Wednesday, May 11, 2016

Antidepressants can cause psychological dependence

Robert Whitaker (who I have mentioned previously eg. see previous post) has posted on the Mad in America blog about the All party parliamentary group for prescribed drug dependence. He includes a link to his slides for his presentation to the group on "Causation, not just correlation: Increased disability in the age of Prozac". The meeting to which he gave this presentation today is a product of the book Cracked: Why psychiatry is doing more harm than good (see my review), which led to the Council for evidenced-based psychiatry (CEP).

There is no doubt that psychotropic medication can lead to psychological dependence. Since my BMJ letter, I have emphasised psychological aspects of antidepressant discontinuation problems (see eg. my Antidepressant discontinuation problems webpage and my book chapter "Why were doctors so slow to recognise antidepressant discontinuation problems?).

As I have also said previously (eg. see post), Robert Whitaker, in his original books Anatomy of an epidemic and Mad in america, has emphasised the vulnerability created by taking psychotropic medication. He may have implied this is more of a physical problem than I think is the case. In his current presentation he mentions the idea of drug-induced oppositional tolerance which comes from Giovanna Fava, which I am not convinced is valid (see previous post). But the correlations Whitaker points to still stand without postulating a biological explanation for why psychiatric drugs may have harmful long-term effects. I think CEP would do better to emphasise the psychological aspects of prescribed drug dependence.

In fact, the problem is not necessarily specific to medication at all. Medicine has always tended to create dependency. This critique of medicine is not new and was famously expounded by Ivan Illich in Limits to medicine (see Jo Moncrieff's recent blog on this classic book). I wouldn't want to go as far as Illich in suggesting there is no need for professional services and that "do it yourself" care is preferable. But there is an onus on doctors to provide proper expert advice and as a society we may well need less medicine not more (see eg. post on my personal blog). 

Saturday, April 23, 2016

Patient safety measures will be associated with suicide reduction when rates are falling

The latest paper from the National Confidential Inquiry into Suicide and Homicide (NCISH) published in The Lancet Psychiatry starts from the hypothesis that implementation of service changes associated with improvements in patient safety have led to a reduction in the rate of suicide. It manages to show an association of about 20-30% reduction in suicide between 1997-2012 with 16 policies and procedures that relate to ward safety (eg. removing non-collapsible curtain rails), availability of community services (eg. implementing a Crisis Resolution and Home Treatment team within community health services), staff training (eg. training clinical staff in suicide risk management), adoption of specific policies (eg. policy regarding response to inpatients who abscond), and adoption of The National Institute for Health and Care Excellence (NICE) guidelines (eg. NICE depression guidelines). An accompanying comment paper hails this finding as a success for clinical governance.

But what if this 20-30% reduction in suicides in the clinical population happened for other reasons rather than anything to do with these 16 service changes? The fact that the incidence rate ratio was very similar for all 16 policies could be said to support this inference of lack of causal effect. The article notes that the incidence rate ratios were higher for the general population than for the patient population in the study, but the patient population in mental health services has also changed over recent years, with probably more minor cases being referred.

Although the paper does acknowledge that this "study was observational therefore we cannot make causal inferences", I can't find any specific mention of the fact that suicide rates were falling during the period under study. If the same study had been done during a period of rising suicide rates, the service changes would have been associated with an increase rather than decrease in suicide. And by writing that "service delivery variables are associated with suicide rates", the paper, as does the comment paper, leads people to think that a causal connection is being inferred, which is what the original hypotheses was. But the study isn't a hypothesis testing paradigm, as the paper notes, because the use of "randomised controlled designs for this research would be extremely challenging".

NCISH seems to have a habit of using data to justify its own prejudices (see previous post). Whatever happened to the principle of scientific scepticism? And how does a paper like this get through The Lancet Psychiatry peer review process?

The gap between neural circuits and understanding people

A new Personal View in The Lancet Psychiatry goes overboard trying to create a taxonomy of brain circuit dysfunctions in depression and anxiety. It suggests 6 neural circuits have been implicated, viz. default mode, salience, negative affect, positive affect, attention and cognitive control:-
Accepting such circuits have been established, eight biotypes of circuit dysfunction in depression and anxiety are then suggested, viz. rumination, anxious avoidance, negative bias, threat dysregulation, anhedonia, context insensitivity, inattention and cognitive dyscontrol:-
It's even suggested how neural circuits might relate to treatments:-

I think what's being proposed is that the precision psychiatry of the future will identify apparent brain circuitry dysfunction and treat on this basis. I guess it won't need to interview patients. The article is certainly a tour de force of imagination, but does it relate to the real world?

As I keep saying, mental function is not well localised in the brain and I'm not sure we've really identified any more localisation of function through identifying the so-called brain circuits mentioned in the article, even if they are valid. As I said in a previous post, "It's a long step to mapping specific mental illnesses to dysfunction of brain circuits". The article suggests that people like me that believe that mental disorders are not brain disorders, which the article concedes is the typical view, have a "limited understanding of real-time coordination in the brain”. I don't think this is the case and the article at least recognises that a lot of money has been spent through the RDoC project (see previous post), the White House's Brain Initiative and DSM-5 (see eg. previous post) to prove me wrong without success. 

The language about brain circuits cannot be incorporated into clinically meaningful taxonomies because, although mental phenomena have a biological substrate, that substrate cannot tell us the meaning of mental phenomena. The psychiatry of the future will still have to interview patients to get them to tell their story. We can't see that in a brain circuit.

Monday, April 18, 2016

Does cannabis cause psychosis?

An article in Biological Psychiatry reviews evidence about the association between cannabis use and psychotic outcomes. Despite the consistent association, the article highlights how difficult it is to infer a causal link because of confounding and bias in the data.

As I said in my BMJ letter, the use of cannabis can cause emotional problems and people may use it to deal with their emotional problems. Cannabis use is likely to be a proxy measure for poor premorbid adjustment associated with psychosis. As the article says, "few studies have adjusted for measures of early life attachment, abuse, and trauma".

Bias may also be introduced as heavy users of cannabis may be rarely unintoxicated, leading to misdiagnosis of the induced psychotic-like experiences, which are usually transient in less heavy users. There is some evidence of a dose-response relationship between cannabis and psychotic diagnosis.

There is also an association between other drugs and psychosis and mixed data about whether the association with cannabis is more specific. Despite the increase in the use of cannabis since the 1960s there is no clear evidence of a corresponding increase in the incidence of psychosis. Cannabis exposure among adolescents and young people is common and psychosis remains rare.

Despite highlighting the methodological difficulties of making causal inferences from observational studies, the article suddenly jumps to the conclusion that, "There is no doubt that a public health message that cannabis use is harmful is appropriate". This leads to today's Guardian editorial saying that what it calls the "small risk of a dreadful outcome", ie. psychotic breakdowns that "smash up lives and can lead to full-blown schizophrenia", is something "well worth a proper public health campaign".

Of course cannabis can cause harm, as can alcohol. But, as the article points out, it is important to have the facts right for any public health campaign to be effective. The causal link between cannabis and psychosis has not been proven.

Saturday, April 09, 2016

Psychosis can be organic in origin

I have been struggling with a post by Vaughan Bell @vaughanbell on the Mind Hacks blog. He suggests that critical mental health writings implicitly demean people with brain disorders, but I don't think they do.

He gives four quotes to support his argument. However, they don't seem to support it. In fact, the first two aren't about brain disorders. The other two mention organic brain problems but are not demeaning of people with these problems. If you don't believe me, look for more detail about these quotes in the appendix to this post.

Essentially, Vaughan Bell does not want to make too sharp a distinction between mental health problems and brain diseases. He thinks critical mental health supporters do this because having a brain disease is demeaning. This is totally missing the point. This isn't the reason for the argument that functional mental illness is not brain disease. In fact, Bell himself acknowledges that there is "no evidence for consistent causal factors". But he goes on to speculate that these factors will be found in the same way as they have for organic brain disease.

Where Bell might have a point is that supporters of the critical mental health approach do not always explicitly state that psychosis can be organic in origin. He uses the example of the BPS report Understanding psychosis, which he says doesn't discuss organic psychosis, although I have already pointed out that, despite its strengths, there are deficiencies with this report (see previous post). To be clear, people can have psychotic symptoms in a toxic confusional state (delirium) and with dementia, such as Alzheimer's disease.

But not being explicit that psychosis can have an organic cause is not the same as being demeaning about people with brain disease. Functional mental health problems are fundamentally social and psychological. It's as important to combat the stigma of organic brain disease as mental health problems.

Attempts have been made to undermine the critical mental health argument by accusations of attacking a 'straw man' (see Guardian article and my response). It seems opponents of critical mental health are not immune to using this form of argument.

Appendix to above

This post has been made as an appendix to the above post. I'm looking in more detail at the quotes Vaughan Bell used to try and justify his argument that critical mental health demeans people with organic brain disease.

The first quote is from Kinderman et al:-
such approaches, by introducing the language of ‘disorder’, undermine a humane response by implying that these experiences indicate an underlying defect
Here the authors of the quote are arguing that mental health problems should not be seen as disorders or pathologised, as they are better seen as understandable responses to difficult circumstances. I do understand what the authors are saying but I have commented before that such a way of viewing mental health problems may be potentially misleading (eg. see previous post). Generally the implication of identifying a mental health problem is that the person's reaction has been maladaptive. This is why the person has gone for help.

Although there is this debate about whether mental health problems should be seen as illness or disorder within the critical mental health movement, I don't see how this quote supports Bell's argument that people with brain disorders are being demeaned by a critical mental health approach. The quote is not talking about people with brain disorders - in fact, it's saying that mental health problems are not brain disorders.

The second quote that Vaughan Bell gives is from Mary Boyle:-
The idea of schizophrenia as a brain disorder might offer further comfort by distancing ‘normal’ from disturbing people. It may do this by placing disturbing people in a separate category and by suggesting uncommon process to account for their behaviour…
Bell seems to have problems with the idea of "distancing". What Mary means is that reducing mental health problems to brain disease may be a way of protecting others from the pain the person is experiencing. Surely this is correct. Again, this quote isn't about people with brain disease.

The third quote is from Lucy Johnstone:-
The fifth category… consists people suffering from conditions of definitely physical origin… where psychiatric symptoms turn out to be indications of an underlying organic disease… medical science has very little to offer most victims of head injury or dementia, since there is no known cure…
Here, Lucy is talking about people with brain disorders. What she is saying is correct that medicine in the literal sense can't cure organic disease. What she goes on to say, which isn't quoted, is that behavioural and social interventions are what is needed. Again, this is correct and isn't being demeaning of people with organic brain disorders.

The final quote is from Doing psychiatry wrong:-
To be sure, these brain diseases significantly affect mental status, causing depression, psychosis, and dementia, particularly in the latter stages of the illness. But Andreasen asks us to believe that these neurological disorders are “mental illnesses” in the same way that anxiety, depression, bipolar disorder, and schizophrenia­ are mental illnesses. This kind of thinking starts us sliding down a slippery slope, blurring distinctions that must be maintained if we are to learn more about why people are anxious, depressed, have severe mood swings, and lose contact with reality.
This quote is saying there is a difference between organic psychosis and functional mental illness, which is correct (eg. see previous post). Again, this isn't demeaning of people with organic brain disorders.

Friday, April 01, 2016

What does it mean to say that psychotherapy is a biological treatment?

BJPsych editorial this month argues that the target of psychotherapy, like pharmacotherapy, is diseased neural functioning. It does recognise that the method of delivery of these said neurobiological changes is different, with pharmacotherapy seemingly working through chemical changes and psychotherapy through the patient-therapist relationship. It starts from the assumption that the brain disease model of mental illness is valid and therefore tries to justify psychotherapy as a treatment by viewing it as biological like pharmacotherapy.

I've commented before on such neuromania (see previous post). Raymond Tallis uses this term 'neuromania', which he critiques, in his book Aping mankind. People do seem to be taken in by such nonsense which is neo-phrenological phantasy (see another previous post).

The problem is that the disease model of mental illness is not valid. Mental phenomena are meaningful. Of course this doesn't mean that mental phenomena don't have a biological substrate. But neuroscience can't tell us anything about the meaning of that biological substrate. If there has been any advance in neurobiology over recent years, it is in recognising the dynamic nature of the brain. Brain cytoarchitecture is fashioned by the social environment but this should lead to an integrated understanding of mind and brain, not promotion of the brain disease model of mental illness.

To suggest that psychotherapy might correct neural functioning presumes that we know what the abnormality was in the first place. However, we don't know the neurobiological basis of mental illness because the abnormality is functional rather than structural. Mental function is not well localised in the brain. In the nineteenth century phrenology attempted to map mental functions onto the outside of the head. This may seem ridiculous now but neuroimaging provides no better explanations. We knew about the limbic system, prefrontal cortex and reticular activating system, for example, before neuroimaging. To suggest that psychotherapy is a biological treatment is counterintuitively stupid not clever. The mind-body problem can't be solved by calling it a myth.

Tuesday, March 29, 2016

Psychiatry is still biomedical, even if not "narrowly biomedical"

Simon Wessely in a Guardian article says that psychiatry does not recognise the narrow biomedical way in which it is sometimes portrayed. Despite what he says, some psychiatrists are narrowly biomedical (see extract from my book chapter). However, I do agree that most psychiatrists are generally more pragmatic.

It's interesting that Simon is an acolyte of Anthony Clare, whose book Psychiatry in dissent was written to create a consensus after the anti-psychiatry debate of the 1960-70s. Clare wanted to avoid psychiatrists having to adopt a model of mental illness (eg. see previous post). This led to the common claim, which I suspect Simon would support, that psychiatrists adopt a biopsychosocial approach to practice (eg. see another previous post).

The problem is that even though most psychiatrists are not narrowly biomedical, they are still biomedical (see my edited book Critical psychiatry). They generally believe that mental illness, at least major mental illness, such as schizophrenia and bipolar I disorder, is due to brain abnormalities, even though the evidence is against this conjecture. It's about time a president of the Royal College of Psychiatrists addressed this issue rather than avoiding and deflecting it, but I don't think Simon will.

Saturday, March 26, 2016

How do we know that IAPT outcomes are not just expectancy effects?

It's some time since I commented on IAPT - Improving Access to Psychological Therapies, now often called Wellbeing Services (eg. see previous post). I've just looked at a recent lecture from David Clark (see video). He's still making claims about outcomes based on lack of comparative data. How do we know that so-called recoveries in the IAPT programme are not due to the placebo effect or spontaneous improvement?

For example, in the lecture Clark makes much of the changes in Buckinghamshire Healthy Minds following a review of notes of the unrecovered patients to identify themes and recurrent patterns in the data (see powerpoint presentation). National figures are that 46% of people are said to recover and a further 15% improve. These are average figures and there is considerable variability by Clinical Commissioning Groups (CCGs). Buckinghamshire was below 50% and by telling staff to increase recovery rates to 65%, lo and behold they did! Isn't this just a Hawthorne effect?

There's a lot of money invested in IAPT so I'm sure Clark doesn't want to think about whether IAPT therapists are mere placebologists. There will always be a problem with assessing the effectiveness of psychotherapy because of the issue of the adequacy of control groups (eg. see my BMJ letter). Psychotherapy trials cannot be conducted double-blind because subjects always know whether they have received the therapy under investigation or a control intervention.

Saturday, March 05, 2016

My baby, psychosis and me

Much of the focus on the two documentaries in the recent BBC In the Mind series has been on the Stephen Fry programme The not so secret life of the manic depressive: Ten years on (see previous post).  The other documentary My baby, psychosis and me was a realistic portrayal of the treatment of two women with puerperal psychosis in a specialised mother and baby unit. One woman, Hannah, made a suicide attempt and was treated with ECT, although the actual treatment was not shown. The other woman, Jenny, was transferred to an intensive care unit, but the treatment there was again not shown. Even the husband was advised not to visit her there.

I have praised the In the Mind series (see previous post as mentioned) for showing what is happening in mental health services. It is important though that the 'sharp end' of psychiatry is not separated off and made invisible.

Definition of sociopsychobiological model of mental illness

I deliberately used the term "sociopsychobiological" in my previous post. This was to try and reverse the eclectic understanding of the biopsychosocial model of mental illness. I do agree with the biopsychosocial model of George Engel (eg. see previous post). But psychiatrists often claim they are biopsychosocial when in fact they are merely supporting a weaker form of the biomedical model (see extract from my last chapter of Critical Psychiatry (2006)).

Promoting the sociopsychobiological approach to mental health

I have been thinking about the motivation of well over 1000 signatories of an open letter to the Director General of the BBC about its coverage of issues on mental health (see previous post). Essentially the complaint is that there is insufficient focus on a sociopsychobiological rather than a biomedical understanding of mental illness. As the signatories to the letter note, this is not primarily a matter of disciplinary conflict. Psychiatrists, such as myself, promote a sociopsychobiological approach. However, the majority of the signatories to the letter are from clinical psychology. I think their anger must express frustration about the dominance of the biomedical model in modern practice. Psychiatry, rather than clinical psychology, may well be the more powerful discipline in this ideological dispute.

Where does this disciplinary power come from? Part of it may be related to the respective roles of psychiatrists and clinical psychologists under the Mental Health Act. Detention under the Mental Health Act requires two medical recommendations. Although clinical psychologists can be Responsible Clinicians, in practice this is not common (see previous post). As I understand it, the British Psychological Society is not prepared to intervene on the issue of whether clinical psychologists who undertake the role of Responsible Clinicians should be paid more like psychiatrists. Perhaps it should to help even out any power disparity.

Sunday, February 21, 2016

What does it mean to say that Stephen Fry's diagnosis has been changed from cyclothymia to bipolar I?

In the recent documentary, The not so secret life of the manic depressive: 10 years on, (see previous post), Stephen Fry's psychiatrist changes his diagnosis from cyclothymia to bipolar I. The implication seem to be that Fry's problems, which may have previously been put down to his personality, are now seen as being due to a real mental illness, whatever that is. 

Does this make any sense? Psychiatric formulation should be about more than a single word diagnosis (see previous post). This doesn't always happen in practice (see another previous post) and patients often complain that psychiatrists don't listen to their story and are just interested in "the diagnosis" and medication. I have also mentioned before my concern about how the diagnosis of bipolar disorder has expanded over recent years (see eg. another previous post), so that its meaning is less clear. Maybe Stephen Fry should resist the extension of his diagnosis. 

The programme makes a distinction between Stephen Fry's symptoms, which tend to be internal to himself, and the presentation of Alika (see his story), which led to him being detained under the Mental Health Act in a manic state. By the way, Alika recovered from this episode, whereas Fry still talks about the problems he has with his "mood swings". Maybe it's better not to classify Fry's presentation in the same way as Alika's, which is what the change to bipolar I might imply. 

Whether Stephen Fry's diagnosis is better understood as cyclothymia or bipolar I, the psychological formulation of his problems in terms of aetiology is still the same. In a way, the single-word diagnosis is the less important part of a formulation. It's only a word used to try and pigeon-hole his difficulties. It doesn't really help him to make sense of them.

Complaining about the dominance of the biomedical model

There have been complaints about the coverage of mental health problems in the recent BBC series In the mind (see open letter). This is because of the lack of challenge to the idea that mental health problems are necessarily manifestations of biological illness. For example, Richard Bentall has also published his open letter to Stephen Fry, who presented the keynote documentary in the series, The not so secret life of the manic depressive: Ten years on. The other main documentary was My baby, psychosis and me. 

This blog has been written to critique the biomedical way of understanding mental health problems. So, you might think I would want to join the list of complainants about the programmes. However, I do not think the Stephen Fry programme explicitly stated that mental health problems are distinct brain conditions. True, psychiatrists are featured in the programme who almost certainly hold that view and the programme did not question this. But I think the programmes were designed to show what's happening in mental health services and, to my mind, the two documentaries did that. However much I wish it wasn't the case, the biomedical view of mental illness is clearly dominant in current practice. Furthermore, the publication of my edited book Critical psychiatry: The limits of madness was intended to try to move beyond the polarisation in the debate about mental illness. I just think that complaining about the programmes is not the most constructive way forward and, in a way, misses the point. 

After all, the documentaries clearly allowed the patients, including Stephen Fry, to explain their perspectives. In particular, I thought the story of Alika Agidi-Jeffs (see clipwas very positive. I also thought Stephen Fry was very brave to talk about the Ugandan incident and the association of his suicide attempt with the stigma of his homosexuality. The complainants believe that patients are experts in their own condition and should be allowed to express their views, so at this level they should welcome the programmes, even if the patients in the programmes themselves may not totally agree with their views. But we shouldn't be surprised by that if they have been treated in a biomedical way.

At one point in the Stephen Fry film, the voiceover said that with her early diagnosis, Cordelia, one of the patients who featured in the programme, knew why she had mood swings. Actually, there's a sense in which just having a diagnostic label like bipolar didn't really help her to understand the reasons for her problems. As I've pointed out in a previous post, the evidence is that patients are ambivalent about a diagnosis of bipolar disorder. A biomedical diagnosis doesn't give a psychological formulation of people's problems, leaving them feeling they haven't really got an explanation. The voiceover in the programme actually in a way acknowledges this by saying that having the diagnosis hasn't helped Cordelia to live with her mood swings.

At another point, the voiceover also says that there is no guarantee of another patient's, Scott's, condition easing. I just wonder if that might be too pessimistic a prognosis. One of the problems with biomedical diagnosis is that it can encourage the sense that one does not have agency to deal with one's problems. Scott's treatment seems to have been primarily medication. It is possible he might have done better with a more psychological approach. 

I think we should applaud Stephen Fry in trying to improve understanding of mental illness in his role as President of Mind. I would encourage him to do even more in this respect by promoting a psychological perspective. Of course it can be difficult to understand why we have the mental health problems that we do. But that shouldn't stop us trying to make sense of them. There was little attempt to do that in the two documentaries. 

Sunday, February 07, 2016

Abandon the notion of mental illness as a distinct, genetic brain disease

Jim van Os makes a case for abandoning the term "schizophrenia" because of its association with suggestions that it is a distinct, genetic brain disease (see BMJ article). He suggests that no such language is associated with other categories of psychotic illness, but I'm not sure this is right, because bipolar disorder may be seen in this way. Van Os also points out that research publications on psychosis tend to concentrate on schizophrenia, although again, I think he probably underestimates the extent of the literature on bipolar disorder. He suggests removing the term "schizophrenia" from psychiatric classifications and recognising the existence of the broad and heterogeneous psychosis spectrum syndrome.

I've previously pointed out (see post) that psychosis has already tended to replace schizophrenia in everyday clinical practice. However, as I've also said, psychiatrists do tend to believe that psychosis is a brain disease (see previous post). I'm all for abandoning the notion of "schizophrenia" if it leads to mental illness not being seen as a brain disease. I agree that language does matter (see another previous post), but what's more important is to change conceptual understanding.

Saturday, January 09, 2016

Now it's mainstream to be critical of MRI brain studies

Daniel Weinberger (who I have mentioned in a previous post) & Eugenia Radulescu (2015) have produced a note of caution about MRI brain scanning in psychiatry. They suggest they are starting a critical perspective on the interpretation of such results. I suppose what's new is that this critique has come from mainstream researchers, who themselves have made claims about brain abnormalities associated with mental illness from such studies. Still, mainstream support for critical psychiatry is welcome. Some adapted quotes from the article in a tweet.

(With thanks to In the News item on Mad in America)

Wednesday, December 16, 2015

Psychiatric interviewing

I have mentioned Susan Lamb before (see eg. previous post). Her most recent article picks up Adolf Meyer's use of the term 'the new psychiatry' (although I don't think he used this phrase that often). Meyer emphasised the importance of history taking and mental state examination rather than neurobiology. To quote from the Meyer reference that Susan gives in the article, "Today it is far more necessary that a physician should learn to cope with the psychic data than even with the anatomy of the cortex." Meyer didn't always express himself that clearly, but what he meant should be apparent and it's still the same today. Psychiatrists need the skill of psychiatric interviewing even more than neurobiological understanding. This isn't always apparent from the way psychiatrists approach their work.

The best Notes on eliciting and recording clinical information were drawn up in a pamphlet by the Teaching Committee at the Institute of Psychiatry and published in 1973. They were used for ensuring a fairly uniform style and layout for recording clinical data throughout the Maudsley and Bethlem Royal Hospitals. These were disseminated throughout the country and I'm glad I was introduced to them in my first placement in psychiatry in Cambridge. It's difficult these days to obtain a copy of this guidance. The copy I currently have was withdrawn from the library of the Kings College School of Medicine and Dentistry, which includes the Institute, as too out of date to be kept on the shelves. But clinical interviewing hasn't really moved on and this edition is clear and concise.

As the pamphlet says, "A high standard of clinical recording is a hallmark of good medical practice and is nowhere more important than in psychiatry". More attention is paid to psychological and social phenomena than in a general medical examination. The interview itself serves as the psychiatrist's main tool of investigation.

Introduction of the anatomoclinical method in medicine in the nineteenth century led to the association of bedside observations of patients with autopsy findings of pathological lesions in organs and tissues. Pathology emerged as a distinct discipline. Microscopic studies established cellular abnormalities for disease and it was generally assumed there would be a histological basis for psychopathology. It was eventually established that dementia paralytica was a late consequence of syphilis. Senile dementia was also seen as having a physical cause such as Alzheimer's disease. 

However, most psychopathology is functional, in the sense that there are no structural abnormalities in the brain. Taking a pragmatic approach, as Susan says, Meyer still used the anatomoclinical method to study psychopathology "functionally in experiences and social interactions" and "not organically, at the level of tissues or cells". This new vision of the clinical skill of psychiatric interviewing made Meyer the dean of American psychiatry in the first half of the twentieth century. 

We need a new "new psychiatry" to help us move on from modern concepts of mental illness as chemical imbalance or some other abnormality in the brain (see previous post). Psychological formulation is a way forward (see previous post), although psychosocial assessment is more embedded in psychiatry than it may often appear in current practice.

Saturday, November 28, 2015

Is 'psychosis' a substitute for 'schizophrenia'?

Huw Green in his article in Social Theory & Health mentions that Mary Boyle reluctantly adopts the word 'psychosis' as a substitute for 'schizophrenia' in order to discuss the topic of psychiatric diagnosis she has chosen to address. He uses this situation to reinforce his view that talk about psychiatric diagnosis is inevitably a form of communication. I have similarly criticised Mary for attempting to abandon psychiatric diagnosis completely (see my article). Psychiatric diagnosis needs to be recognised for what it is - an attempt to describe psychological states. It is, therefore, related to unobservables and not describable in a natural scientific sense. There will inevitably be limitations in the application of psychiatric diagnosis, whatever way symptoms and signs are grouped and conceptualised. Psychiatric practice needs to acknowledge this state of uncertainty. The concepts of mental illness do not need to be abandoned for this reason alone.

It's not surprising, therefore, that Mary reintroduces a notion of psychosis, however much she may think that the concept of schizophrenia is unscientific. But, neither is psychosis an absolute concept. Even the BPS attempt to explain psychosis and schizophrenia in everyday language still uses the terms (see previous post). The usefulness or validity of terms like 'psychosis' and 'schizophrenia' may depend on the ability to identify certain patterns between different patient presentations (see another previous post).

For example, the experience of hearing voices can be a dissociative symptom. This situation may have been used as a rather superficial argument for the abandonment of the diagnosis of schizophrenia but it does create a category of 'dissociative voice hearing'. As Green says, if the new catgory provides "more clinical information than the DSM, there is a chance that [it] will be adopted and applied instead, or even incorporated into that manual". Dissociation, in fact, does feature as a category already in DSM, including dissociative identity disorder (see changes made in DSM-5). It's a weakness of the BPS report, mentioned above, that it makes no attempt to discuss the difference between psychosis/schizophrenia and dissociation. The point I'm making is that it is a meaningful discussion to have and we do need to have words to communicate about it.

As Green concludes, "no psychiatric language is able to 'do justice' to the particulars of any given case". However, it serves a function in giving rise to a general form of pragmatic knowledge. DSM-5 has failed in its attempt to move from symptom-based diagnoses to aetiologically-based diagnoses using the latest advances from neurosciences and genetics (see previous post). We need to make the most of this failure (which should have been predicted anyway) to have a better diagnostic understanding of terms like psychosis and schizophrenia, if they have any meaning at all (see another previous post).

Simplistic notion of antidepressants correcting chemical imbalance in the brain is publically untenable

Jeffrey Lacasse and Jonathan Leo have published an update (see new article) on their article from 10 years ago on drug company advertisements about antidepressants correcting serotonin levels in the brain. As they say, "Some advertisements were more tentative or clever in their wording than others, but it seemed obvious that the drug companies were at least pushing the boundaries" of the scientific evidence. What they've found from data collected in 2014/5 is that the simplistic narrative of chemical imbalance is no longer widespread. Drugs tend to be advertised as "affecting" neurotransmitters rather than normalising transmitter levels. There are still problematic advertisements but the language has been moderated substantially.

I don't think we should necessarily be taken in by this change. Although simplistic notions of biochemical imbalance may no longer be publically tenable or displayed in advertisements, I'm not sure if practising psychiatrists really care that the theory is wrong. In fact, they probably still think that antidepressants correct a chemical imbalance, even if it hasn't definitely been shown in research (eg. see previous post). They like to think antidepressants work in practice, so there must be some reason why they work. So, even if the academic evidence isn't there for 'chemical imbalance', psychiatrists still function as though it justifies their clinical practice. In fact, they may still indicate this to patients. Few psychiatrists tell patients that even in the clinical trials the difference between placebo and active treatment is small. Any difference was called 'clinically insignificant', at least as regards reducing depressive symptoms, by NICE in a previous version of its depression guideline (see my BMJ eletter). There are also a substantial number of patients that do not improve in the clinical trials. Antidepressants are not always as effective as psychiatrists may make out to patients.

Psychiatrists use the chemical imbalance theory as a means of persuading patients to take their medication (see another eletter). The role of psychiatry is to give hope to depressed people. It is also to be honest with them about the cause of their problems and the appropriate treatment. Patients are able to understand that the 'chemical imbalance theory' has only ever been a theory. What they find more difficult to appreciate is why they are told that this theory has been proven, when this is clearly not the case.

Wednesday, November 25, 2015

Uncertainty about the value of Ritalin for ADHD

A comprehensive systematic review has been published in the Cochrane Library of the benefits and harms of methylphenidate (Ritalin) for children and adolescents with attention deficit hyperactivity disorder (ADHD) (see enhanced article). All 185 trials included were assessed to be at high risk of bias. It was possible for people in the trials to know which treatment the children were taking, the reporting of the results was not complete in many trials and for some outcomes the results varied across trials. The authors concluded that the low quality of the underpinning evidence meant they could not be certain of the magnitude of any effects on teacher-reported ADHD symptoms and general behaviour and parent-reported quality of life of the children. The most common adverse events were sleep problems and decreased appetite. To quote from the conclusion, "At the moment, the quality of the available evidence means that we cannot say for sure whether taking methylphenidate will improve the lives of children and adolescents with ADHD".

Saturday, November 14, 2015

Are early intervention services beneficial?

Ghio et al (2015) have published a survey of attitudes of mental health workers towards early interventions in psychiatry. They admit the results may be biased towards a more favourable opinion because the survey was distributed to participants at conferences in Italy on this topic, and these people might have been motivated by specific interests. Overall, professionals seem to have a positive attitude towards early interventions in psychiatry, with perceived outcomes in areas like reducing the severity of long-term social consequences and the disease itself and avoiding chronicity.

As I said in my review of Jo Moncrieff's book The bitterest pills, Jo has provided one of the best summary critiques of early intervention in psychosis (chapter 10 of the book). Duration of untreated psychosis (DUP) is associated with poorer outcome but this was never a new finding as it has always been recognised than more acute onset of psychosis has a better outcome. Despite the attractiveness of early intervention services (EIS), the danger is that they may actually lead to over-treatment.

Whatever the advantages of intensive treatment for reducing readmission, there is little evidence that the underlying psychotic disease process is fundamentally modified by EIS. Two trials of EIS in Copenhagen and Aarhus County, Denmark and Lambeth, London did not specifically examine whether starting anti-psychotic medication early improves outcomes. Nonetheless, drug companies exploit the situation by encouraging early prescribing.

The early intervention approach becomes even more controversial when attempts may be made to bring people into treatment even before they have become psychotic, with the intended aim of reducing DUP even further. Thankfully, psychosis risk syndrome was specifically excluded from DSM-5 for lack of validity and insufficient evidence that early intervention in the so-called prodrome is effective (see previous post).

When I first trained, more people were probably admitted to hospital than now with a first episode of psychosis. However, there was no necessary rush to start anti-psychotic medication. Instead patients may have been assessed drug free for a week, to ensure that the primary diagnosis was psychosis. Overmedicating people with anti-psychotics may create unnecessary dependency and is not good practice.

Thursday, November 12, 2015

Asking the wrong questions about psychiatry

Stephan et al (2015) in two papers in The Lancet Psychiatry entitled 'Charting the landscape of priority problems in psychiatry' (Part I: Classification and diagnosis and Part II: Pathogenesis and aetiology) begin from the fact that "few, if any, breakthroughs in basic scientific research have led to substantive improvements in psychiatric clinical practice". They are right to conclude from this situation that there is a need for refocusing of research agendas in psychiatry.

However, they then start from the wrong premise. They still want to "endow psychiatry with a mechanistic, neuroscientifically informed basis”.  They, therefore, produce a list of 17 problems for psychiatry, created by asking an international group of scientists and clinicians to state what they perceive as “the single most important problem or hypothesis" that needs to be addressed to meet this objective.

How long will it take for psychiatry to realise that its very nature is that it has "major conceptual and practical challenges"? It's no good expecting research to bypass this situation.

Psychiatric diagnoses are simply categories justified by clinical utility. Their value-laden nature are not a sign of scientific deficiency but of their meaningful nature. Mental disorders are not natural kinds and there are inevitably fuzzy boundaries between different syndromes. Psychiatry needs to avoid the reification of diagnostic concepts.

As far as aetiology is concerned, genes set the boundaries of the possible but environments define the actual nature of mental disorder. The human brain is socially constructed in the literal sense that brain cytoarchitecture itself is fashioned by input from the social environment. Minds are enabled but not reducible to brains.

As I keep saying, please do not misunderstand me. Of course mental states map onto the brain. But the localisation of function to structure in the brain is not a new problem. Psychiatry can still be practiced even though there is a mind-brain problem. There's no need to create 17 pseudo-problems to solve by research before progress can be made.

Friday, October 09, 2015

Fixing the brain is not the new world for psychiatry

Joe Herbert starts well in his article on Aeon Why we can't treat mental illness by fixing the brain?. He explains that although we have some understanding of how a brain neurone is activated and how this activation is passed on to another neurone, we do not know the answer to the wider question of "how a collection of neurons makes a thought, a memory, a decision, an emotion". As he says, "The problem of relating events at the level of neurons with the known functions of the brain is a critical one." There is a "mysterious and seemingly unfathomable gap" between psychology and neuroscience, which "bedevils not only psychiatry, but all attempts to understand the meaning of humanity".

Herbert recognises within psychiatry that there is "no evidence at all that the levels of serotonin or noradrenaline in the brains of depressed people are any different from normal". As he says, "a pathologist looking at the brain of a depressed person could not distinguish it from the brain of someone who was mentally well".

This is all well and good. But then he goes on to spoil the article by speculating that "one day, someone, somewhere will make the critical step, or steps, and we will enter a new world of psychiatry". The advance would be one "that can relate what psychiatrists see in their patients to what can be seen in the brain".

I suppose such wishful thinking can be used to justify the research of his Cambridge Centre for Brain Repair. However, there's no need to wait, and I think we'll be waiting forever, for some new breakthrough at a cellular, chemical or 'systems' level. The problem is conceptual and philosophical, not scientific in that sense. Mental health problems can be treated psychosocially now. It's misleading to suggest that the way forward is by moving psychiatry to neurology (see eg. previous post).

Sunday, September 13, 2015

Hokum is not fine by me

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

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

Wednesday, September 09, 2015

Reconsidering psychiatry

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

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

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

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

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

Tuesday, September 01, 2015

Adolf Meyer's legacy

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

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

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

Monday, August 31, 2015

Italian critical psychiatry

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

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

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

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

Wednesday, August 05, 2015

Modern psychiatry's disgrace

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

Saturday, August 01, 2015

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

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

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

Tuesday, July 28, 2015

Smokescreen about the origins of psychosis

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

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

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

Tuesday, July 21, 2015

Patient-centred psychiatry

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

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

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

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

Sunday, July 05, 2015

Need to integrate mental and brain activities

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

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

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

Saturday, July 04, 2015

Biopsychosocial formulation

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

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