Why does the Treatment Advocacy Center (TAC) misrepresent psychological research?
For instance, in its post on its website titled, “STUDY: Manic Symptoms Linked to Specific Criminal Acts,” the unattributed and undated article suggests that a new study was released that demonstrated a causal link between manic symptoms, and well, specific criminal acts.
But when I read the study, and compared it with what was in the article on the TAC website, I saw a complete misunderstanding (or misrepresentation, whether intentional or not) of the new study.
It now makes me question the validity of any information published by the Treatment Advocacy Center on their website, because it appears their bias — to drive home the mistaken idea that mental illness = increased risk of violence — affects their ability to even deliver research news objectively.
It’s pretty clear whoever authored this post is not a researcher and probably shouldn’t be trying to interpret and disseminate research results. The post begins with the mistaken suggestion that the new study (Christopher et al, 2012) found:
Individuals with bipolar disorder are “more than twice as likely as the general population to commit violent crimes and nearly five times as likely to be arrested, jailed or convicted of an offense other than drunk driving,” authors of a new study on the association between manic symptoms and criminal acts report.
While indeed the current authors write that, that’s actually just background information in the study — it does not refer to any new data.
But rather than just take what a researcher says at face value, we do something here other websites don’t provide — a critical analysis. Let’s look at those two statements first, since they set the stage (both for TAC’s and the current researchers’ article).
The current authors (Christopher et al, 2012) write in the introduction to their study:
Persons with bipolar disorder, in particular, are more than twice as likely as the general population to commit violent crimes…
The reference for this statement comes from a single study (Fazel et al., 2010), that examined “violent crime” (which also included crimes such as simply threatening another person), and bipolar disorder in Sweden. (Whether Sweden is like the rest of the world’s population of people with bipolar disorder or who commit violent crimes is an exercise I leave to the reader). Here’s what they actually found:
During follow-up, 314 individuals with bipolar disorder (8.4%) committed violent crime compared with 1312 general population controls (3.5%). The risk was mostly confined to patients with substance abuse comorbidity. [Emphasis added]
That means that the vast majority of the increased doubling of the risk is not from bipolar disorder alone, but rather from someone who has a drug abuse or alcohol problem, who also happens to have bipolar disorder. That’s a big difference, and one conveniently overlooked by the current study’s authors (and duly reported by TAC).
And the second part of the statement:
… and nearly five times as likely to be arrested, jailed, or convicted of an offense other than drunk driving.
This comes from Calabrese and colleagues’ (2003) study of 1,167 subjects from an epidemiologic study of bipolar prevalence using the Mood Disorder Questionnaire (MDQ) to assess for bipolar symptoms. This is an important distinction to note — these were not individuals actually diagnosed with bipolar disorder, but rather were simply assessed with a self-report screening measure they filled out on their own. Whether a person was arrested, jailed or convicted for offenses (of any nature or severity, except for DUIs) was also based upon self-report, not actual jail or court records.
The researchers reported that “MDQ-positive women reported more disruption in social and family life, while MDQ-positive men reported being jailed, arrested, and convicted for crimes.”
But here’s the catch — the researchers never specifically asked about substance or alcohol abuse. Since we know that such abuse is the primary determinant of violent crime and criminal behavior when combined with certain kinds of mental illness, that oversight is significant. It is a confound that means we cannot draw any meaningful conclusions from their findings regarding criminality and bipolar disorder. (Furthermore, it’s unclear why the researchers arbitrarily removed driving while under the influence of alcohol from their results, given its serious nature. They provided no rationale for doing so.)
So both statements that the researchers simply repeated in the current study (without any qualifications) are less than accurate, when you delve into their research support.
But let’s get on with the actual study, shall we?
Prevalence of Involvement in the Criminal Justice System During Severe Mania and Associated Symptomatology
The current study used the NESARC, “the largest U.S. epidemiologic survey to assess psychiatric disorders according to the DSM-IV criteria.” The study used a structured diagnostic interview to generate DSM-IV diagnoses for major axis I and axis II (personality) disorders, a reliable method used by researchers to diagnose disorders in large groups of people.
Here’s what they found:
Among NESARC wave 1 respondents (N=43,093), a total of 42,079 (97.7%) had valid responses to the questions in the mania section and, of these, 1,044 (2.5%) met specified criteria for having experienced at least one episode of mania.
Of these, 135 persons (13.0%) had legal involvement during the episode that they identified as the most severe in their lifetime.
What is “legal involvement”? Is that the same thing as committing a crime or going to jail? Is it the same thing as committing “specific criminal acts,” or a violent crime?
Well, no. It’s one of those fuzzy terms that researchers use when they want to make something seem like a bigger problem that it is. Here’s how they defined it:
Legal involvement was defined as being arrested, held at the police station, or put in jail, during the manic episode that the respondent identified as the most severe in his or her lifetime.
So in America, where you are innocent until proven guilty, researchers who are pursuing their own agenda define things a little differently. These aren’t people who actually were found guilty of committing a crime — they were simply people who may have had a run-in with the police.
The data the researchers do not provide are data that would put that 13 percent into some sort of context. How many people who did not have a manic episode also had “legal involvement?”
Sadly, the researchers do not report that number. An inquiry asking the researchers about this missing data was not returned.
While it’s interesting to see that 13 percent of people who report manic symptoms had some sort of legal involvement — serious or not — it’s a number that exists in a vacuum. It also demonstrates once again that the vast majority of individuals with bipolar disorder and mania had no legal problems.
Other demographic statistics, while not significant, also point in the direction of existing data. For instance, if you’re Black, you’re 35 percent more likely in this study to have reported legal involvement in the study. (Being African-American puts you at greater risk in general for incarceration in America.) If you have less than a high school education, you’re at 45 percent greater risk of having legal involvement.
But when all was said and done, and demographics were taken into account, this is what the researchers ultimately found that had the strongest statistical power (e.g., the most robust results):
When adjusted for demographic and clinical variables not in potential temporal conflict with the most severe lifetime manic episode, being male and having a first manic episode at age 23 or younger were associated with a higher risk of legal involvement.
Surprise! Being a young man — who have an incarceration rate 9 to 11 times that of women — is the strongest predictor of legal involvement. Also have social indiscretions and having both social and occupational impairment are strong risk factors for legal involvement, according the researchers’ data. Again, neither of which are surprising.
And being manic? Well, given the definition of mania (which is different than actually being diagnosed with bipolar disorder, an important distinction blurred by the researchers), it’s little surprise people with more energy, inflated self-esteem, flight of ideas and distractibility might find themselves at occasional odds with societal norms and laws. It’s like noting that you’re more likely to be pulled over for a DUI after you’ve drank too much and then try and drive.
I can’t really answer why TAC misrepresents the psychological research, and doesn’t bother to delve into it more deeply to examine the conclusions drawn by researchers. While I suspect it may be related to their own advocacy agenda, it could also just be due to sloppy reporting on their part.
What the study clearly shows is that manic symptoms are not linked to any specific criminal acts.
Read the blog post yourself: STUDY: Manic Symptoms Linked to Specific Criminal Acts
References:
Calabrese, Joseph R.; Hirschfeld, Robert M. A.; Reed, Michael; Davies, Marilyn A.; Frye, Mark A.; Keck, Paul E., Jr.; Lewis, Lydia; McElroy, Susan L.; McNulty, James P.; Wagner, Karen D. (2003). Impact of bipolar disorder on a U.S community sample. Journal of Clinical Psychiatry, 64, 425-432.
Christopher, P.P, McCabe, P.J., Fisher, W.H. (2012). Prevalence of Involvement in the Criminal Justice System During Severe Mania and Associated Symptomatology. Psychiatric Services, doi: 10.1176/appi.ps.201100174
Fazel, Seena; Lichtenstein, Paul; Grann, Martin; Goodwin, Guy M.; Långström, Niklas; (2010). Bipolar disorder and violent crime: New evidence from population-based longitudinal studies and systematic review. Archives of General Psychiatry, 67, 931-938.
Sheldon, CT, Aubry, TD, Arboleda-Florez, J., Wasylenki, D., & Goering, PN. (2006). Social disadvantage, mental illness and predictors of legal involvement. International Journal of Law and Psychiatry, 29, 249-256.
5 comments
I think this was a great article. It highlights an observation I have noticed about mental health research in general. I am a system designer. In a conversation with a therapist once I said, “If we designed things with the same manor in which the mental health community tests its theories and drugs, planes would fall from the sky for unknown reasons, power plants would just blow up from time to time.†A couple of point I would like to add to the conversation here.
I am going to offer that maybe DUI’s were left out because they are not crimes of aggression. In a way they are not even crimes of intent. Most people don’t leave intentionally to drive drunk. Where assaulting somebody, robbing a bank, or most other jailable offense doesn’t have that direct intent of breaking ethical boundaries.
I do feel that often psychological research rejects the “chicken or the egg†principle. For instance, it as been accepted that bipolar people will often self medicate before seeking help (or being forced into it). Are they addicted to the drugs because they are bipolar, bipolar caused by the drug use, or are the two independent? In my favorite book on the topic, “I hate you. Don’t leave me..†the author says that parents who are emotionally absent due to drug and/ or alcohol abuse often is a factor in becoming bipolar. Same goes for sexual abuse. But we also know children of drug users (and abusers) are at greater risks of becoming so themselves. There are too many variables for the author of this article to make such a statement.
Last I will offer a personal observation from my own experience. My ex and I lived together for 10 years with out so much as a raised voice argument. I have come to believe that she may have been bipolar all along. When I met her she exhibited many of the classic signs. Without knowing it, I did many of the recommendations made to spouses of bipolar personalities. We grew and she over that time stopped these trade mark behaviors. Once she was put on an SSRI and went manic, they all came rushing back. She started attacking me. Couldn’t stop going to the bar. Expressing thought of suicide and of wanting to “shake the babyâ€. It seemed like whatever thought entered her head she executed with out regard to consequence. Upon finding the forum “marriages destroyed by SSRI’s†the reports of this exact same change shortly after. Ironically the warnings about bipolar are included in every one of SSRI’s information.
One perspective I would like to offer with the blurriness between mental health and antisocial personality these days: people with legitimate axis 1 disorders like mood disorders or psychosis run the risk of at least temporary impaired insight and judgment from their disorders, while, and this will probably get me in trouble with some readers but I feel should be said, antisocial individuals really have some insight and judgment abilities but actively choose NOT to use them responsibly.
So, responsible assessment should include collateral reporting when someone is arrested and seems impaired with psychiatric symptoms. People in the defendant’s life who are responsibly and appropriately engaged for support and sympathy will tell it as it is. Manic people can have lousy insight and judgment, and when stable show better choices and decisions. You just can’t ask them themselves at the time of arrest what they are thinking. It is not saying they are absolved, but just maybe meeting the criteria of what is “not criminally responsible” at that time.
One would hope getting arrested just once in the midst of psychiatric impairment would encourage being in treatment and working on acceptable interventions for a good period of time!
Joel, I have to tell you, that sounds good on paper. However, it doesn’t work that way. Included in that impaired judgment is often a lashing out against those that love and care for them. HIPAA can be the patient’s worst enemy at that point. Furthering my story, our relationship came to an end in an drunken, sexually charged to the point of insanity, rage, and violence. A series of events ended with the cops being called and me trying to keep my wife separated from my two yr old child in her state. The cops convinced me to let her into the house where she attacked me in front of them. She had never been violent. It came down to me, who was devastated, hurt, and angry my exes behaviors that I knew nothing more then they seem to have come out of nowhere, to be her court advocate. Her defense attorney recommended that she immediately file for divorce in order to put me into a financial pickle. Either I advocate having the charges dropped, or she goes to jail, looses her job, and I pay more in alimony and child support. (Because acts of drugs and violence is not a reason to assign custody to a father in my neck of the woods.) Ultimately, I did lobby to get the charges dropped. Not because of the underhanded legal angling, but because I loved the person I knew for the 10 yrs prior, and I love my daughter. The difficulty added to my ex’s life by going to jail for a violence charge would have transferred onto my daughter’s future as well. But let me tell you, that decision came with much resistance from my social circles, including my therapist, family, and own divorce attorney. Anybody else I have ever met would have sent her to jail. There is a good chance not doing so may have cost me custody of my daughter. (Anybody who thinks that the use of AD’s only affect the users should have never had to live with a person with a full blown 6 month long episode of mania.)
So, when I finally started getting a handle on what had happened, I tried to contact her doctor, a GP. She wouldn’t talk to me. Her response? Upped the dosage of the AD and for the new found promiscuity issues, prescribed BC to a women who had never asked for them in the past. Yet this was not considered “abnormal behavior†enough to stop the use of the drugs. Likewise, as listed in the pamphlet, no contact was ever made to me to ask about any abnormal behavior. I would have had a story to tell long before it escalated out of control. Luckily, the only one who believed me was the prosecutor who said, “these things usually have a pattern. I don’t know you, the cops have never been called to your house, you guys don’t fit the pattern.†Very often prosecutors will push the charge even though the co-dependant abuse victims are begging them not to. Ultimately in court, she was given the ultimate reward for her bad behavior.
I respect your candor in discussing your experience. You do what you have to do. Every person is an individual and has to be resolved in that specific situation.
My main beef is mental health is gray, yet, the court is often black and white. Which is why I avoid involvement in legal matters.
Stay well and safe in your travels.
You know Joel, one of the problems is that doctors are unwilling to get involved in the legal and policy matters. The fate of children are being decided by lawyers and politicians. Also, I feel a need to speak out. People are afraid to share their mental health experiences. (The courts condemn it.) If we all started talking openly and honestly about our experiences, it would be the greatest forward movement in humanity since the wheel. I am not holding my breath though. Thanks for your time and response. And peace to you too brother.