Death in Mothers of Children with Intellectual Disability or Autism Spectrum Disorder: A Retrospective Cohort Study. PloS one, 9 (12) PMID: 25535971

The health inequalities of schizophrenia

Heart to heart @ Wikipedia  

Dare I start this post by saying that when it comes to many conditions with a behavioural or cognitive aspect to them, there are some worrying trends emerging from the research literature suggestive of stark differences in both access to healthcare and indeed mortality statistics compared with the general population. Think wandering and elopement with autism in mind as one prime risk factor.

I've touched upon health inequality before with autism spectrum disorders in mind, but on this occasion want to briefly discuss some of the literature with schizophrenia spectrum disorders in mind following yet another revelation of more overlap between the conditions.

The paper which brought me to this post is this one from Paul Kurdyak and colleagues* who reported that people diagnosed with schizophrenia were more likely to die as a result of an acute myocardial infarction (heart attack to you and me) and indeed were less likely to receive the appropriate care (including access to a specialist physician) after such an event. 

The quite shocking figures: individuals with schizophrenia were 56% more likely to die within 30 days of discharge and 50% less likely to receive the appropriate after-event healthcare. One could argue on this basis that schizophrenia and its effects go well beyond the psychiatric symptoms that characterise the condition.

Of course there is already quite a lot of suggestion that schizophrenia and related conditions might place an individual at higher risk of quite a few different conditions. So for example, diabetes - type 2 diabetes - is something which has been on the research radar for a while now as per the study by Schoepf and colleagues**. So too issues with obesity, being overweight and other parts of the so-called metabolic syndrome as per reports like the one from Subashini et al*** covering some of the more usual suspects with heart health risk in mind.

The hows and whys of such an increased prevalence of such conditions are complicated. Certainly the research literature seems to suggest that just having a schizophrenia spectrum disorder might increase the risk of engaging in known lifestyle choices linked to poorer heart health. So smoking tobacco, including being heavy tobacco smokers, seems to be more frequent in cases of schizophrenia as per this study by Zhang and colleagues**** (open-access). Physical inactivity has also been reported to be more common too***** and perhaps even tied into illness duration. Not to also mention a role for food choices****** albeit not necessarily consistently*******. There is however some difficulty in unpicking individual behaviours and factors when assessing overall risk.

Before anyone suggests that I am somehow apportioning 'blame' in listing these lifestyle choices, I think it is also important to highlight other factors as potentially contributing to a heighten risk including that of pharmacotherapy. By saying this I'm not going down the 'pharma-bashing' route despite some quite worrying issues recently discussed reiterating that medicines tend to have quite a few more actions that those just indicated on the insert. No, but certainly some of the medicines used to manage schizophrenia and other conditions have long been linked to certain cardiometabolic issues as per editorials like this one from Remington********. Indeed I have a post scheduled soon talking about antipsychotics and autism following the recent NICE guidance published on adult autism which will discuss this further. Good medicines management seems to be key to mitigating the effects of such risks.

Social factors might also play an important role in the accessing of appropriate healthcare for conditions like schizophrenia. Here in the UK we have something called the NHS (National Health Service) which provides healthcare to everyone "free at the point of use". Not everywhere in the world has such a generous policy however as studies like this one by Khaykin and colleagues********* which suggested that around 7% of their cohort with schizophrenia were medically uninsured all year round.

Although perhaps mixing apples and oranges, when you take into account the high rates of unemployment associated with a diagnosis of schizophrenia, upto 96% according to this study by Perkins & Rinaldi**********, having the financial means to access healthcare in some parts of the world must surely be considered an important factor in determining outcome.

I don't claim to have covered all the literature on health inequality and schizophrenia in this post. Indeed the reasons for the figures cited by Kurdyak are likely to be complex and multiple across different people and different situations. What perhaps such data do suggest however is that looking beyond the immediate and overt presentation of mental 'ill-health' should be a priority where general healthcare is concerned. Realising for example, that ticking boxes on a clinical diagnostic schedule and managing current symptoms of that condition might do little for the long-term health of that individual. Indeed when faced with a life expectancy potentially reduced by the order of 14 years*********** there is most definitely a real issue to be tackled here.

To finish a song about blackbirds by the Beatles.

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* Kurdyak P. et al. High mortality and low access to care following incident acute myocardial infarction in individuals with schizophrenia. Schizophr Res. September 2012.

** Schoepf D. et al. Type-2 diabetes mellitus in schizophrenia: increased prevalence and major risk factor of excess mortality in a naturalistic 7-year follow-up. Eur Psychiatry. 2012; 27: 33-42.

*** Subashini R. et al. Prevalence of diabetes, obesity, and metabolic syndrome in subjects with and without schizophrenia (CURES-104). J Postgrad Med. 2011; 57: 272-277.

**** Zhang XY. et al. Cigarette smoking in male patients with chronic schizophrenia in a Chinese population: prevalence and relationship to clinical phenotypes. PLoS One. 2012; 7: e30937.

***** Vancampfort D. et al. A systematic review of correlates of physical activity in patients with schizophrenia. Acta Psychiatr Scand. 2012; 125: 352-362.

****** McCreadie RG. et al. Diet, smoking and cardiovascular risk in people with schizophrenia: descriptive study. Br J Psychiatry. 2003; 183: 534-539.

******* Henderson DC. et al. Dietary intake profile of patients with schizophrenia. Ann Clin Psychiatry. 2006; 18: 99-105.

******** Remington G. Schizophrenia, antipsychotics, and the metabolic Syndrome: is there a silver lining? Am J Psychiatry. 2006; 163: 1132-1134.

********* Khaykin E. et al. Health insurance coverage among persons with schizophrenia in the United States. Psychiatr Serv. 2010; 61: 830-834.

********** Perkins R. & Rinaldi M. Unemployment rates among patients with long-term mental health problems. The Psychiatrist. 2002; 26: 295-298.

*********** Chang CK. et al. Life expectancy at birth for people with serious mental illness and other major disorders from a secondary mental health care case register in London. PLoS One. 2011; 6: e19590

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Kurdyak P, Vigod S, Calzavara A, & Wodchis WP (2012). High mortality and low access to care following incident acute myocardial infarction in individuals with schizophrenia. Schizophrenia research PMID: 23021899