Think about investing in intercultural mental health

My previous entry implied that the 'Grand challenges in global mental health' initiative is a thinly veiled attempt to obtain funding from the Gates Foundation for mental health research. I'm not sure if this is right, as the Gates Foundation Global Health Strategy has "chosen not to focus on research in mental health, even though it is a serious health problem in developing countries, in part because of the very large contributions already being made by the U.S. National Institutes of Health, the pharmaceutical industry, and other funders".

I guess the initiative must be directed at other funders, or maybe it's hoping the Gates Foundation will change its mind. Anyway, well done to the Gates Foundation for not supporting such a project.

Thought needs to be given to the conceptual foundation of any investment in intercultural mental health. 'Grand challenges in global mental health' tied itself to the academic concept of 'global mental health' linked to a past series of Lancet articles. However, there are problems with the validity of the knowledge base for this approach (see Derek Summerfield's BMJ article). The best book in the field of transcultural psychiatry (I prefer the term intercultural - see David Ingleby's chapter from my Critical psychiatry book) is Suman Fernando's Mental health, race and culture.

How to get money for global mental health research

The Grand challenges in global mental health initiative reckons it has identified priorities for research in mental, neurological and substance-use (MNS) disorders (see Nature article). Similar initiatives in global health in general and in chronic non-communicable diseases have led to the commitment of significant new programmes of funding from the Bill and Melinda Gates Foundation amongst other research funders.

The term 'mental health' is seen as a convenient label for MNS disorders, excluding conditions with a vascular or infectious aetiology because these were covered by previous initiatives. This brain disorder bias seems to reflected in the identified priorities. Such priorities obviously also reflect the biases of the assembled international panel. They don't seem particularly interested in what people with mental health problems themselves in different parts of the world want.

Drug companies losing interest in psychiatry is great news

Letter from Sami Timimi in response to BMJ news article about drug companies pulling out of neuroscience research. I've mentioned in a previous post that I'm not sure if this is really the case. But if it is, as Sami points out, that's a good thing - we shouldn't be defensive about it. Psychiatry research has for too long been dependent on drug company sponsorship. The biomedical myth has been used as the justification for too much psychiatry research in general.

Could antidepressants really be a hoax, a mistake or a concept gone wrong?

The New York Times Sunday review has an article by Peter Kramer 'In defense of antidepressants'. He finds it worrisome that antidepressants may be merely placebos with side effects (see previous blog entry).

He suggests that the way pharmaceutical companies produce data submitted to the FDA to obtain a licence for antidepressants is "sloppy" because subjects who don't really have depression are included. He argues that this recruitment bias of an "odd bunch" of people increases the placebo response rate for so-called mild depression, but he doesn't explain why this complication should necessarily change the finding of a small statistical difference between active and placebo groups.

He thinks studies done in specific disorders, such as depression in neurological conditions, eg. stroke, multiple sclerosis and epilepsy; depression caused by interferon; and anxiety disorders in children, have greater external validity. Furthermore, he suggests that results in chronic and recurrent mild depression, such as dysthmia, are more trustworthy, but doesn't give a reference.

He goes on, "Scattered studies suggest that antidepressants bolster confidence or diminish emotional vulnerability — for people with depression but also for healthy people." It was this aspect that was perhaps most questionable about his book Listening to Prozac. He seems to think the placebo effect is a good thing, without realising that what he is describing is a placebo response.

Nor does his argument on maintenance studies wash. He suggests that withdrawing placebo shouldn't have any effect. Again, this does not seem to demonstrate much understanding of the placebo effect. Withdrawing a substance which is believed to have improved mood inevitably will produce a nocebo effect.

Kramer is also critical of a JAMA study picked up by a USA Today piece 'Study: Antidepressant lift may be all in your head'. He suggests the selectivity of the study made it one that "could not quite meet the scientific standard for a firm conclusion". He thinks the media should not embrace what he calls "debunking studies".

He concludes that "it is dangerous for the press to hammer away at the theme that antidepressants are placebos. They’re not. To give the impression that they are is to cause needless suffering." I guess that it's just too difficult to accept that antidepressants could "really be a hoax, a mistake or a concept gone wrong".