Abraham
Rudnick, MD, PhD, CPRP, FRCPC, CCPE,
Professor, Department of Psychiatry and
Behavioural
Neurosciences, McMaster University
Abstract: The quality of inpatient
mental health care, particularly in psychiatric hospitals, has been criticized
for many years to date. A famous critique of such care is related to Rosenhan’s
study (published in 1973), which demonstrated unsound psychiatric diagnosis and
suboptimal inpatient care. Attempting to replicate this study nowadays may be
informative, yet current research standards would not allow conducting it
without modification, as it would now be widely considered methodologically
unsound and ethical unacceptable. In this paper I examine Rosenhan’s study in
light of contemporary methodological and ethical standards and propose
modifications to it for a sound replication attempt.
Keywords: Ethics,
methodology, quality of mental health care, Rosenhan.
Disclosure: None
Acknowledgement: The
inspiration for this article was provided by my correspondence with a patient
advocate.
The quality of
inpatient mental health care, particularly in psychiatric hospitals, has been
criticized for many years to date. This has been the case at least since the
mid-19th century when psychiatric asylums were overcrowded, to which a reaction
starting in the mid-20th century was de-institutionalization and later
provision of more and better community supports (Carling 1995). As part of this
trend, a famous critique of such institutional mental health care is related to
Rosenhan’s study, which demonstrated unsound psychiatric diagnosis and
suboptimal inpatient care (Rosenhan 1973). Rosenhan studied the experience of 8
so-called sane people (some of whom were mental health care professionals) who
falsely reported hearing voices, i.e., having auditory hallucinations, in order
to be admitted to a psychiatric hospital; once admitted, they stopped reporting
hearing voices but were all still provided care for, and eventually discharged
with, a diagnosis of schizophrenia. The principal conclusions from this study
were that psychiatric diagnosis is unsound and that inpatient care in psychiatric
hospitals is suboptimal.
Attempting to
replicate Rosenhan’s study these days may be informative, e.g., to examine
psychiatric diagnosis and inpatient care in contemporary psychiatric hospitals,
with the hope that due to arguable improvements in psychiatric diagnosis
(American Psychiatric Association 2013) and quality of care (Jayaram 2015)
there has been improvement in diagnosis and care in psychiatric hospitals. Yet
current research standards would not allow conducting Rosenhan’s study without
modification, as it would now be widely considered methodologically unsound and
ethical unacceptable. For example, methodologically, although the study sampled
various psychiatric hospitals, it did not specifically assess – and hence was
not controlled for – clinical skills of the service providers. And ethically, most
of the 8 participants were not identified to the participating hospitals, and
were provided care for schizophrenia that they did not have, hence risking
unnecessarily prolonged negative consequences such as serious adverse effects
of medications and stigma. Of note is that there was no standardized regulation
then of human research, as such regulation started in the late 1970s following
the Belmont Report (http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.html#).
To replicate
this study nowadays, it would have to meet current methodological and ethical human
research standards. I propose here a modified study design. The study would
consist of a randomized controlled multi-site trial in psychiatric hospitals
and in psychiatry units of general hospitals with a statistically powered (sufficiently
sized) sample of trained actors simulating schizophrenia; half of the actors simulating
auditory hallucinations with other schizophrenia-related symptoms and another half
simulating auditory hallucinations without other symptoms. Mixed (quantitative
and qualitative) evaluation methods would be used, such as reporting of
admission and discharge diagnoses, care provided and length of admission, as
well as related experiences of the actors, other psychiatric inpatients – who
may sometimes identify simulators of their own mental illness better than staff
do (Rosenhan 1973) – admitted to the study units, and involved staff. Informed
consent of the involved patients (actors and others) and research ethics board
approval, including for initial deceit (of staff), would be required. Other
study designs may also merit consideration.
References
American
Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders,
5th ed. Washington, DC: American Psychiatric Publications, 2013.
Carling PJ.
Return to Community: Building Support Systems for People with Psychiatric
Disabilities. New York: Guilford, 1995.
Jayaram G (ed).
Practicing Patient Safety in Psychiatry. Oxford: Oxford University Press, 2015.
Rosenhan DL. On
being sane in insane places. Science 1973. 179(4070):250-8.
