Mad studies and critical/relational psychiatry

I’ve mentioned before the chapter written by key members involved in the foundation of the Critical Psychiatry Network (see previous post). The book for which it was written has now been published: Mad Studies Reader, edited by Brad Lewis (who has written a guest post for this blog) et al. My chapter with Ameil Joseph in Mat Savelli et al’s edited book highlights how mad studies, critical psychiatry, anti-psychiatry, and decolonizing activism contribute to mental health education and transformation.

Do antidepressants cause emotional numbing?

George Dawson (mentioned eg. in a previous post) and Ronald Pies (also mentioned eg. in another previous post) argue in a Psychiatric Times article that antidepressants do not work by numbing emotions. They wrote the article to counter the claim by Joanna Moncrieff and Mark Horowitz, members of the Critical Psychiatry Network (CPN), that one of the pharmacological actions of antidepressants is emotional numbness and that is how they “work”. This hypothesis builds on Jo’s differentiation of a disease-centred and drug-centred understanding of the mechanism of drug action (see previous post). Psychiatric drugs do not necessarily work because they are correcting a disease process (disease-centred model) but because they have drug effects that may be useful in managing the illness (drug-centred model). Emotional numbing is hypothesised to be of benefit when using antidepressants for depression. 

Also being a member of CPN, I have some concerns about Jo and Mark’s claim. I accept that emotional numbing is a common side effect of antidepressants, particularly in long-term use. I don’t think it’s usually a very immediate consequence of taking antidepressants, for example within the short-term (often about 6 weeks) clinical trials that are used to make claims about the effectiveness of antidepressants. So, I don't quite see how emotional numbing can explain any significant difference between antidepressant and placebo demonstrated in these trials over the short-term. 

But over the longer-term, people often complain that antidepressants seem to have stopped them really dealing with their problems and complain of a flattening of emotional responses which includes feelings of being ‘dulled’, ‘numbed’, ‘flattened’ or completely ‘blocked’, as well as descriptions of feeling ‘blank’ and ‘flat’, affecting their relationships with others and how they see themselves (see previous post). If antidepressants have seemed to help, even if more because of a placebo effect than true antidepressant action, then it's not surprising that people may feel that a physical rather than psychosocial approach to their depression has not really helped. They may express that as emotional numbness and not being in touch with their feelings. They might even still have the same underlying personal and social reasons that led to their depression, which haven't really been dealt with, as such, by mere taking of an antidepressant.

The trouble is that there is only a limited literature about emotional numbing caused by antidepressants that does not allow proper assessment of its significance and mechanism. One study that is commonly quoted is Goodwin at al (2017). They found that emotional blunting is reported by about half of people on antidepressants and is correlated with their depression score ie. a poorer quality of remission is associated with more blunting. However, the screening method used a leading question ‘To what extent have you been experien­cing emotional effects of your antidepressant?’, and followed this up with an explanation that ‘emotional effects vary, but may include, for example, feeling emotionally "numbed" or "blunted" in some way; lacking positive emotions or negative emotions; feeling detached from the world around you; or "just not caring" about things that you used to care about’. Those that gave a positive response were asked to complete a fuller questionnaire about emotional blunting. 

As the paper admits, the data is very much affected by subjective factors. People were guided by the methods used in the study into essentially having a wide understanding of the meaning of emotional numbness or blunting. I tend to think what's meant by emotional numbing is more to do with people feeling antidepressants are masking the real problem and thereby preventing them having their full range of experiences, rather than a direct physiological effect of the drug. Jo and Mark disagree with me about this, but I'm not convinced they've got the evidence for their view. People commonly, at least initially and maybe over time if they can sustain having stopped the antidepressant despite withdrawal symptoms, say that they feel more alive and in touch with their feelings after stopping the drug. That may not be surprising, as there must be relief, at least, that they do not have to take the antidepressant. There must also be a sense that emotions are no longer being controlled by the antidepressant. Trouble is that it's not always very easy stopping antidepressants, perhaps particularly if they were started when there didn't seem to be much alternative and the person has been misled into thinking that there must have been something wrong with their brain. This means that they get stuck in a vicious cycle of wanting to stop antidepressants but fear relapse and withdrawal symptoms if they've previously experienced them. Withdrawal symptoms are very common (see eg. previous post).

It worries me how the notion that antidepressants work by emotional numbing seems to be catching on, perhaps particularly with patients. As I've said, I'm not convinced there's the evidence for the hypothesis. As I've commonly said, I tend to think antidepressants are no better than placebo (see eg. previous post). That doesn't mean that I think they're inert. In fact, the reason I think antidepressants are no better than placebo is because I think the significant difference between antidepressant and placebo found in short term trials may be a methodological artefact. This arises, for example, because trials are not as double-blind as is commonly assumed. Trial participants may well be able to break the blind in randomised controlled trials because of side effects, so I'm not saying antidepressants are inert.

But I do worry that critics of biomedical psychiatry may be creating another myth, like the serotonin hypothesis, that antidepressants work by emotional numbing. In fact, because I don't think antidepressants probably work any better than placebo, in a way I'm saying they don't "work". There's no need, therefore, to even have an explanation of how they "work"! That's not meant to undermine the people that feel that antidepressants have helped (see eg. another previous post) but the limitations of medication do need to be acknowledged. The trouble is that mainstream psychiatry is committed to supporting the use of antidepressants because they are seen as effective.

Fearless speaking about psychiatry

John Heaton has been mentioned in this blog before (eg. in a guest post by Miles Clapham). John wrote a chapter in my edited Critical psychiatry book. He used the Greek notion of parrhesia from Foucault to help explain that critical psychiatry is a practice that states frankly what one thinks about the nature of persons and psychiatry. 

In the Fall Term of 1983, Foucault gave 6 lectures in English at the University of California in Berkeley as part of a seminar entitled ‘Discourse and Truth’ devoted to the study of parrhesia. These were taped recorded and edited by Joseph Pearson and published as Fearless Speech (2001). The general objective of the seminar was to construct a genealogy of the critical attitude in Western philosophy. 

The parrhesiates is someone who uses parrhesia and opens their heart and mind completely to other people through their discourse. The parrhestiastes makes clear they are expressing their own opinion by using the most direct words and expression they can find to express what they actually believe. In a positive sense, they are telling the truth because they know it is true. They are saying something dangerous because it is different from what the majority believe. They expose themselves to harm as the truth may cause hurt or anger but they prefer to be a truth-teller rather than being false to themselves. Parrhesia is therefore a form of criticism from a less powerful position than the one with whom the parrhestiastes speak. 

Parrhesia may become a problem of truth if it is seen as mere frankness in speaking when everyone is equally entitled to give their own opinion. It actually has a relation to knowledge and education. Bad, immoral or ignorant speakers may endanger democratic organisations. Saying what people want to hear avoids the necessity of being critical and the need to attempt to change people’s understanding and will. Parrhesia, in the positive sense, is, therefore, a virtuous personal attitude and quality to speak the truth boldly. 

I’ve commonly said that psychiatry is more like a faith than a science (eg. see previous post). That implies it is not true that primary mental illness is brain disease. Challenging the claim that primary mental illness is brain disease, as does critical/relational psychiatry, is not denying the reality of mental illness. It is a necessary challenge to the power of psychiatry speaking from the position of the parrhesiastes (see recent post ‘Truth-telling in psychiatry’ on my personal blog).

The definition of critical psychiatry

I mentioned before my interview with Awais Aftab (see previous post), which has now been published as a chapter in his edited book Conversations in critical psychiatry. Awais has added an introductory chapter to the interviews he has collected in the book. In that chapter he quotes my comment that “critical psychiatry may be difficult to define precisely” and suggests that the most specific use of the term is merely to make reference to psychiatrists, such as myself, associated with the Critical Psychiatry Network (CPN) (see eg. previous post). This suggestion fails to take account of my further comment that CPN takes an ideological position that primary mental illness cannot be reduced to brain disease. There is a range of views within CPN, true, but it coalesces round a systematic collection of ideas (see eg. previous post) and seeks to move on from the reductionism and positivism of much of modern psychiatry. 

Awais tries to be open to critical perspectives in psychiatry (eg. see previous post), but he is not as explicitly ideological in his position as CPN. The trouble is that he is inclined to see what he calls the integrative tradition as continuous with the critical. He wants to see integrative and critical pluralism as a variant of critical psychiatry. I’m very much in favour of an integrative and pluralistic perspective in psychiatry but this is based on CPN’s ideological position about the nature of psychiatry and the uncertainty in the field, rather than wanting to hold on to the possibility of biomedical perspectives, as does Awais.

As Robin Murray says in his foreword to the book, Awais suggests critical and integrative pluralism as a corrective to what he calls the lack of self-criticism of critical psychiatry. I’m not so convinced that critical psychiatry is lacking in self-criticism. It's more Awais saying he can't accept at least part of its critique. True, there are those within the critical psychiatry movement that want to abolish psychiatry but actually, as Awais acknowledges, members of CPN are psychiatrists themselves. As he says, “They fundamentally see critical psychiatry as a form of psychiatry”. They are open to different perspectives and take a reflexive position in their critique.

Awais is correct that “The folk judgements of 'something has gone wrong’ [in mental illness] might or might not be indicative of failure of a psychological or neurobiological mechanism to perform its ‘natural’ function”. But Awais suggests critical psychiatry creates “various binaries that sort psychiatric conditions into diseases versus problems of living, biologically caused vs representing self-directed behaviours, and illnesses vs understandable reactions to circumstances”. I agree with him that there is a form of critical psychiatry that does that. But it need not, nor do I, as a member of the Critical Psychiatry Network, so therefore representing 'critical psychiatry', at least part of it, in his sense. Those that do, as Awais notes, can be called neo-Szaszian critical psychiatrists.  Critical psychiatry does not need to be neo-Szaszian. I have always emphasised how it needs to be integrated with the mainstream (see eg. previous post). Awais should take on board, as I say in my interview, that "most presentations to psychiatrists do not have an underlying physical cause, even if that is presumed still to be discovered". Psychiatry came out of its previous phase of brain mythology in the 19th century by recognising the structural/functional distinction of mental illness at the beginning of the 20th century (see eg. previous post). Over recent years this distinction has been fudged, if not obliterated (see eg. another previous post). The point is though that psychiatry must stop reducing people to their brains (see eg. yet another previous post).

Awais is clear that he thinks it is plausible that psychiatric medications “act on mechanisms that produce, sustain, and modify symptoms”. I agree with his emphasis on outcome-based prescribing (see eg. previous post). But he is not sufficiently critical of the notion of whether medication “works” (see eg. previous post). He speculates that it “is likely that psychiatric medications act on symptom mechanisms while also producing global psychoactive effects”. He doesn’t want to consider that any effect of psychiatric medication may be primarily due to the placebo effect (see eg. previous post). 

In the same way that Anthony Clare did for a previous generation by emphasising psychiatry's eclecticism (see eg. previous post), mainstream psychiatry seems to be defending itself against the message of critical/relational psychiatry by promoting integrative and critical pluralism. The publication of Awais' book is welcome. The trouble is that although it engages with the critique of psychiatry, it does not properly take its message on board because psychiatry does not want to change. However difficult it may be to hear the critique of critical/relational psychiatry, it does need to be stated boldly in the interests of patients (see eg. another previous post). Otherwise, psychiatry will merely continue to defend and maintain its biologism.

Do antidepressants cause manic switch?

As I said in a previous post, some critics of psychotropic medication do not always seem to apply the same rigorous scepticism to side effects as they do to treatment effects of medication. For example, in my review of Peter Breggin's (2001) The Anti-Depressant Fact Book: What Your Doctor Won't Tell You About Prozac, Zoloft, Paxil, Celexa, and Luvox, I expressed concern that people were being misled about the side effects of antidepressants. One of these controversial areas was whether antidepressants can cause people to shift to manic symptoms, potentially leading to a diagnostic transition from unipolar depression to bipolar disorder. 

Ironically, mainstream psychiatry also tends to believe in a causal relationship between antidepressants and manic switch (see eg. previous post). Current guidelines do not recommend using antidepressants in first-line treatment for acute bipolar depression, at last partly because of the risk of manic switch (see recent American Journal of Psychiatry editorial). Even so, generally the evidence for antidepressant induced mania has been seen as uncertain.

Rhode et al (2024) used data from a Danish health register to compare the occurrence of mania and bipolar depression in the year after discharge from a psychiatric ward of bipolar depressed patients who either received antidepressants or did not. There was no statistically significant association between treatment with an antidepressant and the risk of mania in the full sample, nor in the subsample concomitantly treated with a mood-stabilizing agent, nor in the subsample not treated with a mood-stabilizing agent. Neither was there any statistically significant association between treatment with an antidepressant and bipolar depression recurrence. This study may add to those questioning whether the risk of manic switch is overblown.

Another recent study (Tondo et al, 2024) found that about 6.7% of patients initially diagnosed as unipolar depression followed over a period of a mean of 12.7 years had their diagnosis changed to bipolar disorder, mostly type II (76.7%) rather than type I. This conversion rate may not be as high as expected, considering the fears of manic switch. 

Moreover the way in which the concept of bipolar disorder has expanded over recent years (see eg. previous post), in association with the introduction of mood-stabilising medication (see eg. another previous post), highlights how malleable psychiatric diagnosis is. There is a legitimate issue about what bipolarity means when it has become such an all embracing term, essentially amounting to mood instability, which of course is very common and not always necessarily best described as a mental disorder (see eg. yet another previous post). The mechanism of manic switch is unclear, and psychogenic, rather than physiological factors, may be significant. A sceptical approach to interpreting the inconsistent evidence is required. Manic switch is a risk in the use of antidepressants but how significant this is and whether it is physically caused remains uncertain.

Do people want to hear the message of critical/relational psychiatry?

I said in a previous post that mainstream psychiatry ignores critical psychiatry and I seem to have been wasting my time trying to get my message across in this blog. I have subsequently changed the name of this blog from critical psychiatry to relational psychiatry (see another previous post), partly in case the term 'critical', which tends to have negative connotations, is what puts people off. But it does seem to be the content of the message that people do not want to hear, rather than necessarily the way it's expressed. I'm not convinced psychiatry is really interested in relational psychiatry either. Why is that?

People not wanting to hear the message of critical/relational psychiatry may seem surprising to some, because isn't psychiatry primarily about relationships with people, as the term ‘relational psychiatry’ implies? Surely it's about trying to support them with their difficulties in their personal situation and relationships with others through an independent professional relationship. Is psychiatry then not really about helping people?

Well, yes and no seems to be the answer! Psychiatry does think it is helping people but not apparently necessarily through relationships with them. The focus tends to be on treating their brain problem. Psychiatry believes people's psychosocial difficulties may well be correctable by some physical intervention, such as prescribing medication, or by a simple, brief psychological course of therapy. The person will then be alright, or at least better with that treatment. Is there any more to it?

That’s the positive component to psychiatry's answer, is it? But what about the negative? What's wrong with just accepting this mainstream psychiatric view? However much of a caricature of psychiatry I'm presenting, it does seem to describe the essence of what people think psychiatry is expecting them to believe. No need to wrap it up in an academic critique of psychiatry called critical/relational psychiatry. Just express it in plain terms. That's not to deny that mainstream psychiatry certainly seems to suit some people. If that's all that's needed, all well and good. Keep things simple. That's fine for them at least, maybe!

But is that generally what people want from mental health services? Most people know their problems are more complex. They might hope they can be made simple and corrected easily. But generally, when they think about it, they may well be prepared to admit to themselves that might be wishful thinking. It might well take time and effort to recover from personal difficulties. And anyway, by reducing people's complex emotional difficulties and personal situation to a brain problem, hasn't the essence been lost of trying to understand why they are thinking, feeling and behaving in the unhealthy way they are? Ok, there might be a brain problem behind it. But for the vast majority of presentations to mental health health services, that is not the case.

So, what’s the point of encouraging people to believe that there is a brain problem? There are several reasons for this. As I’ve already said, it’s simpler to reduce the complexity of mental illness to brain disease. Understanding the relationship between mind and brain is difficult. For example, do we think and feel and do things because of our brains? We certainly need a brain to be alive. When we’re dead, it’s definitely not working! But then neither are our other bodily organs. We need a body to be alive. The brain is certainly an important part of that body to create the people we are. To some extent our human functioning is localised in specific parts of the brain, but actually not as well localised as people often think. The brain functions very much as a whole, despite all the attempts in research over the years to localise mental illness within it. Certainly mental illness shows through the brain but not necessarily in particular places within it. Nonetheless it’s attractive to think that mental illness may be localisable within the brain. We then don’t need to bother about what it means to be alive and can avoid having to deal with difficult abstract concepts like the nature of mental illness. Troublesome ethical debates about what psychiatry needs to do to manage such problems can then be short-circuited.

Another advantage of reducing mental illness to brain disease is that it makes mental illness more like physical illness. We can then follow the same kind of physical approach as the rest of medicine, which seems to have been remarkably successful in finding treatments for our various illnesses. Although, in practice, we may often overestimate how successful medical treatments are, it’s seductive to think that psychological medicine may be able to utilise the same scientific principles as the rest of medicine. Any differences between mental illness and other illnesses can, therefore, be minimised, if not obliterated. All well and good! As well as simplifying the conceptual issues, we now have a technological solution to mental illness following the same methods in psychiatry as the rest of medicine.  However much people may be fearful of mental illness, and want to exclude disturbed people from society, psychiatry has provided a way to give itself professional respectability in its dealings with them by making it more like the rest of medicine.

By adopting the same principles as the rest of medicine, psychiatry then creates another apparent advantage. It now needs a massive research industry, with considerable funding behind it, to find the so-called 'answer' to mental illness. It doesn’t matter that people are being reduced to their brains by seeing their mental health problems as being in the brain. It’s anyway more commonsensical, surely after all, to think that people are driven by their brains. There must be a need for neurobiological research to understand what’s gone wrong when people become mentally ill. Psychiatry's now avoided complex conceptual issues, found that it can follow medical methods and technologies, and just needs to invest more in research to make progress.  Psychiatry has created a firm edifice and foundation to provide care for mentally ill people, or has it? The problem is that it may suit us to think solutions are just round the corner but meanwhile there are still a significant number of people with mental health problems that need help, and we’re being distracted from dealing with what matters by seeking unattainable solutions in the future.

Biomedical psychiatry has, therefore, created a remarkably successful economic model. No wonder people don’t want to give it up and feel threatened when it is challenged. The problem is that taking this approach to psychiatry means that it has become more like a faith than a science. It has certain tenets which need to be believed. As we have outlined, these are: firstly, that mental illness will be shown to be due to brain disease and that there’s subsequently no need to get bogged down in complicated conceptual issues about the relationship between mind and brain; secondly, as mental illness has a material basis as do physical illnesses in general, it follows that psychiatry is not that different from the rest of medicine, so psychiatry can follow the same methods and technologies as the rest of medicine; and thirdly, that the scientific ambition of psychiatry and its associated research programme is to uncover the neuroscientific causes of mental illness and great progress has already been made in this aim. These fundamental tenets must not be questioned, otherwise the edifice of modern psychiatry may come tumbling down.

That's fine, maybe, but psychiatry has considerable legal powers, such as being able to detain mentally disordered people in hospital, subject to certain criteria within the Mental Health Act. It may well think it needs a firm foundation to be able to exercise that authority. It can’t really have people undermining its conceptual foundations, when it has such important social responsibilities. However, it is perhaps particularly because of the power that psychiatry has over people with mental health problems, that it's important to be honest about the state of its practice. Psychiatry may not want to to listen to any candid criticisms, but it should. We're now back to where we started this post. If psychiatry is primarily about relationships with people, then it does need to accept this reality. However successful psychiatry may be in marginalising any critique, people do feel obliged to speak openly and fearlessly about how psychiatry needs to change. Otherwise, it may just continue to be designed more for its own interests than the people it purports to serve.

Misleading the public about mental health

Matthew Parris’s Times article entitled ‘Mental health industry is cheating the public’ led to some overdefensive responses from mainstream psychiatry (see Letters). Parris may have overstated his case but, for example, the diagnosis of neurodivergence is out of control (see eg. previous post). It’s legitimate to question whether psychiatry is a science, considering the pseudoscientific claims made by biomedical psychiatry (see eg. another previous post). There have been serious problems with the application of Personal Independence Payments (PIP) since it replaced Disability Living Allowance (see post on my personal blog). Although the economically inactive may not be choosing not to work, as ineptly expressed by Parris, why so many people are not working is a legitimate social question. Mental health problems are definitely being overmedicalised (see eg. yet another previous post) and people do not want to hear that message. 

Will the mistakes of the past be repeated in Mental Health Act reform?

The government has been reported (see Guardian article) as being prepared to slow down Mental Health Act (MHA) reform following the Care Quality Commission (CQC) review of the homicides by Valdo Calocane. Wes Streeting, Secretary of State for Health and Social Care, has been quoted (see another Guardian article) as saying that “three innocent people might still be alive” if the NHS had “done its job” in treating Calocane. As I said in a previous post, it has been a mistake for mental health services no longer to be prioritising assertive outreach (AO) for people with serious mental health problems, like Calocane. This does not necessarily mean reintroducing separate AO teams as previously, but the AO function needs to be restored and prioritised in an integrated, functioning community mental health service.

I welcome time being taken to give proper consideration to the issues of MHA reform, as they do need to be got right and we need to learn from mistakes made following similar tragedies in the past. For example, a 2006 Observer article was written by the father of a man with a 17 year history of schizophrenia who, even though the father accepted that his son’s illness was difficult to treat, wanted to know why the mental health system, of which he was very critical, could not cope. The article appeared in the week following publication of a report into the care of John Barrett, who killed a stranger in Richmond Park, and which was said to reveal a litany of failures in his care. Homicide inquiries all tend to have the same findings that there is a need for improvement in risk assessment, communication, care planning and interagency working. These factors need to be improved in all mental health cases, not just those that lead to homicide. To focus on enforced treatment in the community (Community Treatment Orders (CTOs)) has been a distraction from the need to provide consistent, high quality community care by improving these aspects for all mental health care.

The more recent Guardian articles above show we are still facing similar problems in mental health services today to 2006 before CTOs were introduced. Part of the answer of the patient’s father then was that services were not sufficiently realistic about the lack of insight of people with schizophrenia and did not do enough to provide ongoing, consistent rehabilitative care, including accommodation for his son. Unfortunately services are still not always prioritising and providing high quality care for those with severe mental illness. This is where the focus for improvement should be.

The article was written before the last Labour government amended the MHA in 2007 to introduce community treatment orders (CTOs) amongst other changes. An Observer editorial accompanied this article and several letters were published in response. A Mental Health Bill, which led to the 2007 amendments to the Act, had already been introduced. Rosie Winterton, Minister of State for Mental Health at the time, in one of the published letters, argued that MHA reform was necessary to introduce CTOs to deal with the situation described by the father of the man diagnosed with schizophrenia. She seems to have seen CTOs as the answer to the then failing mental health system.

If services are still so dysfunctional and fragmented, why did CTOs not work? I posted then that CTOs “could well make the culture of mental health services worse by making them more custodial and less therapeutic”, suggesting that CTOs were “not the correct response to the bureaucratic, defensive failings of mental health services” described in the article. Mental health services need to be supported in providing high quality care, rather than being made fearful they will be attacked when something goes wrong. Mental health services have unfortunately become more fearful about what might go wrong in mental health services, rather than concentrating on the task of improving things for people with mental health problems.

The Critical Psychiatry Network (CPN), of which I am a founding member produced a position statement on CTOs in 2007. It argued that it was unethical to apply the MHA to force people to take treatment in the community when they are functioning well enough to be living in the community and have capacity to decide about their treatment. The use of force to remove someone from their home and take them to a "clinical setting" to force them to take medication cannot be justified and exacerbates stigma. CTOs can also frighten people away from psychiatric services, when these are just the people that need to be encouraged to keep in touch with services through informal assertive outreach. The temptation is just to continue CTOs once they are in place, because it is difficult to prove the negative that the person is well enough to be discharged once a decision has been made in the first place that they are justified. Having CTOs as an option, even expectation for some, means that the use of S17 leave and informal community care follow-up is not explored as much as it should be. These informal arrangements could lead to just as good, if not better outcomes (see eg. previous post). The number of people detained under CTOs has been far more than anticipated and they are discriminatory in their application (see eg. another previous post). The years since CTOs were implemented have just confirmed all the fears expressed in the 2007 CPN position statement.

This blog has consistently argued that psychiatry needs to move on from an outdated belief in mental illness as brain disease (see eg. previous post). Mental health practice does need to be rethought (see eg. another previous post). A new 10-year plan for mental health is required. This includes reform of the MHA following recommendations from the Parliamentary Scrutiny Commitee and WHO/OHCHR guidelines (see eg. yet another previous post).

I would go further than working towards abolishing CTOs for civil detentions (see eg. previous post). The Mental Health Tribunal needs to become the Mental Health Rights Tribunal with a single judge hearing appeals on both treatment and detention decisions (see eg. another previous post). Tribunals need to provide robust and objective accountability and effective protection for people with mental health problems. Medical evidence can come from the RC and an independent expert from a new integrated advocacy service of mental health lawyers, IMHAs and independent experts (see eg. yet another previous post). Advocacy services need to help detained patients exercise their rights by assisting patients to access legal advice and support at Tribunal hearings. Second Opinion Approved Doctors (SOADs) could then be abolished. If any hiatus in MHA reform leads to all these issues being taken forward, then all well and good from my point of view.

Pro-psychiatry and psychiatric diagnosis

I've mentioned before Andrew Scull's (2023) article which claims that David Rosenhan's (1973) 'On being sane in insane places' is a "spectacularly successful case of scientific fraud" (see previous post). I agree the evidence suggests Rosenhan at least exaggerated his finding that people could gain admission to psychiatric hospital and mislead psychiatrists into diagnosing schizophrenia to reinforce his belief that psychiatric diagnosis is subjective and does not reflect inherent patient characteristics.

What I want to emphasise, though, is the importance of Rosenhan's study in reinforcing the split between so-called anti-psychiatry and pro-psychiatry. Generally I don't like people using the term 'anti-psychiatry' because it's used as a way of marginalising even legitimate critique of psychiatry (see eg. recent post). 

However, there is a sense in which we need to accept that 'anti-psychiatry' as used by mainstream psychiatry has stuck (see eg. previous post). It's seen as a passing phase in the history of psychiatry from the 1960/70s from which psychiatry has now recovered. In other words, we're now in the period of pro-psychiatry. Tom Burns suggests that four revolutionary books first published in 1960/1 by R.D. Laing, Michel Foucault, Erving Goffman and Thomas Szasz started off this period of anti-psychiatry (see another previous post).

The term 'anti-psychiatry' itself was not really introduced until 1967 by David Cooper in his books Psychiatry and anti-psychiatry (1967) and The dialectics of liberation (1968). The anti-psychiatry movement was taken up by the counter-culture to free itself from what it saw as the oppressive nature of society, which included psychiatry suppressing our true potentialities. With the waning of the counter-culture, anti-psychiatry is also seen as having faded away in significance.

However, the anti-authoritarian, popular, even romantic, attack on psychiatrists' use of diagnosis, drug and ECT treatment and involuntary hospitalisation caused a crisis for mainstream psychiatry. Rosenhan's (1973) paper on psychiatric diagnosis added to that crisis. In particular, Robert Spitzer, as Chair of the Task Force, was so panicked that psychiatric diagnosis may be unreliable that he introduced operational criteria for the definitions of psychiatric disorders in DSM-III, building on work with the Research Diagnostic Criteria (RDC) (see eg. my article). This provided a way for psychiatry to move on from the criticisms of anti-psychiatry, including Rosenhan. 

So, even if it suits pro-psychiatry to discover that Rosenhan's study was fraudulent or at least exaggerated, it still has to deal with the fact that DSM-III was seen as necessary to counter anti-psychiatry. Although Spitzer always insisted DSM-III was atheoretical, it was associated with a resurgence of biomedical thinking in psychiatry, sometimes called neo-Kraepelinian (see eg. previous post). This is now seen as the pro-psychiatry position and any criticism may still be labelled as anti-psychiatry. 

Actually, what psychiatry needs to do is move on from this polarisation between pro-psychiatry and anti-psychiatry, which it’s still not yet done. There are legitimate critiques of the biomedical perspective in psychiatry. Although the biomedical perspective may always have been dominant, psychiatry has been more open-minded in the past and needs to return to being more open and therapeutic in its approach, rather than defending an outdated biological view of primary mental illness (see eg. my article).

Specialist clinics for deprescribing psychotropic medication

I’ve been cautious about being too prescriptive in withdrawing people from antidepressants (see eg. previous post). There should be more monitoring by doctors of people taking antidepressants (see another previous post). The full importance of antidepressant withdrawal is not yet appreciated by the medical profession in my view (see yet another previous post). 

Still, tapering is generally the best way to stop antidepressants, although some people do seem to be able to stop more easily, particularly if they have not been taking antidepressants for too long. An article in Medical Republic highlights that the Royal Australian College of GPs (RACGP) (see its press release) has made the Maudsley Deprescribing Guidlelines freely available for up to 500 members with an interest in psychology or addiction medicine. Mark Horowitz, one of the co-authors of the guidelines, is quoted in the article as saying that too many doctors recommend going back onto antidepressants when patients have withdrawal difficulties, rather than doing what they really should do is say that the drug should be stopped more carefully. I think in my clinical practice, perhaps because of the time needed to support people in withdrawal, I too easily allowed people to go back onto medication (see previous post). I support the development of more specialist clinics for deprescribing.

Mental health services should not be diagnosis-led

As I said in a previous post, services for neurodiversity should be based on need rather than diagnosis-led. Demand for assessment for neurodiversity services, particularly in young people, is out of control. This situation is being exploited by unscrupulous business practices (see eg. another previous post). 

Services should actually be provided on the basis of need for all mental health problems, not just neurodiversity (see previous post). Non-medical approaches to mental health problems can be beneficial and not everyone who attends mental health services is necessarily wanting medication. There needs to be more collaboration between NHS and non-medical mental health services to provide  an ‘integrated front door’ to services.

Assessment for mental health services is primarily about providing understanding. It’s not only about giving a name to people’s problems through a diagnosis but also about gaining some appreciation of the reasons for those problems. Of course it may not be possible to be certain about the factors involved, but that doesn’t mean that it’s not important to try and understand them. A brain problem is rarely the cause of most psychiatric presentations. People should be supported by mental health services on the basis of their need not a one-word label.

What is anti-psychiatry?

I’ve complained before that people continue to use the term ‘anti-psychiatry’ without being clear what they mean (see eg. previous post). There are people that want to abolish psychiatry and maybe that is the only way in which the term ‘antipsychiatry’ (without the hyphen) should be used (see another previous post). 

Psychiatry does need to change. The trouble with using the term anti-psychiatry is that it marginalises legitimate critique. 

Working towards abolishing community treatment orders (CTOs)

As Alex Ruck Keene said in his blog post, last week’s King’s Speech announced the introduction of a Mental Health bill to modernise the Mental Health Act (MHA) 1983. There is a sense in which it could be said to be misleading to imply that the 1983 Act has merely become out of date, which is how the government tends to present the case for reform (see previous post). Both the 1959 and 1983 Acts were progressive Acts in the sense of improving the rights of people with mental health problems. There were some progressive elements to the amendments introduced in 2007 by the previous Labour government, such as the introduction of independent advocacy, although this was never properly funded (see eg. previous post).  Essentially, however, the amended Act was a regressive step, particularly through introducing community treatment orders (CTOs). Hopefully the new Bill will actually further improve the rights of people with mental health problems (see eg. couple of tweets from Mind - first and second) and take into account WHO/OHCHR recent guidance on Mental health, human rights and legislation (see eg. previous post).

The Parliamentary Committee that scrutinised the draft Mental Health bill produced by the last government recommended that CTOs should be abolished for civil patients (see previous post). The Mental Health Alliance was formed in the context of the last Labour government’s attempt at MHA reform which led to the compromise of the 2007 amendments. There were major demonstrations against the Labour government’s proposals at the time (see eg. Early Day Motion). The Critical Psychiatry Network (CPN),  of which I am a founding member, was one of the original members of the Mental Health Alliance, although it resigned from the Alliance when it became clear that the Alliance was prepared to compromise on CTOs (see resignation letter and previous letter of concern to Alliance). Evidence since then has only essentially reinforced the view that CTOs do not work (see eg. previous post). CPN summarised its concerns about CTOs in a 2007 statement). 

The Alliance still exists and is a broader grouping than originally of mental health organisations. It does need to take on board, as does the government, the full implications of the United Nations Convention on the Rights of People with Disabilities (CRPD) (see eg. previous post). Both the World Health Organisation and the World Psychiatric Association urge countries to take action to promote non-coercive practices in mental health. This should include the UK government following the recommendation from the Parliamentary Scrutiny Committee to abolish CTOs for civil patients.

The government plans to introduce MHA reforms in phases as resources allow, and says it will not commence new powers unless there are sufficient staff in place to ensure it is safe to do so (see background briefing). Personally I’m not really convinced increasing the number of Tribunals and providing more access to SOADs and Tribunals, as proposed by the draft Bill, is really needed. It is also where more funding will be required, which could prevent implementation of any new Act. 

Reform of the Mental Health Tribunal to make it more human rights based could start now (see previous post), I think without any necessary legislative changes. Changes could also be made to improve independent advocacy by encouraging more integration between Independent Mental Health Advocates (IMHAs), mental health lawyers and independent experts (see another previous post), I think, again, without any necessary legislative changes. I suspect also that the CQC could ensure that the proposed S56 to introduce a clinical checklist to be followed by Responsible Clinicians and Second Opinion Approved Doctors (SOADs) could be implemented before such a change is reinforced and make legal in a reformed Act (see previous post). More could also be done to prevent the commissioning of secure placements by commissioners restricting, if not completely preventing, such funding for civil detentions. Work could also be undertaken on creating a new Mental Health Commissioner for England, as recommended by the Scrutiny Committee, probably incorporating and building on the current CQC MHA reviewer function (see another previous post). 

As part of taking forward its mental health strategy, the government needs to be clear that MHA reform starts now by improving patients’ rights. This programme of work can be taken forward alongside the development of a new Bill to be presented to parliament. 

The aspirations of psychiatry

King's College London press release announces that the "Wellcome Trust have awarded the funds [£5million] for a new 5-year ground-breaking research project ‘ASPIRE’, aiming to conclusively test if anti-inflammatories can be the right treatment for the right people with depression". Not sure how conclusive the results will be considering the description of the project on the Global Alliance of Mental Illness Advocacy Networks-Europe (GAMIAN-Europe) website. 

Also not quite sure what the Wellcome Trust meant a few years ago when it acknowledged that a radical new approach is needed for mental health research (see previous post), as it now seems to be allocating funding again on the same basis by wasting it on 'pie in the sky’ fantasies about what's possible with mental health treatments. I'm not wanting to polarise debate unnecessarily in psychiatry, and advocate, like Nik Rose (see previous post), for critical friendship between social sciences and neuroscience. However, I think this does need an acknowledgement from neuroscience that too much neuroscience funding is being wasted on the unattainable.

I've been ruthless in my criticism of the conceptual foundations of the psychiatry of Carmine Pariante, the primary investigator of ASPIRE (see eg. previous post). I also did a cutting, satirical review of the book by Ed Bullmore (see previous post), that made the case, like ASPIRE, for anti-inflammatory medications being used as treatment for depression by targeting the right people on the basis of levels of inflammation. To me, it's nonsensical to talk about depression as an inflammatory disorder, like rheumatoid arthritis (see eg. another previous post). More fundamentally, looking for abnormalities of inflammation in the brains of depressed people is a conceptual category error (see eg. last post). 

Summarising the argument of relational psychiatry

Depression of course is mediated via the brain but looking for abnormalities in the brain to explain why people are depressed is a category error. It is a fallacy to identify the brain with the person, in depressed people as much as in people who are not depressed.

I make this statement as a summary of the position of relational psychiatry (see eg. previous post), applying it to all functional mental illness, including schizophrenia and manic-depressive illness, not just depression. As I mentioned in a previous post, Bennett & Hacker call the category mistake of identifying the part with the whole the ‘mereological fallacy’. As I keep saying, psychiatry must stop identifying the brain with the person (see eg. another previous post). 

It is particularly people who have mental health problems who are reduced to their brains, and this is discrimination. However, such thinking permeates modern culture, reducing all people to their brains (see eg. previous post). Children are even being misled about the nature of mental illness (see eg. another previous post). What we need is a change from psychiatry being based on the notion that primary mental illness will be found to have a physical cause, to it moving on to a more relational practice (see eg. my article). 

GP monitoring of those on antidepressants

Tony Kendrick, who I have mentioned before (see eg. previous post) is the first author of a paper about antidepressant withdrawal in general practice. It found that more than 40% of patients could discontinue their antidepressant treatment in a clinical trial, comparing whether adding internet and telephone support to family practitioner review was more effective than practitioner review alone. The numbers that managed to withdraw under the two conditions was not significantly different, although those that had added support had small improvements in depression, antidepressant withdrawal symptoms and mental well-being.

However, only 4.9% of patients who were mailed invitations were eligible and consented to the trial. They had to be well enough to consider discontinuation, wish to do so and be at low risk of relapse. As I said in a previous post, people are generally very reluctant to take part in antidepressant discontinuation trials. There is at least a question about how much the results of the trial are generalisable to all those on antidepressants. Antidepressant discontinuation problems should not be minimised (see eg. last post). 

Nonetheless, if the paper leads to more review by general practitioners of those taking maintenance antidepressants this should be welcomed. Doctors are making far too many patients dependent on antidepressants and need to do more to prevent this happening (see eg. another previous post).

Mainstream psychiatry continues to minimise significance of antidepressant withdrawal

Mainstream psychiatry has minimised the significance of antidepressant withdrawal, as I first pointed out in a BMJ letter in 1997. My complaint then was that the Defeat Depression Campaign, launched in January 1992 by the Royal College of Psychiatrists in association with the Royal College of General Practitioners, advocated educating patients and doctors that discontinuing antidepressant treatment is not a problem. 

As I explained in my book chapter, what caused so much consternation to the Defeat Depression Campaign was that 78% of people in a door-to-door survey of public opinion thought that antidepressants are addictive. I suggested in the BMJ letter that the general public actually understood this issue better than the Royal Colleges of Psychiatrists and General Practitioners. It's common sense to believe that discontinuing taking medication that is thought to improve mood may be difficult. 

The British National Formulary (BNF), which doctors use for reference about medication, has given a warning since 1990 that symptoms may occur if an antidepressant is stopped suddenly after regular administration for 8 weeks or more. In fact, case reports of discontinuation reactions have appeared since antidepressants were first introduced. The Drugs and Therapeutic Bulletin (DTB), which publishes independent, practical, patient-orientated, evidence-based content on medicines for healthcare professionals, recommended in 1999 that if maintenance antidepressant treatment is discontinued that both the doctor and patient need to be alert to the risk of discontinuation effects and the re-emergence of depressive symptoms, which can occur on cessation of any antidepressant. It made clear that antidepressants should not be stopped abruptly, nor treatment courses interrupted, unless there is a good clinical reason, for example a serious adverse effect or patient request.

A new class of antidepressants called serotonin specific reuptake inhibitors (SSRIs) was introduced onto the UK market in 1987. Withdrawal symptoms were only acknowledged by the drug companies after SSRIs had been in widespread clinical use for several years. A consensus meeting of experts, sponsored by Eli Lilly, the manufacturers of fluoxetine, or Prozac™, as it is known by its trade name, was held in Phoenix, Arizona, at the end of 1996. This led to an editorial in the British Medical Journal in 1998 acknowledging that antidepressant  discontinuation problems existed (Haddad et al, 1998). It suggested, though, that they were both preventable and simple to treat. The same authors only two years later acknowledged that discontinuation symptoms are common (Young & Haddad, 2000). 

The National Institute for Health and Clinical Excellence, which evaluates treatments for NHS use, therefore, stated in its 2004 depression guideline the opposite of what was recommended by the Defeat Depression campaign: ie. that all patients prescribed antidepressants should be informed that discontinuation/withdrawal symptoms may occur on stopping, missing doses or, occasionally, on reducing the dose of the drug. It qualified this, though, by saying that symptoms are usually mild and self-limiting but can occasionally be severe, particularly if the drug is stopped abruptly. 

More recently in its 2022 guidance on ‘Medicines associated with dependence or withdrawal symptoms: Safe prescribing and withdrawal management for adults’, NICE clearly states that antidepressants cause withdrawal symptoms even though they have not historically been classified as dependence-forming medicines. In its updated 2022 depression guideline, it now says that withdrawal symptoms can be mild and usually go away within 1 to 2 weeks; can sometimes be more difficult, with symptoms lasting longer (in some cases several weeks, and occasionally several months); and can sometimes be severe, particularly if the antidepressant medication is stopped suddenly. At least the guideline now acknowledges that withdrawal symptoms are not as usually mild and self-limiting as the previous version of the guideline stated. 

This amendment was made after a complaint was made to the Royal College of Psychiatrists, which I signed (see eg. previous post). Although the complaint was initially wrongly dismissed, the College did eventually accept there should be greater recognition of the potential in some people for severe and long-lasting withdrawal symptoms on and after stopping antidepressants and called for NICE to update its guideline on antidepressant withdrawal (see eg. another previous post). 

I still worry, though, that the full importance of antidepressant withdrawal has, after all these years, not been understood by mainstream psychiatry (see previous post). There is in fact limited scientific evidence on this topic and recommendations are too driven by personal opinions or experiences rather than evidence as such (see another previous post). There are also methodological problems with antidepressant discontinuation studies, not least that blinding strategies are often insufficient to properly address placebo and nocebo aspects. What is commonly overlooked is that antidepressant withdrawal symptoms even occur in blinded antidepressant arms when antidepressants are continued. 

This finding has been confirmed in a new systematic review based on short-term industry studies (see Psychology Today article). One in three people were found to have at least one withdrawal symptom in the antidepressant withdrawal arm, but one in six people were still found to have withdrawal symptoms in the control arm even though antidepressants were continued. 

The problem with the new systematic review is that it minimises the frequency of antidepressant withdrawal, suggesting they occur in only 15% of people. But withdrawal symptoms may occur during and despite slow tapering and may persist for a long time (see eg. previous post). Even with the help of CBT to prevent relapse after withdrawal, only 36% of patients succeeded in discontinuing antidepressants over 16 months in a failed trial that found no difference between CBT and controls. Only 28% did not have a recurrence. 

Patients are actually, generally, very reluctant to take part in antidepressant discontinuation trials (see previous post). Fear of recurrence, relapse, or disturbing current mental equilibrium is common and prior failed attempts to discontinue antidepressants reinforce these expectations. People have also commonly been taken in by the myth of chemical imbalance in the brain as the cause of depression (see eg. another previous post) and are, therefore understandably, fearful and uncertain about stopping antidepressants, as the thought is their chemical imbalance could return. This fear overpowers the concern and uncertainty about continuing antidepressants. It's understandable if people think it’s better to be safe than sorry by continuing antidepressants (see eg. yet another previous post). 

So, even though we may have gone from the situation of antidepressant withdrawal symptoms being denied, as in the Defeat Depression campaign, to one in which they are accepted but the significance minimised (see eg. previous post), there is still insufficient understanding of the nature of antidepressant withdrawal. The situation has not really changed from what I wrote in an Openmind article nearly 25 years ago:-

People may form attachments to their medications more because of what they mean to them than what they do. Psychiatric patients often stay on medications, maybe several at once, even though their actual benefit is questionable. Any change threatens an equilibrium related to a complex set of meanings that their medications have acquired. These issues of dependence should not be minimised, yet commonly treatment is reinforced by emphasising that antidepressants, for example, are not addictive.

Even though psychiatrists may want to justify antidepressant treatment, this does not excuse minimising problems caused by taking it. Doctors are advocates of antidepressant treatment and this has led to them overlooking what should have been obvious about the risk of discontinuation problems. Perhaps we shouldn't be too surprised that doctors have been slow to recognise antidepressant discontinuation reactions and continue to minimise their significance, as they focus on short-term fixes of emotional problems (see eg. previous post), they are not properly psychologically minded and they are too quick to peddle medication and oversimplistic psychological interventions (see eg. another previous post). I’m not saying this to polarise debate about modern psychiatry, but the biomedical model that mental illness is due to brain disease has became too dominant and should not be buttressed by denying or minimising the significance of antidepressant withdrawal and other medication side effects.

To keep you in good humour

History of Psychiatry has an interesting article on ‘Cheerfulness in the history of psychiatry’. As the article says, “the notion of the French gaité tends to couple mood with an innate configuration, both procuring laughter, fun and vivacity". It goes on to mention Louis-Antoine Marquis de Caraccioli who was “ a prolific writer of the eighteenth century, [who] dedicated a book to a psychological theme that medicine has forgotten: ‘gaité’ in French". 

The article goes on:-

At the beginning of the nineteenth century, this work inspired two doctoral theses in medicine, … In their texts, Louis Monferran (1785– ?) and Vincent Rémi Giganon (1794–1857) explored the therapeutic benefits of the medical prescription of cheerfulness. In addition to lifestyle recommendations, they focused on the psychotropic substances available to them: alcohol, coca, hemp and opiates. … Giganon [also] … recommended … inhaled nitrous oxide gas.

Well, at least they included lifestyle recommendations as well as various substances. We have learnt a lot about these substances since Montferran and Giganon and can also learn from these authors’ historical theses for the present. Of course psychedelic substances are making a comeback as prescribed medications (see previous post). But, although fighting sadness with cheerfulness may seem to make sense. we also need to be realistic. 

It may be easy to get caught up in the charms of momentary cheerfulness. To quote Giganon from the article. "Laughter, song, wordplay, and jargon may spell doubts and allay suspicions". Or, to quote Monferran, again from the article, "Momentary cheerfulness delights the soul without perturbing it, evokes laughter without ridicule, and refines pleasures without corrupting them”. By contrast, "lasting or internal cheerfulness is based on an inner contentment, a blameless conscience, and the secret applause that follows a good action; this joy is more perfect than momentary cheerfulness". Modern society has become too focused on quick fixes (see previous post) and oversimplistic psychiatric treatment (see another previous post).

Shifting mental health policy

I've mentioned the Beyond Pills All Party Parliamentary Group (APPG) in a previous post. It has recently launched a report entitled Shifting the Balance Towards Social Interventions: A Call for an Overhaul of the Mental Health System. There is a YouTube video available of the excellent launch event of the report, which included presentations by Dainius Pūras (see eg. previous post) and Michelle Funk (see eg. another previous post). 

Mental health practice does need to be rethought (see previous post). Understanding about mental health problems needs to be improved, including what children are told about mental illness (see eg. previous post). The Mental Health Act also needs to be reformed (see another previous post). Rights and recovery-orientated services need to be at the centre, not the margins of mental health services, as currently.

Mental health services need to be realigned with better strategic direction to make them more functional and integrated. For example, there needs to be a mental health hub and community mental health team (CMHT) in each Primary Care Network (PCN). CMHTs have become too large and need to be devolved more locally, alongside non-medical services in the hubs.

Asperger’s autism

Kevin Rebecchi has provided a first English translation and introduction to Hans Asperger’s 1982 chapter ‘Early childhood autism, Asperger type’ published after his death in 1980 (see History of Psychiatry article). Asperger distinguishes his use of the term ‘autistic’ from that of Eugene Bleuler, who gave the name to the apparent impenetrable wall that separated schizophrenic from other people. Leo Kanner separately described what Asperger thought was a rare form of early infantile autism. Asperger differed by seeing people generally as having the ability to behave in an ‘autistic’ manner.

Asperger children were noticeable at school where they were very difficult to discipline and often failed because of their so-called different psyche, being intelligent, highly reflective and observant, seemingly devoid of feelings and yet able to have subtle emotions. Most importantly, it was the visibly limited and self-centred, very idiosyncratic way of dealing with people that was labelled ‘autistic’.

As Rebecchi points out, Lorna Wing introduced the concept of the autistic triad of difficulties in social interaction, communication and imagination and coined the term Asperger’s Syndrome. The study Wing based the autistic triad on was mainly of intellectually disabled children. She disagreed with Asperger and said these children lacked common sense, were not creative but merely logical, did not have high intelligence (several with IQ < 70) and would only repeat things by rote. Asperger’s autism in fact was not really characterised by the autistic triad at all.

Asperger thought the term ‘psychopathy’ applied to the children he described and they were seen as difficult both at home and school. He thought, nonetheless, they should be respected for who they are, and that it was quite wrong to see difficult people who are out of the ordinary as of inferior social value. As far as Asperger was concerned, some autistic people bring much to the world and are “the salt of the earth”. 

As I have said before (see eg. previous post), there is a need for a rethink about autism. It is now seen as part of the umbrella term ‘neurodiversity’ (see another previous post). Its meaning may well have become too vague and restoring understanding, I think, will benefit by looking again at its historical origins, as does Rebecchi.