Sunday, September 13, 2015

Hokum is not fine by me

Max Pemberton, in  this week's Dr Max the Mind Doctor column in the Daily Mail (see section entitled Hokum is fine by me if it works) mentions a recent decision by a judge to reject a patient’s challenge to the Lothian Health Board’s decision to stop funding homeopathy services on the NHS (see BMJ news article). Dr Max admits homeopathy is merely placebo but says he doesn't care as long as it makes the patient feel better. He seems happy enough, I guess like a lot of doctors, to deceive his patients (see my BMJ letter, on bottom of the page from this link).

I do understand that the patient may have a different view. She apparently had found homeopathy helpful for her arthritis and anxiety. I'm not convinced the Health Board has considered the potential harm (nocebo) effect of removing a placebo, for which I guess it could be held accountable, as presumably it was originally funding the homeopathy. What I'm objecting to is Dr Max supporting the use of homeopathy, which he regards as "utter hokum".

Wednesday, September 09, 2015

Reconsidering psychiatry

Hugh Middleton (who I have mentioned in a previous post) has recently published Psychiatry reconsidered: From medical treatment to supportive understanding. As he is the current co-chair of the Critical Psychiatry Network, of which I am a founding member, you may well think I would agree with a lot of what he says, and I do. However, I have some concerns about how he expresses the critical psychiatry position. These concerns are similar to those I have expressed about Peter Kinderman's book A prescription for psychiatry (see previous blog and links to other posts on his book from that blog).

Where Hugh and I agree is that mental health difficulties are not brain diseases. The implication is that psychiatric diagnosis is not about identifying brain abnormalities and treatment is not about correcting such abnormalities, such as biochemical imbalances in the brain. Rather, referrals to psychiatric services are made for psychosocial reasons because of people's distress and/or the disruption they cause to others. Mental health problems are primarily functional and not organic (eg. see previous post).

It follows that there are differences between psychiatry and the rest of medicine. However, Hugh makes too much of these differences from my perspective. He points to "the unsuitability of locating provision for people with 'mental health difficulties' alongside other aspects of medical practice" (p. 8). He also suggests "psychiatry is not proper medicine" [his italics] (p. 9-10) and that psychiatry is "not about treating illnesses" (p. 9). My own view is that this position, at least potentially, is misleading.

Our difference arises from our understanding of 'mental illness'. I think that abnormalities of mental function can be understood as 'illnesses' in the same way as bodily dysfunction. On the other hand, Hugh restricts 'illness' to physical pathology. He is, therefore, inclined to follow Thomas Szasz, who was very clear that the concept of mental illness is a category error, because he defines 'illness' as bodily pathology (eg. see previous post). The trouble is, from my point of view, that this distinction is not so absolute. People commonly complain of physical symptoms which have a psychogenic origin - what medicine these days calls 'medically unexplained symptoms', or previously may have called psychosomatic illness. These presentations are so common, in some ways, that they are central to medical practice. In other words, psychiatry is proper medicine. Medical practice should take a patient-centred perspective (see previous post), which inevitably requires engagement with mental health problems. I don't want to polarise the difference between patient-centred and disease-centred medicine, and diagnosis and treatment in medicine need to be patient-centred even when treating physical disease.

I'm also not entirely happy with Hugh leaving the issue of coercion to the last chapter, entitled Afterword. As he says, historically psychiatry "was commonly brutal" (p. 204). In fact, institutional practice can still be abusive. Human rights are a central issue for psychiatry. Because of its social role, psychiatry inevitably manages madness on behalf of society (eg. see my book chapter). This was why modern psychiatry originated in the 19th century, however much psychotherapy and other informal, voluntary services now dominate practice. But, these more modern developments haven't made the 'sharp end' of psychiatry irrelevant. They have led to the closure of the traditional asylum, but people are still detained under the Mental Health Act in hospital and, for some, this makes them eligible for the imposition of conditions under a Community Treatment Order (CTO). True, Hugh does recognise this situation, and here he differs from Szasz, although he uses it as a dubious justification for electroconvulsive therapy (ECT) in limited circumstances. And, it was the reform of the Mental Health Act, that produced the 2007 amendments, that led to the formation of the Critical Psychiatry Network in 1999. I think these issues should have warranted more than an afterword when reconsidering psychiatry.

Tuesday, September 01, 2015

Adolf Meyer's legacy

I have mentioned Susan Lamb's Pathologist of the mind in a previous post. The book has been reviewed by Andrew Scull in the TLS (see WSJ version). Andrew argues that "comprehensive reassessment of Meyer’s life, career and influence is long overdue" (is Andrew writing this thesis?) but suggests Susan's book isn't that work because it scarcely considers his later career. I think this judgement may be a bit harsh as Susan primarily seeks to defend Meyer's theoretical position, which was called "psychobiology", which I think was consistent through Meyer's life once he had switched from neuropathology. Andrew isn't convinced that Susan's been successful in her aim.

I've commented on Meyer favourably in previous posts (eg. see The psychogenic legacy of Adolf Meyer). I've argued that critical psychiatry is a neo-Meyerian perspective. This doesn't mean, like Andrew, that I'm suggesting a straightforward following of Meyer or 'resurrecting his ghost' (eg. see previous post). But Andrew says Meyer's programme was "largely devoid of substance" and that he was an emperor with no clothes. I agree Meyer's obsessional "quest for data" could become futile, but at least it ensured that the psychosocial reasons for patients' presentations were considered, which can't be said for much of modern psychiatric assessment. The problem is that the reality of psychiatry may be that it is "essentially empty" in Andrew's sense. It probably doesn't boil down to much more than relationships between people. If Andrew's hoping for more from psychiatry, I suspect he'll be disillusioned.

The biomedical model has an intrinsic advantage over psychobiology in that it provides an apparent clarity. But modern psychiatry seems more willing to hide behind absolute definitions rather than face the uncertainty of human action. Psychobiology is not an aetiological psychiatry, in the sense of providing psychoanalytical mechanisms or Kraepelinian disease entities. True, Meyer's tendency to fudge and compromise may not have always provided the best of ethical foundations for psychiatry. But I don't think Andrew should be quite so dismissive of Meyer's theoretical position, or Susan's attempt to explain it.

Monday, August 31, 2015

Italian critical psychiatry

I mentioned John Foot's new book The man who closed the asylums: Franco Basaglia and the revolution in mental health care in a previous post before it was published in english. There has been very little published in english about Basaglia, which makes John's book very welcome. He tells the story of Basaglia's move from academia to direct the asylum at Gorizia in 1961, leading up to the passing in Italy in 1978 of law 180, which prevented new admissions to existing mental hospitals and shifted the perspective from segregation and control in the asylum to treatment and rehabilitation in society. Despite the opposition at the time, psychiatric hospitals have closed anyway over most of the Western world, as they became increasingly irrelevant to modern mental health services.

This story is interesting because, as Basaglia said in his own words, he became famous "because I 'opened up' a psychiatric hospital". He was charged twice with criminal liability following serious patient homicides because he was the "man that freed the mad".

However, what most interested me about the book was how little I know about Italian critical psychiatry, particularly the writing of Giovanni Jervis, who worked for a few years with Basaglia at Gorizia. From there he went to Reggio Emilia to develop community services.  His Manuale critico di psichiatria was reprinted continuously from 1975-97. With Gilberto Corbellini, he wrote La razionalità negata. Psichiatria e antipsichiatria in Italia (2008). It would be nice to be able to read both these books (and other related books) in english.

Jervis was not in total agreement with Basaglia. He accepted the social role of psychiatry, but still tried to expose the "margins of dissent and dysfunctionality in the system". Within the Centre for Mental Hygiene in Reggio Emilia, there was a split between Jervis and Giorgio Antonucci, who was more anti-psychiatry, in that he "aimed to destroy psychiatry as a separate technique". Within english language 'anti-psychiatry' there was a similar tension between Laing and Szsaz. I think modern critical psychiatry may well benefit from understanding the Italian historical tradition better.

Wednesday, August 05, 2015

Modern psychiatry's disgrace

I've mentioned before the unethical nature of modern psychiatry (eg. see previous post). Robert Whitaker and Lisa Cosgrove in their book Psychiatry under the influence call it institutional corruption. They highlight the over-marketing of stimulants for ADHD, the expansion of the notion of depression, the extension of SSRI antidepressants for other neurotic conditions besides depression and for children, and the promotion of mood stabilisers. Psychiatry has been happy to go along with these developments and of course it has suited the drug industry. But, it has required a less than rigorous examination of the evidence and a weak drug regulatory system. The book argues that declaration of conflict of interests is insufficient to correct the problem (see previous post).

Saturday, August 01, 2015

The possibility of a causal link between tobacco use and psychosis does not merit further examination

Following my previous post, yet another article on the association between smoking and psychosis has been published in The Lancet Psychiatry. Usefully the article makes reference to the Bradford Hill criteria for deciding whether an association should be interpreted as causal. It suggests that the association is plausibly causal because nicotine may increase dopamine consistent with the excess striatal dopamine theory of schizophrenia. Trouble is that efforts to validate the dopamine theory of schizophrenia empirically have failed (Kendler & Schaffner, 2011).

As the comment in the same issue of The Lancet Psychiatry says, "The most likely explanation ... is that cigarette smoking is associated with an increased risk for schizophrenia." Factors in the social environment, such as family history, urban environment and childhood adversity, are associated with both smoking and psychosis. A social environmental explanation of both psychosis and smoking is much more plausible than a biochemical explanation that the empirical evidence contradicts.

Tuesday, July 28, 2015

Smokescreen about the origins of psychosis

I said in a previous post that it was illogical to interpret an association between cigarette smoking and psychosis as causal, but this hasn't stopped Gage & Munafo in correspondence in Lancet Psychiatry trying. This publication was rushed through online first, presumably because the journal thinks it is potentially important. It follows a comment in the same journal by Fergusson et al published this month

As the correspondence authors say, "Of course, these data alone are not definitive". To reiterate, as they also said in a previous Lancet Psychiatry comment, "Although evidence of a causal effect of cigarette smoking on schizophrenia risk is consistent, it is certainly not definitive".

Please tell me why cigarette smoking can't be a proxy measure for poor premorbid adjustment associated with psychosis! Are people so blind to the psychosocial origins of psychosis that we have to be led down such aberrant research alleys? There seems to be a more fundamental need for revising our understanding of the psychosocial origins of psychosis than speculating wrongly about whether cigarette smoking causes psychosis.

Tuesday, July 21, 2015

Patient-centred psychiatry

I was pleased to hear from Anna Ludvigsen that the Royal College of Psychiatrists has a scoping group to look at how to make training more patient-centred. Believe it or not, medicine hasn't always been patient-centred. Historically, clinical training has emphasised a doctor-centred or disease-centred approach, which involves diagnosing the patient's disease and prescribing a management plan appropriate to the diagnosis. A patient-centred approach is designed to attain an understanding of the patient as well as the disease.

Patient-centred medicine is based on the University of Western Ontario method (Levenstein et al 1986, Stewart et al 2003). It is not technology-centred, doctor-centred, hospital-centred or disease-centred. Instead, it explores patients' main reasons for consultation, their concerns and their need for information. It seeks an integrated understanding of the whole person, including emotional needs and life issues. It finds common ground with patients on what the problem is and mutually agrees about how to manage the problem. Its focus encourages prevention and health promotion. It also emphasises the continuing relationship between the patient and the doctor. It provides a realistic and effective use of time in the consultation. It also has to be sensitive to context as, for example, an acutely ill patient may require more focus on disease. It also has to be sensitive to patient preference as, for example, some patients may require more information than others.

The approach may well have its origins with Michael and Enid Balint, both psychoanalysts, who began work in the 1950s to help general practitioners reach a better understanding of the emotional content of the doctor patient-relationship. and so improve their therapeutic potential (see UK Balint Society). Patient-centredness may be a poorly understood concept. Doctors vary in the degree to which their practice is patient-centred, although on the whole most doctors provide patients with partially patient-centred care.

Critical psychiatry is the application of the patient-centred method in psychiatry. Inherently it is a challenge to biomedical psychiatry. In my publications, I have tried to emphasise how it restates the conceptual position of Adolf Meyer and George Engel (eg. see my article).

Sunday, July 05, 2015

Need to integrate mental and brain activities

Following my previous post, Ed Pinkney @mwproject sent a tweet asking me to elaborate on what I meant by the "need to integrate mental and brain activities" and I said I would. Psychiatry functions within the mind-brain philosophical problem. Psychiatrists don't need to be philosophers but they do need to realise there's an issue in this respect.

Nineteenth century medicine developed on the basis of the anatomoclinical method, which recognised disease as having a bodily pathological origin. Psychiatry didn't quite fit with this, although it was recognised that dementia paralytica was a late consequence of syphilis, senile dementia had a physical cause such as Alzheimer's disease, that there could be focal abnormalities in the brain and that learning disability could also have physical causes (eg. see my book chapter). However, most psychiatric illnesses are functional, in the sense that there are no structural abnormalities in the brain.

As this is the case, how should psychiatry be practiced? All medicine should be patient-centred. The danger is that if doctors focus on disease, they may be distracted from dealing with the ill person. There may actually be some self-protective element in this, considering the emotional consequences of dealing with the suffering of patients, but ultimately medical training is about learning to focus on the ill person. This situation is even more prominent in psychiatry, as the symptoms and signs that patients have are part of them as people rather than due to a structural abnormality in the brain. Don't misunderstand me! Of course, the thoughts, feelings and behaviour of people who are not mentally ill are due to their brain. We have an integrated understanding of their mental and brain activities. In the same way, we should have an integrated understanding of the mental and brain activities of people who are mentally ill.

Saturday, July 04, 2015

Biopsychosocial formulation

There is an article in Lancet Psychiatry about rethinking biosychosocial formulation. I think the article is a little unfair on George Engel but I do understand what it means about the eclectic way in which the biopsychosocial model is implemented. It wasn't how Engel meant it to work to encourage "students to think about the patient from three different perspectives, rather than beginning with the premise that everything that happens to the patient is biological". This comment also reminds me of the emphasis of Susan Lamb in her book on Adolf Meyer (see previous post). What's needed is to integrate mental and brain activities.

The describe/review/link model may well help us to move on from the eclecticism of modern psychiatry for which this mistaken implementation of the biopsychosocial model may be blamed (see my review of Nassir Ghaemi's book and his response). I agree with the authors of the article about the importance of formulation (eg. see previous post).

Friday, July 03, 2015

Psychiatry's 'nemesis'

I don't want to make a habit of commenting on trainees' articles when they get them published in Royal College of Psychiatrists' journals (see previous posts - Neurology-psychiatry integration and Being explicit about the nature of mental illness), but I just wanted to pick up a comment from Helen Henfrey in her recent BJPsych editorial. She suggests that, "Psychiatry is unique among other specialties in that it has its own ‘nemesis’ in the form of the ‘antipsychiatry movement’". True, she has put the word 'nemesis' in inverted commas. Psychiatry in fact needs to be critical and I think it would help recruitment to psychiatry, which is what her article is about, if it engaged with anti-psychiatry.

If anti-psychiatry is psychiatry's nemesis, it is partly psychiatry's creation by including RD Laing and Thomas Szasz within its remit (eg. see my book chapter). Of course there are people that want to abolish psychiatry. Laing and Szasz were legitimate psychiatrists in challenging the biomedical model of mental illness (eg. see previous post on Szsaz). I've commented before (eg. see previous post) that recruitment to psychiatry would be improved by encouraging debate about the basis of psychiatry. Helen Henfrey shouldn't be frightened of conflict with so-called anti-psychiatry. Psychiatry by its very nature is conflictual and that's part of its attraction as a career.

Thursday, July 02, 2015

Do psychiatric medications correct a chemical abnormality in the brain?

I don't think David Taylor, Director of Pharmacy and Pathology, South London and Maudsley NHS Foundation Trust & Professor of Psychopharmacology, King's College, London can be a prescriber. This may be why, in his BJPsych Advances article, he suggests that psychiatrists don't infer that people with a diagnosis of schizophrenia need antipsychotics to block a surfeit of dopamine. If so, why is this what some psychiatrists tell patients? Medical students may even be taught to explain to patients that this is the reason they need antipsychotics. Perhaps Taylor needs to be more explicit that psychiatrists are wrong to tell people that medications correct a chemical imbalance and, if he does some medical student examining, mark students wrong when they suggest this.

I do agree with him that, "Rarely is there any certainty about [psychiatric] diagnosis". I think psychiatrists will still regard quetiapine as something to do with dopamine by calling it a dopamine multifunctional receptor antagonist (DAmF-RAn). They will just believe that they can use it for more conditions besides schizophrenia. I accept that the rationale for psychiatric prescribing is often not properly thought through (eg. see previous post).

Framing the model of drug action as drug-centre rather than disease-centred is primarily a critique of the biomedical model (eg. see my book review). It emphasises the non-specific effects of medication. I suspect that Taylor still thinks psychiatric medications correct a chemical abnormality in the brain. In that sense, he is not drug-centred, even disease-centred. What he means is that he doesn't accept simplistic hypotheses of biochemical imbalance. All well and good, but the critique of the biomedical model is more fundamental. There may be no difference between the chemical processes underlying mental illness and our "normal" behaviour.

Friday, June 05, 2015

Neurology-psychiatry integration

I've hesitated before (see previous post) in case I undermine an enthusiastic psychiatric trainee, who has just been successful in getting a journal paper published. In the same issue of BJPsych Bulletin, mentioned in my previous post, Thomas Reilly has a special article concluding there is no dividing line between neurology and psychiatry (see article). Perhaps he needs to read my previous post because he incorrectly comes to this conclusion because he believes psychiatric illness is a neuropathological disorder.

What worries me is what trainees are being taught. I've no objection to Thomas Reilly getting neurological training. It might help in his understanding of the differences between neurology and psychiatry. Of course all doctors should have a biopsychosocial understanding, as he suggests. I'm not wanting to overemphasise the difference between psychiatry and the rest of medicine. But psychiatry primarily treats functional disorders not organic. Of course, conversion disorders may present to neurologists but it may well be the skill of their neurological examination that makes the diagnosis, because they don't find the expected signs. Medicine is full of cases with "unexplained symptoms" that never get referred to a psychiatrist and the psychological origin of the problems is missed. I hope that Thomas Reilly does become slick in neurological examination, as the best of neurologists are. But in practice, he'll not need that skill very much in his assessment of psychiatric patients. What he needs to develop is his psychological formulation of cases (see another previous post).

Tuesday, June 02, 2015

Functional and organic psychiatry

Alwyn Lishman (see interview in The Psychiatrist), the author of the classic book Organic Psychiatry, knows more about neuropsychiatry than most people, so when he says that Wilhelm Griesinger was too narrow in his approach to psychiatry, this needs to be taken seriously. Nonetheless, Michael Fitzgerald looks to Griesinger to justify his argument in a BJPsych Bulletin editorial that neurology and psychiatry should merge into a single speciality, although he agrees that Griesinger went too far in ignoring environmental influences. In fact, Griesinger was not quite as reductionistic in his view that mental diseases are brain diseases as is commonly assumed (Marx, 1972). He suggested that the initial phase of mental illness did not involve structural changes. Structural change only occurred in what he called the second phase, in which mental image formation or will were affected, and also in the third phase, which implied deterioration and incurability (see my book chapter).

I've commented before on the issue about the merger of neurology and psychiatry when two of the main references from Fitzgerald's paper were first published (see previous post and BMJ letter). Ronald Pies is more of an advocate for Fitzgerald's position than Fitzgerald seems to realise, although if the merger happened, Pies thinks there will be a need for “certain kinds of linguistic and philosophical ‘bridging devices’” (see my book review). The main problem with the proposal for merger is that it is based on a mistaken notion that mental illness is brain disease (eg. see previous post). Ernst von Feuchtersleben published his book in the same year as Griesinger in 1845 and questioned whether mental disorders were always due only to disorders of the brain.  He argued for a functional understanding of mental disorder, which of course has a biological basis. As I keep saying, although mind is enabled by the brain, it is not reducible to it.

Psychiatry should look to von Feuchtersleben for its origins rather than Griesinger. This would cement its relationship with the rest of medicine better than Fitzgerald's proposal. It is in fact Fitzgerald's misunderstanding that undermines the relationship between doctor and patient.  Relations between people should not be reduced to objective connections in the brain. I've said before (eg. see previous post) that psychiatry should be seen as the pre-eminent medical speciality. The current president of the Royal College of Psychiatrists seems to agree with me in a tweet.

Wednesday, May 27, 2015

Misguided medical training in psychiatry

Niall Boyce has clarified in a tweet what he means in a Lancet Psychiatry editorial about the critique of the biomedical model in psychiatry. He thinks the critique is "worth considering". But he is relaxed about it because he knows neuroscientific findings will eventually affect practice. Actually the point of the critique is that this is a myth. Psychiatry has always had this wish and it's about time that it realised that this is "pie in the sky".

And, as Anne Cooke points out in a tweet in response, Niall has conflated his arguments in his rebuttal by promoting a medical training for mental health practice. I've always said that there are advantages to a medical training (eg. see previous post). However, there are disadvantages as well in that it encourages a biomedical approach, which Niall obviously finds difficult to give up.

Saturday, May 16, 2015

Reducing psychotropic medication prescribing

Peter Gøtzsche, who I have mentioned before (eg. see previous post), has caused controversy at a Maudsley debate and in a BMJ Head to head by suggesting that psychotropic medication should be reduced to 2% of its current level of prescribing. As far as he is concerned, it "should almost exclusively be used in acute situations and always with a firm plan for tapering off, which can be difficult for many patients".

His argument is that the results of clinical trials are biased by unblinding and what he calls the 'cold turkey' effect of the washout period. Any remaining benefit, if there is any, is not justified by the mortality caused by medication.

Whether psychotropic medication increases mortality is controversial. I have mentioned before (see eg. previous post) that it may create a vulnerability to relapse. People may actually do better if they manage to work through their problems without medication. Peter Gøtzsche's stark presentation of the issue at least encourages this debate, even if it risks overstatement.

Wednesday, May 13, 2015

Renewing mental health practice

I have been re-reading the final chapter of my edited book Critical psychiatry: The limits of madness. Next year will be 10 years since the book was published. The first chapter outlines the various chapters written by the contributors. The book came out of three conferences held in Sheffield, Birmingham and London in 2001-3.

It's also 16 years since the Critical Psychiatry Network was first formed. I've mused before about the impact of critical psychiatry (see previous post), maybe, as I said, because I am approaching full pension. How should critical psychiatry be taken forward?

Tuesday, May 12, 2015

Psychiatric research folly

A perspective in Science by Thomas Insel & Bruce Cuthbert should make american psychiatry fearful about the scientific credibility of its NIMH director. He's gone completely 'over the top' in his speculation about RDoC and precision medicine (see previous post). He thinks there's been a "tectonic shift" to now considering mental disorders as brain disorders. Following his lead, this folie à plusieurs has apparently led to "nearly 1000 papers addressing various aspects of RDoC over the past year". 

I've made fun of Daniel Amen suggesting there are 7 types of ADD (see previous post). However, Insel believes three subtypes of ADHD have been discovered with different responses to stimulant medication. He suggests biologically meaningful subgroups of psychotic or mood disorders are being discovered. He does admit these are "preliminary reports" and the "results will need replication". RDoC domains are supposed to be better at predicting length of hospital stay or hospital readmission than symptom-based diagnoses. 

Even though Insel accepts that "many challenges must be faced", I'm sorry but I'm not part of what he calls the "emerging consensus that such new approaches are necessary to move the field forward". Psychiatry's going 'off beam'. People may appear to be going along with Insel because he holds the research funding purse strings. His speculation builds on his 'brain circuitry disorders' concept of mental illness (see previous post). Science demeans its name by publishing such phantasy.

Wednesday, May 06, 2015

Being explicit about the nature of mental illness

I am not sure why Ketan Jethwa has moved to a core training post in medicine from an academic psychiatry training post. Could it reflect his disillusionment with psychiatry or is he wanting to ensure  an adequate medical foundation for his psychiatric career? I don't want to undermine him because he has written a good quality article for BJPsych Advances. However, I think his piece does require comment.

He suggests psychiatry has an identity crisis because of the nature of mental illness. I'm not sure if I would call it an 'identity crisis', but I agree that how the nature of mental illness is understood does matter. Jethwa argues for psychiatry being a clinical neuroscience and suggests, following Bullmore et al (2009) (see previous post), that British psychiatry over recent years has taken an increasing 'neurophobic' position. He goes on, "It is imperative that the scientific underpinnings of psychiatry are explicit within mental health services and in interactions with patients and the public in general". The trouble is that he hasn't been explicit about the neuroscientific basis of psychiatry. He seems disappointed that psychiatry can't be more explicit. I have said before (eg. see previous post) that modern psychiatry is setting itself up to disillusion trainees by promoting neuroscience as the solution to mental illness in the way Jethwa hopes it can be. I fear that it may have lost another good quality trainee in his case. I hope I'm wrong!

Saturday, May 02, 2015

Bipolar craziness

Much of Edward Shorter's recent book, What psychiatry left out of the DSM-5: Historical mental disorders today, is, to my mind, speculative nonsense. However, there is a chapter on 'Bipolar craziness', which I think has some useful references. I've mentioned before (eg. see previous post) how the concept of bipolar spectrum has extended during my working lifetime to a notion whose meaning must be questioned. As Shorter says at the end of his chapter:-
Unlike in previous editions, when DSM- 5 was launched in 2013 the discussion of bipolar disorder was no longer merely a section of an "affective disorders" chapter but had a chapter of its own, as though the previous hundred years of world psychiatry had never existed.

Unipolar and bipolar disorders are now seen as separate disorders whereas they used to be seen as two subcategories of manic-depressive illness. I am not necessarily saying that the previous way of looking at this diagnostic issue was better, but it is clear that at least some of the motivation for the change has been to promote mood stabilisers for bipolar disorder (see eg. previous post).

It's suggested antidepressants should be avoided in treating patients with bipolar disorder in favour of mood stabilisers. However, I've also mentioned before that the risk of manic switch when using antidepressants has been exaggerated. NIMH has endorsed the use of the diagnosis bipolar disorder not otherwise specified to categorise bipolar disorder as on a spectrum (see press release). It affirmed that such patients were being inappropriately treated by giving antidepressants or other psychotropic medication in the absence of mood stabilisers. However, systematic reviews have not found evidence that switching to mania is a complication of antidepressant treatment (Gijsman et al 2004, Visser & Van Der Mast 2005). In a placebo-controlled trial, use of adjunctive, standard antidepressant medication, as compared with the use of mood stabilisers, was not associated with an increased risk of treatment-emergent affective switch (Sachs et al 2007). Moreover, there was no difference in efficacy.

The limitation of medication, whether antidepressants or mood stabilisers, needs to be recognised. Just because antidepressants are not always effective does not necessarily mean that even mood stabilisers will be helpful in so-called bipolar spectrum.

Saturday, April 25, 2015

Madness in civilisation

I'm not sure if it really works, as I did in my previous post, collecting together tweets of quotes or amended quotes from a book which I've sent when I'm reading it. Another book I've recently read is Andrew Scull's Madness in civilization: A cultural history of insanity from the Bible to Freud, from the madhouse to modern medicine. It has been reviewed by Phil Thomas on Madness in America. I don't think the book is as good as some of Scull's previous books, such as Madhouse (see my BMJ review). It's trying to provide a wide-ranging survey of the history of madness over the last 3000 years. 

What I tweeted about from Scull's new book was the way that we seem to need myths to understand madness and illness in general. For example, the theory of the four humours - blood, phlegm, black bile and yellow bile - remained a major influence in understanding the working of the body until well into the 1800s. But we haven't really advanced:-
Biomedical hypothesis justifies modern psychiatric practice in same way as humoral theory justified bleeding, purging and use of emetics
29/03/2015 10:56
Humoral theory of disease was immensely powerful, making sense of symptoms and pointing the way towards remedies for what had gone wrong.
28/03/2015 20:22
Humoral theory provided reassurance to the patient and an elaborate rationale for the interventions of the physician
28/03/2015 20:24
This wasn't the only theory:-
Religious and secular, supernatural and what purported to be naturalistic explanations of illness persisted down the centuries
28/03/2015 20:27
Notion that madness might sometimes be a means to truth (divine madness, as some would have it) would resurface repeatedly
28/03/2015 20:27
Anti-phlogistic physicians saw disease as fundamentally a problem of inflammation and fever.
28/03/2015 20:29
Bleeding, purging and making use of emetics, all designed to counteract and to deplete the over-active, over-heated body
28/03/2015 20:30
Religious and spiritual interventions might be tried alongside the bleeding, purging and emetics of the anti-phlogistic physicians
28/03/2015 20:31
So, the notion of chemical imbalance in the brain (eg. see previous post) even though it's wrong, like humoral theory, persists because it provides an 'aura of factuality' (see previous post). The historical perspective provided by books like Madness in civilisation helps us to realise that modern claims about brain dysfunction in mental illness are not really facts but part of a myth, even delusion, to suggest an understanding of mental illness and justification for its treatment.

Friday, April 24, 2015

Pathologist of the mind

As I have been reading it, I have been tweeting quotes or amended quotes from Pathologist of the mind: Adolf Meyer and the origins of American psychiatry by Susan Lamb (who I have already quoted in a previous post). I thought I would bring some of these tweets together to try and explain the importance of Adolf Meyer's work.

Susan's book (see her website) is a scholarly account that the literature has needed. Meyer himself failed to be explicit in getting across his theory of psychiatry, which was called Psychobiology (eg. see my article). Susan includes clinical material from his archives which also helps to relate his theory to his practice.

As Susan says in her conclusion, one of the key insights is that:-
Meyer viewed mental activity and brain activity as a single biological response
24/04/2015 13:12
She goes on, "to overlook this principle is to risk misconstruing Meyer's thinking, practice, and teaching". Or, as she says in another tweet:-
The tendency to equate the descriptor 'biological' with 'physical, bodily or somatic' can render anything Meyer said or did unintelligible
08/03/2015 20:15
The second key insight is "to appreciate the essentially medical orientation of Meyer's thinking, practice, and teaching". For Meyer:-
Mental dysfunction, as much as brain disease, is a medical condition resulting from pathological processes
08/03/2015 17:34
This meant that:-
Meyer framed prevalent forms of mental illness not as distinct brain diseases, as did majority of his peers, but as failed adaptation
08/03/2015 17:37
This is why I have emphasised the views of Adolf Meyer in discussions of psychiatric diagnosis on this blog (eg. see previous post). Meyer was also clear that:-
Brain research is comparative neurology not psychiatry
08/03/2015 20:58
In other words, Meyer warned against going beyond statements about the person to wishful 'neurologising tautology' about the brain. Even though:-
Kraepelin was part of first wave in the generational backlash against the hegemony of brain mythology in the late 19th century
26/03/2015 16:59
Meyer lamented the Kraepelinian craze to diagnose, classify and to generate statistics
26/03/2015 17:11
Meyer took over the Huxleyan notion of science as being organised common sense. 
Science is defined by application of rigour to observing, documenting, comparing and ordering data
08/03/2015 22:01
Science is not defined by principles of physics or chemistry, nor by experimental techniques
08/03/2015 22:00
In summary:-
Psychobiology provided basis to liberate psychiatry from dogma that explained mental activity in reductive, dualistic or deterministic terms
24/04/2015 13:09
To emphasise, Meyer was primarily interested in the implication of these ideas for clinical practice. 
Meyer was no philosopher. He was a pathologist on a mission
17/03/2015 08:59
Susan also agrees with me in my spat with Nasser Ghaemi (see previous post) that:-
The pluralism of psychobiology was neither arbitrary nor uncritical
17/03/2015 09:00

Tuesday, April 07, 2015

No one should believe the chemical imbalance theory

post on Slate Star Codex argues that the idea that "depression is a drop-dead simple serotonin deficiency was never taken seriously by mainstream psychiatry". There may be some truth in this view, but there's no doubt that many people have been taken in by the theory (see eg. previous post). They're surprised that the theory hasn't been proven. They may even have been told by a psychiatrist that their depression is due to a chemical imbalance.

And there's no doubt that drug companies have taken advantage of these beliefs as shown in the Zoloft (sertraline) advertisement above. True, the commercial does say that the cause of depression is unknown. But it then goes on to suggest that sertraline corrects a chemical imbalance to which depression may be related. And Slate Star Codex doesn't want to totally abandon the idea that "it's very likely it [depression] will involve chemicals in some way".

Actually, the 'chemicals in depression' may not be much different from those that create normal feelings. It may not make much sense to view depression as a neurochemical disorder. The kinds of processes that underlie mental illness at the biochemical level may be no different from those that produce thoughts, feelings and behaviour amongst the 'normal'. We tend to assume that there must be a neuropathological basis for mental illness, as there is a pathological basis for physical illness. But 'mental illness' is very different from physical illness, if only because of the mind-body philosophical problem.

And, the sertraline advert is also misleading in that it says that sertraline "is not habit forming". Antidepressant discontinuation problems do occur with SSRI antidepressants, like sertraline (eg. see previous post). It's not surprising that people may get psychologically dependent on a drug which they think has improved their mood (see my book chapter).

Thursday, April 02, 2015

Psychiatrists do believe psychosis is a brain disease

Ronald Pies (whose recent book I have reviewed) has criticised the BPS report on psychosis (see previous post) in a Psychiatric Times article for underestimating the potential seriousness of psychosis and misconceiving its nature by focusing on hearing "voices". I agree that the report, for example, does not try and distinguish psychosis from dissociative identity disorder, in which people may also hear voices.

Pies also says that the report's argument against descriptive diagnosis is "historically ill-informed and medically naive" for suggesting psychiatric diagnosis should provide an explanation of people's problems. Again, I agree that psychiatric diagnosis is primarily phenomenological, in that it involves assessment of a person's mental state. Nor, as Pies says, is the "existence of societal prejudice and discrimination" a valid argument against psychiatric diagnosis, as inevitably the implication of a psychiatric diagnosis is that something has 'gone wrong' with the person's psychosocial functioning.

As I have explained in my book review, where I do have a problem with Pies is that I do not think he sufficiently knowledges that minds are not reducible to brains. For example, in another Psychiatric Times article on the BPS report, he says that "schizophrenia is often associated with neuropathology". He deliberately highlights the word "associated" because he does not want to imply causation necessarily. However, he tends to imply just that and it's difficult to see that he means otherwise. Psychiatrists do believe schizophrenia and psychosis are brain diseases and I think Ronald Pies does as well.

(With thanks to Around The Web post on Mad in America)

Sunday, March 29, 2015

The psychogenic legacy of Adolf Meyer

Useful paper by Jordan Devylder on Adolf Meyer's psychogenic model of schizophrenia (dementia praecox), relevant to a previous post, summarises what I have been trying to say about Meyer. The article describes the development of Meyer's psychogenic theory in the context of related work in the period from Kraepelin to Bleuler. It reminds us that Kraepelin provided a "provisional and very indefinite" hypothesis that the biological cause of dementia praecox was intoxication from the sex glands causing a poisoning of the brain during puberty. As Meyer said, this was a theory that was "so vague as to demand consideration only if actual facts can be adduced and other facts should fail".

The article argues that we are beginning to see a revival of Meyerian psychiatry. I'm not convinced by Devylder's attempt to link this with the stress-vulnerability model, which is essentially still biomedical. However, as he says, "Meyer's legacy ... is the psychogenic perspective" (see my chapter The biopsychological approach in psychiatry: The Meyerian legacy in my edited book Critical psychiatry: The limits of madness).

The importance of antidepressant discontinuation problems

Giovanni Fava (who I have mentioned in a previous post) et al (2015) have produced what seems to be the first systematic review of clinical aspects of the discontinuation of serotonin specific reuptake inhibitor (SSRI) antidepressants. As they point out, the limited attention to this topic is surprising, considering its importance as SSRIs are widely used in practice.

Discontinuation symptoms may occur with any type of SSRI but seem to be more frequent with paroxetine. Gradual tapering does not eliminate the risk. The syndrome typically occurs within a few days and lasts a few weeks but many variations are possible, including late onset and/or longer persistence. A wide range of psychological and physical symptoms may occur. As I mentioned in a previous post, a survey has confirmed that the primary symptom is anxiety. In my book chapterWhy were doctors so slow to recognise antidepressant discontinuation problems?, I made reference to the paper by Schatzberg et al (1997), which described the core psychological symptoms as anxiety/agitation, crying spells and irritability. That paper also divided the physical symptoms into five clusters: disequilibrium, gastrointestinal, flu-like, sensory and sleep disturbances. There are many similarities with the withdrawal symptoms from benzodiazepines and other antidepressants. Discontinuation symptoms may easily be misidentified as signs of impending relapse.

As Fava et al point out, the use of the term 'discontinuation syndrome', rather than 'withdrawal syndrome' was heavily supported by the pharmaceutical industry to emphasise that SSRIs do not cause addiction or dependence. I have always emphasised the psychological dependence caused by SSRIs since my letter to the BMJ and my Antidepressant discontinuation reactions website. This vulnerability should not be minimised.

Friday, March 20, 2015

The miracle of psychiatry

Like Robert Whitaker (see previous post), I bought Shrinks: The Untold Story of Psychiatry by Jeffery Lieberman (see eg. another previous post) because I intended to blog on it, but after reading it I initially thought I wouldn't bother (see Robert's blog post).  Lieberman makes claims about brain abnormalities associated with mental illness, which need challenging. However, it's difficult to do so, because there are no references in the book, although there is a list of sources and additional reading at the end. I'm also not sure what has been untold about his story of psychiatry, because there doesn't seem to be much new in the book. Perhaps he thinks that what he calls anti-psychiatry has the dominant narrative in the history of psychiatry and he needs to replace it with his own.

Like Robert, what grated on me was the messianic nature of the book. Lieberman needs to be more circumspect about his claims for psychiatric treatment effectiveness. His tale of psychiatry, as he himself says, is of the "dramatic transformation from profession of shrinks to profession of pill-pushers". Although he is "under no illusion that the specters of psychiatry's past have vanished, or that my profession has freed itself from suspicion and scorn", he believes in the "mind-boggling effectiveness of medication". Steady on! He describes what he calls the "accidental discoveries of miracle medications". The introduction of psychiatric medications may well have been serendipitous but was it miraculous? When chlorpromazine was first introduced in state-funded mental institutions in America, as far as he is concerned, "the results were breathtaking". His enthusiasm for psychiatric medication extends to ECT. This is because he's seen "patients nearly comatose with depression joyfully bound off their cot within minutes of completing their ECT". As Robert Whitaker says, this is "a modern-day story of Jesus, curing the lame, who could now throw away their crutches and walk".

At the beginning of the book, Lieberman gives the history of a psychotic patient he calls Elena Conway, the daughter of a well-known celebrity. Three weeks treatment with risperidone, "a very effective antipsychotic medication", as far as he is concerned, and care in hospital led to a "dramatic improvement". The trouble is that he doesn't say what happened to Elena long-term, apart from suggesting that if she had carried on with aftercare treatment she would have had a "good recovery". Shouldn't we be told if she had a poor long-term outcome?

The combination of psychiatrists' belief in their treatments and patients' faith in psychiatrists may produce a powerful placebo remedy. Psychiatrists, like Lieberman, may be deluded into believing that their prescribing is having specific effects. Lieberman suggests that "instead of Daniel Amen's unproven claims for SPECT-based diagnosis of mental illness [see previous post], we will have scientifically proven methods of diagnosis [in the future] using brain-imaging procedures". But such simplistic and biologically reductionist accounts of mental illness are no different from those of Amen or some of the historical treatment excesses Lieberman describes in the book. Such faith and self-deception still sustains modern pharmacotherapy. The wish-fulling claims of modern psychiatry need to be shrunk to more realistic proportions.

Saturday, March 07, 2015

"There are serious critics of psychiatric diagnosis and ... treatment ..."

Allen Frances, who I have mentioned in a previous post, has been attacked by Paula Caplan (see her article) for being very well paid by Johnson and Johnson (J&J) for producing guidelines which promoted the use of its drug, risperidone, as "first choice" in schizophrenia. Frances, in reply, argues that this is what he believed at the time, but admits it was unwise to have done this with drug industry funding. It suited both doctors and patients to believe that the atypical antipsychotics, like risperidone, were an advance in treatment (see my OpenMind column).

There has also been illegal over-marketing of risperidone. J&J pleaded guilty to a misdemeanor criminal charge of improperly marketing risperidone as a treatment for elderly dementia patients (see NYT article). It has also settled in cases where it has been accused of other "off-label" marketing, particularly in children, and of overstating the safety and effectiveness of the medication (eg. see report on Texas case).

Even some of the most biomedical of psychiatrists have expressed concern about unethical practice in psychiatry (eg. see my book review). The corruption of modern psychiatry does influence the academic debate about diagnosis and treatment (eg. see previous post).

Friday, February 27, 2015

Critical psychiatry position on schizophrenia

Joanna Moncrieff and Hugh Middleton, the co-chairs of the Critical Psychiatry Network, have produced a critical psychiatry perspective on schizophrenia (see article). They argue that the concept of 'schizophrenia' is neither valid, nor useful, and suggest replacing it with more generic concepts such as 'psychosis' or 'madness'. The replacement of the term 'schizophrenia' by 'psychosis' has already happened to some extent in everyday clinical practice, as reflected in the updating of NICE guidance, now called Psychosis and schizophrenia in adults: treatment and management, whereas previous editions just referred to schizophrenia. The recent BPS report was also entitled Understanding psychosis and schizophrenia (see previous post).

Psychosis, like schizophrenia, is of course not an absolute concept and there may well be clinical disagreement about whether mental symptoms should be seen as psychosis. Jo and Hugh argue against the suitability of seeing mental disorders as illness and disease. As I have said before (see eg. previous post mentioned above), I do not have a problem with the term 'mental illness'. As I see it, the critical psychiatry position is that mental illness, such as schizophrenia, is not a brain disease.

It is true, as Jo and Hugh note, that Emil Kraepelin formulated the concept of dementia praecox (which was renamed schizophrenia by Eugen Bleuler) "with the goal of delineating something whose biological origins could then be uncovered". What they don't mention is that Adolf Meyer argued at the time against the attempt to create disease entities in psychiatry (see eg. Meyer's 1906 paper). As expressed by Susan Lamb (whose paper I have mentioned in a previous post) in her book Pathologist of the mind (see her website):-
A patient did not contract a disease called schizophrenia any more than he or she became a schizophrenic, both of which implied that the disorder was an ontological entity distinct from the person. He [Meyer] urged that many prevalent forms of psychopathology were not the result of an attack on the organism (like syphilitic insanity, for example) but developed as part of its adaptive performance. "Every individual is capable of reacting to a very great variety of situations by [adopting] a limited number of reaction types," Meyer proposed in 1906, and he deemed this true of both healthy and pathological reactions. Schizophrenia ... described a particular type of maladaptation. Rather than a nosological term, then, he suggested a diagnostic adjective that would precede the term reaction-type. Instead of schizophrenia, he proposed "schizophrenic reaction-type."

Bleuler, like Kraepelin, also assumed that schizophrenia ultimately derived from an unknown organic cause. He nonetheless attempted to understand the psychological conflict that triggered the latent disease. Against Kraepelin, he disputed that schizophrenia was a degenerative condition. Schizophrenia has always been essentially a phenomenological diagnosis, even if the assumption is made that an underlying biological cause will be found. Jo and Hugh concede that "certain patterns might be recognised". The usefulness or validity of the term schizophrenia may depend on the identification of these patterns. Like Meyer, though, I agree the problem with any attempt at psychiatric classification is the reification of psychiatric concepts, such as schizophrenia. If the concept 'schizophrenia' is of value, it does not represent an entity or a thing. 

Monday, February 23, 2015

Psychiatric indignation

Jeffery Lieberman (who I have mentioned in a previous post) is angry about Tanya Luhrmann's article in The New York Times (see his video post on Medscape Psychiatry). He's worried that people reading Luhrmann's article may think they don't have a mental illness when they do and, thereby, not get the treatment they need. He's also clear, despite what Luhrmann says, that antipsychotic drugs correct a biological abnormality. He must know that he can't say psychosis is due to dopamine hyperactivity, just because antipsychotics may block dopamine, so I don't understand what he means. I do agree with him, though, that it's stretching a point to align Thomas Insel's rejection of DSM-5 (see previous post) with the thesis of the BPS report on psychosis (see another previous post). Insel is still very much a biological psychiatrist (e.g. see another previous post).

Lieberman is indignant that he has to deal with an anthropologist, like Luhrmann, commenting on such a "disciplined, bound in evidence, and scientifically anchored" subject such as psychiatry. Luhrmann in fact studied psychiatry by participant observation in her excellent book Of two minds. What Lieberman finds difficult is any scepticism about the effectiveness of psychotropic medication. As he says, debate about this issue should be encouraged.

Tuesday, February 10, 2015

Is the insanity defence valid?

Peter Kinderman's latest post on the Salomons blog questions whether we need the idea of mental illness in criminal justice. He's not saying that the criminal justice system shouldn't take account of people's personal and social circumstances. But he is worried that courts may think that mental illness makes people commit crimes. In fact, as I've pointed out before in a previous post, he doesn't think there's a place for psychiatric diagnosis.

It does worry me that the critical mental health movement gets caught up in an apparent split about the validity of the insanity defence. Thomas Szasz, of course, famously argued against the insanity defence, as he did not believe in the notion of mental illness. Essentially, he thought there is no need for any specific mental health legislation (see eg. previous post). Whilst I agree that mental health services should not insist that people accept that their problems are symptoms of an underlying illness, Peter seems to be verging, at least, on rejecting the notion of mental illness altogether. We might benefit from more clarity about whether he thinks there should be a Mental Health Act.

The point is that what is designated as mental illness may lead to mental incapacity. People who are psychotic may not make the  most rational of decisions because of their mental illness. Crimes, including homicide, may be committed for psychotic reasons. It is generally accepted that it is wrong to punish a person deprived, even if only temporarily, of the capacity to form a necessary mental intent that the definition of crime requires. People should be presumed to have a sufficient degree of reason to be responsible for their crimes unless the contrary can be proved. But, in some cases people do appear to have acted irrationally because of mental disorder in committing their crime.

The legal test of criminal insanity in England was developed in the trial of Daniel McNaughton. On the 20th January 1843, Daniel McNaughton fired a pistol at point blank range into the back of Edward Drummond, the private secretary of the Prime Minister, Robert Peel. McNaughton may well have  thought he was shooting the prime minister. In the magistrates court the next day he said, "The Tories in my native city have compelled me to do this. They follow, persecute me wherever I go, and have entirely destroyed my peace of mind." Although the court did not examine whether there was any element of truth to his claim and it was not explained why he had a bank receipt for a large sum of money on him when arrested, both the prosecution and defence agreed he suffered from delusions of persecution. No medical evidence was offered to say he was not deluded and the jury returned a verdict of not guilty by reason of insanity. McNaughton was admitted to Bethlem hospital and transferred to Broadmoor when it opened, where he died in 1865. His diminished responsibility for the homicide was accepted on the basis of his mental illness.

In practice, courts may well be sceptical of psychiatrists' assessment of mental illness. For example, see my post about the case of Anders Breivik. I do understand what Peter means when he asks whether we really need the notion of mental illness to determine a Court adjudication. He seems happier with the notion of psychosis, so maybe we should use that term. Whatever we call it, mental dysfunction can diminish responsibility for a crime. Personally, I am happy to see such psychotic dysfunction as illness, in the same way as bodily dysfunction is illness. The real problem is seeing mental illness as brain disease (e.g. see another previous post).