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):-


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)
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

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.

Friday, December 13, 2013

Exploiting the antidepressant placebo effect

Stuart Jessop, a patient with depression, in response to a BMJ article, says patients don't care whether antidepressants are merely placebos. He seems to suggest that the placebo effect shouldn't be "explained away". He even suggests GPs should prescribe herbal medicines, presumably even if these remedies have not been shown to be better than placebo.

I do agree with his motivation to avoid patients with mild depression being sent away "empty handed". But is Jessop really encouraging doctors to deceive their patients? I agree the value of the placebo effect shouldn't be minimised and the relationship between doctor and patient is important. But using dummy drugs and other phoney interventions is unethical (see my BMJ letter). Placebos (and antidepressants if they are merely placebos) should not be used to exploit patients.

Monday, October 28, 2013

What's psychosocial reductionism?

Allen Francis has clarified his position on psychiatric diagnosis in his Saving Normal series on Psychology Today (see article). Although he's been critical of DSM-5, in response to Lucy Johnstone, he makes clear that, for him, the biological model is essential and that neuroscience has been "enormously successful in helping us understand normal brain functioning and that over time, in very small steps, this will result in better understanding of abnormal brain functioning". However, he doesn't explain what he means by this.

And he doesn't seem to understand the meaning of reductionism. Reducing the psychosocial to physiological processes is what psychiatry does all the time. I'm not sure how the psychosocial can be reduced to the psychosocial. Presumably Francis is suggesting that the psychosocial is a simpler form of something more complex, but is it?

Wednesday, October 16, 2013

Reinvigorating community mental health care

It's worth looking at the article by Peter Tyrer in The Psychiatrist on community psychiatry in the context of today's report from BBC News and Community Care about what they call the crisis in mental health care. To quote from Peter's article:-
The general mantra of ‘community psychiatry good, hospital psychiatry bad’ has … led to the neglect of the proper function of in-patient care, a combination of asylum and rehabilitation. …[A] fundamental wish to improve patients’ autonomy is being removed by an overbureaucratised system of community care that is obsessed by risk, and in danger of promoting greater institutionalisation by a complex regulatory framework that denies the flexibility that is essential to good community psychiatric practice.  
Where in the UK community psychiatry used to be flexible, adventurous, creative and bold, with the many changes imposed from policy managers in recent years it has become constricted, controlled, limiting and self-serving. Autonomy for practitioners has almost entirely disappeared and been replaced by a rigid system of care that leads to patients encountering a bewildering number of health professionals, who carry out specific regimented tasks but who rarely have the chance to develop meaningful relationships with the people they treat.
His solution is to remind ourselves of the core principles of good care:-
  1. if good facilities are available for patients to be treated outside hospital, they should be used as much as possible;
  2. if a hospital bed is necessary it should be available when required and should be as close as possible to the patient’s home; hospital should be able to serve as a place of refuge and respite as well as a treatment centre;
  3. continuity of care may not always be possible but should be striven for as a matter of principle, and all community teams should stay in touch with their patients no matter where they are placed;
  4. individual or team-based treatment both have merits and their choice should be determined in collaboration with the patient and his or her carers, and maintained irrespective of treatment setting.
He goes on:-
This can only be achieved by allowing greater autonomy within teams to maintain priorities, reducing the size of the catchment area for each team so that they do not become overwhelmed and depersonalised in their attitudes.... [M]orale [needs to be raised] of a service that has been relegated to the backwaters of care for too long. 

Monday, October 14, 2013

Increase in patient suicides has followed introduction of CTOs

The headline for this piece is deliberately tongue in cheek. It's not supposed to imply that the introduction of community treatment orders (CTOs) has led to an increase in suicides, although, of course, I am aware that this is how it could be taken. It's just that the latest report from the National Confidential Inquiry (NCI) into Suicides and Homicides by People with Mental Illness has implied that CTOs have reduced homicides. I just thought it important to point out, if that claim is being made, that CTOs have not reduced suicides. In theory, CTOs could have either increased or decreased deaths by suicide and homicide. And NCI expected CTOs to have a greater impact on absolute numbers of suicides than homicides. Or maybe it thinks the increase in suicides would have been a lot worse without CTOs.

To be clear, what the report points out is that homicide by mental health patients has fallen substantially since a peak in 2006. This might not have been obvious from recent headlines in The Sun (see previous post). The report goes on to say that one of the clinical explanations may be the introduction of CTOs in 2008.

The report also notes that the number of patient suicides increased in 2011. Although the figures are provisional because the data is incomplete, a higher number of patient suicides is predicted in 2011 than in recent years. There's no speculation that this is due to CTOs; instead the "rise probably reflects the rise in suicide in the general population, which has been attributed to current economic difficulties".

After all, it was NCI that argued for the introduction of CTOs to reduce homicide and suicide. It even went as far as to predict in Safer services that 30 suicides and 2 homicides would be prevented each year. A later report, Safety first, increased that figure to 32 suicides and 3 homicides. The trouble is that the logic used to produce such estimates did not stand up, as all NCI did was assume that CTOs would prevent deaths and then produce figures based on this premise. The fact is that whatever figure was produced is not evidence of the value of CTOs, as it was only an estimate assuming they were going to be effective. Maybe that's why the latest report latches on to the reduction in homicides. NCI needs some evidence to justify its previous speculation, which it couched in pseudoscientific terms. But, of course, this isn't evidence as such because there are all sorts of reasons why the homicide figure may have gone down, in the same way as there are all sorts of reasons why the suicide figure has gone up.

Saturday, October 12, 2013

Irrational homicide risk management

The Sun has been taken to task for producing the front page headline that 1200 people have been killed by mental patients in the last 10 years (see Guardian and New Statesman articles). The Daily Star had a similar report. This article quotes from Marjorie Wallace, whose intentions, I think, are to improve funding for mental health services, but her campaigning on behalf of her mental health charity, SANE, has, in my view, actually undermined services.

She complained to The Sun that a failure of communication between one agency and another has been found in 90% of homicide inquiry cases. But, communication is not perfect in everyday practice. In fact, it is commonplace for staff to have to cover 'gaps', such as not having complete information. Such imperfections are usually managed without adverse consequences.

The question is whether such homicides really reflect failings in Britain's mental health system. There has certainly been overreaction in some homicide inquiries, which do not always apply accountability sensibly. It is a phantasy, which we need to disabuse ourselves of, to believe that mental health services can have absolute control in preventing homicides by their patients (see my unpublished article and associated conference presentation).

Sunday, September 29, 2013

Psychiatry shooting itself in the foot

Just to reinforce my previous post, the President of the American Psychiatric Association has said that the mass shooting in the Navy Yard in Washington, D.C., like previous such tragedies, "reflects the failings of the U.S. mental health care system" (see post). The answer to my question about why psychiatry accepts this projection is that he believes this will increase the social and political will to provide quality mental health services.

Even if his motive is to provide every person with a mental illness and/or substance use disorder with "access to affordable, quality mental health treatment", he doesn't provide any evidence that psychiatry can identify and treat perpetrators of mass shootings. To encourage this phantasy is a folie a deux between psychiatry and the public.

Saturday, September 21, 2013

The omnipotence of the mental health system

Gallup have found that 48% of Americans say that they blame the mental health system "a great deal" and 32% "a fair amount" (ie. 80% total blame) for mass shootings in the United States (see report). Comparative total figures for blaming guns and blaming drugs are 61% and 66 % respectively. The report on Gallup Politics interprets this to mean that Americans believe "more can be done on the mental health side", but it doesn't say what it thinks can be done.

Actually research has shown that the removal of semi-automatic and pump-action shotguns from civilian possession after the 1996 firearm massacre in Tasmania led to no mass shootings in Australia in the 10.5 years afterwards, whereas in the 18 years before the gun law reforms there were 13 (see article). Does the American public really think services have the ability to detect and treat mentally unstable people capable of such crimes? Do they really mean what they say? If so, they seem to think psychiatry is all-powerful. Perhaps that's where psychiatry is going wrong by accepting this projection.

Friday, September 13, 2013

Is psychiatry our necessary shadow?

Tom Burns, who I have mentioned in a previous post, has written a bland apology for psychiatry, Our necessary shadow: The nature and meaning of psychiatry. As he says, he is "convinced psychiatry is a major force for good or I would not have spent my whole adult life in it". Having also spent most of my adult life as a psychiatrist, I suppose I'm inclined to be an apologist as well, but I would only say that psychiatry can do good not that it does. Burns recognises what he calls psychiatry's "mistakes" but sees these as failings that need to be put in perspective, rather than, as I do, something more fundamental about the nature of psychiatry.

Burns describes a new group of anti-psychiatrists, which he says "are, as it were, evidenced-based anti-psychiatrists" [his italics]. In this group he selects from what he calls an "almost endless" list of books: Richard Bentall's Doctoring the mind (see my previous post) and Madness explained; Jo Moncrieff's The myth of the chemical cure (see my post about Jo's new book); and Peter Breggin's Toxic psychiatry and Brain disabling treatments in psychiatry. (See my book recommendations on my critical psychiatry website.)

Burns suggests these new anti-psychiatrists (see previous post about use of the term 'anti-psychiatrist'), although they may share "a deep suspicion of the fundamental legitimacy of psychiatry and psychiatric diagnoses" are more concerned about "the damage done by psychiatry and psychiatrists" [his italics]. From his point of view, "their arguments are generally that psychiatry is too full of itself, or is corrupted by pharmaceutical companies, or that it makes endless mistakes". One of his reasons for writing his book is to "try and explain why psychiatry survives despite this tsunami of criticism". He goes on:
If psychiatrists are false prophets it is because they fail to deliver what they promise; it is not their mistaken metaphysics. It is their incompetence rather than their omnipotence that is the issue.

If I understand him right, he doesn't want to engage with conceptual issues about the nature of mental illness. This is not dissimilar from the position of Anthony Clare in Psychiatry in dissent (see previous post) and fits with Burns ambition to see his book as this generation's "attempt to explain psychiatry fully to the interested outsider", as Clare's book was for a previous generation. I think Burns is setting the barrier of competence too high for psychiatrists! He clearly does have an ideological position eg. he accepts the rather trite position that schizophrenia has a heritability of 80%. Despite what he thinks, as I keep saying, it is important to move on from the biomedical paradigm (see previous post). Burns atheoretical approach does not salvage psychiatry.

Thursday, September 12, 2013

Stop thinking about DSM-6

Collection of psychiatrists' views about DSM-5, including those of Charles Nemeroff (see previous post) and Simon Wessely (see another previous post), have been published by BMC Medicine.

Nemeroff and Daniel Weinberger suggest the motivation for DSM-5 was (1) unrealistic anticipations of being able to include genetic markers for mental disorders following the sequencing of the human genome, and (2) unrealistic enthusiasm that brain imaging studies would produce pathognomonic findings about the neurobiology of mental disorders. Their wishful thinking means that only in retrospect do they find this surprising, blaming the complexity of the brain. Actually, it's not just the complexity of the brain that's the issue, but their naivety that the brain-mind problem could be solved. We need to move on from the biomedical paradigm (see previous post).

Nor, as they imply, did the explicit criteria of DSM-III solve the subjectivity and uncertainty of psychiatric diagnosis, which is actually intrinsic to its nature. There needs to be a change of thinking about psychiatric classification. As I said in my previous post in relation to Simon Wessely, please stop talking about DSM-6, at least until there's a proper conceptual understanding of the nature of mental illness. Nemeroff and Weinberger's unrealistic hopes are an insufficient basis on which to proceed.

Tuesday, September 03, 2013

The truth about antipsychotics is hard to swallow

This website has been given a 20% discount for the important, soon to be published book The bitterest pills by Jo Moncrieff. Order through and use code WBitterest2013. (Do check, though, that this is the best deal - currently seems to be cheaper on the Amazon site).

Saturday, August 24, 2013

Current fashion in antidepressant research

Just to reinforce my previous post, Psychiatric Times has a video article suggesting that the next fashion in antidepressant research will be based on glutamine not serotonin. At least one of the apparent drivers for this research is the realisation that antidepressants don't always work (see previous post). But, let's please not let any of these new agents onto the market if they're no better than the old ones.

Saturday, July 27, 2013

Serotonin hypothesis of depression was wrong

Move over serotonin; let's exploit glutamate in the treatment of depression. So suggests the journalist, Samantha Murphy, in a New Scientist article. Her argument is that the rise in treatment resistant depression reflects a realisation that antidepressants don't work. She holds out new hope for repetitive transcranial magnetic stimulation (rTMS) (see previous post), cranial electrical stimulation and ketamine. The speculation is that the release of glutamate by these treatments repairs the shrivelled dendrites of depressed people's neurones. She says at least 5 pharmaceutical companies are working on developing ketamine derivatives.

The academic paper to support this journalistic hype may be that by Duman & Aghajanian (2012) in Science. Look out for the promotion of a synaptogenic hypothesis of depression and treatment response. Scientific progress? Surely not.

Friday, July 26, 2013

Is APA prepared to engage with critical psychiatry?

At least Jeffrey Lieberman is prepared to engage with criticism of psychiatry in his role as President of the American Psychiatric Association (see his recent article in Psychiatric News). This is to be welcomed as mainstream psychiatry has tended to marginalise critique (eg. see previous post). True, Lieberman does tend to dismiss questioning of the integrity of psychiatry as Cartesian anti-psychiatry. He clearly has more work to do in taking this issue forward.

He sees psychiatry as a "scientific discipline and full-fledged medical speciality", but then doesn't explain what he means by this. Nor does he say what is meant by "the progress that has been made to deconstruct the almost unfathomable complexity of the brain into its constituent neurobiological mechanisms that mediate emotion, perception, and cognition". If there has been such progress he ought to be able to tell us what it is. He indicates that the technologies of "psychopharmacology, modern neuroimaging methods, and molecular genetics" are what have begun this process, but, again, does not spell out the references. He confidently states that "recent advances in research have shown us that they [mental disorders] are biological in nature and caused by genetics and environmental factors". However, we're clearly supposed to understand more for this claim than the merely tautologous connection.

I agree psychiatry has nothing to be defensive about this "noble mission", unless it's all a myth. Lieberman has a duty to clarify whether he's being realistic or pursuing a wishfulfilling phantasy.

(With thanks to Phil Hickey for a post on his Behaviorism and Mental Health blog).

Saturday, June 22, 2013

Why does the APA need new editions of DSM?

Simon Wessely in his blog post about an IOP conference on DSM-5 assumes there will be a DSM-6. Have we now come to expect continuous revision of psychiatric classification? If so, it's difficult to understand why. There has never really been any expansion of "the scientific basis for psychiatric diagnosis and classification" despite this being the apparent impetus for DSM-5 (see website). Maybe APA's motivation for continuous revision is merely financial gain. DSM-IV made at least $100 million, but, even so, DSM-5 should be free open access to all on the internet.

The reason for the DSM-III revision was very clear (eg. see my article). From mainstream psychiatry's point of view, diagnosis was in crisis because of its unreliability. Operational criteria were therefore developed. Unfortunately these may be no more valid than commonsense definitions. So, we could put up with amendments through DSM-III-R, DSM-IV and DSM-IV-TR, but tinkering further with DSM-5 is a step too far.

As Simon says, "The aspiration that DSM-5 would represent as significant a break with the past as DSM-III had been, effecting a second revolution by moving from symptom based diagnosis to aetiologically based diagnosis using the latest advances from neurosciences and genetics turned out to be just that, an aspiration". That's why the current NIMH director has turned his back on DSM-5 (see previous post), although his predecessor was one of the originators of the DSM-5 process in 1999. However, despite all the DSM revisions, there's no getting away from the poor validity and reliability of psychiatric diagnosis. That's its nature and psychiatry's wishful failed ambition needs to be recognised for what it is.

Wednesday, June 19, 2013

Ban face down restraint in psychiatric hospitals

To his credit, Norman Lamb (who I have mentioned on my personal blog eg. see previous post), Minister of State at the Department of Health, says he is considering just banning face down restraint in psychiatric hospitals (see BBC news story). This is following a call from Mind demanding national standards on the use of physical restraint, accredited training and an end to face down restraint on the basis of data they have secured from NHS trusts under FOI requests (see news item).

It was a pity that the take up from the Blofeld report on the death of Rocky Bennett some years ago focused on institutional racism rather than also on restraint. As I said in my BMJ eletter, "Death of a patient under restraint should help us to refocus on the need for a therapeutic approach rather than just custodial practice in mental health services." Organisational interventions can dramatically reduce the use of seclusion and restraint, reflected in the wide variation found by Mind in their survey. Hence government intervention in the way considered by Lamb could have significant effects.

As I said in another eletter about this issue, we need to highlight "... the importance of the culture of mental health services in limiting the use of such restrictive procedures". The focus on defensive practice over recent years has not been helpful. Restraint may be better seen as an indication of treatment failure, rather than treatment as such.

Sunday, June 02, 2013

The ethical corruption of academic psychiatry

Phil Thomas asks why Charles Nemeroff has been asked to give the inaugural annual lecture of the new Centre for Affective Disorders at the Institute of Psychiatry (IOP) (see blog post). After all, Nemeroff has been one of the most blatant examples of psychiatrists' wrongdoing by under-reporting of pharmaceutical company earnings (see previous post). It's this sort of thing that makes even the most biological of psychiatrists concerned about the moral integrity of modern psychiatry (eg. see post by Michael A Taylor).

Ironically, from his previous published research (eg. Nemeroff et al 2003), Nemeroff may be seen as promoting psychotherapy in his lecture rather than necessarily any psychotropic medication. Nonetheless, of course, he does think monaminergic drugs are therapeutic in depression. His speculation is that the reason some people survive early life stress (ELS) is because of their genes. In a clinical trial, it was found that depressed patients with a history of early childhood trauma did better with psychotherapy alone than antidepressant monotherapy. Don't be misled by this! Maybe paradoxically, Nemeroff thinks psychotherapy is a "biological treatment". He believes it changes gene expression. As I've warned previously (see previous post), don't be taken in by such neuropsychotherapy.

Nemeroff's lecture at IOP may not be that much different from the one he gave at NYU last year (see video). It may not be that exciting or interesting. His NIH grant in 2012 caused controversy because of his past ethical problems (eg. see letter from Senator Grassley). The project information for the study explains that he's wishfully looking for the genetic risk factors for PTSD. Maybe the Centre for Affective Disorders will also undertake similarly misguided research. Let's at least know from IOP where it's getting its funding from, because choosing Nemeroff as its inaugural lecturer for its new centre does not bode well.

Saturday, May 11, 2013

Abandoning diagnostic criteria for research in mental health

The blog entry by Thomas Insel, NIMH director, has created much comment (eg. New Scientist article and blog post by Phil Thomas). I've mentioned before how grandiose Insel can become in his claims for mental disorders as biological disorders involving brain circuits (eg. see previous post). His RDoC project will not create a new nosology despite his wishful thinking. As he says, we lack the data to "design a system based on biomarkers or cognitive performance". We need to accept the uncertainty of psychiatric practice and medicine in general, rather than promote 'precision medicine' as the solution to mental disorders as he proposes.

Nonetheless, we should welcome NIMH re-orientating its research away from DSM categories. It may actually be progress if this means funding research on patients without relying on diagnostic criteria.

Invitation to Radical Caucus Events at APA on May 18th



Saturday May 18, 2013: 9AM to 12 Noon: Moscone Center, Street Level, Gateway Ballroom 102
Presidential Symposium: “Envisioning a New Psychiatry: Radical Perspectives”
Chairs: Carl I. Cohen , MD; Kenneth Thompson, MD;
Discussants: Sami Timimi, M.D., Helena Hansen, M.D., Ph.D.
· Jean Furtos, MD: “Globalization and Mental Health: The Weight of the World, the Size of the Sky
· Sandro Galea, M.D.: “Re-Engaging Research Around the Socail and Economic Production of Mental Health:Toward a Comprehensive Model of Mental Illness”
· Pat Bracken, M.D, Ph.D: ” Beyond the Technological Paradigm: A Positive Path for psychiatry”
· Steven Moffic, M.D.: Eco-Psychiatry: Why We Need to Keep the Environment in Mind”
· Keris J. Myrick, MBA, Ph.D(cand): Alternative, Complimentary, or Traditional: A Radical Approach from the C/S/X Perspective”

Saturday May 18, 2013; 3:30PM -5:00PM; Moscone Center
Issue Workshop: “United Kingdom Critical Psychiatry Network: Implications for the APA and Global Psychiatry”
Chairs: Helena Hansen, M.D. , Ph.D.; Bradley Lewis, M.D., Ph.D.
Dr Hugh Middleton, MA. MD. MRCP. FRCPsych.
Professor Sami Timimi, MBChB FRCPsych
Dr Pat Bracken, DPM,MA,MD,PhD,MRCPsych

Saturday, May 18, 2013; 6:30PM -8:30PM Hilton San Francisco; Union Square Rooms 19/20 4th Floor, Tower 3
“Radical Caucus Meeting–Open Discussion and Planning Session”
Light Snacks and Beverages

8:30 PM Radical Caucus Annual Dinner Dinner (note new location) 
Basil Canteen located on Folsom street at 11th1489 Folsum St (at 11th St); 415-552-3963.
All Welcome!!!!
For more information contact:
Also visit our new Web site at
Please post comments and suggestions.

Carl I. Cohen , M.D.

SUNY Distinguished Service Professor & Director
Division of Geriatric Psychiatry
SUNY Downstate Medical Center
Box 1203
450 Clarkson Avenue
Brooklyn, N.Y. 11203
ph: 718-287-4806
fax: 718-287-03377

Friday, May 03, 2013

Phantasy dreams about NEI congress

I've mentioned before the apparent fun people have at NEI congresses (see previous post). The latest video from neipsychopharm gives an idea about what you missed from the recent congress. I suppose we can hope that what happened at the congress may help patient care but it's difficult to see how it would.

Call to embrace social paradigm

Leaders of British academic social psychiatry argue in BJPsych editorial that the rules regulating research and the dominant neurobiological paradigm may have stifled creativity. The new charity MQ: Transforming Mental may need to take this perspective more on board. (Why's it called MQ?)

Saturday, April 13, 2013

Clutching at genetic straws for impersonal treatment

Jeremy Laurance in The Independent says that a study led by Hugh Gurling has opened up the prospect of so-called personalised treatment of bipolar disorder with drugs targeting the metabotropic glutamate receptor 3 (mGluR3). This is based on a finding that the Kozak sequence variant of the glutamate receptor 3 (GRM3) gene, which encodes for mGluR3, was overrepresented in a sample of bipolar disorder cases compared with controls. As the paper concludes, confirmation of this finding is needed before accepting this potential marker. It could just be a chance finding based on screening until a significant result is found.

As the paper also points out, "The GRM3 gene has been investigated in bipolar affective disorder as part of several genome-wide association studies (GWASs) but failed to reach genome-wide significance in any of these investigations." Still research goes on with this gene because it is assumed the failure to find genetic association is "probably the result of the presence of low-frequency disease alleles and the high degree of etiologic genetic heterogeneity".  Actually it's more likely that there's no genetic link.

I haven't forgotten Hugh Gurling's false claim in Nature in 1988 that he'd found strong evidence for the involvement of a single gene on chromosome 5 in the causation of schizophrenia. Jeremy Laurance shouldn't be so easily taken in by claims for so-called personalised (actually there's nothing personal about it in the sense of relating to patients) psychiatry.

Friday, March 29, 2013

More compulsory community treatment does not reduce readmission rate

Results of OCTET study comparing use of S17 leave and CTO has been published (see paper). The rate of readmission was not reduced by CTO compared to use of S17 leave. Other studies have also shown no reduction in readmission. As might have been expected, this finding was despite the period of supervised community treatment being on average more than three times longer on CTO than by using S17 leave

CTOs were actually introduced because it was believed they would reduce death by suicide and homicide, supported by fantasy estimates of how many lives would be saved (see my unpublished paper). Three people died in the CTO group (two by suicide and one by accidental death) and two people died in the S17 leave group (one by suicide and one by natural causes). As death is a rare event, it's not going to be possible to demonstrate in a randomised controlled trial whether CTO reduces death. However, as the authors of the study say, because of the restrictions on patients' liberty, the costs and benefits of CTOs do need to be assessed.

Sunday, March 24, 2013

Antidepressant discontinuation problems can be persistent

Article describes patient online reporting of antidepressant discontinuation problems. Persistent post-withdrawal symptoms after 6 weeks are common and can continue for months or years if drug not restarted. I'm not sure how valid the distinction is between immediate withdrawal symptoms and the post-withdrawal phase, but at least this article emphasises that antidepressant discontinuation can be an persistent problem.

(With thanks to post on Mad in America)

Tuesday, March 19, 2013

Frank Bruno’s 12 rounds to knockout mental health problems

Frank Bruno has spoken to the minister for care services about his treatment by mental health services last year (see EDP report). He had already spoken to the Sunday Mirror. As he says on his website, he wants to highlight "what is wrong in the treatment of mental health patients". 

We're not all exercise fanatics like Frank, and some of his other points may need refining, but his campaign should be supported. I had a letter published in the Observer when he was also sectioned in 2003.

Tuesday, January 29, 2013

Is the media distorting findings about antidepressant effectiveness?

Adrian Preda in a rapid response to the debate about whether antidepressants are over-prescribed, which I have mentioned previously (eg. see post), makes reference to his blog entry that blames the media for distorting findings and misleading patients. He makes clear that he is worried that depressed patients may not take antidepressant medication.

I think it is clear that Irving Kirsch is making the case that antidepressants are amplified placebos (see previous post). Preda doesn't really deal with this issue. As I keep saying, there doesn't seem to be any argument that the drug placebo difference in clinical trials is small. The question is whether it can be explained by expectancy effects through unblinding in clinical trials.

Saturday, January 26, 2013

The challenge of reducing and stopping antidepressants

In a rapid response to the BMJ debate I mentioned in my previous post, Philip Gaskell has highlighted the problem of discontinuation of antidepressants. His clinical experience is that "the suggestion that they [patients] might move to stopping such tablets is greeted with fear and resistance". 

I have focused on antidepressant discontinuation problems since my original BMJ letter and the development of my antidepressant discontinuation reactions webpage. The issue continues to create debate on this blog and the Royal College of Psychiatrists has already produced the results of its survey to which Gaskell refers (see previous post).

Lies, damned lies and statistics of antidepressant effectiveness

The BMJ has published a head-to-head about whether antidepressants are overprescribed, with Des Spence saying Yes and Ian Reid saying No. Reid quotes the study by Fountoulakis & Möller (2011) that provided a re-analysis and re-interpretation of the Kirsch data, which I have mentioned previously (eg. see post). Reid concludes, "Sadly, demonstrations of methodological flaws and selective reporting suggest that the conclusions [of Kirsch] were 'unjustified.'"

What Reid doesn't quote is the response by Kirsch et al (2012) which shows that the original calculations were in fact correct. The discrepancy comes from using different statistical techniques, the effect of which is that the analysis by Fountoulakis & Möller treats individual studies as though they are equivalently powered. This is contrary to the standard meta-analytic technique of weighting studies with a large sample size more than the ones with a small sample size.

Let's not get too hung up about the statistics! What is significant is that Reid uses a discrepancy like this to try and undermine Kirsch's conclusion. The fact is that the effect size in antidepressant trials is much smaller than is commonly assumed. Not everyone responds to antidepressants even in the clinical trials. It is possible that the small effect size could be explained by expectancy effects introduced through unblinding (eg. see the article by Jo Moncrieff and myself).

Saturday, January 19, 2013

Event for psychiatrists

Following the special article in the British Journal of Psychiatry (see previous post),  the Critical Psychiatry Network has organised a day at the University of  Nottingham on 15th April 2013 (see provisional programme).