Speak out against psychiatry

I like to think of critical psychiatry as a broad church. For example, the last Critical Psychiatry Network conference I organised in Norwich in 2009 was called 'Promoting the critical mental health movement'. As I wrote in the blurb:-

The critical mental health movement is comprised of various perspectives developing a critique of the current psychiatric system. These range from reform to revolution. Although there may be debate about how much can be achieved within psychiatry, the movement is held together by recognition of the need for fundamental change.

Speak Out Against Psychiatry is organising an event at the Royal College of Psychiatrists in London on 27 July. This is a group of people who have either used, or have been in close contact with people who have used, psychiatric services. A lot of the people they have spoken to have had a very negative experience of psychiatry, and many feel they have not been treated like human beings - that they are labeled as “ill” and given drugs rather than being listened to and offered support. The experiences are particularly painful for people who have been detained under the Mental Health Act. When detained in hospital, people can be forced to take medication, and often feel that anything they say is dismissed as a symptom of their “illness” rather than their genuine fears and frustrations of being imprisoned in what can be a terrifying environment.

Speak Out Against Psychiatry wants to give these people the chance to come together and speak about their experiences, and are going to be doing this outside the Royal College of Psychiatrists on the 27th of July between 4pm and 6pm. They also want to give people the opportunity to discuss alternative, humane ways of helping people in distress.

I have always said that the root problem in modern psychiatry is the belief that mental illness is a brain disorder. My personal view is that psychiatry can be practised without the justification of postulating brain pathology as the basis for mental illness. This position should not be misunderstood as implying that mind and brain are separate. Perhaps a way to express what I am saying is that mental disorders must show through the brain but not always in the brain.

I think it is important that there is a forum for debate both within critical psychiatry and between critical and mainstream psychiatry. I have suggested setting up an International Critical Mental Health Movement (see previous blog entry).

Although the manifesto of Speak Out may be more radical than I would express myself, I do think it is important that psychiatry engages in this debate. In this sense, mental health services would be truly centred on users of services. The views of critical psychiatry are not marginal to the present situation in modern mental health services.

Survey about stopping antidepressants

The Royal College of Psychiatrists is doing a survey to look at people's experience of stopping antidepressants. This is to help produce a 'Stopping antidepressants' leaflet. The problems produced by discontinuing antidepressants are seen as an area of disagreement.

Some time ago I set up my Antidepressant discontination reactions website. This was following a letter (at the bottom of the letters on this link) I had published in the BMJ. Psychiatrists were slow to recognise antidepressant discontinuation problems (see powerpoint from a talk).

Psychiatric classic

Nice to see that the BMJ in its Views & Reviews series regards Arthur Kleinman's Rethinking psychiatry as a medical classic. I include it my critical psychiatry website book recommendations page.

A focus on culture arises out of the combination of anthropology and psychiatry. Indigenous healing systems worldwide use nonspecific symbolic techniques to counteract demoralisation. Kleinman promotes a paradigm shift in medical and psychiatric practice to create a robust relationship between psychiatry and the social sciences.

The review was written by a junior doctor (in anaesthetics) who says he was left "uninspired by the basic sociology taught at university". Rethinking psychiatry invigorated a renewed interest for him. This confirms what I said in a previous post about what might attract young doctors into psychiatry.

Psychiatrists do not believe that psychotropic drugs fix chemical imbalances in the brain

A book review of Anatomy of an epidemic is critical of Robert Whitaker for "settling for a simple but crude interpretation: those drugs messed you up". There may be some validity in pointing to the "totalising argument" and the "expansive sweep" of his interpretation. Actually, as I've noted before, I think the value of Whitaker's books is the way he describes the evidence for the vulnerability created by taking medication.

Perhaps surprisingly, the reviewer deflects Whitaker's argument by suggesting he knows of "no serious psychiatrist who believes that psychotropic drugs 'fix chemical imbalances in the brains' of their patients". That's good, because as a recent article in Philosophy, Psychiatry and Psychology points out, theories, such as the dopamine hypothesis of schizophrenia, have "held the status of a scientific paradigm defended by some with great avidity". The article suggests the psychiatric field "needs to become more self-critical about the validity of its theories". There is a sense in which chemical imbalance theories have persisted despite the contrary evidence. Many patients believe them because they think that's what psychiatrists believe.

Attracting people into psychiatry

Thomas Insel, in his NIMH Director's blog, views clinical neuroscience as the answer to psychiatry's recruitment problem. The dean of the Royal College of Psychiatrists, Rob Howard, has also said that recruitment into psychiatry is at a crisis point (see his May 2009 newsletter). Solutions were discussed at a London division academic day (see Frontier Psychiatrist blog).

The problem with Insel's remedy  is that too many young psychiatrists, if they believe him, will become disillusioned. He makes reference to an NIMH Neuroscience and Psychiatry module Translating neural circuits into novel therapeutics, which suggests that impaired GABA neurotransmission in chandelier neurons in the dorsolateral prefrontal cortex contributes to cognitive impairments in schizophrenia, which may be corrected by an agonist for GABA_A alpha 2 subunit receptors. The module mentions a small RCT using such a drug, MK-0777, which seemed to find evidence of improved performance on memory tasks, but doesn't mention a larger scale study which failed to show any improvement in cognition.

Putting on one side that cognitive impairment in schizophrenia may well be functional, the complexity of speculation is supposed to excite people into understanding the pathological basis of psychiatry so that they can develop so-called rational treatments that then undergo rigorous testing. But are hypothetical, wishfulling phantasies really going to attract a new batch of recruits?

Personally, I suspect we need to remind ourselves of the interest in psychiatry which Aubrey Lewis stimulated at the Maudsley Hospital Medical School after he was appointed Professor of Psychiatry in 1948. For him, postgraduate psychiatry should be for "ardent, critical, lively, disputatious and reflective, eager minds" (Lewis, 1947). He encouraged a sceptical approach to psychiatry. He had little patience for imprecision or poorly thought-out ideas.

As Michael Shepherd pointed out in a BJPsych article, "Throughout his professional life Sir Aubrey was at all times an educator who was much concerned with the problems of recruitment into psychiatry, more especially with quality rather than quantity." Doctors with open minds, who are sceptical of psychiatric quackery, need to be attracted into psychiatry.