Monday, November 23, 2020

Debate about models of mental health problems

As Anne Cooke et al (2019) say in their article, "There is considerable debate about the nature and causes of ... 'mental health problems', and therefore about the best way/s to intervene". They juxtapose the frameworks of the 'medical model' and the 'psychosocial model' and point out that there have been attempts to create an intermediate 'biopsychosocial model'.

I think the debate is more complex than this polarisation may suggest. The article defines the 'medical model' as denoting "the idea that mental health problems are best understood as 'illnesses like any other'". Even though there may be people that define and apply the 'medical model' in this way, I think most people do recognise a difference between mental and physical illness. Again, some people may want to minimise the difference between mental and neurological illness (eg. see previous post), but psychiatry is a separate speciality from neurology. The reason for this is that the two specialities deal with different kinds of medical problems. Those that want to work towards merging neurology and psychiatry at least realise we have not got there yet.

The article references Mary Boyle to define the 'psychosocial model' as a "framework that removes biology from the position of privilege in favour of a focus on the relational, interpersonal and social contexts of distress". This is fundamental to a critique of the biomedical model in that we need psychosocial explanations of mental health problems rather than reducing such problems to brain disease (see eg. previous post). 

What worries me is the way the 'biopsychosocial model' is seen as a way of reconciling the 'medical model' and 'psychosocial model' in the senses defined by the article. Engel's biopsychosocial model is is fact the same as the article defines as the 'psychosocial model' (see eg. previous post). True, the people that the article references in relation to the definition of the 'biopsychosocial model', such as Allen Frances (see eg. previous post) and Robin Murray (see eg. another previous post), do use the term in an eclectic way. But this was not what Engel meant.

Monday, November 16, 2020

Changing the medium of psychiatry to relations

Dumas-Mallett and Gonon (2020) helpfully summarise the bias in biomedical psychiatric research. They also describe how these misrepresentations are spread through the mass media and call for the public to receive correct information.

The trouble is that they do not want to go as far as questioning biological psychiatry per se. That's what's really needed to make progress. Biomedical psychiatry holds out the attractions of a predictive and systematic way of understanding and treating mental health problems. No wonder people hope it may be true and psychiatrists act as though we have got there, or at least are not far away from it.

But as the article says we're being misled. It’s not only the message that is wrong but also the expectation about what can be achieved. Do we really think we can solve the problem of consciousness (see previous post), or more generally how life originates from inanimate matter? As Kant said, this is an insight which is denied to us (see another previous post). 

But that doesn't mean that psychiatry is defunct. It should never have had such fanciful notions. Nonetheless people still need understanding and treatment for their mental health problems.

Saturday, November 14, 2020

Psychiatry has the wrong biology

Daniel Nicholson (who I’ve mentioned before eg. see previous post) has a paper on ‘Is the cell really a machine?'. As he says, "The conventional mechanical, reductionistic, and deterministic view is gradually giving way to an understanding of the cell that emphasizes its fluidity, plasticity, and stochasticity." Human cognition also needs to be understood in this dynamic, integrated, enactive way as it is embodied in the brain and the body more generally, and embedded in the environment, which is social and cultural, affording various possibilities of action to the person (see eg. previous post).

We need to move on from a mechanistic approach to life in general, including human life, to a more interpretative one (eg. see previous post). The advantage of seeing life as self-organising is that its plasticity is acknowledged without neglecting its ongoing stability (see another previous post). Cells and bodies are not well-defined structures but actually stabilised processes. What persists over time are their form not their matter. As David Nicholson says, “Cells are empirically revealing themselves to be inherently dynamic, self-organizing systems that respond stochastically and nonlinearly to environmental stimuli.” Cells and life in general are not determined spatiotemporal arrangements (see eg. previous post). 

Psychiatry needs to take on board this need for a more dynamic biology, not only for clinical practice but also for research (see eg. previous post). The physical disease model of mental illness is outdated because of progress in understanding not only in human cognition, but also more fundamentally about life processes (see another previous post). 

Psychiatry deconstructs itself, wow!

I made a serious attempt in a previous post to deconstruct the American Psychiatric Association in how it presented itself at an annual meeting. Actually I'd already realised (in another previous post) that Stephen Stahl and his NEI Psychopharm had done the job of hilariously self-deconstructing psychiatry, however undeliberate, in its series of videos. Unfortunately the congress opener for the 2011 NEI Global Psychopharmacology Congress that I mentioned in that post seems to have been taken down. As far as I can remember it had Stephen Stahl dancing in it. Anyway, you can laugh at the more recent 2019 NEI Congress Opener. And you can still see Stahl starring and dancing in this video about DSM-5.

More seriously, Stahl explains that he had to take Psychiatra-Gain to deal with the boredom he was feeling in working with patients (see another video). This created his Alice in Wonderland worldview (see video). It leads to trying out lots of medications on patients in a fun way (see video), although the original psychotropics are still the best (see another video). Thank goodness someone at least is taking psychiatry seriously.

Thursday, November 12, 2020

The violence of psychiatry

I've said before (see eg. tweet) that it's not surprising psychiatry is controversial when it has the power to detain people against their will on the basis of their health or safety or for the protection of others because of mental disorder, which are criteria that are bound to be open to interpretation. It is the dominance of the biomedical model in psychiatry that causes problems. The criteria in mental health legislation that allow coercive treatment are too wide to prevent abuse (see previous post). The UK government is currently producing a White paper for reform of the Mental Health Act but almost certainly will not go far enough - at least initially - to preserve the dignity and respect of detained patients (see eg. another previous post). There does need to be a campaign to stop psychiatric abuse (see yet another previous post).

More generally psychiatry's tendency to reduce people to objects means that its practices are too restrictive and not therapeutic enough. This tendency has increased over recent years with the overemphasis on risk. Community care has become as bureaucratic at times as the worst institutional practices of the asylum. 

My hope is that the government will produce a green paper to discuss these issues more widely, but I suspect it will go straight to a White paper because of the independent review led by Simon Wessely. There needs to be renewed debate about these issues, as it has been paused by the coronavirus pandemic. My personal hobby horse has been that detained people should have a right to a second opinion of their choice. Both detention and treatment decisions should be adjudicated by a single judge in the Mental Health Tribunal (doing away with the need for medical and lay members). Second Opinion Approved Doctors (SOADs) will also no longer be needed and anyway have tended to become a 'rubber-stamping 'exercise. The Mental Health Act arm of the Care Quality Commission needs to be given the specific responsibility of preserving the dignity and respect of detained patients. Its role in maintaining basic human rights needs to be reinforced.

(With thanks to a tweet from @Heather28258253)

Sunday, November 08, 2020

Embarrassing use of the term ‘anti-psychiatry’

I’ve mentioned before (eg. see last post) that it was David Cooper that first used the term ‘anti-psychiatry’. Adrian Chapman has an interesting article about him. He references a Guardian piece by David Gale, who saw Cooper for therapy for 4 years. 

As Chapman says, “Cooper overreached [himself]”. This is, I think, a rather generous assessment of what happened to Cooper’s anti-psychiatry, which as RD Laing said became rather embarrassing. Chapman also notes that Adrian Laing, the son of RD Laing, in his biography of his father says there was only ever one anti-psychiatrist. That was David Cooper. Those that still use the term ‘anti-psychiatry’ generally don’t mean Cooper when they use the term. Instead they are usually trying to denigrate criticisms of psychiatry (see eg. previous post).

It’s also rather outrageous to include classic works like Erving Goffman’s Asylums and Michel Foucault’s History of Madness within a denigratory use of the work ‘anti-psychiatry’ (see another previous post) As I’ve said before, I think people should stop using the term. It was a historical phase that psychiatry went through, which actually was not as negative as is commonly made out. Psychiatry needs to learn to take on board criticisms of its tendencies to reductionism and positivism.

Saturday, October 31, 2020

Renaming this blog

This blog has been renamed ‘Relational psychiatry’ from ‘Critical psychiatry’. It’s not the first time I’ve renamed a website. My ‘Critical Psychiatry website’ (now largely defunct) was original called the ‘Anti-psychiatry website’, but I changed the name because of the confusion it caused (see previous post). Doing that hasn’t stopped me wrongly continuing to be called an anti-psychiatrist.

‘Anti-psychiatry’ was a term originally used by David Cooper (see my book chapter). It was also used by mainstream psychiatrists, such as Martin Roth, to denote what he considered to be an international movement against psychiatry (see another previous post). Anti-psychiatry came to be most associated with R.D. Laing and Thomas Szasz, who actually had very different views. It is generally seen as a passing phase in the history of psychiatry, although Bonnie Burstow tried to resurrect the term ‘antipsychiatry’ without the hyphen (see previous post). If the term now means anything, I think it should be reserved for the abolition of psychiatry, which is the sense in which Burstow meant it. Cooper’s anti-psychiatry became a rather bizarre mixture of family, sexual and revolutionary politics, which even R.D. Laing found embarrassing (see my Lancet Psychiatry letter). Laing himself was taken up by the counter-culture of the 1960/70s and ultimately became more interested in personal growth and authenticity than changing psychiatry.

The trouble with Roth’s use of the term is that anti-psychiatry wasn’t merely a negative contribution to psychiatry. There were excesses but the extent to which anti-psychiatry provided a critique of reductionism and positivism in psychiatry was of value. There are problems with a mechanistic approach to mental illness. I have been trying to get this message across by using the term ‘critical psychiatry’. But I think we now need to move on from an outdated physical disease model of mental illness to a more relational mental health practice (see previous post).

I’ve always emphasised the continuities of critical and relational psychiatry with mainstream psychiatry. I also do not agree with the approach of the ‘drop the disorder’ movement, which is leading to too much polarisation and misunderstanding (see eg. previous post). Recent developments from anti-cognitivist phenomenological and enactive accounts of psychopathology may well help relational psychiatry to come afresh at the modern crisis in psychiatry (see previous post).

Saturday, October 17, 2020

Understanding psychosis

At least the new guide Understanding psychosis: Voices, visions and distressing beliefs is clear that psychotic experiences do not result from a brain disease. The document has been edited by Anne Cooke from the original British Psychological Society (BPS) publication Understanding psychosis and schizophrenia. Anne was also one of the co-editors of the BPS report on Understanding depression, which I defended as a helpful, balanced report in my last post.

If only to show that I'm not merely a BPS acolyte, just to reiterate, I have been more critical of the psychosis report than the depression one (eg. see previous post). A strength of both reports is that they provide personalistic explanations of mental health problems, taking a holistic perspective rather than narrowly focusing on the brain. But I don't think, for example, that the psychosis report makes clear that psychotic symptoms can occur in delirium and dementia (see eg. previous post). Nor that psychosis may well not be associated with people asking for help because they have no insight into their problems. For example, it does not distinguish dissociation from psychosis (see eg. another previous post). 

Another strength of both documents is the attempt to explain mental health problems in everyday language. Psychiatry is not an exact science and therefore controversial, and unfortunately debates can become polarised. I would like to see more focus on the BPS position expressed in both documents that mental illness is not a brain disease (see eg. my Lancet Psychiatry letter and previous post). 

Friday, October 16, 2020

Understanding depression

The new British Psychological Society (BPS) document on 'Understanding depression' has created controversy, at least on twitter. For example, @ProfRobHoward sent a tweet saying that it is "stigmatising and politically motivated", and @wendyburn in her tweet linked to what she called a "powerful and disturbing" blog post by Lucy Dimbylow (@lucywriter), who in turn had sent a tweet saying the report "trivialises depression, gaslights sufferers and suggests it's [depression's] not even an illness".

Actually the report says there can be advantages in thinking of depression as an illness and some people find medication helpful. Depression of course can be a normal experience and there can be benefits for some people of 'normalising' depression. The report also makes clear that depression can be debilitating and associated with psychosis at the other end of the spectrum. A strength of the report is that it provides personalistic explanations of depression, taking a holistic perspective rather than narrowly focusing on the brain.  I don't think the report is misleading or undermines depression as an illness. It is a helpful, balanced report written in everyday language.

The argument on twitter about whether depression is an illness deflects from taking on board a key message of the report that depression is not a brain abnormality. I wish these debates would become less polarised and focus on the fact that depression is not the result of a brain disease. The symptoms and signs of depressive illness, although enabled by the brain, are not merely epiphenomena of a causal brain process. Depression needs to be understood in interpersonal context. Maybe that's why some people feel so threatened by the BPS report, because they know that depression is not a brain abnormality but wish it was. 

Monday, October 12, 2020

Fear of stopping antidepressants

In a trial of withdrawing antidepressants in patients who no longer needed the medication, Eveleigh et al (2017) found that half of the patients in the intervention group did not comply with advice to stop antidepressants. Only a few of the patients who were willing to follow the advice actually managed to stop, which was about the same number as in the control group who stopped their medication in the year of the study without the specific intervention. The patients in the intervention group also reported a higher rate of relapse than the control group.

To investigate further why so many people were unwilling to even try stopping their antidepressant medication despite it not being indicated, Eveleigh at al (2019) interviewed some of the participants in the trial. They found that fear (of recurrence, relapse, or to disturb the equilibrium) was the most prominent barrier, and prior attempts fuelled these anticipations (see eg. previous post). Another important barrier was the notion that antidepressants are necessary to correct deficient serotonin levels (see previous post). As Verbeek-Heida & Mathot (2006) found, the fear and uncertainty about stopping were stronger than the fear and uncertainty about continuing. Users of antidepressants tend to think they are better off 'safe than sorry' by continuing medication (see another previous post). Patients are uncertain and fearful about what they will be like without medication (Leydon et al, 2007).

The evidence for what it is worth is that continuing antidepressant treatment reduces the risk of relapse. Relapse rates in discontinuation trials can be substantial. Although fear of relapse may be biasing the results of such studies through unblinding, doctors have to be realistic that discontinuing antidepressants may not be easy. Patients tend to think doctors should take responsibility for initiating contact about discontinuation (Bosman et al, 2016), but in practice this tends not to happen. A good proportion of the increase in antidepressant prescribing over recent years is because of long-term repeat prescribing (see previous post). 

Taking antidepressants can be identity altering (see previous post). Patient's preferences and concerns affect their decisions about medication (Malpass et al, 2009). These sort of factors should have been obvious to doctors (see my book chapter). As I keep emphasising, psychological factors cannot be denied in causing antidepressant discontinuation problems (see eg. previous post). The question is whether they are a sufficient explanation or whether underlying clinically significant brain changes also contribute (see last post).

(With thanks to a MIA blog post by Peter Simons)

Thursday, October 08, 2020

Outcome-based prescribing

In her recent MIA blog post, Joanna Moncrieff concentrates on what psychiatric drugs actually do. She's right that it's commonly wrongly assumed they are correcting some sort of brain imbalance, which she calls the disease-centred model of drug action (see eg. previous post). 

She also mentions the harms caused by psychiatric drugs. For example, antipsychotic medication can cause brain shrinkage, although I think the clinical significance of this finding is unclear (see eg. previous post). Antidepressant discontinuation problems may have become better recognised since a formal complaint made to the Royal College of Psychiatrists two years ago (see eg. previous post). I actually think that believing the disease-centred model of antidepressant action is likely to increase the risk of discontinuation problems (see another previous post). 

Joanna defends what she calls a drug-centred rather than disease-centred model of drug action (see eg. another  blog post from her). As she also notes, psychiatrists may have an outcome-based understanding of drug action, without necessarily any apparent particular commitment to an explanation of the drug's action. I certainly don't believe in the disease-based model, but still prescribed psychotropic medication when I was working because the evidence, for what it is worth, is generally said to be that such medication is effective within NICE guidelines. It was difficult for me to refuse a request for medication within these parameters. This is despite my scepticism about the evidence (see eg. previous post) and recognition that any effect may be due to placebo (see eg. another previous post). I don't want to undermine people's belief in their medication, but not everyone is helped in the clinical trials and the difference between placebo and active medication in these trials is generally much smaller than most people realise. Because of psychological factors, I was very aware of the risk of discontinuation problems and often it seemed easier for patients maintained on medication to continue with it rather than stop (see eg. another previous post).

An advantage of the drug-centred model is that it makes us realise, as Jo says, "how little we really know about these drugs". Modern psychopharmacology started with the introduction of chlorpromazine in the 1950s. When testing drugs for treatment of protozoal infections and parasitic worms, chlorpromazine was noted to have strong anti-histamine properties. It was therefore investigated with allergic patients and reported to cause drowsiness. This 'drowsiness' effect was explored by Henri Laborit, a French surgeon, using chlorpromazine to potentiate anaesthesia with other agents by preventing surgical shock. He reported it induced 'detachment' in his patients, suggesting it produced an 'artificial hibernation' because of its hypothermic and hypnotic qualities. Jean Delay and Pierre Deniker, therefore, investigated the potential for the drug on its own at higher doses in calming manic patients. Their papers talked about chlorpromazine causing a 'chemical lobotomy' different from other sedatives. They coined the term 'neuroleptic syndrome' referring to a slowing down of motor activity, affective indifference and emotional neutrality. Trials of chlorpromazine undertaken by Heinz Lehmann in Montreal facilitated the new drug's introduction to North America. Extrapyramidal effects, such as parkinsonism, were difficult to differentiate from any anti-psychotic properties.

Imipramine, the first antidepressant, has a similar chemical structure to the phenothiazines, like chlorpromazine, but different psychoactive effects. Initial trials in schizophrenia failed but it was said to be spectacularly effective in vital depression (see previous post). As Jo says, the SSRI antidepressants seemed to be "relatively innocuous" compared to the tricyclic antidepressants, like imipramine. She speculates about how they might be "changing the brain in significant ways that we do not understand".

The trouble is that these are only speculations and psychological dependence could be a sufficient explanation of antidepressant discontinuation problems (see eg. previous post). I agree with Jo that we should concentrate on psychiatric harm (see eg. another previous post) and the way to do that is to be much clearer about the pharmacological effects of psychotropic medication. 

Saturday, October 03, 2020

Psychiatry and its critics

I've mentioned before (see previous post), that it's about time we moved on from the debate about 'anti-psychiatry'. It is generally seen as a passing phase from the 1960s/70s in the history of psychiatry. The trouble is that the term continues to be used (eg. see Psychology Today blog post). Part of the reason for wanting to move on is because of the confused way in which the term is used, which the Psychology Today piece to me seems to exemplify.

As I've also mentioned before, there actually was some value in the work of anti-psychiatry (see previous post). It shouldn't be seen merely as a negative contribution to psychiatry. As I wrote in my editorial, "it is difficult to accept that there was no value in the approach and what may be more beneficial is to look for the continuities, rather than discontinuities, with orthodox psychiatry" (see also my essay review). Personally I've always tended to emphasise the links of critical psychiatry (which I differentiate from anti-psychiatry) with mainstream psychiatry (see another previous post).

The term 'anti-psychiatry' was coined by David Cooper (see eg. previous post). It came to incorporate earlier writings by R.D. Laing, Michel Foucault, Erving Goffman and Thomas Szasz. It was most associated with the views of Laing and Szasz, who actually had very different perspectives (see eg. another previous post). Szasz, for example, equally rejected both mainstream psychiatry and Laing’s views. The emphasis on therapeutic communities in the Laingian version of anti-psychiatry led to positive developments such as the Philadelphia Association (see previous post) and the Arbours Association. The anti-institutional concerns of anti-psychiatry contributed to the rundown of the traditional asylum, with political impact such as that of Franco Basaglia in Italy (see previous post). The application of social labelling theory to mental illness, for example by Thomas Scheff (see my book review), had particular implications in the study 'On being sane in insane places' by David Rosenhan, which caused a crisis of confidence for psychiatric diagnosis at least for American psychiatry (see previous post). This was countered by the development of DSM-III. There were also international perspectives to anti-psychiatry, such as: French anti-psychiatry, particularly identified with Gilles Deleuze and Felix Guattari; Frantz Fanon in Algeria; and Jan Foudraine in the Netherlands (see my book chapter).

Maybe the term 'antipsychiatry' (without the hyphen) should now be reserved for the argument for the abolition of psychiatry (see previous post). But, I'm afraid it's still being used in the same way (eg. in the Psychology Today blog post mentioned above) as it was originally by mainstream psychiatry to denigrate any criticism, including valid criticism, of the biomedical model in psychiatry. I think this usage goes back to articles such as that by Martin Roth (1973).

In the article, Roth frames the debate about anti-psychiatry as an attack on the deterministic scientific nature of psychiatry. He recognises that this issue raises difficult philosophical questions and creates a need to reconcile deterministic concepts of causation with the inner experience of free will. He sees psychiatry as making progress towards this end by, for example, being able to describe the medical and social profile of those who commit suicide. He believes the Enlightenment represented the replacement of moralistic and transcendental attitudes with rational and deterministic explanations. 

Roth is correct that the conflict between determinism and free will is ultimately unresolvable. However, critical psychiatry does not take the same positivistic view of biological and biomedical sciences. In fact, the postpsychiatry version of critical psychiatry explicitly sees such a modernist agenda as untenable (see eg. previous post). 

A mechanistic worldview, which Roth calls science, confers an apparent advantage by providing a predictive and systematic way of understanding and manipulating nature. However, this leaves the phenomenon of life in an equivocal position because it cannot be totally stripped of its intrinsic purposiveness (see previous post). Rene Descartes (1596-1650) regarded both animate and inanimate matter by the same mechanistic principles. Animals are therefore machines; and human physiology is also mechanistic. Descartes stopped short, though, of including the human mind in this mechanistic framework. The soul was denied any influence in physiology. Descartes, thereby, avoided the materialistic implication that man himself is a machine. 

Although Georg Ernst Stahl (1659-1734) claimed erroneously that living things possess a vital entity, his dualistic notion was different from Descartes, in that he differentiated organic life from the inorganic, not the soul from the body. Unlike Descartes, the soul and body were not separate but integrated in the organism. Stahl originated an organismic perspective in the life and human sciences. This perspective formed the basis for Stahl having an emphasis on psychosomatic medicine, and a focus on clinical medicine rather than the physical sciences. 

Despite what Roth implies about the modernism of enlightenment thinking in the second half of the eighteenth century, the critical philosophy of Immanuel Kant (1724-1804) was clear that it is absurd and futile to expect to be able to understand and explain life in terms of merely mechanical principles of nature (see previous post). A mechanistic conception of nature fails to provide a complete characterisation of living systems. Organisms, unlike machines, are self-organising and self-reproducing systems. Different modes of explanation are therefore required for teleological and mechanical points of views. 

What's needed is a pragmatic approach which focuses on nature and experience and the centrality of the organism-environment interaction. Life’s dynamic, systemic and purposive character needs to be promoted as a way of moving on from physico-chemical reductionism, which tends to eliminate the meaning of human action. Life is continuously and dynamically preserving its internal environment and is therefore a perpetual stream of matter and energy, better understood as a process than a static unchanging entity (see previous post). 

Roth rightly recognises that it is the mechanistic approach to mental illness that is being criticised and notes the difficulties in identifying the social cause of mental illness. But his reason for rejecting a social perspective is not valid. This is because he expects social explanations to be determinist, which they are not. Moreover, he resorts to genetic factors to avoid environmental explanations. I agree with Roth’s conclusion that constructive endeavour is required to resolve the manifold problems of contemporary psychiatry. However, his labelling of any criticism of the biomedical model of psychiatry as ‘anti-psychiatry’ has hidden the extent to which the critique of reductionism and positivism in psychiatry is valid. Modern apologists for psychiatry by labelling their critics as ‘anti-psychiatry’ are doing the same. Instead they should examine how much psychiatry reduces people to objects and uses an inappropriate mechanistic psychology and biology.

Friday, September 25, 2020

Information about antidepressant withdrawal

I expressed concern about the position statement on antidepressants and depression produced by the Royal College of Psychiatrists (RCPsych) last year (see previous post). The College has now produced an online resource on stopping antidepressants. Even though the document has a disclaimer, I’m not convinced the information for patients is as good as it should be.

For a start, the licensed indications for the various antidepressants on the market do not only include depressive illness, anxiety disorder or obsessive-compulsive disorder. Licences have been granted for other indications that RCPsych does not mention eg. bulimia nervosa.

I think it would have been helpful if the document made clearer that continuation treatment of antidepressants is only really recommended if the medication helps. Some people with depression are not helped within six weeks and there is unlikely to be much point in persisting with the same treatment beyond this period. A change of antidepressant is often tried, and even though no antidepressant has been found to be any better than any other, this change may seem to help. But not everyone benefits from antidepressants, even in the clinical trials.

I can’t find any mention in the document of what I think is probably the most important advice about withdrawal symptoms (which is included in the NICE depression guideline). This is that people should be warned of the risk of discontinuation/withdrawal problems when they first start medication. I commonly used to make a comment like “try not to get too dependent on your medication”. I’ve no evidence that this sort of advice necessarily helps, but I think it stands to reason that it might. People can get psychologically dependent on all sorts of things. Starting antidepressants when one might be feeling desperate and unwell, hoping that the medication may help with such negative feelings, is almost inevitably likely to create a psychological dependence, perhaps particularly if the medication seems to help. When I was working, I always found that patients generally understood what I was saying about the risk of psychological dependence (see previous post).

I’m not quite sure what the evidence is for the position taken in the document that the severity of risk of withdrawal symptoms varies with different antidepressants. For example, as I mention on my ‘Antidepressant discontinuation reactions‘ webpage, fluoxetine was reported to be less likely to cause discontinuation problems, maybe because of its longer half-life, but there was conflict of interest in this work, as it could have had marketing implications for fluoxetine. Perhaps more significantly, no mention is made of the similarity of antidepressant withdrawal with the symptoms of benzodiazepine withdrawal.

Although the document says that the cause of antidepressant discontinuation problems is poorly understand, it does seem to very much favour the idea of re-regulation of receptors. But I’m not sure what the evidence is for this speculation (see eg. previous post). It also uses this speculation to support the argument for tapering, but if this is the explanation for the cause of withdrawal symptoms, then why, for example, is it generally easier to withdraw from antidepressants if they have been prescribed for a shorter period of time? I’m not saying that tapering is not important, which it usually is, but some people do seem to be able to stop suddenly, and the need for tapering also fits with my hypothesis of psychological dependence.

I’m also unclear what the evidence is when the document states that only one third to one half of people experience withdrawal symptoms. For example, in a failed trial of CBT to prevent relapse when withdrawing antidepressants, only 36% of patients succeeded in discontinuing antidepressants over 16 months (see previous post).

Although the document says, “Withdrawal symptoms normally start soon after your medication is reduced or stopped”, I’m not sure if the authors believe in delayed withdrawal problems. Late onset can occur (see previous post).

It is a common misunderstanding that antidepressants take weeks to work (see previous post). Where this comes from is that it generally takes 4-6 weeks for a statistically significant difference between active and placebo treatment to be detected in clinical trials. But this is an artefact of the way in which statistical significance is measured. Larger size clinical trials will detect a statistical difference earlier than trials with smaller numbers of subjects. Actually, the largest improvement per unit time produced by antidepressants occurs within the first 2 weeks of treatment.

There’s no mention in the document about making sure that people close to you are supporting you if you are withdrawing from medication. I think it’s much more difficult to withdraw from antidepressants if your relatives, for example, do not agree that you should be stopping.

I wonder whether it should have been made clearer in the document that gradual tapering does not completely eliminate the risk of withdrawal symptoms. Moreover, taking antidepressants also seems to increase the vulnerability to relapse, as well as cause withdrawal symptoms. That’s why continuation treatment was proposed in the first place.

Monday, September 21, 2020

Personal reflection on critical psychiatry

My invited submission to BJPsych Advances on ‘Clinical reflections on critical psychiatry’ has been rejected. As I’ve mentioned before (see previous post), an advantage of the internet is that these rejected manuscripts don’t have to just be put in a file drawer, never to be seen again. 

The invitation to submit followed a tweet in a conversation with @TheBJPsych suggesting I submit a proposal to BJPsych Advances for a special issue on critical psychiatry. I contacted the journal saying I didn’t know how seriously to consider the suggestion, and the journal answered that it would be pleased to consider a proposal if I would like to submit one, which I duly did. When the editorial board discussed the proposal, it felt that as it already had three special issues in the pipeline for the coming year, it would be better to commission and publish select pieces individually. This led to three of the original contributions to my proposal not being commissioned at all, and at least my contribution to the proposal being rejected.

I have discussed before (see previous post) the difficulties in getting critical psychiatry into mainstream journals. Twitter conversations with @TheBJPsych have tended to be more openminded. It’s even possible that Kam Bhui, as BJPsych editor, had an influence over the acceptance of my recent editorials in BJPsych and BJPsych Bulletin.

Thursday, September 17, 2020

Towards a more relational psychiatry

I have mentioned 'relational psychiatry' before (see previous post). Even though I come from a critical psychiatry position, which has never hidden that it grew out of what mainstream psychiatry called 'anti-psychiatry', there are more recent developments from anti-cognitivist phenomenological and enactive accounts of psychopathology that come to the same conclusion about the biomedical model of mental illness. For example, I have mentioned books like Sanneke de Haan's Enactive psychiatry (see eg. previous post) and Thomas Fuch's Ecology of the brain (see another previous post). 

Laurence Kirmayer summarises his perspective on what he calls ‘ecosocial psychiatry’ in an article in World Social Psychiatry. As he says, "Cognitive science supports the view that mental processes are intrinsically social, embodied, and enacted through metaphor, narrative, and discursive practices". As I've argued throughout this blog (eg. see previous post), there needs to be a shift in perspective from a narrow biomedical perspective towards a more truly biopsychosocial approach. As Laurence puts it, what's required is "a shift in perspective from a psychiatry centered on brain circuitry and disorders toward one that recognizes social predicaments as the central focus of clinical concern and social systems or networks as a crucial site for explanation and intervention". In this quote and the article in general, Laurence also helpfully illustrates the importance of social psychiatry, as focusing on the person inevitably means including the interpersonal dimension. This leads, as Laurence says, to an emphasis on "the powerful effects of structural violence and social inequality as key determinants of health".

Reductionism leads to the loss of meaning of human action and a mechanistic psychology cannot be realised in practice (see eg. previous post). This critique of reductionism and positivism in psychiatry, including mechanistic psychological approaches, creates a framework that focuses on the person and has ethical, therapeutic and political implications for clinical practice. It also has consequences for psychiatric research, which has become far too focused on speculative neurobiological notions. 

Descriptive psychopathology is not studied organically at the level of neurobiology. History and mental state examination instead produce a formulation of people’s problems in terms of differential diagnosis and aetiology. Examining the brain in a scanner, for example, does not tell us anything about the cause of thoughts, emotions and behaviour. An integrated understanding of mental dysfunction in the context of the whole person, including emotional needs and life issues, forms the basis for patient-centred and relational psychiatry. The physical disease model of mental illness is outdated and needs to be replaced by a relational psychiatry.

Misdirected aspirations for psychiatric classification

Peter Zachar et al (2019) have published an oral history of the development of DSM-5. For some reason, this does not seem to have included interviewing David Kupfer, the chair of the Task Force, so I do wonder if the article has been affected by the retrospective glosses of Darrel Regier, one of the co-authors of the paper and vice-chair of the Task Force, and Kenneth Kendler, another co-author and chair of the Scientific Review Committee appointed by the President of the American Psychiatric Association (APA). I hadn't realised how much the APA Board of Trustees (BOT) had a role in the DSM-5 process, including appointing Task Force members. 

As Zachar et al note, what was originally envisioned was a shift to a "more scientific basis of psychiatric classification" to take account of the aetiology of mental disorders (see eg. previous post). The paper suggests that any hope for a shift from descriptive to aetiologically-based diagnostic criteria had been largely abandoned by the time the workgroups were finally formed in 2008, not least because the human genome project had not produced candidate genes for mental disorders and there was more questioning about what neuroimaging could achieve.

Darrel Regier reports that DSM-5 leaders were not willing to delay publication, even though the National Institute of Mental Health (NIMH) were about to launch its experimental approach that became the Research Domain Criteria (RDoC) (see previous post). This was because of "what amounted to a resurrection of those very aspirations [that had initially motivated DSM-5]". If this was really the case, then DSM-5 had some foresight, as speculation about neural circuits has gone overboard (see previous post) and Thomas Insel, the previous NIMH director, in my view led NIMH completely 'off beam' with RDoC and so-called precision medicine (see another previous post). 

The paper suggests any decisions about changes were left to the workgroups. To give more direction to the process, BOT created an oversight committee in summer 2009. New guidelines accepted that “DSM-5 will not ‘in itself’ represent a paradigm shift, nor abandon the categorical system of classification, but will start a process that will lead to more useful ways of classifying and diagnosing disorders”. I’m not convinced it really did so, ending up merely with a tinkering with diagnostic criteria far short of the original misguided intentions. It would have been better if the time had been spent rethinking the basis of psychiatric classification (see eg. previous post).

Monday, September 14, 2020

Treatment of depression with antidepressants is primarily a placebo treatment

I’ve mentioned before that NICE may be laying itself open to judicial review about its depression guideline (see previous post). I’ve also emphasised the lack of clear evidence from clinical trials that antidepressants are effective, because placebo amplification may be an explanation of any statistically significant results (see eg. another previous post). This means we should have more of a psychological rather than pharmaceutical model of antidepressant action (Ankarberg & Falkenström, 2008).

Although it should not be surprising, empirical findings confirm that one of the most influential factors in the treatment of depression is the quality of the early therapeutic relationship, not necessarily medication (Blatt & Zuroff, 2005). Pretreatment characteristics of patients may also be factors in outcome. Training in the treatment of depression, therefore, needs to focus on teaching competence in establishing effective therapeutic relationships. Randomised controlled trials, which NICE tends to concentrate on, may be considered the gold standard of experimental design, but naturalistic studies may well have more external validity. The long-term outcome of treatment for depression may not necessarily be that good (see previous post). I’m not encouraging exploitation of the placebo effect, but merely acknowledgement of the importance of the doctor-patient dynamic, even when medication is used (see my BMJ letter). Perhaps NICE should start from a position of therapeutic nihilism before it makes any recommendations about treatment (see last post), but at least it should be clear that the therapeutic relationship is significant and almost certainly affects outcome.

Saturday, September 12, 2020

The argument for medical nihilism

Jacob Stegenga published his book on Medical nihilism in 2018. He aligns himself with therapeutic nihilism meaning that "it is impossible to cure people or societies of their ills through treatment' (see Wikipedia entry). This view is contrary to the widespread faith that people tend to have in medical practice. Financial incentives, even corruption, influence medical science. Its research methods are malleable enough to lead to exaggerated claims for effectiveness. We should not be confident about such claims and should be sceptical that medical interventions are effective.

Jacob comes to a position of medical nihilism without apparently fully taking on board the scientîfic challenges in the application of randomised controlled trials (see eg. Kramer & Shapiro, 1984), perhaps particularly the problem of unblinding (see eg. my letter and follow-up). He emphasises the common small effect size of clinical trials, and the fact that some interventions are removed from clinical practice because they are later found to do more harm than good. Few drugs are ‘magic bullets’ in the sense of specifically targeting the cause of a disease. In practice not all clinical trials generally show a benefit for a drug. Bias, even fraud, in clinical research tends to be minimised.

Jacob makes clear he is not saying that no medical intervention is effective. But assessing the effectiveness of medical treatment generally is not merely an empirical matter because of the methodological problems of such research. Research methodology does need to be improved, which will reduce effectiveness estimates, but even so there are still problems about interpreting the data. There is a sense in which it is impossible to be objectively certain about the effectiveness of the vast bulk of treatment. 

Medicine has not really advanced as much as we might like. Broader socioeconomic conditions of health may well be more important than medical treatment itself. In general, there is too much medicine (see eg. post on my personal blog). Jacob encourages medicine to be gentler in its approach, and not so radically aggressive. There needs to be enhanced regulation of medical interventions. The profit motive in medical research is distorting social priorities. The art and science of medicine needs to be rethought (see another post on my personal blog).

Friday, September 11, 2020

“[P]ast 20 years have not been good for the quality of care [in mental health services]”.

BJPsych Bulletin
has an interview with Tom Burns, who I have mentioned previously (eg. see previous post). He talks about the OCTET study on community treatment orders (CTOs), which I have also discussed before (see post). Personally I think CTOs should never have been introduced (see eg. another previous post) and Tom now thinks he made a mistake in promoting them. It always strikes me as ironic that there used to be so much concern that a few detained patients were being kept on S17 leave too long, whereas essentially CTOs provide just such a 'long-leash' arrangement. As far as I can see, the introduction of CTOs has led to insufficient use of S17 trial leave. This almost certainly has reduced the opportunity for arranging informal community care without CTO.

Tom is also critical of DSM-5 (see eg. previous post). He's right to focus on descriptive psychopathology as a strength of psychiatry. He calls it 'diagnosis', which can be misleading because history and mental state examination actually lead to a formulation which includes differential (not necessarily a single and certain) diagnosis and aetiology. Diagnosis should not be overemphasised in psychiatric assessment (see eg. previous post). 

Tom's also right about the fragmentation of services over the last 20 years. Hopefully the community mental health framework for adults and older adults will provide a basis for development but it does need leadership to implement it. Despite what Tom says, I haven't abandoned the use of the term 'patient', although also use the term 'service user', even 'survivor', certainly recognising the importance of mental health advocacy (does he?). Tom rightly expresses concern about clustering, which was supposed to support so-called payment by results, which seems to have been quietly dropped (see post on my personal blog). As he also indicates the overpreoccupation with risk has been damaging (see eg. my unpublished article and talk).

A younger version of Tom Burns sounded more optimistic in an e-interview. He even noted the "sense of excitement and 'importance' of psychiatry" created by RD Laing and how anti-psychiatry made the profession "glamorous, albeit controversial". He's still writing about the history of anti-psychiatry (see previous post and my letter).

(With thanks to Suman Fernando who alerted me to the recent interview)

Wednesday, August 19, 2020

What is a case of depression in the coronavirus period? A case for what?

The Office for National Statistics (ONS) reported yesterday that the Patient Health Questionaire (PHQ-8) scores for most people had increased in June 2020 compared to a score recorded sometime between July 2019 and March 2020 (although had actually decreased for 3.5% of the population). Considering the anxiety caused by coronavirus, social distancing and lockdown, I guess this finding should not be surprising.

These figures were used by the Royal College of Psychiatrists to warn again about a "looming mental health crisis and the tsunami of referrals we are expecting over the coming months" to reinforce their argument for significant investment in mental health services (see Guardian article). Headlines were that depression had doubled during the coronavirus period. But as Elaine Fox said to BBC news online, "It is important to remember that this [PHQ-8] does not give a diagnosis but rather an indication of everyday depressive feelings and behaviours". Certainly it’s misleading to imply that the number of depression cases has doubled because of coronavirus.

I don't want to underestimate the impact of the pandemic on mental health. But I'm not necessarily convinced there will be an inevitable vast increase in cases coming forward for, or even needing, antidepressants, psychological therapy or other mental health treatment. We've all had to adjust to it, and such adjustment does not necessarily create mental health problems.

I'm reminded of the book of the symposium What is a case? (1981) edited by Wing et al. As David Goldberg noted (see article), a contribution at the symposium by:-

Copeland (1981) reminds us that the concept of a case is a chimera ... . Rather than regard the concept as a sort of Platonic ideal he suggests that investigators should ask - 'a case for what?'

Despite whatever symptoms are measured on the PHQ-8, people's coping mechanisms may not have necessarily broken down because of the pandemic; nor would they necessarily seek, or need, medical or psychological help even if they have difficulties. Feelings as recorded on the PHQ-8 may well be understandable in the circumstances. It is important to ask if the Royal College of Psychiatrists, for example, may be manipulating the ONS data to its own advantage to obtain more resources. I wouldn't want to discourage people who need help from coming forward, but they actually may have considerable personal resources and resilience to be able to overcome and adapt to any difficulties caused by the pandemic. Mental health treatment can be helpful, but it isn't always.

Tuesday, August 18, 2020

Developing a non-medical mental health service

I've said before (eg. see previous post) that I'm keen to see how non-medical mental health services could be developed within the NHS. Doing so would make explicit that treatment on offer in such a service does not include medication (despite there now being a limited amount of non-medical prescribing by healthcare professionals other than doctors and dentists). Psychological therapy of course is non-medical in this sense, and non-medical treatment is in fact much wider, including all psychosocial interventions.

Improving Access to Psychological Therapies (IAPT) was originally designed as a non-medical service. In the NHS plan, IAPT has now become the service for common mental health problems, for example being renamed within NHS Trusts as Wellbeing Services. Severe mental illness is managed within the traditional community mental health team (CMHT). Unfortunately, this means that some people who are explicitly seeking a non-medical service are told they are "too complex" for IAPT and become quite confused when they are referred on to the CMHT.

I've mentioned before (see eg. previous post) that some clinical psychologists, such as Peter Kinderman, want mental health services to become non-medical. There's even support from within psychiatry for such a position (see eg. another previous post). Although the motivation for such a change may largely be coming from a 'drop the disorder' argument, in the sense that it's thought to be wrong to regard mental health problems as 'illnesses', it is possible that a non-medical mental health service could actually encompass a range of different views about the nature of mental illness/ health problems. Its fundamental feature would rather be about managing mental health problems without medication. Such a service would provide real options for patients, alongside more medically based services to deal with medication and psychosomatic issues.

There are plans to increase the number of people working in the psychological professions in NHS commissioned health care (see vision). Increasing the number of clinical psychologists makes sense, considering the difficulties in recruitment to other mental health professions at present. Clinical psychology has no difficulty with recruitment, and in fact could be made even more attractive, by its training being geared towards creating the new leaders in a non-medical mental health service. 

I'm not undermining the importance of medication in treatment or the role of the doctor in mental health work, having been a doctor myself in my working life. I just think that a division between medical and non-medical mental health services may well make more sense than the current division between services for common versus severe mental health problems. 

Sunday, August 16, 2020

Minds are not disembodied

Thomas Fuchs, who I have mentioned before (eg. see previous post), has a useful summary (see article) of the concept of circularity from an embodied and enactive point of view. Living beings have the two aspects of lived or subject body (Leib) and living or object body (Körper). These correspond to two different attitudes respectively: the personalistic, which takes a holistic view of the person experiencing the body from the first person perspective and the others’ body from a second person perspective; and the more narrow naturalistic, which observes and investigates the body from a third person perspective. 

Neuroscience, by turning only to the physical, sidelines the circular interaction of the brain, body, and environment. Examining the brain in a scanner does not tell us anything about the cause of thoughts, emotions and behaviour. These need to be understood by considering the circular causality of embodied subjectivity, it’s situation and history. As Thomas Fuchs says:-
The brain is not the locus of subjectivity but only a mediating component of the cycles of self-regulation, sensorimotor, and social interaction, in which the life of a human person consists.

Monday, July 06, 2020

Brain effects of antipsychotic medication

An article in JAMA Psychiatry reports a secondary analysis of a randomised controlled trial of antipsychotic medication to show that antipsychotic medication is associated with changes in brain structure. Exposure to olanzapine compared with placebo was associated with significant decreases in cortical thickness in the left hemisphere in those who sustained remission. This kind of finding is is not new (see previous post). Postmortem studies in animals have been linked to imaging findings (Vernon et al, 2013, Konopaske et al, 2007). 

The clinical significance of these findings is unclear. How adverse these apparent brains changes are requires further elucidation.

(With thanks to Mad in America research news item by Peter Simons)

Reifying the mind

Mohammed Abouelleil Rashed (whose book I have recently reviewed) has an article on ‘The identity of psychiatry and the challenge of mad activism: Rethinking the clinical encounter’. He suggests that medicine is committed to the hypostatic abstraction (from Charles Pierce) which implies that doctors treat "things" that people "have". Mohammed does recognise that physicians frame their work to take account of the whole person and psychiatry is different from the rest of medicine because it focuses on mental disorders rather than physical disorders. 

I have argued throughout this blog (eg. see previous post) that psychiatry should not reify psychiatric disorder. Mohammed does acknowledge that some psychiatrists do not think the hypostatic abstraction is central to their work. He accepts that the clinical encounter can provide understanding and have therapeutic aims without such an assumption, but falls short of wanting to "rethink the entirety of mental health practice".

As I've said before (eg. see previous post), our modern concept of illness only really goes back to the mid-nineteenth century. Understanding illness in terms of underlying physical pathology does make disease a thing that people have (in Mohammed's terms). The trouble is that psychiatry never really fitted with this development of the anatomoclinical method, which related clinical symptoms and signs to underlying pathology. Most mental illness (apart from organic illness) is functional, in the sense that there is no underlying pathology in the brain (see eg. another previous post).

This situation was why Engel proposed the biopsychosocial model (see eg. previous post). Medicine needs to be person-centred (see eg. another previous post) and this is more obviously the case in psychiatry where there is no physical illness. I'm not suggesting taking the challenge of mad activism as far as abolishing the notion of mental disorder (see eg. yet another previous post) but I would encourage Mohammed to take further his analysis of the critical challenge to the biomedical model of psychiatry. Despite what he seems to think, psychiatry does not need to accept the hypostatic abstraction to be a medical speciality (see eg. previous post). 

Friday, June 19, 2020

Demarcating 'abnormality' from 'normality'

I've said before (eg. see previous post) that insisting on avoiding pathologising in mental health services can be misleading. I understand why people may want to do this because, for example, they think that pathologising mental problems implies brain disorder, when this is not the case.

Sanneke de Haan in her book Enactive psychiatry (see previous post) discusses what she calls 'sense-making' (see another previous post). Organisms need to make sense of their environment to survive. We need to understand the organism-environment as a system not an isolated individual, let alone its brain. 

How do we distinguish pathological from normal sense-making? Of course there are differences between people. It is normal to struggle with life at times. The appropriateness of sense-making depends on context and sense-making needs to be attuned to the real world. Norms can vary over time and shared sense-making or the common sense of people in cultural context is what matters. People can still be eccentric but the stance one takes on oneself and one's situation can mean that one fails to recognise the inappropriateness and inflexibility of one's ways of interacting. One's stance can become unbalanced. Problematic sense-making can cause suffering, although not necessarily so. Patterns of sense-making may be identified which are abnormal.

As I've also pointed out, the concept of illness goes back further than our modern understanding since the middle of the nineteenth century of illness as physical lesion (see eg. previous post). We use the same criteria to decide whether an illness is mental or physical and, even though the concept of illness as physical lesion is relatively recent, we tend to think that we are extending the principles of physical illness to the concept of mental illness. 

In fact, the concept of psychological illness had been opened up before the application of the anatomoclinical method in medicine (see previous post). The recognition of psychosomatic illness focused on the doctor-patient relationship creating a new space for mental pathology (see previous post). We may now have more modern understandings of psychosomatic medicine (eg. see previous post), but, as I've pointed out before (eg. see previous post), those that want to move away from the concept of mental pathology, do not seem to deal with the issue of psychosomatic pathology very well. 

Of course madness has always been recognised. Still, medical psychology created a descriptive psychopathology (see eg. previous post) and how we make sense of delusional thinking is still an important issue (see previous post). Normalising mental pathology can fail to do justice to the sense in which something may have gone wrong in mental functioning.

Monday, June 08, 2020

Psychiatry in need of a paradigm

In his letter to the editor of Acta Psychiatrica Scandinavica, Gordon Parker argues for "multiple niched paradigms" in psychiatry. Parker's letter was written in response to a letter from Tilman Steinert arguing that psychiatry needs a new paradigm. Parker contends that psychiatry doesn't need a single over-arching paradigm, but instead should "determine which paradigm (of many current and candidate ones) best explains why this individual is suffering this condition at this particular risk period".

I agree with Parker than psychiatric assessment should be individualised, but I'm not sure this is to do with paradigms as such. Like Steinert, I too was trained in a hierarchical approach to psychiatric assessment and diagnosis, with organic factors trumping psychotic, then neurotic then personality factors. Karl Jaspers understood the history of modern psychiatry as a conflict between two factions of somatic and psychic approaches rather than a simple chronological development. Georges Lanteri-Laura divided modern psychiatry into three sequential paradigms (see previous post), although I tend to prefer the implication of what Jaspers was saying, that there's always been a conflict in the origins of medical psychology in its attempt to move on from Cartesianism (see my editorial).

I also agree with Steinhart that psychiatry has got quite muddled in how it understands mental disorder. As he says, there's a need for "an effort of rethinking, sorting, and grouping of available findings". That's partly been the motivation of this blog! For example, Pat Bracken has argued for the need to move from reductionism to hermeneutics in psychiatry (see previous post). A BJPsych 2012 special article talked about the need to move beyond the current paradigm in psychiatry (see another previous post). More recently, as another example, I've pointed out the value of enactive psychiatry (see eg. previous post).

George Engel proposed his biopsychosocial model as a middle way between biomedical reductionism and Thomas Szasz's 'myth of mental illness' position, which Engel called exclusionist. Since Engel's time, psychiatry has become quite muddled about what 'biopsychosocial' means (see eg. previous post). We do need to be clearer about the aetiology of mental disorder (eg. see previous post). I also think the mistaken abolition of the distinction between organic and functional mental disorders by DSM-IV has clouded perspectives (see eg. another previous post).

It seems to me that Gordon Parker has not really taken these issues seriously. I suspect this is because he wants to perpetuate the current eclecticism of psychiatry to avoid dealing with fundamental ideological issues. Psychiatry found it difficult coping with the onslaught from so-called "anti-psychiatry" and, to my mind, has still not really recovered a balanced perspective (eg. see my editorial).