Sunday, October 19, 2014

Keeping Tom Szasz's ideas alive

John Breeding is concerned about the legacy of Thomas Szasz in his article in SAGE open. He rightly emphasises Szasz's focus on "greater autonomy and higher levels of personal responsibility". As John Breeding points out, Szasz never really wanted to be a doctor. Instead he trained to be a psychoanalyst. Szasz practiced autonomous psychotherapy, although he didn't like the term 'therapy'. I understand how John Breeding as a counsellor sees that he can 'practice Szasz'.

That's fine for patients who have mental capacity. People decide to undertake psychotherapy and counselling. However, people who are psychotic may not make the most rational of decisions because of their mental illness. Society might have a role to intervene and psychiatrists manage madness on behalf of society. Psychotherapists and counsellors don't need to undertake these murky responsibilities.

Hence, using quotes from the article, Tom Szasz thought that, "A person should be deprived of liberty only if proved guilty of breaking the law". To reiterate, he said, "if the 'patient' is not a criminal, then he or she has a right to liberty; and if the patient is a criminal, then he or she ought to be restrained and punished by the criminal law, like anyone else". Essentially, Szasz didn't think society should have mental health legislation.

I suppose it could be said I'm only defending my role as a psychiatrist, but I don't agree with Szasz on this point (see previous post). He was also pretty scathing about the Critical Psychiatry Network of which I'm a founding member (see another previous post). I'm sure I could learn to be clearer in expressing my views, like him, although I do accept uncertainty and perspectives may not always be as black and white as he often argued. However, his critique of the biological basis of mental illness will survive.

(With thanks to Around the Web item on Mad in America)

Saturday, October 18, 2014

Psychiatric diagnostic uncertainty

Mary Boyle and Lucy Johnstone (@clinpsychlucy) argue for alternatives to psychiatric diagnosis in a Lancet Psychiatry comment. As I have said in an article, Mary has contributed significantly to the critique of psychiatric diagnosis. Lucy has as well, particularly in her recent A straight talking guide to psychiatric diagnosis. As I also said in my article, "The problem with biomedical diagnosis is that it potentially produces the facade that [personal] understanding has been created".

However, my article also suggested that the proposal to abandon psychiatric diagnosis is potentially misleading. Joseph Hayes and Vaughan Bell (@vaughanbell) in their comment in response to Mary and Lucy point out that formulation and diagnosis are complementary. I worry though about their inability to see the difference between functional and organic mental disorders (eg. see previous post). I do think that DSM has been so overtaken by biomedical assumptions that it should be abandoned (eg. see another previous post). But, as I said in response to Peter Kinderman's new book (see post), psychiatric diagnosis needs to be recognised for what it is. Peter essentially agrees with Mary and Lucy. The process of psychiatric assessment is primarily psychosocial not biomedical.

Tuesday, October 14, 2014

One million pageviews

According to Blogger statistics, this blog has now had more than one million pageviews. Is this correct? And why is this post the most popular, with getting on for a quarter of a million pageviews?

Wednesday, October 08, 2014

"Something is wrong with my mood"

Yesterday was Bipolar UK's third annual national bipolar awareness day. What Bipolar UK is concerned about is that people may have to wait an average of 13 years for diagnosis (see press release for the first bipolar awareness day in 2012).

On the same day, Anne Cooke tweeted to remind us of the BPS document Understanding bipolar disorder. I also received an email from the National Institute for Health and Care Excellence (NICE) with the publication details of the update for the Bipolar disorder clinical guideline (see full guideline).

Bipolar UK changed its name from the Manic Depression Fellowship in 2011. I wish it hadn't. Since the term manic-depression was changed to bipolar in DSM-III in 1980, the concept has become so broad that its validity must be in question (eg. see previous post). Some may want to question the validity of any psychiatric diagnosis (eg. see another previous post). However, I think there is some meaning in the original concept of manic-depression, which goes back to Emil Kraepelin. This condition was recognised previously, for example, by Falret in 1851 as la folie circulaire. Mania was a psychotic diagnosis and its lesser form, hypomania, was seen as an indication that a person could be on the verge of developing a full-blown mania. The change to bipolar has allowed the inclusion of non-psychotic presentations. In particular, bipolar II only requires episodes of hypomania. Asking people with depression whether they have had episodes of being 'high' may uncover non-clinical such episodes and may not be a very rigorous way of deciding whether someone has had true hypomania. Such people may well not have been psychotic.

Furthermore, recognising the continuity with normal mood variation has encouraged a 'softer' version of bipolar spectrum. Almost anyone with a history of mood swings or instability can be seen as being on the spectrum. It may be important to note that NICE emphasises that, "The clinical utility of these proposed ['softer'] diagnoses has yet to be established and there is currently no indication whether treatment is necessary or effective". We shouldn't be using mood stabilisers for bipolar spectrum.

After all, the development of mood stabilising medication must have been a factor in promoting the bipolar concept (see previous post). We may well look for simple solutions to our emotional problems. To quote from Goodwin & Malhi (2007), "Put simply, the term mood stabilizer sounds comforting and may reflect our fond and perhaps somewhat naive hopes." Mental tranquility may sound attractive when feeling volatile.

Strong feelings derive from one's circumstances. Abnormal emotional states are likely to arise from the difficult situations we find ourselves in. 'Peace of mind' may not always be that easy to find.

Friday, September 26, 2014

From reductionism to hermeneutics

Pat Bracken in an article in World Psychiatry says psychiatry is in trouble and needs to move from reductionism to hermeneutics. He builds on the 'Bracken manfesto' paper (see previous post), as named by Peter Kinderman (eg. see another previous post), that the problem is the technological paradigm which dominates psychiatry. As Pat says, "Hermeneutics is based on the idea that the meaning of any particular experience can only be grasped through an understanding of the context (including the temporal context) in which a person lives and through which that particular experience has significance." Most medicine and surgery is concerned with the natural order, whilst psychiatry is mostly concerned with the human order.

Mario Maj in an editorial argues that the Bracken manifesto has gone too far in rejecting the technical aspects of care. He can't be as sceptical about the value of psychiatric medication or even that non-psychiatric medication could be just as ineffective (see previous post). He raises the spectres of the Italian reforms following the introduction of law 180 and the concept of the 'schizophrenogenic mother' to boost his argument of the dangers of a non-technical approach. However, evaluation of the influence of Franco Basaglia has been controversial. It is also obviously wrong and naive to blame families for causing schizophrenia. However, the problem with the reaction against the 'schizophrenogenic mother' idea is that it has undermined further legitimate family studies of schizophrenia. Maj also sees early intervention to reduce duration of untreated psychosis as a benefit of the technical approach without mentioning the critique of the early intervention approach (eg. see Jo Moncrieff's book The bitterest pills). Nor is it clear, as Maj suggests, that a non-technical understanding of psychiatric diagnosis necessarily leads to the abandonment of any attempt at classification (see previous post).

Still, it's good that there has been some mainstream response to the Bracken manifesto, rather than just ignoring it.

Wednesday, September 24, 2014

Controversy in psychiatry

A Lancet Psychiatry editorial argues for compromise in debates about mental health issues. I do agree that "the opportunities for global discussion on blogs and social media [shouldn't be] ... squandered". However, it is important, if there is going to be any change in mental health services, that the critical psychiatry position is stated explicitly.

The danger of accommodating all perspectives is that what is being said becomes "intellectually empty" and "ethically blind". This was the verdict, for example, of Andrew Scull on Meyerian psychobiology in his book Madhouse about Henry Cotton, whose programme of radical surgery led to significant mutilation and death by removing parts of the bodies of patients to eliminate what Cotton thought were focal infections believed to be the cause of mental illness. Meyer seemed unable to acknowledge the damage Cotton caused, instead writing a favourable obituary, suggesting he had "an extraordinary record of achievement". When Cotton was alive, Meyer suppressed a report of the poor outcome of Cotton's work in the forlorn hope he could persuade Cotton to accept the reality of his results.

I have indicated several times in this blog that Meyer's theoretical position was not dissimilar from critical psychiatry. However, his compromising position meant that he did not follow through on his challenge to biomedical psychiatry. I quote in my article from a heartfelt note written in the early hours of the morning a few years before he died, where he questions whether he "pussyfoot[ed] too much". He wished he had made himself "clear and in outspoken opposition, instead of a mild semblance of harmony" [his emphasis]. I would actually like mainstream psychiatry to engage more with critical psychiatry, rather than marginalising it.

Tuesday, September 23, 2014

Reducing numbers of psychiatrists in community mental health teams

Following up previous posts (What place for diagnosis in mental health care? and Responsible clinicians under the Mental Health Act) on Peter Kinderman's new book A prescription for psychiatry, I want to comment on a central theme of the book about replacing psychiatrists with GPs. I'm not necessarily against this suggestion. Too many psychiatrists are too biomedically orientated and may as well be replaced by GPs with a more psychosocial orientation. What GPs want from a mental health service is good assessment and management of their patients with mental health problems. Peter is clear that mental health care should reject the notion that it is (or should be) 'treating illnesses'. He would go along with the view of some mainstream psychiatrists, responding to what they see as the threat to their professional role (eg. see previous post), that psychiatry should focus its efforts on what it sees as the medical aspects of healthcare, specifically biological aspects of mental healthcare. Less psychiatrists may well be needed to do this.

I know what Peter means when he suggests mental health problems are not illnesses. This blog has often enough emphasised the lack of biomarkers for mental illness. Nineteenth century medicine developed because of its anatomoclinical understanding of disease. Just how misguided to expect the same advances in psychiatry is demonstrated by the awarding of the Nobel Prize in Physiology or Medicine to Wagner-Jauregg for malarial treatment of dementia paralytica and Moniz for leucotomy, and the nomination for the same prize of Sakel for insulin coma therapy, von Meduna for shock therapy with metrazol and Cerletti for ECT treatment of schizophrenia and manic-depressive illness. Have these really been the main advances in psychiatry?

I am happy to use the terms 'mental health problems' and 'mental disorder'. And, I am less worried about using the term 'mental illness' than Peter. In fact, I go along with Bill Fulford in Moral theory and medical practice that medicine is primarily an ethical activity. In that sense, psychiatry is the pre-eminent medical speciality. Many people go to their doctor with physical complaints whose origins are psychosocial. Peter doesn't mention this issue in his book. In Germany, for example, psychosomatic medicine has developed as a separate speciality. There may not be that much advantage in me having a medical training for much of my work as a psychiatrist, but at least I do understand psychiatric problems in their medical context. I'm certainly not advocating neuropsychiatry as the solution to the commonly identified crisis in the role of a psychiatrist (eg. see book review). What's needed is a more patient-centred approach to medicine in general. Peter's prescription for psychiatry may provoke this response. But encouraging psychiatrists to be neuropsychiatrists is not the right way to do it. This is a central theme of what Peter calls the 'Bracken manifesto' (see previous post). And clinical psychologists and other mental health professionals do need psychosomatic understanding to be complete practitioners.

Monday, September 22, 2014

Responsible clinicians under the Mental Health Act

As I said in my previous post, I have been reading Peter Kinderman's new book, A prescription for psychiatry. He suggests that, "In time, I believe it should be routine for the 'responsible clinician' [under the Mental Health Act] to be a psychologist or social worker". He makes an interesting reference to discussions on New Ways of Working in which he was involved on behalf of the British Psychological Society. He objected to a phrase, which did not appear in the final report, about the "clinical primacy of the consultant [psychiatrist] in dealing with treatment resistant, acute, severe or dangerous clinical situations". Peter does not agree with the concept of 'clinical primacy'. However, if it does have any meaning, it may arise because generally consultant psychiatrists, not psychologists or social workers, undertake the responsible clinician role.

I've commented before on this issue (see previous post) in relation to an eletter by Sam Thomson and Peter in response to what Peter calls in his book the 'Bracken Manifesto'. Clinical psychologists have been split about whether they should take on the role of responsible clinician. Peter quotes from David Smail, who unfortunately recently died (see tweet), who thought that it was good that "the only power we have [as clinical psychologists] is power of persuasion". Peter thinks what's more important is the "markedly different framework of knowledge and skills" of clinical psychologists, rather than their "historical absence of formal power" under the Mental Health Act.

I would have liked to have seen more discussion of this issue in Peter's book. Would Peter go as far as suggesting that recommendations for detention under the Mental Health Act should not be restricted to doctors? I think the logic of his position suggests he would.

Tuesday, September 16, 2014

What place for diagnosis in mental health care?

I have been reading Peter Kinderman's (see previous post) new book A prescription for psychiatry. Peter is very clear that "there is no place for medical diagnosis in mental health care". He suggests this is "a challenging assumption" and "may sound revolutionary". He even recognises it "may go against decades of accepted wisdom in psychiatric circles".

I'm not sure how many decades Peter wants to go back! The publication of DSM-III in 1980 marked a return to medical diagnosis in Peter's sense. However, he might have been happier with Karl Menninger's The vital balance published in 1963, which represented a pragmatic consensus, at least in American psychiatry. And going back even further, Adolf Meyer, regarded as the dean of American psychiatry in the first half the 20th century, developed psychobiology which has parallels with Peter's psychobiosocial approach. As Menninger put it, "As a result of his efforts ..., American psychiatrists began to ask, not "What is the name of this affiction?" but rather, "How is this man reacting and to what?"". DSM-III replaced the Meyerian approach to diagnosis, which it saw as too woolly.

Meyer said of the American Medico-Psychological Association's (1918) Statistical manual for the use of institutions for the insane, "I have no use for the essentially 'one person, one disease' view". He went further and suggested that "... statistics published ... are a dead loss ... and an annual ceremony misdirecting the interests of staff". Susan Lamb has described Meyer's psychiatric development from neuropathologist to psychobiologist (see previous post).

For my position on diagnosis, you might want to look at the slides from my presentation 'Some aspects of the moral basis of diagnosis: The challenge of Meyer's psychobiology'. My views are:-
(1) Psychiatry should not abandon diagnosis but recognise it for what it is
(2) Psychiatry should not be panicked by the unreliability of psychiatric diagnosis
(3) Psychiatry should avoid the reification of diagnostic concepts
I think this is a similar but more subtle, maybe, manifesto than Peter's.

Friday, August 29, 2014


Soteria Network (UK): AGM and Open Forum
Saturday, 20 September 2014 11 am – 4 pm, Manchester
Promoting the development of drug-free and minimum medication therapeutic support for people experiencing 'psychosis' or extreme states
Part of an international movement of service users, survivors, activists, carers and professionals fighting for more humane, non-coercive mental health services

Please come and join us at our Annual General Meeting and open Forum event for a day filled with the sharing and exchanging of ideas, knowledge and discoveries, the exploration of opportunities, and inspiration for new initiatives.

We will begin the day reporting on the activities of Soteria Network over the past year, our aspirations as we move forward; our financial position and the election of trustees.

The afternoon will be dedicated to Soteria groups, speakers, and poetry. There will be time for you to ask questions, participate in discussions and share your experiences throughout the day.

We are pleased to announce that we will be launching our new website at the event and, premiering a short film we have made, interviewing Peter Stastny (INTAR founder) on his time and recollections of Loren Mosher. Loren opened the first ever Soteria House*; the man who is the inspiration and reason all Soteria-related organisations exist.

This event is free of charge and open to all.
Complimentary lunch and refreshments will be provided
Further information, including how to book a place at the event is coming soon!

*Soteria House began life in 1971 as an experimental research project in America which was designed to see whether people experiencing a ‘first episode’ acute psychosis, who might otherwise be diagnosed with schizophrenia and treated with medication in hospital, might fare just as well in a house with minimum medication, but with maximum support
Soteria Network (UK) Registered Charity number:1146183

Saturday, August 23, 2014

Psychiatric coercion

I've been re-reading one of Thomas Szasz's last papers (see previous post) in which he is quite scathing about the Critical Psychiatry Network (CPN). He says "The CPN's position is not psychiatric criticism, it is a plea for prettifying the psychiatric plantations." The choice of the word 'plantation' is deliberate, as what he wants to do is unshackle "the psychiatric slave from his psychiatric master". He suggests Dorothea Dix soothed American families and communities "with the fiction that her proposed psychiatric plantations would make the slaves healthy and happy".

Such rhetoric may increase the force of his argument that the "psychiatric critic's primary duty is, and always has been, to reject the legal-political legitimacy of the use of psychiatric force and fraud". However, I'm not trying to abolish psychiatry, which Szasz makes clear was his aim. I'm not justifying torture as treatment and can distinguish coercion from torture. Torture does involve coercion but not all coercion involves the infliction of pain. Torture is a type of coercion and ethical practice in psychiatry avoids it.

Monday, August 18, 2014

Explaining neuroscientific basis of mental disorder

I've just tweeted the link to Peter Kinderman's recent post on Mad in America. Peter may overuse the term "distress" from my point of view, as I think people can be mentally disordered without necessarily experiencing it as distress. However, I look forward to the publication of his book. He explains far better than me what I have been going on about all these years with critical psychiatry. To quote from him:-
Some neuroscientists have asserted that all emotional distress can ultimately be explained in terms of the functioning of our neural synapses and their neurotransmitter signallers. But this logic applies to all human behaviour and every human emotion – falling in love, declaring war, solving Fermat’s last theorem. It clearly doesn’t differentiate between distress – explained as a product of chemical ‘imbalances’ – and ‘normal’ emotions.
Why should the way we explain mental illness be any different from our normal emotions? Why should there even be a different neural substrate? Peter seems to think this idea might be catching on. I do hope so.

Sunday, July 13, 2014

A historical perspective on academic psychiatry in Sheffield

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

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

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

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


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

Thursday, July 10, 2014

Death of founding editor of Asylum Magazine announced

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

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

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

Saturday, July 05, 2014

The americanisation of critical psychiatry

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

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

Saturday, June 21, 2014

The sense in saying antidepressants don't work

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

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

Monday, June 09, 2014

The benefit-to-harm ratio of antidepressants

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

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

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

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

Thursday, June 05, 2014

Finnish psychologist sacked after expressing critical views about antidepressants on TV

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

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


(With thanks to Jeremy Wallace)

Sunday, June 01, 2014

Psychiatry for a new generation

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

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

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

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

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

Wednesday, May 21, 2014

Human rights and mental health worldwide

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

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

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

Friday, May 16, 2014

Don't be tricked into taking antidepressants

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

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

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

Saturday, May 10, 2014

Still depressed even though treated for bipolar

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

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

Wednesday, April 02, 2014

Removing psychotropic drugs from the market

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

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

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

(With thanks to Olga Runciman)

Tuesday, March 11, 2014

Educating people about the brain is a good thing

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

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

Monday, March 10, 2014

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

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

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

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

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

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

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

Saturday, March 08, 2014

Do mood stabilisers treat mood instability?

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

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

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

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

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

Friday, March 07, 2014

Pharma pipeline for schizophrenia

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

Targacept

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

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


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

Sunday, March 02, 2014

Onward Christian soldiers

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

Sunday, February 23, 2014

Misdirecting mental health research

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

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

(With thanks to Peter Kinderman)

Saturday, February 08, 2014

Overemphasis on the importance of psychiatric diagnosis

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

Monday, January 06, 2014

Share your story about coming off antipsychotics

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

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

Sunday, December 15, 2013

Getting psychiatry to see the blindingly obvious

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