Sunday, July 13, 2014

A historical perspective on academic psychiatry in Sheffield

Following his death (see previous post), I have been re-reading Alec Jenner's personal memoir (1) of Erwin Stengel, his predecessor as Professor of Psychiatry in Sheffield. Alec also wrote Stengel's Lancet obituary. Stengel founded the University Department of Psychiatry in Sheffield in 1957. Alec stepped into his shoes in 1967. 

Stengel was from Vienna, as was Freud, and I remember Alec showing me an imitation Graeco-Egyptian pot that Freud gave Stengel for treating his maid. As Alec put it, "despite considerable neurological sophistication, there is a struggle to find humanistic explanations" in Stengel's writings. 

Alec himself had an interest in philosophy even when Director of the MRC Unit for Metabolic Studies. Early in his career, he did nonetheless think he would explain manic-depressive illness biochemically, and probably never gave up the idea that a biological solution to mental illness may be found. Still, after his retirement there were those who sought to undermine his open-minded interest in democratic psychiatry, which they called "anti-psychiatry", and replace his emphasis with neuroscience. The current research interest of Sheffield academic clinical psychiatry is "biological investigation of psychiatric disorders, and includes the use of neuroimaging techniques to investigate psychotic and other psychiatric disorders".

Such a narrow modern focus on neuroscience is in contrast to the broader interests of Stengel and Alec Jenner and we at least need to return to a more pluralistic, if not critical, understanding of psychiatry.


(1) Jenner FA. (1991) Erwin Stengel. A personal memoir". In: Berrios GE & Freeman H: 150 Years of British Psychiatry 1841–1991. London: Gaskell. pp. 436–44.

Thursday, July 10, 2014

Death of founding editor of Asylum Magazine announced

Professor Alec Jenner, founding editor of Asylum Magazine, died on July 3rd. The funeral service will be held in St Nicholas Church, High Bradfield, Sheffield on Wednesday 16th July at 12:00. Following the funeral service the family would like to invite attendees to join them at the Old Horns, Towngate, Jane St., High Bradfield, Sheffield where refreshments will be served and where good memories of Alec can be shared.

I'm particularly sorry to hear of his death. In 1989, he appointed me Lecturer in Psychiatry in Sheffield University, when nowhere else wanted me for senior registrar training. He was professor there for 25 years. He organised regular fortnightly outside speakers in term time on Tuesday evenings, which Tim Kendall and I carried on after he retired, until I left Sheffield in 1996. 

Alec's contribution to critical psychiatry was immense. He may have preferred to call it democratic psychiatry following Franco Basaglia. More to follow to honour his life and work, but for the moment look at his own view as a psychiatrist from the alternative textbook of psychiatry, which Lin Bigwood and he helped Phil Virden to write.

Saturday, July 05, 2014

The americanisation of critical psychiatry

Sandra Steingard has posted a video of a talk "Why I became a critical psychiatrist" on her Anatomy of a Psychiatric Practice blog on Mad in America. She also posted last November the introduction to the forum on the Critical Psychiatry Network (CPN) - North America webpage of the International Critical Psychiatry Network (ICPN) website.

Freud was always fairly pessimistic that the move of psychoanalysis to America would preserve his key ideas. It may be said that he was proved right in this expectation. On the other hand, I have always seen critical psychiatry as a broad church (eg. see previous post). So, the American take up of critical psychiatry shouldn't be plagued by similar arguments about doctrinal purity. And I think it would be good if Americans did embrace critical psychiatry as they did psychoanalysis. Thanks to Sandra for her lead.

Saturday, June 21, 2014

The sense in saying antidepressants don't work

According to a Times article, Sir Simon Wessely, President-elect of the Royal College of Psychiatrists, thinks it is "nonsense to say that antidepressants do not work". I presume he's saying that antidepressants are more than placebos. He may know more than I do, but he doesn't seem to think that the small effect size in clinical trials could be due to placebo amplification due to unblinding (eg. see previous post).

I guess he has to believe this as head of the Royal College of Psychiatrists. My scepticism means I'm never going to fulfill this role! It's alright for Simon to say that he doesn't really buy parents promoting the idea that their children who get into Oxford are mildly autistic. And, that modern services couldn't be less well designed to join up physical and mental health care. But it's beyond the pale to suggest that psychotropic medication is not effective.

Monday, June 09, 2014

The benefit-to-harm ratio of antidepressants

A Lancet Psychiatry article attacks Peter Gøtzsche (who I have mentioned in a previous post) for saying that antidepressants do more harm than good. Although his Guardian article has this headline, in fact what he wrote was "the way we currently use psychiatric drugs is causing more harm than good" [my emphasis]. He doesn't seem to be advocating not using antidepressants at all, but "much less, for shorter periods of time, and always with a plan for tapering off, to prevent people from being medicated for the rest of their lives".

As I commented in my previous post about Gøtzsche, the problem is that attacking him in this way deflects from the validity of what he is saying. I wish mainstream psychiatry would engage more with me. I do know it is important to avoid overstatement (see previous post). The Lancet Psychiatry article emphasises the effect size found in antidepressant trials. What it doesn't discuss is whether this finding could be explained by placebo amplification due to unblinding in clinical trials (eg. see previous post). Nor does it discuss the bias in the literature introduced through selective publication. These days this is because data submitted by the drug companies to the regulatory authorities is not always examined completely. Previously, with older trials, this was because of what was called the 'file drawer problem' (see further information) in that negative trials did not always get published. This may well have affected the amitriptyline data that the Lancet Psychiatry article cites.

As I said in a comment on a previous post, it's important not to get too hung up by the size of effect in clinical trials. Maybe I'm too sceptical, but the finding that non-psychiatric drugs have similar effect sizes in clinical trials does not imply that psychiatric drugs are effective, but that medical as well as psychiatric clinical trials are subject to the same biases of unblinding (see previous post).

The authors of the article speculate about the reasons for doctors questioning the effectiveness of antidepressants, suggesting it is the anti-psychological bias of doctors that makes them want to believe that there can't be a physical treatment that could possibly be effective for mental illness. So, they try to turn the tables on critics by suggesting it's the critics not them that are stigmatising mental illness. They feel insulted by the critique but it is important to be open to argument and not prejudiced.

Thursday, June 05, 2014

Finnish psychologist sacked after expressing critical views about antidepressants on TV

Aku Kopakkala, who worked for Mehiläinen, a private health care organisation in Finland, has been sacked after appearing on a TV programme about antidepressants with Peter Gøtzsche (who I have mentioned in a previous post). Can someone create a better transcript of the programme for me than Google translate? Critical views about psychiatry are discriminated against (see previous post) and this may well be an unfair dismissal.

I see that the Vice President, Working Life Services at Mehiläinen was managing director at Pfizer Oy. And, Erkki Isometsä, Professor of psychiatry at the University of Helsinki, does not seem to have liked being asked on the programme how much he was paid for public speaking by the drug companies. However, this is relevant as he is chair of the Task Force for the National Current Care Guideline for the Treatment of Depression. Confrontation about these conflicts of interest can have destructive consequences.


(With thanks to Jeremy Wallace)

Sunday, June 01, 2014

Psychiatry for a new generation

Maybe because I am approaching pension age, I have been thinking about the impact of critical psychiatry on practice. There seems to be little shift in mainstream biomedical bias, which tends to ignore any challenge to its approach. I seem to have been wasting my time trying to get critical psychiatry's message across.

In a previous post, I mentioned Aubrey Lewis, who influenced the generation of professors that I saw retire. I think there's now less passion for thinking about the basis of psychiatry, which he encouraged. That passion has been diverted into promoting neuroscience as the solution to mental illness (eg. see previous post). Trainees are supposed to get excited about discovering the scientific cause of mental illness rather than be interested in the conceptual foundations of psychiatry. I think this is a recipe for disillusionment as fulfillment of this wish is unobtainable.

Of course, psychiatry has always held out the hope that the biological basis of mental illness will be uncovered. However, at times, it seems to have been more open to recognising the uncertainty of human action. For example, Adolf Meyer (see previous post) and George Engel (see conference presentation) encouraged a patient-centred approach to psychiatry. These days, however, a full personal assessment of a patient is almost seen as out of date in psychiatry (see another previous post). Do trainees even know who Adolf Meyer and George Engel were?

So, how can younger mental health professionals be interested in critical psychiatry? They need to be reassured about its legitimacy and not have their careers blighted because they express an interest. Critical psychiatry is not anti-psychiatry, in the sense that it denies the reality of mental illness. It may be almost unbelievable that mental illness is not associated with neuropathology, considering the research effort put into trying to find just that association. But, in fact, the neurobiology of mental illness may be no different from that of our "normal" behaviour (see my article).

I haven't seen any debate about these issues on the Early career psychiatry webpage at Psychiatric Times.

Wednesday, May 21, 2014

Human rights and mental health worldwide

The Movement for Global Mental Health emerged from a 2007 Lancet series, which concluded with a call for action. According to Vikram Patel (2011), the demand for effective implementation of human rights is as important a goal as the increase in availability of and access to a range of mental health services in the global south. People with mental illness can be abused worldwide. As Arthur Kleinman (2009) says:-
I have personally witnessed individuals with mental disorders in east and southeast Asian towns and villages chained to their beds; caged in small cells built behind houses; hospitalised in for-profit asylums where they are kept in isolation in concrete rooms with a hole in the floor for urine and faeces; abused by traditional healers such that they become malnourished and infected with tuberculosis; scarred by burns resulting from inadequate protection from cooking fires; forced to dress in prison-like clothes in asylums with shaven heads and made to perform child-like dances and songs for gawping visitors; knocked to the ground and forcefully held down for electroconvulsive therapy when psychotic in an emergency room; laughed at by the police; hidden by families; stoned by neighbourhood children; and treated without dignity, respect, or protection by medical personnel.
For example, the Human Rights Watch report, "Like a death sentence", describes abuses against people with mental disabilities in Ghana. The three public psychiatric institutions in Ghana and 8 prayer camps in the southern parts of the country were visited. All the camp leaders interviewed considered mental disability to be caused by evil spirits or demons. Most people brought to the camps for healing for mental disabilities were chained to logs, trees or other fixed spots. Hospitals were found to have poor sanitation. Individuals are routinely institutionalised by their family or police and denied the right to refuse or appeal their confinement, which may include forced treatment, physical abuse and seclusion. The report of the UN Special Rapporteur on torture expressed concern about the use of electroshock with the use of restraints, without adequate anaesthesia.

The call for "scaling up" of mental health services in low and middle-income countries (LMICs) has caused controversy. For example, books by Suman Fernando, Mental health worldwide: Culture, globalization and development, and China Mills, Decolonizing global mental health: The psychiatrization of the majority world have criticised the Movement for Global Mental Health. This is because LMICs may do better to develop their own solutions rather than emulate high-income countries (HICs). Do LMICs really want to develop the same pharmaceutical emphasis as so-called developed countries? Being disempowered and living in conditions of persistent poverty may not be improved by perceiving the emotional consequences of such social disadvantages as a brain problem. Wellbeing may be more than a medical problem.

As Suman says, "care is needed in how the concept of 'human rights' is interpreted" and may not mean having the right to the same psychiatric treatment practiced in the West. As he also says, "Perhaps asylums should never have been introduced in LMICs". Human rights are violated in these institutions, which requires urgent attention. Some religious healing activities may need to be controlled. Suman agrees that injustices must be remedied, but I'm not sure if I agree that legislative changes (which clearly must take account of local services rather than merely being copied wholesale from legislation in HICs) should have less priority than community service development. I do agree, though, with his view that a paradigm shift envisaged by Bracken et al (2012) (see previous post) is required to create a psychiatric practice "sufficiently flexible to play a constructive role in mental health systems worldwide". Such an approach must be driven by the human rights of people with mental health problems.

Friday, May 16, 2014

Don't be tricked into taking antidepressants

Bruce Levine, one of whose books I reviewed some time ago, has an article on the Greanville Post which asks "Why has the American public not heard psychiatrists in positions of influence on the mass media debunking the chemical imbalance theory?" As Levine says, and as I have previously discussed several times (eg. in an BJPsych eletter), the reason is that the theory is used to persuade patients to take their medication. It may make it easier for patients to accept their depression and take their medication if they believe they have a chemical imbalance in the brain.

Actually, I do find that patients are generally able to understand that the "chemical imbalance theory" is only a theory. In fact the evidence is against it. What they find more difficult to appreciate is why they are told that the theory has been proven, when this is clearly not the case.

Big Pharma is commonly blamed for encouraging the chemical imbalance theory. Actually, drug companies sometimes only say that it is a commonly believed theory, maybe implying but stopping short of indicating that they believe it. The theory wouldn't have survived if it wasn't for psychiatrists' complicity with it. Bruce is right to direct his criticism at psychiatrists themselves.

Saturday, May 10, 2014

Still depressed even though treated for bipolar

I've commented before on the expansion in the diagnosis of bipolar II disorder (eg. see previous post). Reading Nassir Ghaemi's forward to Jim Phelps' book, Why am I still depressed?, indicates that at least part of the motivation for this development was to "move away from simple-minded diagnoses and prescriptions about depression". The necessity for this was because antidepressants are not "the panacea that many once thought". However, are the benefits and limits of so-called mood-stabilisers any different from antidepressants (eg. see another previous post)? And is the concept of bipolar II disorder valid or merely motivated by wishful fantasy?

And once the concept of bipolar disorder II has been accepted, then the notion is that antidepressants may actually make the disorder worse by increasing the risk of (hypo)mania. Better stick with just mood stabilisers in the treatment of bipolar II disorder. But is manic switch more theoretical than what actually happens in practice, particularly in bipolar patients compared to unipolar? The evidence, for what it's worth, is that the switch risk has been overinterpreted. Keep quiet about this so the myth of bipolar II disorder can be perpetuated.

Wednesday, April 02, 2014

Removing psychotropic drugs from the market

An article by Peter Gøtzsche (english translation posted on Mad in America blog), containing what he sees as 10 myths about psychotropic medication, has led to a letter from the Danish Psychiatric Association addressed to the Cochrane Collaboration, which has replied. Peter has also responded further on the blog to criticism of his original article.

The Danish psychiatrists find points in Peter's article "irrelevant, .... incorrect and misleading" but then do not go on to say what these points are. Instead they attack his comment that the "citizens [of Denmark] would be far better off if we removed all the psychotropic drugs from the market". It's clear from Peter's article that he is aware of discontinuation problems with psychotropic medication - in fact he criticises the myths that "It’s no problem to stop treatment with antidepressants" and "Happy pills are not addictive". So he would be aware of the problems of a wholesale removal of such drugs from the market.

The danger is that deflecting his argument in this way avoids answering his points in the article. Cochrane, as far as I can see, haven't said it is going to do that. I'm not saying I necessarily totally agree with his points, eg. I've got a more open mind about the data on suicide risk of antidepressants in children and adolescents. But he is clearly correct about the myths that "Your disease is caused by a chemical imbalance in the brain" and that "Psychotropic drugs for mental illness are like insulin for diabetes". I also think the data on whether psychotropic medication creates a vulnerability to relapse merits more debate that it receives.

(With thanks to Olga Runciman)

Tuesday, March 11, 2014

Educating people about the brain is a good thing

Thomas Insel's latest post on his NIMH director's blog focuses on March being Brain Awareness Month. Although as Insel admits, we don't know much about the working of the brain, what we do know is important, fascinating and people should be more aware of it. I think it's important to emphasise the dynamic nature of the brain.

I just don't think Insel's so good on the limits of brain neuroscience, starting with his claim that mental disorders are brain disorders. Of course, there's a sense in which such a statement is merely tautologous. But, he goes further to state that "with the powerful tools of neuroscience, we can now use the brain to understand the mind" but then doesn't explain how exactly. He's even not correct, I don't think, about Freud's project for a scientific psychology. Freud may well have thought that psychoanalysis may have eventually been replaced by chemical treatment, but he believed his theory of the mind would endure (read John Heaton's book). I'm sure Insel does not agree with Freud that his theory of the mind was scientific.

Monday, March 10, 2014

What's wrong with believing in the chemical imbalance theory of depression?

Recruits from an undergraduate psychology course with a past or current episode of depression were led to believe that the purpose of a study (Kemp et al 2014) was to improve understanding of how people respond to learning the cause of their depression. They were administered the Rapid Depression Test (RDT), which they were deceived into believing is a "test of neurotransmitter levels whose results would allow participants to determine whether or not their depressive episode(s) were caused by a chemical imbalance in the brain".

The test
entailed swabbing the inside of the participants' cheeks with a sterile cotton swab and placing the cotton swab into a sterile collection container. Participants were told their saliva sample would be tested in the lab. The experimenter returned 10 minutes later with the results.

In the chemical imbalance
condition, participants were informed that test results indicated that their past/current depression was caused by an imbalance in the neurotransmitter serotonin. Participants were presented with a bar graph of their test results depicting very low serotonin levels relative to levels of other neurotransmitters, all of which were in the normal range. Participants in the control condition, on the other hand, were told their past/current depression was not the result of a chemical imbalance, based on purported test results (and a corresponding bar graph) indicating that all neurotransmitter levels were in the normal range.

The chemical imbalance test feedback made participants significantly more likely to attribute their depression to chemical imbalance, demonstrating that the intervention was effective. Self-stigma was unaffected but chemical imbalance feedback made participants significantly more pessimistic about prognosis. There was some evidence of lowered perceived ability to regulate negative mood states. Participants
in the chemical imbalance condition rated pharmacotherapy as more likely to be effective than psychotherapy. By contrast, expectancies for pharmacotherapy and psychotherapy did not differ significantly in the control condition.

The authors conclude that doctors may be causing harm by encouraging belief in chemical imbalance. The theory may be used as a means of getting patients to take their medication (eg. see my eletter). It can be a surprise to patients when they discover the theory has never been proven. They might be even more upset when they realise they might have done better not to believe it.

(With thanks to blog by Kermit Cole on Mad in America)

Saturday, March 08, 2014

Do mood stabilisers treat mood instability?

What is mood instability? As the article by Marwaha et al (2012) says there is a "lack of a clear, accepted and well-validated definition". However, the impression given when people are prescribed so-called mood stabilisers is that we know what we are talking about.

13.9% of the population aged over 16 in the 2007 Adult Psychiatric Morbidity Survey answered yes to the question "Do you have a lot of sudden mood changes?" Marwaha et al take this as their definition of mood instability. And, patients referred to mental health teams commonly complain of this symptom (without perhaps being very clear about what they mean). For example, Gilbert et al (2005) found that 83.8% of patients referred to two city CMHTs in Derby ticked mood instability on a checklist and this was the most commonly endorsed symptom of any on the list.

In an article this month in BJPsych, Bilderbeck et al (2014) interviewed 28 patients referred to secondary mental healthcare teams (including a specialist mood disorder clinic) in Oxfordshire and Buckinghamshire. Mood instability had been cited as a reason for referral. What was found was that patients placed a primary emphasis on finding an explanation for their problems. Not everyone was helped by a formal diagnosis of, say, bipolar disorder. For example, receiving a diagnosis could be experienced as dismissive, in a way that was linked to a perceived lack of adequate explanation and/or support. What may be more important than a diagnosis is a good professional relationship with the doctor.

In an accompanying editorial, Robert Dudas makes the common statement that "few people would now challenge the view that it [bipolar disorder] is a major mental illness with a strong biological vulnerability" without being clear whether he is being more than trite in referring to the biological dimension. Nor does he discuss the expansion in the diagnosis of bipolar disorder (eg. see previous post).

Dudas also makes reference to another qualitative study of the process of making sense of a diagnosis of bipolar disorder. This study again notes the ambivalence about the diagnosis. More should be made of this finding. Maybe patients are right to be uncertain about psychiatrists focusing too much on mood instability as a mental disorder. I am, of course, not saying that 'tranquility of the mind' may not be important for wellbeing but mood instability is not uncommon and may clearly be a reflection of personal difficulties rather than necessarily a mental illness as such.

Friday, March 07, 2014

Pharma pipeline for schizophrenia

I've been told in an email that these are the pharma pipleine presentations at the 4th Schizophrenia International Research Society Conference in Florence in April this year. (I've added some links):-

Targacept

Dr. David Hosford – Targacept Pharma Pipeline
La Roche
Dr. Dragana Bugarski-Kirola - Efficacy and Safety of Adjunctive Bitopertin versus Placebo in Subjects with Persistent Predominant Negative Symptoms of Schizophrenia Treated with Antipsychotics – update from the SearchLyte Programme (see media release)
Omeros 
Dr. Yu - Early Clinical Results of the Phospodiesterase 10 Inhibitor OMS643762 in Development for the Treatment of Schizophrenia and Huntington’s Disease
Dr. Jonathan Rabinowitz
Randomized, Double-Blind, Active-Controlled, Phase 2/3 Study to Determine the Short-Term (6-Week) and Long-Term (6 Month) Cognitive and Anti-Psychotic Efficacy, Safety and Tolerability of CYP-1020 Compared to Risperidone
Ragy Girgis
Dopamine-1 Receptor Stimulation in Schizophrenia: a Randomized, Clinical Trial
Intracellular Therapies
Kimberly Vanover, ITI-007 a New Approach to the Treatment of Schizophrenia

Hey, I thought the pipeline was supposed to have dried up (see previous post)! Even NIMH admits "treatment development" has been slow (see recent Director's blog by Thomas Insel), although its solution with so-called experimental medicine seems biased towards neural pathways rather than psychosocial treatments (which apparently need to demonstrate their worth through phoney neural pathways). Seems as though I was wrong (although I was just being hopeful!) about abandoning diagnostic crieria for research with RDoC (see previous post).


The reason for these changes according to Insel is that "The pharmaceutical industry pipeline for medications is depleted, after several decades of 'me too' drugs" made by competing companies. He goes on, "Industry has reduced investments in medications for mental disorders and payers are raising questions about the quality of evidence for psychosocial treatments." As proposed by Marcia Angell (see my book review), what's really needed is (1) license approval only to be given to genuinely innovative drugs, rather than as at present to me-too drugs (2) an "Institute for Prescription Drug Trials" within the National Institutes of Health to take over from drug companies, who should no longer be permitted to control clinical testing of their own drugs.

Sunday, March 02, 2014

Onward Christian soldiers

Article in Journal of Nervous and Mental Disease discusses why psychiatrists came to different conclusions about whether Anders Breivik was insane in 2011, when he detonated a fertilizer bomb near government buildings in Oslo, killing eight people, and then killed a further 69 people on a nearby island where the Labor Party was holding a youth camp (see previous post). Breivik didn't invent the Knights Templar. Luckily it's not psychiatrists that make the final decision on insanity in court.

Sunday, February 23, 2014

Misdirecting mental health research

Cynthia Joyce, the chief executive of MQ: Transforming Mental Health (see previous post), in her post on the Wellcome Trust blog, does not doubt that the reason biomarkers for depression have not been found is because of the "complexity of the disorder as well as a deficiency of tools and technologies to help solve the problem". Oh dear, she thinks biobehavioural combinations of psychological symptoms and body fluid measures is the answer. The reason elevated morning cortisol isn't a biomarker, she reckons, could be because we haven't combined it with high depressive symptoms as a risk factor for major depression, at least for adolescent boys.

Don't waste your money giving MQ the opportunity to follow another blind alley, which if it's being responsible, it shouldn't have misled you into.

(With thanks to Peter Kinderman)

Saturday, February 08, 2014

Overemphasis on the importance of psychiatric diagnosis

Craddock & Mynors-Wallis make the case for psychiatric diagnosis in a BJPsych editorial, although I'm not sure why they think its importance is increasing rather than decreasing. I don't want to overemphasise the difference between psychiatric and medical diagnosis, but, despite what they say, there is a difference. I know they're waiting for specific tests "to confirm or refute diagnoses based on clinical assessment" but this is pie in the sky. See my article The overemphasis on biomedical diagnosis in psychiatry.

Monday, January 06, 2014

Share your story about coming off antipsychotics

Rachel Waddingham, Adam Juhgroo, Rob Allison and Phil Thomas have put out a call to recruit people who might be interested to tell their stories about their experience of reducing or coming off antipsychotic drugs. Initial information is available at their book's Facebook page

They intend to collect between 30 to 50 stories, and have signed a contract with Palgrave Macmillan who have agreed to publish. There is also an email address for people to contact them at comingoff.book@gmail.com.

Sunday, December 15, 2013

Getting psychiatry to see the blindingly obvious

An article in Acta Psychiatrica Scandinavica, giving a wake up call to European psychiatry, starts quite well:-
The DSM-5 was published in May 2013. Its publication has been associated with increasing controversy about some specific diagnoses but is not a ‘paradigm shift’. Furthermore, US psychiatric leaders want to ‘sell us’ the belief that the future integration of neuroscience with psychiatric diagnosis will ‘cure and prevent’ mental illness. In 100 years, these words will seem as laughable as similar statements Kraepelin made when he was marketing his Research Institute.
This author proposes that the DSM-5 is a dead end for the historical process initiated in 1980 with the publication of the DSM-III, which was an important step in the history of psychiatric vocabulary. ....
This article proposes that the DSM-III put European psychiatry to sleep; it now must wake up and establish a 21st century language of psychiatry .... to advance its scientific development and practical utility.
The article may lose its way a little later, but makes the essential point that:-
... when psychiatric symptoms are related to 'semantics’ (communication between human beings), a neuroscience approach and methods such as brain imaging make no methodological sense, because these symptoms can only be understood, in the sense of Jaspers, and not explained by brain disturbances. These relatively simple concepts are bad news for psychiatric researchers. 
Jaspers, of course, emphasised the distinction between understanding and explanation. If this is the way of getting the message through about why DSM-5 has failed, then so be it. As I've said in previous posts (eg. Stop thinking about DSM-6), there needs to be a proper conceptual understanding of mental illness before progress can be made. I agree with the author of the article that DSM-5 needs to be recognised as a dead end in the history of psychiatric vocabulary. Holding out the hope of an integration between psychiatric understanding and neuroscience is an illusion. True, psychiatry has always had this wishful hope but DSM-5's failure may have made this basic situation starkly obvious.

Friday, December 13, 2013

Exploiting the antidepressant placebo effect

Stuart Jessop, a patient with depression, in response to a BMJ article, says patients don't care whether antidepressants are merely placebos. He seems to suggest that the placebo effect shouldn't be "explained away". He even suggests GPs should prescribe herbal medicines, presumably even if these remedies have not been shown to be better than placebo.

I do agree with his motivation to avoid patients with mild depression being sent away "empty handed". But is Jessop really encouraging doctors to deceive their patients? I agree the value of the placebo effect shouldn't be minimised and the relationship between doctor and patient is important. But using dummy drugs and other phoney interventions is unethical (see my BMJ letter). Placebos (and antidepressants if they are merely placebos) should not be used to exploit patients.

Monday, October 28, 2013

What's psychosocial reductionism?

Allen Francis has clarified his position on psychiatric diagnosis in his Saving Normal series on Psychology Today (see article). Although he's been critical of DSM-5, in response to Lucy Johnstone, he makes clear that, for him, the biological model is essential and that neuroscience has been "enormously successful in helping us understand normal brain functioning and that over time, in very small steps, this will result in better understanding of abnormal brain functioning". However, he doesn't explain what he means by this.

And he doesn't seem to understand the meaning of reductionism. Reducing the psychosocial to physiological processes is what psychiatry does all the time. I'm not sure how the psychosocial can be reduced to the psychosocial. Presumably Francis is suggesting that the psychosocial is a simpler form of something more complex, but is it?

Wednesday, October 16, 2013

Reinvigorating community mental health care

It's worth looking at the article by Peter Tyrer in The Psychiatrist on community psychiatry in the context of today's report from BBC News and Community Care about what they call the crisis in mental health care. To quote from Peter's article:-
The general mantra of ‘community psychiatry good, hospital psychiatry bad’ has … led to the neglect of the proper function of in-patient care, a combination of asylum and rehabilitation. …[A] fundamental wish to improve patients’ autonomy is being removed by an overbureaucratised system of community care that is obsessed by risk, and in danger of promoting greater institutionalisation by a complex regulatory framework that denies the flexibility that is essential to good community psychiatric practice.  
Where in the UK community psychiatry used to be flexible, adventurous, creative and bold, with the many changes imposed from policy managers in recent years it has become constricted, controlled, limiting and self-serving. Autonomy for practitioners has almost entirely disappeared and been replaced by a rigid system of care that leads to patients encountering a bewildering number of health professionals, who carry out specific regimented tasks but who rarely have the chance to develop meaningful relationships with the people they treat.
His solution is to remind ourselves of the core principles of good care:-
  1. if good facilities are available for patients to be treated outside hospital, they should be used as much as possible;
  2. if a hospital bed is necessary it should be available when required and should be as close as possible to the patient’s home; hospital should be able to serve as a place of refuge and respite as well as a treatment centre;
  3. continuity of care may not always be possible but should be striven for as a matter of principle, and all community teams should stay in touch with their patients no matter where they are placed;
  4. individual or team-based treatment both have merits and their choice should be determined in collaboration with the patient and his or her carers, and maintained irrespective of treatment setting.
He goes on:-
This can only be achieved by allowing greater autonomy within teams to maintain priorities, reducing the size of the catchment area for each team so that they do not become overwhelmed and depersonalised in their attitudes.... [M]orale [needs to be raised] of a service that has been relegated to the backwaters of care for too long. 

Monday, October 14, 2013

Increase in patient suicides has followed introduction of CTOs

The headline for this piece is deliberately tongue in cheek. It's not supposed to imply that the introduction of community treatment orders (CTOs) has led to an increase in suicides, although, of course, I am aware that this is how it could be taken. It's just that the latest report from the National Confidential Inquiry (NCI) into Suicides and Homicides by People with Mental Illness has implied that CTOs have reduced homicides. I just thought it important to point out, if that claim is being made, that CTOs have not reduced suicides. In theory, CTOs could have either increased or decreased deaths by suicide and homicide. And NCI expected CTOs to have a greater impact on absolute numbers of suicides than homicides. Or maybe it thinks the increase in suicides would have been a lot worse without CTOs.

To be clear, what the report points out is that homicide by mental health patients has fallen substantially since a peak in 2006. This might not have been obvious from recent headlines in The Sun (see previous post). The report goes on to say that one of the clinical explanations may be the introduction of CTOs in 2008.

The report also notes that the number of patient suicides increased in 2011. Although the figures are provisional because the data is incomplete, a higher number of patient suicides is predicted in 2011 than in recent years. There's no speculation that this is due to CTOs; instead the "rise probably reflects the rise in suicide in the general population, which has been attributed to current economic difficulties".

After all, it was NCI that argued for the introduction of CTOs to reduce homicide and suicide. It even went as far as to predict in Safer services that 30 suicides and 2 homicides would be prevented each year. A later report, Safety first, increased that figure to 32 suicides and 3 homicides. The trouble is that the logic used to produce such estimates did not stand up, as all NCI did was assume that CTOs would prevent deaths and then produce figures based on this premise. The fact is that whatever figure was produced is not evidence of the value of CTOs, as it was only an estimate assuming they were going to be effective. Maybe that's why the latest report latches on to the reduction in homicides. NCI needs some evidence to justify its previous speculation, which it couched in pseudoscientific terms. But, of course, this isn't evidence as such because there are all sorts of reasons why the homicide figure may have gone down, in the same way as there are all sorts of reasons why the suicide figure has gone up.

Saturday, October 12, 2013

Irrational homicide risk management

The Sun has been taken to task for producing the front page headline that 1200 people have been killed by mental patients in the last 10 years (see Guardian and New Statesman articles). The Daily Star had a similar report. This article quotes from Marjorie Wallace, whose intentions, I think, are to improve funding for mental health services, but her campaigning on behalf of her mental health charity, SANE, has, in my view, actually undermined services.

She complained to The Sun that a failure of communication between one agency and another has been found in 90% of homicide inquiry cases. But, communication is not perfect in everyday practice. In fact, it is commonplace for staff to have to cover 'gaps', such as not having complete information. Such imperfections are usually managed without adverse consequences.

The question is whether such homicides really reflect failings in Britain's mental health system. There has certainly been overreaction in some homicide inquiries, which do not always apply accountability sensibly. It is a phantasy, which we need to disabuse ourselves of, to believe that mental health services can have absolute control in preventing homicides by their patients (see my unpublished article and associated conference presentation).

Sunday, September 29, 2013

Psychiatry shooting itself in the foot

Just to reinforce my previous post, the President of the American Psychiatric Association has said that the mass shooting in the Navy Yard in Washington, D.C., like previous such tragedies, "reflects the failings of the U.S. mental health care system" (see post). The answer to my question about why psychiatry accepts this projection is that he believes this will increase the social and political will to provide quality mental health services.

Even if his motive is to provide every person with a mental illness and/or substance use disorder with "access to affordable, quality mental health treatment", he doesn't provide any evidence that psychiatry can identify and treat perpetrators of mass shootings. To encourage this phantasy is a folie a deux between psychiatry and the public.

Saturday, September 21, 2013

The omnipotence of the mental health system

Gallup have found that 48% of Americans say that they blame the mental health system "a great deal" and 32% "a fair amount" (ie. 80% total blame) for mass shootings in the United States (see report). Comparative total figures for blaming guns and blaming drugs are 61% and 66 % respectively. The report on Gallup Politics interprets this to mean that Americans believe "more can be done on the mental health side", but it doesn't say what it thinks can be done.

Actually research has shown that the removal of semi-automatic and pump-action shotguns from civilian possession after the 1996 firearm massacre in Tasmania led to no mass shootings in Australia in the 10.5 years afterwards, whereas in the 18 years before the gun law reforms there were 13 (see article). Does the American public really think services have the ability to detect and treat mentally unstable people capable of such crimes? Do they really mean what they say? If so, they seem to think psychiatry is all-powerful. Perhaps that's where psychiatry is going wrong by accepting this projection.

Friday, September 13, 2013

Is psychiatry our necessary shadow?

Tom Burns, who I have mentioned in a previous post, has written a bland apology for psychiatry, Our necessary shadow: The nature and meaning of psychiatry. As he says, he is "convinced psychiatry is a major force for good or I would not have spent my whole adult life in it". Having also spent most of my adult life as a psychiatrist, I suppose I'm inclined to be an apologist as well, but I would only say that psychiatry can do good not that it does. Burns recognises what he calls psychiatry's "mistakes" but sees these as failings that need to be put in perspective, rather than, as I do, something more fundamental about the nature of psychiatry.

Burns describes a new group of anti-psychiatrists, which he says "are, as it were, evidenced-based anti-psychiatrists" [his italics]. In this group he selects from what he calls an "almost endless" list of books: Richard Bentall's Doctoring the mind (see my previous post) and Madness explained; Jo Moncrieff's The myth of the chemical cure (see my post about Jo's new book); and Peter Breggin's Toxic psychiatry and Brain disabling treatments in psychiatry. (See my book recommendations on my critical psychiatry website.)

Burns suggests these new anti-psychiatrists (see previous post about use of the term 'anti-psychiatrist'), although they may share "a deep suspicion of the fundamental legitimacy of psychiatry and psychiatric diagnoses" are more concerned about "the damage done by psychiatry and psychiatrists" [his italics]. From his point of view, "their arguments are generally that psychiatry is too full of itself, or is corrupted by pharmaceutical companies, or that it makes endless mistakes". One of his reasons for writing his book is to "try and explain why psychiatry survives despite this tsunami of criticism". He goes on:
If psychiatrists are false prophets it is because they fail to deliver what they promise; it is not their mistaken metaphysics. It is their incompetence rather than their omnipotence that is the issue.

If I understand him right, he doesn't want to engage with conceptual issues about the nature of mental illness. This is not dissimilar from the position of Anthony Clare in Psychiatry in dissent (see previous post) and fits with Burns ambition to see his book as this generation's "attempt to explain psychiatry fully to the interested outsider", as Clare's book was for a previous generation. I think Burns is setting the barrier of competence too high for psychiatrists! He clearly does have an ideological position eg. he accepts the rather trite position that schizophrenia has a heritability of 80%. Despite what he thinks, as I keep saying, it is important to move on from the biomedical paradigm (see previous post). Burns atheoretical approach does not salvage psychiatry.

Thursday, September 12, 2013

Stop thinking about DSM-6

Collection of psychiatrists' views about DSM-5, including those of Charles Nemeroff (see previous post) and Simon Wessely (see another previous post), have been published by BMC Medicine.

Nemeroff and Daniel Weinberger suggest the motivation for DSM-5 was (1) unrealistic anticipations of being able to include genetic markers for mental disorders following the sequencing of the human genome, and (2) unrealistic enthusiasm that brain imaging studies would produce pathognomonic findings about the neurobiology of mental disorders. Their wishful thinking means that only in retrospect do they find this surprising, blaming the complexity of the brain. Actually, it's not just the complexity of the brain that's the issue, but their naivety that the brain-mind problem could be solved. We need to move on from the biomedical paradigm (see previous post).

Nor, as they imply, did the explicit criteria of DSM-III solve the subjectivity and uncertainty of psychiatric diagnosis, which is actually intrinsic to its nature. There needs to be a change of thinking about psychiatric classification. As I said in my previous post in relation to Simon Wessely, please stop talking about DSM-6, at least until there's a proper conceptual understanding of the nature of mental illness. Nemeroff and Weinberger's unrealistic hopes are an insufficient basis on which to proceed.

Tuesday, September 03, 2013

The truth about antipsychotics is hard to swallow

This website has been given a 20% discount for the important, soon to be published book The bitterest pills by Jo Moncrieff. Order through Palgave.com and use code WBitterest2013. (Do check, though, that this is the best deal - currently seems to be cheaper on the Amazon site).

Saturday, August 24, 2013

Current fashion in antidepressant research

Just to reinforce my previous post, Psychiatric Times has a video article suggesting that the next fashion in antidepressant research will be based on glutamine not serotonin. At least one of the apparent drivers for this research is the realisation that antidepressants don't always work (see previous post). But, let's please not let any of these new agents onto the market if they're no better than the old ones.

Saturday, July 27, 2013

Serotonin hypothesis of depression was wrong

Move over serotonin; let's exploit glutamate in the treatment of depression. So suggests the journalist, Samantha Murphy, in a New Scientist article. Her argument is that the rise in treatment resistant depression reflects a realisation that antidepressants don't work. She holds out new hope for repetitive transcranial magnetic stimulation (rTMS) (see previous post), cranial electrical stimulation and ketamine. The speculation is that the release of glutamate by these treatments repairs the shrivelled dendrites of depressed people's neurones. She says at least 5 pharmaceutical companies are working on developing ketamine derivatives.

The academic paper to support this journalistic hype may be that by Duman & Aghajanian (2012) in Science. Look out for the promotion of a synaptogenic hypothesis of depression and treatment response. Scientific progress? Surely not.

Friday, July 26, 2013

Is APA prepared to engage with critical psychiatry?

At least Jeffrey Lieberman is prepared to engage with criticism of psychiatry in his role as President of the American Psychiatric Association (see his recent article in Psychiatric News). This is to be welcomed as mainstream psychiatry has tended to marginalise critique (eg. see previous post). True, Lieberman does tend to dismiss questioning of the integrity of psychiatry as Cartesian anti-psychiatry. He clearly has more work to do in taking this issue forward.

He sees psychiatry as a "scientific discipline and full-fledged medical speciality", but then doesn't explain what he means by this. Nor does he say what is meant by "the progress that has been made to deconstruct the almost unfathomable complexity of the brain into its constituent neurobiological mechanisms that mediate emotion, perception, and cognition". If there has been such progress he ought to be able to tell us what it is. He indicates that the technologies of "psychopharmacology, modern neuroimaging methods, and molecular genetics" are what have begun this process, but, again, does not spell out the references. He confidently states that "recent advances in research have shown us that they [mental disorders] are biological in nature and caused by genetics and environmental factors". However, we're clearly supposed to understand more for this claim than the merely tautologous connection.

I agree psychiatry has nothing to be defensive about this "noble mission", unless it's all a myth. Lieberman has a duty to clarify whether he's being realistic or pursuing a wishfulfilling phantasy.

(With thanks to Phil Hickey for a post on his Behaviorism and Mental Health blog).

Saturday, June 22, 2013

Why does the APA need new editions of DSM?

Simon Wessely in his blog post about an IOP conference on DSM-5 assumes there will be a DSM-6. Have we now come to expect continuous revision of psychiatric classification? If so, it's difficult to understand why. There has never really been any expansion of "the scientific basis for psychiatric diagnosis and classification" despite this being the apparent impetus for DSM-5 (see website). Maybe APA's motivation for continuous revision is merely financial gain. DSM-IV made at least $100 million, but, even so, DSM-5 should be free open access to all on the internet.

The reason for the DSM-III revision was very clear (eg. see my article). From mainstream psychiatry's point of view, diagnosis was in crisis because of its unreliability. Operational criteria were therefore developed. Unfortunately these may be no more valid than commonsense definitions. So, we could put up with amendments through DSM-III-R, DSM-IV and DSM-IV-TR, but tinkering further with DSM-5 is a step too far.

As Simon says, "The aspiration that DSM-5 would represent as significant a break with the past as DSM-III had been, effecting a second revolution by moving from symptom based diagnosis to aetiologically based diagnosis using the latest advances from neurosciences and genetics turned out to be just that, an aspiration". That's why the current NIMH director has turned his back on DSM-5 (see previous post), although his predecessor was one of the originators of the DSM-5 process in 1999. However, despite all the DSM revisions, there's no getting away from the poor validity and reliability of psychiatric diagnosis. That's its nature and psychiatry's wishful failed ambition needs to be recognised for what it is.

Wednesday, June 19, 2013

Ban face down restraint in psychiatric hospitals

To his credit, Norman Lamb (who I have mentioned on my personal blog eg. see previous post), Minister of State at the Department of Health, says he is considering just banning face down restraint in psychiatric hospitals (see BBC news story). This is following a call from Mind demanding national standards on the use of physical restraint, accredited training and an end to face down restraint on the basis of data they have secured from NHS trusts under FOI requests (see news item).

It was a pity that the take up from the Blofeld report on the death of Rocky Bennett some years ago focused on institutional racism rather than also on restraint. As I said in my BMJ eletter, "Death of a patient under restraint should help us to refocus on the need for a therapeutic approach rather than just custodial practice in mental health services." Organisational interventions can dramatically reduce the use of seclusion and restraint, reflected in the wide variation found by Mind in their survey. Hence government intervention in the way considered by Lamb could have significant effects.

As I said in another eletter about this issue, we need to highlight "... the importance of the culture of mental health services in limiting the use of such restrictive procedures". The focus on defensive practice over recent years has not been helpful. Restraint may be better seen as an indication of treatment failure, rather than treatment as such.

Sunday, June 02, 2013

The ethical corruption of academic psychiatry

Phil Thomas asks why Charles Nemeroff has been asked to give the inaugural annual lecture of the new Centre for Affective Disorders at the Institute of Psychiatry (IOP) (see blog post). After all, Nemeroff has been one of the most blatant examples of psychiatrists' wrongdoing by under-reporting of pharmaceutical company earnings (see previous post). It's this sort of thing that makes even the most biological of psychiatrists concerned about the moral integrity of modern psychiatry (eg. see post by Michael A Taylor).

Ironically, from his previous published research (eg. Nemeroff et al 2003), Nemeroff may be seen as promoting psychotherapy in his lecture rather than necessarily any psychotropic medication. Nonetheless, of course, he does think monaminergic drugs are therapeutic in depression. His speculation is that the reason some people survive early life stress (ELS) is because of their genes. In a clinical trial, it was found that depressed patients with a history of early childhood trauma did better with psychotherapy alone than antidepressant monotherapy. Don't be misled by this! Maybe paradoxically, Nemeroff thinks psychotherapy is a "biological treatment". He believes it changes gene expression. As I've warned previously (see previous post), don't be taken in by such neuropsychotherapy.

Nemeroff's lecture at IOP may not be that much different from the one he gave at NYU last year (see video). It may not be that exciting or interesting. His NIH grant in 2012 caused controversy because of his past ethical problems (eg. see letter from Senator Grassley). The project information for the study explains that he's wishfully looking for the genetic risk factors for PTSD. Maybe the Centre for Affective Disorders will also undertake similarly misguided research. Let's at least know from IOP where it's getting its funding from, because choosing Nemeroff as its inaugural lecturer for its new centre does not bode well.

Saturday, May 11, 2013

Abandoning diagnostic criteria for research in mental health

The blog entry by Thomas Insel, NIMH director, has created much comment (eg. New Scientist article and blog post by Phil Thomas). I've mentioned before how grandiose Insel can become in his claims for mental disorders as biological disorders involving brain circuits (eg. see previous post). His RDoC project will not create a new nosology despite his wishful thinking. As he says, we lack the data to "design a system based on biomarkers or cognitive performance". We need to accept the uncertainty of psychiatric practice and medicine in general, rather than promote 'precision medicine' as the solution to mental disorders as he proposes.

Nonetheless, we should welcome NIMH re-orientating its research away from DSM categories. It may actually be progress if this means funding research on patients without relying on diagnostic criteria.

Invitation to Radical Caucus Events at APA on May 18th


THE RADICAL CAUCUS HAS MANY IMPORTANT ACTIVITIES THIS YEAR, AND OUR COLLEAGUES FROM THE CRITICAL PSYCHIATRY NETWORK WILL BE JOINING US. PLEASE COME TO DISCUSS PLANS FOR COLLABORATIVE GLOBAL ACTIVITIES. (NOTE: IF YOU PLAN TO COME TO DINNER PLEASE LET ME KNOW, ALTHOUGH LAST MINUTE GUESTS ARE STILL WELCOME.) ALSO NOTE NEW LOCATION FOR DINNER.

RADICAL CAUCUS EVENTS AT THE 2013 AMERICAN PSYCHIATRIC ASSOCIATION ANNUAL MEETING IN SAN FRANCISCO

Saturday May 18, 2013: 9AM to 12 Noon: Moscone Center, Street Level, Gateway Ballroom 102
Presidential Symposium: “Envisioning a New Psychiatry: Radical Perspectives”
Chairs: Carl I. Cohen , MD; Kenneth Thompson, MD;
Discussants: Sami Timimi, M.D., Helena Hansen, M.D., Ph.D.
Presentations:
· Jean Furtos, MD: “Globalization and Mental Health: The Weight of the World, the Size of the Sky
· Sandro Galea, M.D.: “Re-Engaging Research Around the Socail and Economic Production of Mental Health:Toward a Comprehensive Model of Mental Illness”
· Pat Bracken, M.D, Ph.D: ” Beyond the Technological Paradigm: A Positive Path for psychiatry”
· Steven Moffic, M.D.: Eco-Psychiatry: Why We Need to Keep the Environment in Mind”
· Keris J. Myrick, MBA, Ph.D(cand): Alternative, Complimentary, or Traditional: A Radical Approach from the C/S/X Perspective”

Saturday May 18, 2013; 3:30PM -5:00PM; Moscone Center
Issue Workshop: “United Kingdom Critical Psychiatry Network: Implications for the APA and Global Psychiatry”
Chairs: Helena Hansen, M.D. , Ph.D.; Bradley Lewis, M.D., Ph.D.
Presenters:
Dr Hugh Middleton, MA. MD. MRCP. FRCPsych.
Professor Sami Timimi, MBChB FRCPsych
Dr Pat Bracken, DPM,MA,MD,PhD,MRCPsych

Saturday, May 18, 2013; 6:30PM -8:30PM Hilton San Francisco; Union Square Rooms 19/20 4th Floor, Tower 3
“Radical Caucus Meeting–Open Discussion and Planning Session”
Light Snacks and Beverages

8:30 PM Radical Caucus Annual Dinner Dinner (note new location) 
Basil Canteen located on Folsom street at 11th1489 Folsum St (at 11th St); 415-552-3963.
All Welcome!!!!
For more information contact: carl.cohen@downstate.edu.
Also visit our new Web site at http://www.radicalcaucus.com.
Please post comments and suggestions.

Carl I. Cohen , M.D.

SUNY Distinguished Service Professor & Director
Division of Geriatric Psychiatry
SUNY Downstate Medical Center
Box 1203
450 Clarkson Avenue
Brooklyn, N.Y. 11203
ph: 718-287-4806
fax: 718-287-03377