Sunday, June 02, 2019

Being honest about antidepressants

Adrian James, Registrar at the Royal College of Psychiatrists, said in his recent Radio 4 interview (see transcript) that “we need to have an honest discussion about side effects” of antidepressants. This  should go without saying and it’s helpful the College is being explicit. But I worry that James’ interview demonstrates, as I have said previously (see post), that the College is not making a significant enough concession on antidepressant discontinuation problems.

The reason James and the College minimise antidepressant discontinuation problems is because they want people to take their antidepressants if needed. The College exists as an institution to justify psychiatric treatment, such as antidepressant medication (see previous post).

James therefore emphasises that any side effects from antidepressants may be mild and self-limiting. He may be talking about side effects on starting antidepressants, as it is true that antidepressants are usually reasonably well tolerated, although not always so (and, again, the College has not made enough of the small number of people that do have a severe adverse reaction to antidepressants). But discontinuation problems are not always mild and self-limiting. The College has recognised that people can have severe withdrawal symptoms over a long period of time, but James insists this is “a very small number”, which I’m not convinced is the case.

It’s possible that Rachel Kelly’s experience is more typical (see her Times article). She says coming off the drugs after two significant depressive episodes, which left her hospitalised, was "terrifying". Each time she did so, she "feared she would relapse". She goes on, "Indeed the resulting anxiety was so high that I had to use other drugs, chiefly tranquillisers, to ease the process." As I said over 20 years ago in a BMJ letter, the "general public might reasonably expect psychiatrists specialising in disorders of the mind to recognise psychological dependence, base their advice on clinical experience, and use their common sense".

Friday, May 31, 2019

Getting the right position on antidepressants

The Royal College of Psychiatrists (RCPsych) has been widely praised (eg. by the Council for Evidence-based Psychiatry (CEP) - see press release) for its call for NICE to update its guideline on antidepressant withdrawal (see RCPsych press release). This new statement follows a complaint made to RCPsych - which was wrongly dismissed without, as far as I know, any apology - about a claim, made by its President and Psychopharmacology Committee Chair, that discontinuation problems on stopping antidepressants resolve within two weeks for the vast majority of patients (see previous post).

Instead RCPsych now accepts that “there should be greater recognition of the potential in some people for severe and long-lasting withdrawal symptoms on and after stopping antidepressants”. This is a welcome development and I don’t want to seem negative about it. But I do have concerns overall about the recently released RCPsych position statement on antidepressants and depression.

For example, as far as discontinuation problems are concerned, the statement says “withdrawal symptoms ... are often mild and self-limiting”. I’m not sure this is right. They can be mild and self-limiting, but I’m not convinced they are often so. Nor do I find anywhere in the statement a proposal for research to establish the reason for these problems. This is particularly pertinent because, as the statement points out, there is a lack of evidence that antidepressants are physically addictive.

More generally, the statement overestimates the value of antidepressant treatment. For example, it makes several statements about how long people need to stay on antidepressants, without any references to support this advice. It also makes too much of what it calls the "partial understanding" of how antidepressants work, even assuming that they do work! Although it may indicate we need to move on from the chemical imbalance theory of depression (eg. see previous post), it still seems enamoured of biological theories of antidepressant action, such as neural plasticity. There's no way the RCPsych could consider that the placebo amplification hypothesis to explain trial data could possibly be valid, even though Cipriani et al (2018) (authors it praises) only say antidepressants "might work" (see previous post).

Rhiannon Lucy Cosslett in a Guardian article asks why it took so long for psychiatrists to listen to patients about antidepressant discontinuation problems. The answer is that they tend to focus on short-term fixes, they tend not to be psychologically-minded and they can be too quick to peddle medication (see my book chapter). RCPsych has got a long way to go to deal with these tendencies within its ranks.

Saturday, May 25, 2019

Critical psychiatry is reformist

Bonnie Burstow's chapter entitled 'From 'bed-push' to book activism: Anti/Critical psychiatry activism' in the Routledge handbook of political activism (2019) helpfully summarises her antipsychiatry position. She makes clear that "The chapter is written from an anarchist perspective". Antipsychiatry is distinguished by the fact that
... all antipsychiatry activists seek the total abolition of institutional psychiatry (and this distinction is crucial) not some just part of it and not the mere 'reform' of the institution. This, in practice, would mean that insofar as anything vaguely resembling psychiatry continued to exist, it would have no state powers, no state funding or promotion and no authoritative 'medical’ status [emphasis in original].

I've complained before about how the americanisation of critical psychiatry seems to be devaluing its meaning. For example, the Mad in America website reduces critical psychiatry to a general term for alternatives to the biomedical model in psychiatry (eg. see my book review). At places in her chapter, Bonnie Burstow seems to use the terms 'critical psychiatry' and 'antipsychiatry' interchangeably (as apparently, for example, in the subtitle of the chapter), but I'm not sure if this is intentional.

Rather than allowing the highjacking of the term 'critical psychiatry' by antipsychiatry, I think I need to make clear that critical psychiatry is a reformist movement. There are differences within the movement (see previous post) and although I'm more at the reformist end, I'm not against seeing critical psychiatry as a broad spectrum, which it is (eg. see previous post). But it's unrealistic to expect that the wish to find a physical basis for mental illness will ever go away completely. There's always been this wish, even before our modern understanding of medical psychology developed at the end of the 18th century. I've even argued that critical psychiatry was present in the origins of modern psychiatry (eg. see previous post). Critical psychiatry is certainly a medical enterprise (again, see eg. previous post).

I'm not against activism such as the 'Fast for Freedom' hunger strike in 2003 by six 'psychiatric survivors' (eg. see previous post). I attended an Occupy American Psychiatric Association meeting in the past (see previous post) and I do think there are particular issues about American psychiatry (see eg. previous post) that may require a more radical response. I also use social media as a form of activism, and some of the motivation for doing this is because of the difficulty in getting my perspective into mainstream psychiatric journals.

However, I'm not convinced that there really is what Bonnie Burstow calls "an unstoppable radical politic". But I do respect her position. and value her attempt to restate an antipsychiatry position. I originally called my Critical Psychiatry website the Anti-psychiatry website (see previous post), although it has became more defunct as it has now essentially been taken over by this blog. But I'm glad I changed the name because I never intended to promote anarchy. I'm sure that's what some people fear about critical psychiatry, but that's a misunderstanding.

I agree with Bonnie Burstow that "the mad and the antipsychiatry movements in themselves present challenges". I'm not against reconsidering my politics. But my ultimate aim is to make psychiatry more pluralistic, not to abolish it.

Thursday, May 16, 2019

Schizophrenia is not a chronic brain disorder

I've been asked how the American Psychiatric Association (APA) is allowed to call schizophrenia a "chronic brain disorder" on its information webpage about 'What is schizophrenia?'. The answer is that professional bodies, including the Royal College of Psychiatrists (see eg. previous post), can't be relied on for information about psychiatry. There was a time when American psychiatry would have been more cautious about making such a claim. For example, neurobiology was only represented in a few sections of the 1959 American Handbook of Psychiatry (see my book chapter). Any influence of psychoanalysis and Meyerian psychiatry is now difficult to find in modern American psychiatry (see eg. another book chapter).

I'm reminded of the hunger strike on the 16 August 2003 by six "psychiatric survivors" to challenge the APA for evidence to support common claims that major mental illnesses are "proven biological diseases of the brain" and that emotional distress results from "chemical imbalances" in the brain (see Fast for Freedom information webpage). I wrote an article about this situation. It’s still the case that the APA needs to take a more balanced view of the evidence about the neurobiological basis of mental illness. 

Tuesday, May 07, 2019

People made dependent on psychotropic medication have not abused or misused the drugs

Twitter conversation this morning (see thread leading to my tweet) has made me realise that it may be misleading to say that people who have experienced antidepressant discontinuation problems have become addicted to antidepressants. I'm certainly not wanting to imply that people made dependent on antidepressants have abused or misused the drugs. There is confusion in the nomenclature (see eg. previous post and my Antidepressant Discontinuation Reactions webpage) and I don't want to add to it.

Friday, May 03, 2019

Integrating critical psychiatry into the mainstream

Although the Critical Psychiatry Network was formed over twenty years ago (see my editorial), critical psychiatry remains marginal to mainstream practice. This may be because of its association with so-called antipsychiatry (eg. see previous post).

Critical psychiatry’s challenge to the ‘disease model’ of mental illness is legitimate (eg. see previous post and my Lancet Psychiatry letter). As I've pointed out in this blog before (eg. see previous post), its point of view has actually always been present historically and philosophically since the origins of modern psychiatry. It is not just a new fad, and grapples with the same conceptual issues that were present with the origin of modern psychiatry. It's always been a minority perspective.

For example, present day psychiatry tends to see itself as ‘biopsychosocial’ (eg. see previous post). It is not only concerned with biological but also psychological and social aspects of disease. Anthony Clare articulated this perspective as the outcome of the anti-psychiatry debate (eg. see previous post). He encouraged the avoidance of doctrinaire devotion to ideology in psychiatry. This ill-defined basis for practice may create theoretical inconsistency, such as viewing more minor psychological disorder as psychosocial, whereas more severe mental illness is identified as biological in origin. It may also lead to the combination of psychotherapy and biological treatments without any systematic theory to support such a strategy ( see my book chapter).

Nassir Ghaemi is critical of such eclecticism, although he incorrectly blames George Engel and Adolf Meyer for this situation (see my review of Ghaemi's book and responses). Both Engel and Meyer had an integrated mind-brain understanding, as does critical psychiatry. Engel’s biopsychosocial model promoted a holistic psychiatry and, like critical psychiatry, is a challenge to biomedical dogmatism (see eg. previous post). True, Meyer’s embracing of the uncertainty of psychiatric practice led to him being prepared to compromise with opposing opinions. He failed to challenge biomedical excesses, complaining that the research evidence was lacking (see another previous post and my article). But Meyer’s Psychobiology, which dominated American psychiatry in the first half of the twentieth century, is a legitimate theoretical framework for the more recent critical psychiatry movement.

The fundamental issue of the relation of mind and body creates the context for conceptual conflict in psychiatry. The first to apply a mechanistic approach to life was René Descartes (1596-1650) (see previous post). Animate and inanimate matter were understood 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. The split he created between mind and brain is referred to as Cartesianism. However, living beings, including humans, have a purposiveness that cannot be derived from mere physical-chemical processes. Organic life needs to be distinguished from the inorganic, not the soul from the body. Despite Descartes, the soul and body are not separate but integrated in the organism. Critical psychiatry takes an organismic, rather than mechanistic, perspective in the life and human sciences and is not Cartesian.

In the second half of the eighteenth century, reacting against Cartesianism, anthropology established itself as an independent discipline, concerned with the study of man as a psychophysical individual. In this context, medical psychology had its origin with two major variants of anthropological thinking (Verwey, 1985). A medically-orientated anthropology represented by Ernst Platner, among others, was one version. The other was Immanuel Kant’s pragmatic anthropology. Kant, like critical psychiatry, was clear that it is futile to expect to be able to understand and explain life in terms of merely mechanical principles of nature (Zumbach, 1984).

In the same year, 1845, that saw the publication in German of the book that gave Wilhelm Griesinger his reputation in psychiatry, Ernst von Feuchtersleben produced his psychiatric textbook based on Kantian principles (see previous post). Griesinger was dedicated to the idea of the pathology and therapy of mental diseases as a mechanical natural science, although he remained aware of the gap between this ideal and reality. Nonetheless he set the trend for this positivist biomedical understanding that has dominated psychiatry since the middle of the nineteenth century. Such a positivist reduction of mental illness to brain disease is what causes such concern for critical psychiatry. Feuchtersleben, by contrast, like critical psychiatry, recognised that the mind-brain problem is an enigma that can never be solved. He has been called a ‘forgotten psychiatrist’, but should be remembered as creating a framework for critical psychiatry based on Kant’s philosophy.

Critical psychiatry has foundations that go back to the origin of modern psychiatry. It is integral to its history and it is, therefore, a mistake for psychiatry to marginalise it from the mainstream. Critical psychiatry can be understood as a truly biopsychosocial, neo-Meyerian approach to psychiatry based on Kant’s critical philosophy.

Thursday, May 02, 2019

Anti-reductionism and critical psychiatry

Immanual Kant in the section on the ‘Critique of Teleological Judgement’ in his Critique of Judgement (1790) said:-
For it is quite certain that we can never adequately come to know the organized beings [living things] and their internal possibility in accordance with merely mechanical principles of nature, let alone explain them; and indeed this is so certain that we can boldly say that it would be absurd for humans even to make such an attempt or to hope that there may yet arise a Newton who could make comprehensible even the generation of a blade of grass according to natural laws that no intention has ordered; rather, we must absolutely deny this insight to human beings.   

What did Kant mean by this and what is its application to psychiatry? As a critical psychiatrist I think I am applying Kant’s critical philosophy to psychiatry.

What Kant was saying is that a mechanistic psychology is impossible. Not that people cannot be studied in a mechanical way, particularly parts of themselves - and as far as psychology is concerned this is the brain - nor that we cannot produce descriptions of thoughts, emotions and behaviour. But a mechanistic conception of nature fails to provide a complete characterisation of living systems.

Why is this? Living things are different from inanimate objects. They have functional and goal-directed characteristics. They have designed and designer-like aspects. They seem to be intended for a definite purpose and they have the ability to form their parts. Living things are purposiveness systems, or to use Kant’s words, teleological systems. A machine is different. It does not serve its own interests but the interests of its maker or user. Organisms, unlike machines, are self-organising and self-reproducing systems.

We therefore need different modes of explanation for teleological and mechanical points of views. For example, understanding the meaning of human action is a different kind of explanation from mechanical explanation. The mechanistic conception of causality fails to provide a complete understanding of human and living systems in general.

In fact, Kant goes further than this. What he says is that how living wholes cause their parts is unknowable to us. We just have to accept that our knowledge is limited because we conceptualise organic matter in a different way to inorganic matter. Life and human sciences are doomed to a kind of pre-scientific descriptivism rather than becoming a natural science.

We can never have theoretical knowledge that anything in nature is teleological, but such judgment is nonetheless necessary and beneficial for us. Which is why we attempt to understand human and living behaviour in mechanical terms. We may well wish we could explain life in mechanistic scientific terms and so-called science has often embarked on what Kant called a “daring adventure of reason”. Despite Kant recognising the wish to have a physical understanding of life and human behaviour, nonetheless he argued that it is absurd and futile to expect to be able to explain mental processes in physical terms.

I want to try and apply this kind of thinking to psychiatry. Mental illness is commonly perceived to be due to brain pathology. This is standard understanding. People may even be told by doctors that their mental health problems are due to a chemical imbalance in the brain or some other biological disease. You may even have heard or read something like this yourself. But critical psychiatry is saying you are being misled by perspectives like this.

Of course acute brain disorders can present as a toxic confusional state. More chronically they can lead to a dementia. But most mental health problems are functional in the sense that they are not structurally represented in the brain.

I don’t want to be misunderstood. Of course I’m not saying that mental health problems have nothing to do with the brain. The mind is clearly enabled by the brain. But what I’m saying is that mental health problems should not be reduced to the brain. And, like Kant, this is primarily a statement about how one explains mental health problems. I’m not saying that mind and brain are different substances. I’m not anti-materialist in this sense. Nor am I saying that it’s not important to use scientific methods. In fact, a lot of what passes for science, certainly in mental health, is more to do with speculation than the real world. Considering the amount of money that’s been spent on mental health research, one might hope that progress would have been made. But essentially results are so clouded by inconsistencies and confounders that it’s not been possible to say anything definitive about the biological basis of mental illness.

You may be surprised by me taking such a position as this. And, you may well not be alone. I am taking a minority view within psychiatry. In fact, psychiatry is more like a faith that doctors are expected to believe in rather than a science as such. If I don’t follow the faith of believing that mental illness is a brain disease, then I’m seen as unorthodox. I do, however, have a few other psychiatrists who agree with me. Twenty years ago we formed the Critical Psychiatry Network. If you’re interested in finding out more, there’s an editorial in February's British Journal of Psychiatry entitled ‘Twenty years of the Critical Psychiatry Network’.

(Adaptation of talk given to Cambridge University Psychology Society, 21 February 2019)

Wednesday, May 01, 2019

Who's going to take responsibility for promoting the chemical imbalance theory of mental Illness?

I reviewed Ronald Pies' book Psychiatry on the Edge a few years ago (see review and previous post). A recent Psychiatric Times article picks up his theme of debunking the chemical imbalance myths of depression and schizophrenia. I think I do understand his view that these notions were never really taken seriously by most well-informed psychiatrists (see previous post). He does admit, though, that it's not surprising the theory has "taken hold in the minds of so many in the general public". It worries me, though, that he may be seen to be blaming Laura Delano (whose New Yorker article led to his response) for her view, as a patient, "that [her] depression was caused by a precisely defined chemical imbalance, which her medications were designed to recalibrate". I hope he's not.

I'm not quite sure what's achieved by arguing that "there was never a unified, concerted effort within American psychiatry to promote a 'chemical imbalance theory' of mental illness in general", if that's the impression that's been created in Laura Delano and the public in general. Whose fault was it then? Certainly patients are given this professional opinion by psychiatrists (whether they really believe it or not) (see previous post). As I said in my review, Pies thinks that:-
Doctors know it’s an oversimplification ... but use it so patients don’t feel so blameworthy. He does agree this is “a little lazy” ... on the doctors’ part and doesn’t excuse their behavior, but says they are very pressed for time with so many patients to see.

I also agree with Pies that most psychiatrists are more eclectic than just biological (eg. see previous post). In fact, Pies is quite biological in his approach to psychiatry and admits for example that he's enamoured of the idea that depression is a form of inflammation, even though I think this hypothesis is nonsense (eg. see last post). I think Pies is just trying to say that psychiatrists are not simplistic in their biological (which doesn't omit psychosocial aspects) theories of mental illness. That's as may be and it's good he admits the chemical imbalance theory is bogus. But, if he doesn't attribute the chemical imbalance theory to psychiatrists, who take a much more complex view about the nature of mental illness, then who's been responsible for its promotion? Surely he doesn't think it's the silly patients who’ve believed it.

Saturday, April 13, 2019

Surely enough money’s been made out of antidepressants

An editorial in Acta Psychiatrica Scandinavica asks whether the time has come to treat depression with anti-inflammatory medication. This is based on a meta-analysis which provides evidence that anti-inflammatory treatment can be beneficial. Throughout this blog (eg. see previous post), I have emphasised bias in clinical trials, so I’m not encouraging the use of anti-inflammatory medication to treat depression. Not least, the trials in the meta-analysis show a high risk of bias and tend to be done by using the anti-inflammatory drug as an add-on to antidepressant treatment, or in patients who have somatic disease, so an anti-inflammatory effect on somatic disease may be the reason for any improvement in depression scores, rather than a true antidepressant effect.

What I want to note is why anti-inflammatory medication, despite the apparent evidence for its benefit, has not managed to be included in guidelines for depression. To gain approval, a large scale trial would need to be done to show that anti-inflammatory medication offers the prospect of better treatment than current treatments, but would be very expensive. As the editorial says, only drugs with a high likelihood of generating future profit are put through such trials. The editorial goes on:-
In the case of the traditionally used, safe and tolerable anti-inflammatory agents that are already on the market, there is no financial incentive for the pharmaceutical industry to conduct these costly, large-scale RCTs. Rather, they are more likely to fund newly discovered immunotherapies with a poorly characterized safety profile, as such novel immunomodulatory treatments can be patented and monetized. 

Unlike the editorial, I am not suggesting government funding for such trials. As I indicated in my review of Ed Bullmore’s book (see previous post), it’s non-sensical to think that depression is a form of inflammation. Any apparent increase in inflammatory markers in depression is far less than inflammatory disease in general, and has non-specific causes rather than being a marker for depressive disease as such (see previous post).

The market for depression has been flooded. The pharmaceutical companies themselves seem to have realised this years ago (see previous post). If people want medication treatment, let’s at least keep it cheap. We should be suspicious of any attempt to make further money out of medication treatment for depression. Marketing and commercial, rather than scientific and therapeutic, interests have always determined which drugs are prescribed.

Thursday, April 04, 2019

The stigma of anti-psychiatry

As I said in my previous post, challenging the biomedical model of psychiatry is not anti-psychiatry. Another example of how the term 'anti-psychiatry' is being used by mainstream psychiatry is in a session at the International Congress of the Royal College of Psychiatrists in July this year (see full programme) entitled 'The new anti-psychiatry: Responding to novel critiques on the legitimacy of psychiatry'. The chair of the session is Rob Poole, who I have mentioned in a previous post. The speakers are Paul Salkovskis (again, see another previous post), Dariusz Galasiński (see his blog post about anti-psychiatry) and Linda Gask (see another previous post).

I'm presuming critical psychiatry is what the session calls the 'new anti-psychiatry'. I've argued in a previous post that the Power Threat Meaning Framework that Paul Salkovskis is critiquing is not anti-psychiatry. I'm not sure how new the critiques of critical psychiatry really are; nor that they challenge the legitimacy of psychiatry as such. But I guess this is what mainstream psychiatry thinks is the case, which is why they use the term 'anti-psychiatry’ in the title of the session. As I've said before, it's a pity mainstream psychiatry finds critical psychiatry so threatening (eg. see previous post and extract from chapter 1 of my edited book Critical Psychiatry). There were excesses in anti-psychiatry (see my book chapter) but critical psychiatry shouldn't continue to be tarnished by this rotten reputation.

My own proposal for the International Congress on 'Integrating critical approaches into the training of psychiatrists' was turned down. Jo Moncrieff was going to chair it and the three sessions were on (1) Integrating service user/survivor perspectives (2) Integrating transcultural psychiatry and global psychologies (see new book by Suman Fernando and Roy Moodley) and (3) Integrating critical psychiatry. Maybe the session wasn't accepted because it was seen as too anti-psychiatry. If so, perceptions do need to change about the value of critical psychiatry.

Challenging the biomedical model is not anti-psychiatry

Lisa Cosgove and Jon Jureidini have responded (see article) to a Debate article in the Australian & New Zealand Journal of Psychiatry (ANZJP) criticising the Report, which I have mentioned previously (eg. see previous post), of the United Nations Special Rapporteur on the right to health, Dainius Pūras. This report has also been criticised by the European Psychiatric Association (see previous post). The World Psychiatric Association has also criticised an associated report of Dainius on corruption and the right to health, with a special focus on mental health (see another previous post).

The Debate article is entitled 'Responding to the UN Special Rapporteur’s anti-psychiatry bias'. What it means by 'anti-psychiatry' is challenging the biomedical model and, rather remarkably, it includes the British Psychological Society (BPS) in the global anti-psychiatry movement. The Division of Clinical Psychology within the BPS has produced a valuable position statement on giving up the disease model of mental disorder (see previous post).

The Debate article usefully highlights the right to access to mental health care but seems to limit this right to access to pharmaceuticals. As Lisa and Jon point out, the article mistakenly quotes from Dainius' report saying that it "views inpatient psychiatric care as ‘inconsistent with the principle of doing no harm'" [emphasis in original]. What Dainius actually said was "Overreliance on ... in-patient treatment is inconsistent with the principle of doing no harm, as well as with human rights" [my emphasis]. Furthermore, by quoting Fountoulakis and Möller (2011),  the Debate article seems to think that it has undermined the Kirsch meta-analysis of the effectiveness of antidepressants, which is not the case (see previous post). I don't know what evidence the Debate article is referring to that leads to its conclusion "that many psychiatric presentations are effectively and quickly treated with purely biological treatments".

The term 'anti-psychiatry' has general been used by mainstream psychiatry rather than critics themselves. I don't think it's helpful to polarise debate too much but the Debate article should not use the term 'anti-psychiatry' in this sense. Challenging the biomedical model is legitimate within mainstream psychiatry (see previous post). Critical psychiatry is an advance over anti-psychiatry (see previous post) and anti-psychiatry should not be seen as having had no value (see another previous post). It's difficult to get the right balance about how oppositional to be (see previous post). Certainly dogmatic positions such as that taken by the Debate article need to be challenged.

I'm not sure where the apparent quote in the Debate article comes from about the "creeping devaluation of medicine in UK psychiatry ... [being] likened to ‘throwing the baby out with the bathwater’". As far as I know this isn't happening. In fact, although British psychiatry continues to marginalise critical psychiatry, the British Journal of Psychiatry did publish my editorial on 'Twenty years of the Critical Psychiatry Network'. Let's hope there might be more debate about critical psychiatry in Australia and New Zealand, as well as globally in general (eg. see previous post).


(With thanks to Mad in America post by Zenobia Morrill)

Sunday, March 31, 2019

Rising antidepressant prescriptions and primary care mental health

Antidepressant prescriptions dispensed in England have almost doubled since 2008 (see BBC News article). Helen Stokes-Lampard, Chair of the Royal College of GPs, has responded to this recent release of prescription data by NHS Digital (see press release). She is keen that the rising rate is not necessarily seen as a "bad thing, as research has shown they [antidepressants] can be very effective drugs when used appropriately". I'm not quite sure what she means about antidepressants being effective, as I keep emphasising in this blog that the evidence is still open to interpretation (eg. see previous post).

She suggests improvement in the identification and diagnosis of mental health conditions could help to explain the rise. GPs were traditionally found to fail to diagnose up to half of cases of depression or anxiety on initial presentation (Goldberg & Huxley, 1992). Over the longer term, this figure may not be as high or as clinically important as this initial impression may suggest. Some depressed patients are given a diagnosis at subsequent consultations or recover without a GP’s diagnosis. However, there is still a significant minority of patients (Kessler et al., 2002 found 14% in their study) with a diagnosis of persistent depression that is undetected  The failure of detection of depression is commonly presumed to arise because of a lack of psychological mindedness amongst doctors. In general, doctors value objective evidence of disease more than subjective experience. This tendency creates a bias towards the over-diagnosis of physical disease, rather than the detection of mental health problems.

Maybe GPs are now treating and referring more people with anxiety/depression to mental health services, perhaps partly encouraged by the opening up of services by the development of Improving Access to Psychological Therapies (IAPT) over the last 10 years (see graph of increasing numbers of people seen by IAPT) . The number of referrals to general adult mental health services has also increased and figures suggest the number of people seen has more than doubled since 2003, excluding IAPT referrals (see tweet).

Primary care is an essential element of the provision of mental health services and has always traditionally seen more patients with mental health problems than secondary care. Helen Stokes-Lampard complains that access to alternative treatments to medication, such as CBT and talking therapies, is " patchy across the country". She says this despite the introduction of IAPT which was supposed to bridge this gap.

I want to pick up, though, the way in which Helen Stokes-Lampard seems to dichotomise the treatment of mental health problems between medication and talking therapies. In fact, most people seen by secondary mental health services do not receive psychological therapy as such. Even within IAPT, many people do not even receive short-term therapy but instead guided self-help. Polarising treatment between medication and psychological therapy forgets that much mental health treatment is social intervention - helping people understand and recover from the problems with support and becoming as independent as they are able and capable of being. GPs used to do a lot of this work with patients, perhaps particularly when there was continuity of care in general practice. But maybe primary mental health care has become more difficult with the fragmentation and dysfunctionality within health services in general over recent years.

I'm not defending a rise in antidepressant prescribing as Helen Stokes-Lampard could be said to be doing, but I agree with her that these issues - including the role of primary care in mental health treatment - need to be discussed more widely.

Monday, March 11, 2019

Overstating the impact of psychiatric research

Medium has a new mental health publication - 'Inspire the Mind' - produced by the Stress, Psychiatry and Immunology (SPI) Lab at the Institute of Psychiatry, Psychology and Neuroscience at King’ College London led by Professor Carmine Pariante, who I have mentioned previously (eg. see previous post). It has reprinted 'Facts You Should Know About Psychiatry and Why It Is Helping the Person Next to You' from a HuffPost article, although it's dropped the reference to 29 facts we should know, I think because the booklet from the Royal College of Psychiatrists to which the original article refers no longer exists (if it was ever published). Maybe the College had second thoughts about making such 'scientific' claims (eg. see previous post).

It is important to encourage debate about the potential harm of recreational drugs and whether substitute prescribing of methadone leads to harm reduction, but Pariante seems to think it is clear that cannabis causes schizophrenia, which is not the case (see eg. previous post). Like him, I also agree the development of psychological therapies should be evidenced-based, but he doesn't describe the realities of the Improving Access to Psychological Therapies (IAPT) programme (see previous post), nor mention the evidence bias towards specific therapies, such as CBT, or even the problem of the adequacy of controls in evaluating psychological therapy (eg. see previous post). Nor am I sure where his apparently inflated figure of 80% recover for psychological therapy of panic disorder and social anxiety comes from. I doubt research is really needed to show that reducing the maximum pack size of over-the-counter sales of paracetamol, and limiting sale to one pack, reduces paracetamol overdoses (although has such research actually been done?). But Pariante needs to be more careful about making claims for the value of the National Confidential Inquiry into Suicide and Homicide in improving patient safety (eg. see previous post).

I do understand why Pariante wants to answer criticisms of psychiatry. He admits himself that the article is a "little bit of PR". But his attempt to create a positive view of psychiatry shouldn't lead to him unscientifically overstating his case.

Monday, February 18, 2019

The realities of working in IAPT

Despite me saying (eg. see previous post) that people must be more realistic about the effectiveness of Improving Access to Psychological Therapies (IAPT) and stop saying that it is a "marvellous treatment", a recent self-congratulatory event (see programme) celebrating 10 years of IAPT led to a further bout of overhype for the programme (apparently to obtain further funding - note that the Chief Executive of the NHS and the Secretary of State for Health and Social Care were both speaking). For example, Claire Murdoch, NHS England's National Mental Health Director, in a tweet to me said that she was sad that I was dismissing the "brilliant IAPT work".

I'm actually not undermining the work of IAPT. I just want IAPT therapists more recognised for the difficult work they do. Helping people is not always as straightforward as following an IAPT protocol. Luckily the natural history and spontaneous improvement of anxiety and depression over the short-term is about 50% or above, which is what the IAPT programme calls its recovery rate (see previous post). But, particularly over the long-term, it's not always easy to help people deal with their suffering, dependency and vulnerability (see another previous post). IAPT is perverting care, as Rosemary Rizq said (see her article). It shouldn't be seen as a simple programme that people just need to follow and everything will be alright, which is how Claire Murdoch's comment could be interpreted. Politicians seem prepared to invest in IAPT further, maybe to meet the so-called 'parity of esteem' target required to treat mental health services at least as well as they do physical care, even though we don't hear much now about the original reason for the programme being agreed, which was because politicians were persuaded it would take people off benefits.

David Clark (who I have mentioned before, see eg. previous post) in his blog on IAPT at 10, seems to see the only challenge for the IAPT programme as being the need for further expansion. As I said in my talk, David Clark has said that his initial research interest was in psychotropic medication not psychotherapy. He has merely succeeded in encouraging the exploitation of the placebo effect with psychological therapy in the same way as for medication. Although people on average may well prefer talking therapy to medication, let's try and be more realistic about how we develop mental health services.

Monday, January 28, 2019

Progress in mental health research

The Wellcome Trust has said it believes "a radical new approach is needed [in mental health] to drive science forward and improve people’s lives" (see its webpage). I couldn't agree more. As it says, "some underlying problems need to be addressed before the field can make significant progress ... We want to bring ... [a] sense of common purpose to mental health, with different disciplines working together to collaborate in a new super-discipline of mental health science.“

As I have said throughout this blog, the underlying problems that need to be addressed are more conceptual than empirical. There's no point (eg. see previous post) pursuing the reductionist agenda that has come to a halt (eg. see previous post). We need an organismic rather than mechanistic perspective. Psychiatric research has become too focused on speculative neurobiological notions which produce studies plagued by inconsistencies and confounders (see my BJPsych editorial). Would Wellcome be interested in funding the Institute of Critical Psychiatry?

Sunday, January 27, 2019

Critical psychiatry is not Cartesian (nor vitalist)

I want to pick up on the way people who take a reductionist view on psychiatry, such as Ed Bullmore (see previous post), accuse their critics, such as myself, of being Cartesian. René Descartes (1596-1650) was the first to apply a natural scientific mechanistic approach to life (see previous post). Animate and inanimate matter were understood 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. The split he created between mind and brain is what is referred to as Cartesianism.

One of the first to challenge this perspective was Georg Ernst Stahl (1659-1734). Living beings, including humans, have a purposiveness which cannot be derived from mere physical-chemical processes. For Stahl, the anima or soul provides what he regarded as the key element of movement to matter within the living body (motus tonicus vitalis). However limited this concept may have been by the understanding of mechanics and physiology at the time, Stahl’s 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. I have several times (eg. see previous post) emphasised how critical psychiatry integrates mind and brain. It is not Cartesian. This perspective formed the basis for Stahl having an emphasis on psychosomatic medicine, and a focus on clinical medicine rather than the physical sciences. 

Yet, Stahl took a mistakenly conceived vitalist position that reductionists deride as much as Cartesianism. Vitalism is the claim that living things possess something else - a vital entity - that is neither physical or chemical in nature. In fact, Stahl's anima was a force within the body, an explanatory agent within physiology, rather than a religious transcendent soul. But, still, Stahl conceptualised the soul as an immaterial ordering principle of movement. Despite this erroneous element in Stahl's thinking, we do need to build on his organismic perspective. 

Those that suggest that life cannot be explained in mechanical terms, as Stahl did and I do (eg. see previous post), may seem to be open to the charge of vitalism. But I'm not anti-physicalist. Biological wholes do not literally cause their parts. Nor am I suggesting that living matter has a level of organisation above the physicochemical level that makes it different ontologically. Biological processes do not have causes (such as a vital entity) outside of physicochemical terms.

Neither am I saying that living processes cannot be studied mechanically. The mechanistic conception of nature, however, fails to provide a complete characterisation of living systems (see previous post). Understanding the meaning of human action is a different kind of explanation from mechanical explanation. We explain the parts of biological wholes in functional not structural terms. Non-organic mental illness, for example, is a functional disorder and cannot be explained structurally as brain pathology (eg. see previous post)

Reductionists of course do appreciate there is a mind-body philosophical problem (eg. see previous post). They think, though, that this problem will eventually be solved (see previous post). I take the same view as Kant that the irreducibility of biology to physics is permanent. Our knowledge is limited. We conceptualise organic matter in a different way to inorganic matter. Our understanding is discursive and how living wholes cause their parts is unknowable to us. In fact, it's the discursive nature of our understanding that creates the possibility of mental illness (eg. see previous post). Summarising Kant's Critique of Judgement, we can never have theoretical knowledge that anything in nature is teleological, but such judgment is nonetheless necessary and beneficial for us. We have to accept this enigma to practise psychiatry (eg. see previous post).

Friday, December 28, 2018

More research required on withdrawal from antidepressants

Fava & Balaise (2018) in a Psychotherapy and Psychosomatics editorial comment on a failed trial (see letter) of CBT to prevent relapse after withdrawal of antidepressants in remitted anxiety disorder. Despite guidance, only 36% of patients succeeded in discontinuing antidepressants over 16 months and only 28% did not have a recurrence and there were no differences between the CBT group and controls.

As Fava & Balaise say, the trial wasn't futile as it has confirmed that:-
Withdrawal symptoms and syndromes may occur during and despite slow tapering, do not magically vanish after a couple of weeks from discontinuation and may persist for a long time, leading to postwithdrawal syndromes.
As they also say:-
.. discontinuation that is performed without medical consultation and adequate psychotherapeutic support entails substantial risks for the patient and is often bound to fail

Fava and Balaise tend to emphasise their model of oppositional tolerance, which I have said before does not convince me (see previous post). Personally I have tended to argue for the importance of psychological dependence (eg. see previous post). This does get me into trouble with the 'prescribed harm' patient community, but despite what they may think, I am not minimising their problems, which mainstream psychiatry does (eg. see previous post). As Fava & Balaise conclude:-
The time has come to initiate research on withdrawal phenomena related to AD [antidepressants], and to redefine the use and indications of these medications

Sunday, December 23, 2018

Repeal Mental Health and Mental Capacity Acts

The Independent Review of the Mental Health Act 1983 (see previous post) has produced its final report ‘Modernising the Mental Health Act: Increasing choice, reducing compulsion’. It is disappointing, as Suman Fernando says in his blog, although not surprisingly so. It gets the government ‘off the hook’ of having to do anything about the observations from the Committee on the Rights of People with Disabilities about the UK government’s response to the United Nations Convention on the Rights of Persons with Disabilities (CRPD). The proposals made for change are minimal and will do little to prevent the unacceptable, including racist and abusive, treatment of detained patients (eg. see another previous post). CRPD is being ignored by suggesting that it prevents involuntary detention, which I don’t think is the case and in fact the Independent Review concedes this. Instead current legislation should be repealed and replaced by new legislation to preserve the dignity and respect of detained patients.

Thursday, December 20, 2018

Progress in psychiatry

Peter Tyrer (who I have mentioned before, eg. see previous post) has recognised the value of critical psychiatry, however grudgingly, in his commentary on a BJPsych Advances article by Hugh Middleton & Joanna Moncrieff (also previously mentioned eg. see post). However, Tyrer thinks critical psychiatry is Luddite by hindering progress in psychiatry. Psychiatry has always had the forlorn hope that it will discover the biological basis of mental illness, and I don’t think that Tyrer has given up this wishful thinking. The examples he gives of progress in psychiatry include lithium for bipolar disorder and methylphenidate for ADHD, and these must be suspect, and even CBT for traumatic stress disorders is questionable.

I actually agree with him that critical psychiatry should be constructive. I also agree critical psychiatry’s views on psychiatric diagnosis can appear confused, but this is because there are actually different views within the critical psychiatry movement about whether psychiatric diagnosis is valid and whether mental disorder should be seen as illness (eg. see point 3 in previous post). Critical psychologists within the critical psychiatry movement, such as David Pilgrim, who Tyrer quotes, tend to be against psychiatric diagnosis. Michel Foucault, who again Tyrer mentions, actually probably wasn’t against diagnosis as such. What he was against was the positivist reduction of mental illness to brain disease (see last post). Despite what Tyrer says, incorporating positivism into psychiatry has actually made it less scientific not more (see another previous post).

Psychiatry, as well as human and life sciences in general (see previous post), need to take Kant’s explanatory anti-reductionism seriously. Kant was clear that it is absurd to expect to understand goal-directed mental disorder in physical terms. Epistemologically it’s just not possible. Consciousness is a puzzle we’d like to be able to solve but we can’t (see previous post). That doesn’t mean that we can’t study part-functions such as the brain, but we need an organismic psychiatry to treat the whole person. Such a view was present in the origins of psychiatry, such as Ernst von Feuchtersleben’s Principles of Medical Psychology (see eg. point (1) on previous post). Psychiatry needs to go back to its roots to make progress. Critical psychiatry is arguing for a positive way forward by promoting an organismic psychiatry. Psychiatry has never really been able to achieve this because of its dominant biomedical positivism.

Thursday, November 22, 2018

Was Foucault an anti-psychiatrist?

John Iliopoulos in his book History of reason in the age of madness, which I have mentioned in a previous post, has a chapter entitled ‘Is Foucault an anti-psychiatrist?’. As I said in my book chapter on ‘Historical perspectives on anti-psychiatry’, Foucault’s Madness and civilisation is included in anti-psychiatry because Foucault is said to have viewed the Enlightenment as oppressive.” Actually, I think Iliopoulos’ position is correct that Foucault was neither for or against the Enlightenment.

As Iliopoulos says, Foucault stresses he was ignorant of anti-psychiatry at the time of writing History of madness. Iliopoulos corrects the position of post-psychiatry (see previous post) that “Foucault is engaged in an anti-psychiatric endeavour using counter-Enlightenment discourse” (p.101). Instead, Foucault accepted the validity of the anthropological project of the late eighteenth century with its phenomenological diagnostic approach to madness. Where psychiatry went wrong was its positivist reduction of mental illness to brain disease in mid-nineteenth century. In Iliopoulos’ words:-
[T]he subjugated, disempowered status of current psychiatry authority and the value-laden and pseudo-scientific definition of mental illness are not the result of the infantile epistemological level of psychiatry, its axiological nature or its inherently coercive role, but the product of a new, all-encompassing rationality denying and suppressing the anthropological kernel of psychiatric discourse. (p.98)

Tuesday, November 13, 2018

Reading Foucault’s History of Madness

Jean Khalfa, in his Introduction to his edited edition of Michel Foucault’s History of Madness, says that the book “has yet to be read”. Certainly I haven’t made an attempt to read it until of late. I have been too influenced by the “cursory caricature of Foucault’s work”, to which, as Colin Gordon suggested, even Roy Porter was prone (see Gordon’s review of History of Madness). Andrew Scull’s TLS review has been particularly misleading about the value of Foucault’s work (see, again, Gordon’s response to Scull). Even R.D. Laing’s enthusiastic reader’s report (see image above) for publication of the abridged version, Madness and Civilisation, may have given the wrong impression. Gordon wonders whether Scull has really read the book and Laing’s brief report (I presume this was all he submitted), again, makes me wonder whether he even read the abridged version.

Laing was right, nonetheless, that this is “an exceptional book of very high calibre”. As Gordon says, the book “is the work of a young genius, a work of masterful accomplishment and prodigious and prodigal energy, grasp and daring”.  More needs to be made of it (see previous post).

Friday, October 19, 2018

Holding onto delusional thinking

I went to a talk yesterday by Lisa Bortolotti in the Cambridge University Psychiatry department (see tweet). This was based on her chapter in a recent book. Delusions are not necessarily un-understandable, nor always "bad for us", nor even particularly an exceptional way of thinking.

Picking up this last point from a previous post, we believe all sorts of things, partly often because there isn't clear evidence one way or another for some of the things we believe, eg. belief in God. We also live in societies where power relations can determine what we believe. In fact, following Foucault (see previous post), psychiatry had its origins in the Enlightenment with a focus on human rights, the questioning of dogmatic beliefs and the development of science, particularly social science. Reason itself now questioned the rational foundations of what is accepted as reason. Alongside reflection on the state of the human mind, alienists identified unreason and madness as an un-understandably, different state. The madman’s delusional thinking is central to this fundamental distinction between reason and unreason. Lisa Bortolotti usefully reminds us that this distinction is not really so absolute. 


All this happened before the development of our modern understanding of disease (eg. see previous post). Although there has been progress since the middle of the nineteenth century in our understanding of physical disease, the functional rather than structural nature of mental illness has been difficult to appreciate in this context. The assumption that mental illness is due to brain disease, like delusional thinking, isn’t actually based on logic, but on faith, desire and wish fulfilment (see previous post). It seems to challenge our viability as psychiatrists to believe otherwise (see another previous post). This belief seems to be held onto almost with the same intensity as delusions.

Monday, October 01, 2018

Drugs culture

The Times had a leading article last week that took up from its news article the day before. It stated that "David Baldwin, a government adviser on the use of antidepressants, has resigned after a vituperative social media campaign against him". The leading article does mention the Public Health England (PHE) review set up by the Parliamentary Under Secretary of State for Public Health and Primary Care to review the evidence for dependence on, and withdrawal from, prescribed medicines, but doesn't make clear that Baldwin has resigned from this review. He's still Chair of the Royal College of Psychiatrists' Psychopharmacology Committee.

The Times says that scientists should not attack advocates of antidepressants because antidepressants are a "gain to human wellbeing". I'm not quite sure what it means by this, because there is an ongoing debate in the academic literature about the efficacy of antidepressants (see previous post). Instead The Times has already concluded that the "evidence base is impressive".

The leading article also makes much of the difference between clinical depression and everyday moments of low mood and sadness, although this distinction is of course relative and not absolute.  Medication has in fact always been used in the history of psychiatry but what happened in the 1950s was that tricyclic antidepressants were marketed as a specific treatment (eg. see previous post). These drugs were closely related to the chemical structure of chlorpromazine, the first marketed specific neuroleptic treatment for schizophrenia. Before then drugs tended to be used in non-specific ways.

The Times does recognise the value of talking therapy as well as medication. Helping people understand their problems and deal with them psychosocially has actually always been the mainstay of psychiatric treatment. And, of course, a multitude of different psychological therapies have developed after psychoanalysis - The Times mentions principally cognitive behavioural therapy and interpersonal therapy.

The Times quotes the statement made by David Baldwin (and Wendy Burn, President of the Royal College of Psychiatrists), which led to the complaint which I signed about antidepressant discontinuation problems being minimised (see eg. previous post). But it doesn't say that the complaint was signed by 30 people, not just psychiatrists and psychologists, but also people who have experienced antidepressant discontinuation problems. Instead it misleadingly says that 10 psychiatrists and a psychologist from the PHE panel complained. I'm one of the 10 psychiatrists that the leading article is referring to, but I'm not on the PHE panel!

I also signed a subsequent letter, as I was concerned that Baldwin's conflicts of interests could compromise his work on the PHE review group. The letter suggested he should be replaced with someone who had no such conflicts of interest (see Mad in the UK post). I'm not sure whether PHE had any concern about his declaration of interests. Certainly the Royal College of Psychiatrists had no such concerns (see press release). However, there are problems with institutional corruption within the Royal College of Psychiatrists (see previous post). Our complaint was not a personal attack on Baldwin but to ensure that the issues within the PHE group are discussed in as unbiased a way as possible. I'm sorry if David Baldwin felt distressed by the concern expressed about his role on the issue of antidepressant discontinuation but he is in a responsible position in the College.

What happened was that @Truthman30 became aware of Baldwin after the joint statement with Wendy Burns. He has produced a blog since 2007 on what he calls the Seroxat Scandal. This issue is much wider than just antidepressant discontinuation problems. This includes the role of paroxetine (original trade name Seroxat) in producing suicide and violence. Personally I'm more sceptical about these claims (see eg. my review of Peter Breggin's book) but @Truthman30 regards Seroxat as perhaps one of the most dangerous drugs ever made. He knows this from his personal experience and 10 years of research for his blog.

So @Truthman30's research into David Baldwin led to posts on his blog, which he described as being about David Baldwin's "long, incestuous, and financially lucrative relationship with the Pharmaceutical industry". This is where the term "pharma-whore" mentioned by The Times was used and @Truthman30 sought to defend its use. The "worse than Hitler" label comes from a comment on the blog by kiwi (not actually anonymous as The Times news article said, although the google profile has not been completed). @Truthman30 is unhappy that Baldwin described Seroxat in 1998 (the year @Truthman30 was first prescribed it) as "one of the safest drugs ever made" because of course this is not his personal experience, nor has it been backed up by the results of his research for his blog.

As The Times says, "Inflammatory and calumnious invective is unfortunately part of online discussion on many issues." I agree that scientific research should be based on evidence and I look forward to the report that will come out of the PHE review. I would like to see more discussion in the academic literature about antidepressant efficacy and discontinuation problems (see previous post). I would also like to see more academic discussion about the issues of safety raised by @Truthman30 (even though I tend not to agree with all he says). It's important to stick to the issues. It's also a privilege to be able to discuss these issues publicly on social media and this privilege should not be compromised. I'm glad to be able to do so on my blog.

Sunday, September 30, 2018

Analysing the evidence about antidepressants and other psychiatric medication

Editorial in The Lancet Psychiatry helpfully calls for a “dispassionate analysis of the evidence” about psychiatric medication. It seems to be particularly concerned about what it calls “Hooked on happy pills” headlines that have appeared in British newspapers over recent years (see one example). 

By criticising these articles without dealing with the issues, the editorial could be taken as another example of minimising the significance of antidepressant discontinuation problems (see previous post). This issue does need to be taken seriously. 

Why doesn’t The Lancet Psychiatry commission a review of the evidence? Or more generally, why doesn’t it commission an analysis of the placebo amplification hypothesis of antidepressant efficacy (see previous post). Rather than platitudes in an editorial, it should be doing its job of analysing the evidence. There are too many issues about psychiatric medication that are being fought out in the press rather than psychiatric journals dealing with these matters scientifically.

Saturday, September 29, 2018

The wish for a biological basis for mental illness will never go away

James Davies in his book Cracked (see my review), was surprised when Robert Spitzer, chair of the DSM-III task force, said no biological markers had been identified for functional mental illness (see recent @ClinpsychLucy tweet). Spitzer understood that organic mental illness is different from functional mental illness. It was DSM-IV, led by Allen Frances, that abolished the distinction. This was a mistake (eg. see previous post).

I have mentioned in a previous post how Sami Timimi couldn’t understand why he was indoctrinated in his psychiatric training. Similarly, I remember the discussions I had with Alec Jenner, my professor of psychiatry in Sheffield (see previous post), about why people believed what they did about psychiatry. The problem is that the belief in the biological basis of functional mental illness will never go away (see my tweet in response to @ClinpsychLucy). I’m not one who hopes for a radical, new psychiatry that will replace biomedical psychiatry. But we do need to break the dominance of the biomedical model and recreate a more pluralistic psychiatry. This situation is not helped by dissolving the distinction between functional and organic mental illness, which needs to be reinstated.