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RE: Acute transient psychotic disorder precipitated by Brexit vote (1)
Authors: Dr Sally Maryosh and Dr Madhavan Seshadri
Primary Author: Dr Sally Maryosh, Foundation Year 2 Trainee in Psychiatry, Herefordshire Mental Health and Learning Disability Services, Stonebow Unit, Hereford.
Additional Author: Dr Madhavan Seshadri, Consultant Psychiatrist, Herefordshire Mental Health and Learning Disability Services, Stonebow Unit, Hereford.
Dear Editorial Team,
We read this article with great interest as Brexit has clearly created significant stress and impact on everyone’s life in the U.K. This article has also been widely quoted in major Newspapers including The Sun, The Guardian and The Independent creating an interesting debate by portraying a picture that Brexit could cause psychosis. Hence, we wanted to critically appraise this article using Sir Austin Bradford Hill’s Criteria (2).
In 1965, Sir Austin Bradford Hill proposed a set of 9 criteria to provide evidence of a causal relationship between a presumed cause and an observed effect (2). Using his criteria we are able to examine epidemiological studies and factors to understand better how environmental factors relate to health and the advancement of disease.
The development of psychotic disorders is multifactorial, the article itself identifies “that additional work and family related stresses may have contributed” to this patient’s ATPD (1). The...
The development of psychotic disorders is multifactorial, the article itself identifies “that additional work and family related stresses may have contributed” to this patient’s ATPD (1). The author themselves highlight multiple social stressors occurring around the time of presentation, these include losing a court case and family pressures1. If we apply Bradford Hill’s criteria of specificity (2) to this scenario, we cannot be certain that result of the Brexit referendum was the driving factor for this patient’s development of ATPD (1). This is further strengthened by the author stating a similar episode was experienced by the patient “following work related stress, 13 years previously” (1).
To support Bradford Hill’s criteria of reproducibility (2), we would expect that three years following the Brexit referendum, there would be multiple witnessed cases of ATPD precipitated by Brexit, especially in patients who are vulnerable to psychotic episodes. Try as we might to avoid it, Brexit is currently a topic dominating the media and general conversation. Therefore, if we were to apply Bradford Hill’s “biological gradient” criterion which stipulates that a greater exposure generally leads to a greater incidence of the effect, we should be witnessing more reported cases of Brexit-precipitated ATPD. Despite this, the article lists only one other transient psychotic episode precipitated by a political event - a case from the USA - unrelated to Brexit.
We feel that it is a bold statement to imply that Brexit can precipitate an acute and transient psychotic disorder (ATPD) without considering the rules comparing causation and correlation. Brexit might be associated with an acute psychotic episode, and could be an associated symptom of this patient’s psychosis however; conclusion that it might have a causative role may be an arbitrary inference.
1. Katshu M. Acute transient psychotic disorder precipitated by Brexit vote. BMJ Case Reports. 2019;12(10):e232363.
2. Lucas R, McMichael A. Association or causation: evaluating links between "environment and disease". The Royal Society of Medicine. 2005;83(10):792-795.