Have fun with drugs

Looks beautiful in Colorado Springs where the 2011 NEI Global Psychopharmacology Congress has just been held. Not sure about the congress opener though. I'm still waiting for Stephen Stahl to post about the RSM meeting on pharmaceutical sponsorship of psychiatry research (see previous post).

What if the drugs don't work?

Article in the Independent with this title. It mentions a debate between Ian Anderson (see previous blog entry) and Irving Kirsch (see another previous blog entry) with the motion "Antidepressants are useful in the treatment of depression" coming up at the 4th International Congress on Psychopharmacology of the Turkish Association for Psychopharmacology.

There's also a quote from Daniel Carlat (who blogs at The Carlat Psychiatry blog), who admits that, "When I find myself using phrases like 'chemical imbalance' and 'serotonin deficiency', it is usually because I'm trying to convince a reluctant patient to take a medication. Using these words makes their illness seem more biological, taking some of the stigma away." As I wrote in a BJPsych eletter, patients are able to understand that the chemical imbalance theory is only a theory. What they find more difficult to appreciate is why they are told that the theory has been proven when this is clearly not the case (see another previous blog entry).

Pleased also to see that Irving Kirsch is talking more about the nocebo effect from coming off antidepressants, as I have for some time (eg. summarised in my chapter in recent book Demedicalizing misery) . To quote from the Independent article, "If you expect to feel bad when you come off antidepressants, you will, because 'we tend to notice random small negative changes and interpret them as evidence that we are in fact getting worse', Kirsch says".

Psychiatrists should know what they're doing with medication

An editorial this month in the British Journal of Psychiatry is entitled 'No psychiatry without psychopharmacology'. It suggests there is insufficient prioritisation of psychopharmacology in psychiatric training. It asks for psychopharmacology to be affirmed as an integral and significant component of psychiatry, and a consequent expectation of a commensurately high level of knowledge and practice.

As I mentioned in my previous post, I've just come back from a conference in Newcastle. Paul Harrison, the main author of the editorial, gave a presentation at the meeting with the same title as the editorial. He thought that the low priority apparently given to psychopharmacology may be related to what he called the 'anti-pharmacological lobby'.  I suppose I would be seen as part of this lobby, but, despite what Harrison implies, I agree that psychiatrists should be well trained in psychopharmacology.

What I didn't hear in his talk, but is mentioned twice in the editorial, is unquestioned belief in the efficacy of psychiatric medication. To quote from the editorial, research shows that "contemporary psychotropic medications are effective". Again, it says that "the evidence that psychotropic drugs are beneficial when used in the right way and for the correct indications is unequivocal".

Good psychopharmacological training will highlight the weaknesses and bias of randomised controlled trials (eg. see my Bias in controlled trials webpage). The trouble with much prescribing is that it is beyond the evidence (and not even conforming to guidelines such as those produced by NICE). Psychiatrists are insufficiently critical of the evidence base for medication.

Are antidepressants really placebos?

I've just come back from Newcastle, where the Faculty of General and Community Psychiatry of the Royal College of Psychiatrists has been holding its Annual General Meeting (see programme). One of the talks was by Professor Ian Anderson entitled 'Are antidepressants really placebos?' As he himself said, as might be expected, his answer was no.

I'm not sure if the talk really had much more in it than a letter he had published in the British Journal of Psychiatry several years ago. Anderson makes a lot of the fact that continuation studies show high relapse rates. Following the results of the meta-analysis by Geddes et al (2003), the average rate of relapse on placebo is 41% compared with 18% on active treatment. In other words, continuing treatment with antidepressants reduces the odds of relapse by 70%. Anderson doesn't think this could possibly be a placebo effect.

Doctors have always underestimated the difficulties of discontinuing antidepressants (see my Antidepressant discontinuation reactions website). If patients are significantly unblinded in discontinuation studies, the negative placebo (nocebo) response could explain these results because of how reliant people have become on their medication. Any change threatens an equilibrium related to a complex set of meanings that their medication has acquired.

No more psychiatric labels

I have joined the campaign to abolish psychiatric diagnostic systems like DSM called "No more psychiatric labels". There is an overemphasis on biomedical diagnosis in psychiatry (eg. see my article with this title). Psychiatry does need to recognise diagnosis for what it is (eg. see presentation from a talk of mine).

Even Allen Francis, Chair of the DSM-IV taskforce, is critical of the approval of new fad diagnoses in DSM-5 (eg. It's not too late to save 'normal' and a more recent Psychiatric Times article). I think we'd be better off without any psychiatric diagnostic system at all for a while rather than go along with DSM-5.

Are the chinese really taking over drug companies?

Stephen Stahl, whose Essential psychopharmacology book now has his name in the title, has a post on his NEI (Neuroscience Education Institute) blog about drug company research. He mentions a crisis meeting at the Royal Society of Medicine this month, which he says he will report on when he gets back. I look forward to hearing more.

He regrets that "Nobody likes drug companies these days". I don't think he's helping their press by seeming to support drug company sponsorship of medical education and illegal marketing of their drugs. At least he admits that half of prescribing in psychiatry is "off label".

Nor is his case helped by misrepresentation of those who express concern about these practices as believers in psychiatric illnesses being "pure inventions of Pharma". As I've pointed out in a previous post, there's no need to be defensive if pharmaceutical companies really are pulling out of psychiatric research.


(With thanks to a post on Carlat Psychiatry Blog).

Unthinkable? R.D. Laing in Guardian editorial

Not sure what prompted an editorial in the Guardian about R.D. Laing in its Unthinkable? series. The editorial makes reference to a production of Knots at the King's Head Theatre. It suggests it is time for a reassessment of Laing in "an era of big pharma and proliferating diagnoses". Samantha Bark in her response says she was thrilled to see the editorial and makes reference to her PhD thesis on Laing, which I have added as a link on my articles critical of psychiatry webpage.

Critical psychiatry has never hidden its origins in the work of R.D. Laing (see my book chapter Historical perspectives on anti-psychiatry). There were excesses in 'anti-psychiatry'. Critical psychiatry aims to avoid the marginalisation experienced by R.D. Laing and others like him designated as 'anti-psychiatrists'.

Mental illness not same as focal brain lesions

Thomas Insel in his NIMH Director's Blog asks whether a neurological approach to mental illness is helpful. He admits it is an "NIMH mantra" to describe mental disorders as brain disorders. I have previously mentioned his view that mental illnesses are disorders of brain circuits.

He suggests mental illnesses are analogous to heart arrhythmias which may not have a demonstable lesion in the heart. He holds out the hope that mapping patterns of cortical function will find abnormal brain circuitry. The example he gives is of apparent delayed cortical maturation in ADHD. Well, let's see - is this conclusion based on one study ie. Shaw et al (2007), which hasn't been replicated? He also speculates that neuroimaging could allow early detection of so-called circuit disorders.

Insel goes on to state that neuroimaging is beginning to yield biomarkers, but then doesn't say what the biomarkers are. He suggests that deep brain stimulation is demonstrating how changing the activity of specific circuits leads to a remission of refractory depression, but doesn't say what circuits are being changed.

Finally, he at least concedes that, "In truth, we still do not know how to define a circuit". He also concludes that "One thing we can say ... is that earlier notions of mental disorders as chemical imbalances or as social constructs are beginning to look antiquated." Not sure why he includes 'social constructs' in this broadbrush remark, as he's not considered this possibility. His faith in the value of neuroscience to help people recover from mental disorders has been the wish-fulfilling phantasy of modern psychiatry since the 19th century.

NHS treatment of eating disorders

I have already mentioned Bryan Lask in a previous post about eating disorders. He has responded to a Guardian leader about specialist treatment for anorexic children. He believes that eating disorders are "highly complex genetically determined, brain-based disorders". However, he doesn't explain why he thinks this.

He expresses concern about the reduction in the number of young people admitted to specialist inpatient units and suggests that they are being admitted to paediatric units instead. I'm not sure where he gets his figures from. He argues that the motivation for closure of specialist units is financial.

I presume he means that NHS savings mean that the number of referrals to private units has decreased. He is no longer medical advisor to the Huntercombe group which runs three such units. Maybe he's worried they'll be forced to close. Current reforms of the NHS (see my personal blog) may well eventually open up the market for the management of eating disorders, but it's not necessarily always been the best use of money to ship difficult to manage patients out of the NHS (again, see another personal blog entry).

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".

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.

Whistling in the wind

Edward Shorter, in his response to an article by Thomas Szasz, says there are solid biological findings in psychiatry. Shorter, who I've mentioned in a previous post, is the Hannah Professor of the History of Medicine at the University of Toronto. In 1996 he was cross-appointed to a professorship in psychiatry. As a non-clinician, has this professional association gone to his head?

The examples he gives of "obvious evidence" are the role of panicogens in triggering panic disorder; the response of catatonia to barbiturates and benzodiazepines; and what he calls the reliable accompanying of melancholic depression by hypothalamic-pituitary-adrenal dysregulation, as reflected in high levels of serum cortisol, a positive dexametasone suppression test (DST) and a shortened rapid eye movement sleep latency.

The reference Shorter gives for the importance of panicogens is from the proceedings of the 32nd annual meeting of the American Society of Clinical Investigation held in Atlantic City on 6 May 1940. In this study, patients with anxiety neurosis were found to increase sighing respiration more than controls when exposed to carbon dioxide and rebreathing. The feelings that they had during this rebreathing tended to resemble or be identical to their panic attacks. Shorter suggests that studies such as this were marginalised because of the influence of psychoanalysis. He doesn't make any mention of the controversy in the literature about the mechanism of action of lactate, which has been seen as the common pathway for the mechanism of action of carbon dioxide and several other panicogens.

The reference he gives for the evidence of the organicity of catatonia was a study of 4 cases, which were actually thought to be neuroleptic-induced, which responded to intravenous lorazepam. Shorter also mentions the response of catatonia to barbiturates. William Bleckwenn's use of intravenous amobarbital to produce lucid intervals in catatonic patients quickly led to the development of the so-called "truth serum".  How's this proved the organic basis of catatonia?

The reference Shorter gives for the biological basis of melancholic depression is his own recent book, written with Max Fink, entitled Endocrine Psychiatry. Fink has been an advocate of ECT over the years. I need to read the book. The DST was rejected as a biological marker because it was insufficiently sensitive and specific. I know that Fink thinks it shouldn't have been rejected, but this does seem to be a very idiosyncratic view. I'll come back to this when I've read the book.

Shorter seems to be using his historical expertise to suggest that modern psychiatry has overlooked evidence of its biological basis. As I have repeatedly said, please do not misunderstand me. Of course mental illness has a biological basis, as does our "normal" behaviour. But to be suggesting that biological markers have been established, or even overlooked in history, is whistling in the wind. This is what Shorter accuses Szasz of doing by claiming the opposite. As Szasz makes clear in his article, what he is stating is what he calls an "analytic truth", not dependent on scientific research.

Furthermore, Shorter suggests views such as those of Szsaz (he actually says the makers of the movie One flew over the cuckoo's nest) have led to many people committing suicide because they've avoided treatment. Not surprisingly, he doesn't give any reference for this opinion. As I've commented in a previous post, it's a pity debates such as this get so polarised.

And I'm not saying this because I totally agree with Szasz (eg. see my book review). But on the point on which Shorter has attacked him, he's correct. Shorter may be right that mainstream psychiatry now acknowledges a neurological basis for much psychiatric illness, whereas when Szasz was first writing psychoanalysis was more influential (see my article). But it's just as wrong to take a biomedical view now as it was then.

Where should first meeting of International Critical Mental Health Movement be held?

In a previous post I mentioned the idea of setting up an International Critical Mental Health Movement. Is there any momentum for this? I'm happy to help organise the first conference. Where should it be held?

Why did the balance between the genders for psychiatric detention switch?

Kate Millett, the feminist and survivor of mental health services, at a seminar organised by Anthony Stadlen that I attended last Sunday, said that more women than men are detained in psychiatric hospital. My thought, although I did not have the figures, was that in fact more men, particularly young men, are detained because of their violence.

It seems we were both right in a way. Up to 1994-5, when Kate Millett was surviving mental health services, more women than men were formally admitted under civil procedures using the Mental Health Act in the UK. After that time more men were detained (Audini and Lelliott, 2002). And it is particularly younger men where there is the imbalance (see figure). And once admitted they tend to stay in hospital longer, as the ratio of men to women resident in hospital at any one time is even higher (see table).

There does not seem to have been much comment about this switch. Women's disadvantaged social status is commonly seen as a factor generating mental health problems, but this doesn't explain the rise in men being detained. Maybe the emphasis over recent years on risk management and accountability is responsible. Ideas please and I'd also be interested in any references in the literature as I can't easily find them.

There should be concern if children are being prescribed medication as a quick fix.

As I mentioned in a previous post, reviewers have been critical of Richard Bentall's book Doctoring the mind for taking aim at child psychiatrists. They also suggest that he characterises psychologists as better educated and trained than psychiatrists to "understand people and the human experience and to provide healing therapy".

I'm not sure if this is the case, but I do know that psychiatrists are more likely to take a biomedical rather than biopsychological approach. I'm a member of both the Royal College of Psychiatrists and the British Psychological Society (see my talk Psychiatrists can have understanding too).

And, it's the British Psychological Society that has supported a call for a national review of the use of medication to treat children’s behavioural issues (see Treating children's behaviour). Peter Kinderman, Chair of the Division of Clinical Psychology, seems confident that psychiatry colleagues would be equally concerned if there is evidence of inappropriate use of drugs or medication.

I don't know how much these sort of reviews achieve. A previous technical report for MPs is a bit out of date now. Still Richard Bentall is concerned that there is inappropriate use of medication, whereas it seems Peter Kinderman would only be concerned if there was. Perhaps we do need an authorative view to let us know. And the reviewers criticised Richard for not providing a reference to back up his view, so he would at least then have one.

Facts about NAMI funding

In my previous post, I noted that reviewers of Richard Bentall's book Doctoring the mind, which I recommend on my Critical Psychiatry website book recommendations page, criticised him, amongst other reasons, for indicating that the National Alliance on Mental Illness (NAMI) is funded primarily by Big Pharma. According to an article in the NewYork Times, "drug makers from 2006 to 2008 contributed nearly $23 million to the alliance, about three-quarters of its donations".

NAMI now lists on a quarterly basis in its website registry all major corporate and foundation grants and contributions above $5,000. What NAMI emphasises is that, as a matter of policy, it does not endorse any specific treatment or service.

NAMI-Vermont has recently decided to diverge from national policy and no longer accept direct corporate contributions from pharmaceutical companies (see message to the membership). On their website, NAMI-Vermont Board President Ellen Vaut of South Burlington explains: “Though NAMI-Vermont has only received between three and seven percent of its total revenues from pharmaceutical companies in each of the past six years and none during the past fiscal year, we voted to dispel any concerns or public perception that our programs and/or organizational practices are influenced by pharmaceutical company money.”

I guess that the national organsiation will find it difficult to follow this lead because of the higher proportion of pharmaceutical funding. Still, quite why the reviewers of Richard's book criticise him for stating the truth is not clear. Perhaps the truth is "incendiary and divisive".

More heat in the debate about psychiatry

A review in Psychiatric Services is reluctant to recommend Richard Bentall's book Doctoring the Mind because it is said to be "incendiary and devisive". The reviewers are frightened that the book exaggerates issues for service users.

I'm not sure who's doing the exaggerating. Richard is said to suggest that there is a long-standing battle for supremacy between psychologists, "who are educated and trained to understand people and the human experience and to provide healing therapy", and psychiatrists, who are "indoctrinated with the medical model, have unwittingly carried Nazi-era notions of the genetic origins of psychosis into the present and are intent on pumping people full of as much useless, dangerous medicine as possible while simultaneously avoiding any conversation".

Richard is also criticised for saying that as many as 50% of psychotic patients would be better off without taking drugs, for claiming that the term "schizophrenia spectrum disorder" was introduced to get the results wanted in genetic research and for indicating that the National Alliance on Mental Illness is funded primarily by Big Pharma. Furthermore, he is said to provide no reference for his suggestion that child psychiatrists do not seem to be troubled by the as yet unknown long-term impact of psychotropic drugs on the developing brain and for his impression that medications are often prescribed by child psychiatrists without any serious attempt to understand or remedy the awful social circumstances in which psychologically disturbed children often live.

It's unfortunate that Richard's argument noted by the reviewers that "the case for a genetic cause of mental illness has been overstated by psychiatrists and that symptoms are much more the result of psychosocial stressors" including behaviour by families, gets lost in this polarisation of the debate. As I've indicated in a previous post, there seems to be some difficulty in having a calm discussion of these matters.

There were even some flames about my own Critical Psychiatry book (see another previous post), although I never managed to get a review in a mainstream psychiatric journal. Still there was a reasonably generous BMJ review. So maybe we should be grateful that books such as Richard's are at least being considered, even if dismissed, by mainstream psychiatry..

Is deep brain stimulation promising?

Deep brain stimulation (DBS) involves placing one or two thin wires into specific locations deep within the brain and then connecting the wires to a battery situated just beneath the skin. A recent article in the American Journal of Psychiatry reports on the  follow-up of 20 patients who received DBS for treatment-resistant depression.

Unfortunately two of these 20 patients died from suicide and one died from colonic cancer. As I said in my psychiatric update for Openmind, there is no clinical trial data about the effectiveness of DBS. I'm sure case reports, such as the latest article, will be used to justify continuing experimentation with it, however limited. I just wish that psychiatry could focus its efforts on providing more hope and effective treatment than DBS.

What should alternative to biomedical model be called?

Tim Thornton has posted a chapter on his In the Space of Reasons blog entitled "The recovery model, values and narrative understanding ". He points to the confusion about the meaning of recovery, and even more so about what a recovery model might be.

As I wrote in my paper "Redressing the chemical imbalance", the concept of recovery is inherently critical of the biomedical model, and Tim Thornton seems to agree with me. I think the problem is its acceptance into official policy and nullification of its impact by interpretation within the biomedical context.

The use of the term 'recovery model' is unlikely to help fully define an alternative psychosocial paradigm. Nor, despite its merits, do I think the notion of 'narrative' will either. I've always said that the origin of the psychosocial approach was with Ernst von Feuchtersleben's The principles of medical psychology, first published in german in 1845 (see my article).

An optimisitic moralism, such as an emphasis on recovery, has always had its moments, perhaps particularly identified in the progressive outlook before the First World war. This can be contrasted with the materialism of an emphasis on structural pathology, producing a therapeutic pessimism, minimising the potential of people to change. It is important to give people hope in mental health services. This strand is one of the sources for a psychosocial alternative to the biomedical model, but I think it's unlikely to define the whole paradigm.

Has the concept of bipolar spectrum been broadened too far?

Catherine Zeta-Jones booked herself into a clinic for 5 days for treatment of her bipolar II disorder (see Guardian story). I don't want to underestimate the emotional impact of dealing with her husband's throat cancer. She has been praised for raising the profile of mental health issues.

One issue that might be worth commenting on further is the way in which the concept of bipolar disorder has been expanded since it became the new name for manic-depressive illness (see my book review for some background). I'm not saying that Catherine Zeta-Jones doesn't have bipolar II disorder, but it might be worth understanding what this diagnosis means.

The expansion in the concept of bipolar spectrum is not dissimilar to what happened to schizophrenia in the 1960s and 70s, particularly in USA, leading to the American Diagnostic and Statistical Manual in its third revision tightening up the definition, so that it was more reliably applied. People may find it helpful to put a label to their mental health problems, but I do have concerns that the diagnosis of bipolar spectrum has become so variable that its validity must be in question.

I've been dismissed as "postmodern" for this sort of questioning of the nosological basis of bipolar depression (see comments following another book review, also previous blog entry). What I am clear about is the need to avoid reification of psychiatric diagnosis. There's always a danger that we tend to assume that a diagnostic concept implies an entity of some kind. But a diagnosis is not a "thing". It's merely an abstract device which is useful for thinking about mental health issues.

I just have concerns that bipolar depression is not as useful as some people make out. And I don't think the argument can be dismissed that one of the reasons people have found the new concept useful is because of the development of so-called mood stabilising medication. There's even been a marketing ploy to develop medication specifically for bipolar depression (see previous blog entry).

Don't get too heated in the debate about psychiatry

Two reviews in Psychiatric Services recommend reading Robert Whitaker's book Anatomy of an Epidemic even if it makes you angry and you want to dismiss him as an anti-psychiatric activist. It's apparently good to read biased, flawed books like this to be able to marshall a response to defend psychiatry. Let's please have this debate. It's not really dealing with the issues by just expressing disappointment that Whitaker blames biomedical psychiatry and suggesting he's illogical to connect the taking of medication with poor outcomes.

Actually, I think all he's asking for is a debate about how drugs increase the risk that people will become chronically ill (see previous post).

Challenging myths about psychiatry

Nada Stotland was the 2008-9 President of the American Psychiatric Association. She writes on Huffpost Health challenging "myths about psychiatry". The trouble is she has promoted just such a myth. She writes, "Using brain scans ... we now can distinguish between the brain of a person with depression and a person who is not depressed". Evidence please. And perhaps she could explain what the "many, many other such observations" are.

Political nature of psychiatry

Interesting seminar last week, which I attended, organised by Tony Stadlen, invited Vladimir Bukovsky, the anti-communist, to talk about his experiences of being detained in psychiatric hospital in the Soviet Union. Luckily for him, he was never given psychiatric medication and there was a dispute amongst psychiatrists about his diagnosis.

His case nonetheless highlights, which Bukovsky himself did, the political nature of psychiatric diagnosis and its potential for misuse. In Soviet psychiatry, the particular problem was the development of diagnoses such as sluggish or creeping schizophrenia and paranoid development of the personality, and the Soviets withdrew from the World Psychiatric Association for a while because of criticisms of their political abuse of psychiatry. People who do not fit into society are at risk of being regarded as mentally ill and such a mechanism can be exploited by the state.

Many factors affect the number of antidepressant prescriptions dispensed in particular areas

The Guardian has published a map of GP antidepressant prescribing. Its article based on the data makes a lot of the finding that it tends to be Northern parts of England with higher numbers of prescriptions.

However, as the care services minister commented, "There are many factors that affect the number of antidepressant prescriptions dispensed in one particular area". For a start the Guardian data is not age standardised. There are significant differences between GP practices in the same area, which can be greater than the average differences between areas. The article doesn't mention the high rates in Norfolk and Waveney where I work.

Deprivation is likely to be a factor in prescribing as mental health need is correlated with deprivation. Pharmaceutical company marketing influences cannot be ignored.

Rank order of antipsychotics for producing weight gain

A review in the Archives of General Psychiatry looks at the evidence for weight gain and changes in other cardiovascular risk factors caused by antipsychotic treatment. It has produced a rank order of the different drugs with olanzapine noted to cause more weight gain than all other second-generation antipsychotics except clozapine. Clozapine causes more weight gain than risperidone, risperidone more than amisulpride, and sertindole more than risperidone. The average weight gain after 6 to 8 weeks taking olanzapine was found to be 5 to 6 kg, which was significantly higher than the average weight gained while taking risperidone (4 kg) or haloperidol (3 kg).

Antipsychotic medication does seem to reduce brain volume

I have mentioned a study in a previous blog entry that seemed to show that antipsychotic medication reduces brain volume. This study was referred to in an interview with Nancy Andreasen. The point I was making in the previous entry was that the research had been "sat on" for fear it may lead to people stopping their medication.

The study has now been published in the Archives of General Psychiatry. The authors mention, as I did in my previous blog entry, that an association does not necessarily mean a causal connection. However, the evidence is quite strong considering that illness severity and substance misuse had minimal or no effects and data from animal studies also suggests brain tissue loss.

Of course we have known for some time from clinical evidence that antipsychotics cause brain damage in that tardive dyskinesia is not necessarily reversible when antipsychotic medication is discontinued. This is reflected in the finding of a specific increase in size in the putamen in the present study. We don't know that brain changes are necessarily "bad" for patients, but, as the study itself concludes, we have to entertain the possibility that antipsychotics may have potentially undesirable effects of brain tissue volume reduction.

Understanding psychosis

This post has the same title as the latest post from the Healthy Minds. Health Lives blog, my favourite for commenting on because it is published under the auspices of the American Psychiatric Association (APA) (see previous post). The APA blogger suggests that it helps to understand psychosis by recognising its connection with the brain. Does it really? It's merely tautologous. Of course it's something to do with the brain. So what? Knowledge of the brain doesn't give any understanding about personal and social factors.

Actually understanding the irrational may require more than being logical. What makes us think that someone is mentally ill may be that what they are saying is difficult to follow and understand. It makes us think there is something wrong mentally. It doesn't help to wishfully speculate about brain processes when what is required is considerable effort to understand why someone may have crazy experiences and express themselves in a mad way. We don't live in the real world for all sorts of reasons, including our own convenience about understanding the world. And it suits the APA blogger to have her biomedical belief about psychosis.

Menacing cloud hovering near prospective patients

Seroquel is the best-selling psychiatric medication in the US and, as pointed out in a feature in Medical Marketing and Media (MM&M), its patent is due to expire in 2012. Its manufacturers, AstraZeneca, last year reached an agreement to settle US product liability litigation over Seroquel for about $198 million (see Wall Street Journal article). Earlier in the year it also paid $520 million to resolve allegations that it marketed regular Seroquel for off-label uses between 2001 and 2006.

However, this doesn't seem to matter to Astrazeneca financially with global Seroquel sales of $4.9 billion in 2009. And it is MM&M's Large Pharma Marketing Team of the Year. It has approval for an XR formulation which extends the use of the drug under patent. This formulation has been approved as an add-on to antidepressants for the treatment of major depressive disorder. 

There's a full page advert for it on the back of this week's BMA News, which does not use the cloud as in the US campaign. The image of the depressed woman curled up in her kitchen unable to do her washing, which is used to advertise seroquel XL (it's called XL, not XR, in the UK) to UK doctors, for some reason seems to be different from that used for direct-to-consumer US advertising.

Off-label use of atypical antipsychotics

A Reuters report based on an article in Pharmacoepidemiology and Drug Safety suggests atypical antipsychotics are overused. The article looked at trends in outpatient prescribing in the US. Antipsychotic use for indications without FDA approval increased between 1995 and 2008 with an estimated cost associated with off-label use in 2008 of US$6.0 billion. Atypical use has grown far beyond substitution for the now infrequently used typical agents.

(With thanks to Vince Boehm)

Opportunities and threats for psychiatry

In an e-interview in The Psychiatrist, John G. Csernansky was asked what he saw as the most promising opportunity facing the psychiatric profession and what he saw as the greatest threat. He said the most promising opportunity was the introduction of new knowledge about neuroscience into the practice of psychiatry. The greatest threat was that the public has become impatient with the lack of progress of biomedical research and may begin to withdraw its support for it.

Psychiatry has seen itself on the verge of neuroscientific breakthrough ever since its modern origins over 150 years ago. We are no nearer being "finally on the threshold of knowing enough to develop reasonable models of the pathophysiology of neuropsychiatric diseases and how to treat them", as Csernansky believes, than we were then. It's not so much that the public has become impatient with the lack of progress but that there needs to be a conceptual shift in understanding. The reason progress hasn't been made in biomedical research is that it is "barking up the wrong tree". The sorts of neurobiological processes underlying mental disorder may be no different from the basis of our "normal" thinking, feelings and behaviour.

By the way, when Csernansky was asked what single change would substantially improve quality of care, he said simplification of how we pay for mental healthcare. This is just at the time when the UK government is reforming health care (eg. see my personal blog entry), which will lead to the introduction of a mental health tariff based on clusters of patients which people don't, at least currently, understand. Still, it will be possible to undercut the national tariff, so maybe the new clustering system will never get off the ground. Anyway, the introduction of a tariff complicates block contract arrangements which we have got used to in the NHS and there is a lack of evidence that this change will lead to an improvement in services.

A cute little video about a visit to a psychiatrist

(With thanks to Adinah's post on ICSPP Discussion Group giving the link. See also her comment on another blog.)