Don't be taken in by neuropsychoanalysis

Oh dear! - in an eletter in response to the article that I keep mentioning about paradigm shift in psychiatry (eg. see previous post), a past chair of the Faculty of Psychotherapy of the Royal College of Psychiatrists confirms he's been taken in by neuropsychoanalysis (see his editorial to which he refers in the eletter). He doesn't mention the case against neuropsychoanalysis (eg. Blass & Carmeli, 2007). I had my own views confirmed in person recently by attending a seminar by Rachel Blass organised by Anthony Stadlen.

Holmes is worried that psychodynamic psychotherapy has become "something of an endangered species", in a similar way to those proposing remedicalised psychiatry are worried that psychiatrists could become extinct (see previous post). I do understand what he is saying about the brain being dynamic rather than static but to believe that psychoanalysis has gained credibility because physical correlates of its "black-box postulates" can now be envisaged on a fMRI scan is neo-phrenological phantasy. Sorry, psychiatry does have to deal with the complexity and uncertainty of human relationships, however "vague and anodyne" Holmes may find this. I take a more pragmatic than postmodern view of psychiatry (see previous post), but still prefer my neo-Meyerian approach to his environmental neuroscience.

I think it's a shame to see the history of psychoanalysis and psychodynamic psychotherapy being given up to modern neuromania.

Clinical psychologists should take on more responsibility

Peter Kinderman and Sam Thompson, in an eletter in response to the article I mentioned in a previous post, suggest replacing psychiatrists with clinical psychologists. I'm not against this development and have even promoted clinical psychology, being a general member of the Division of Clinical Psychology of the British Psychological Society myself. I often tell the story of when I applied for clinical psychology training years ago that I was advised to go back and complete my medical training, which I had given up midstream, as I would then have more influence as a psychiatrist with my views about mental health services.

I would like clinical psychologists to take more responsibility as clinicians, even becoming responsible clinicians under the Mental Health Act (see previous post). They tend to retreat into becoming cognitive behavioural or some other psychological therapist, which is fine for those that want to do it, but mental health services are about more than psychological therapy (and some clinical psychologists don't even get that right eg. see another previous post). I support clinical psychology creating a career structure that pays them more for taking on more clinical responsibility.

How to mislead people with IAPT

Following up my previous post about IAPT (Improving Access to Psychological Therapies), I  have looked at the evaluation by Glenys Parry et al (2011) of the two demonstration sites for the programme. Although this report was published last year, it seems to have raised little interest. I can't even find it referenced on the IAPT website. Perhaps the IAPT programme doesn't want to take note of its findings.

I have been complaining that proponents of IAPT have been making claims for its effectiveness (including numbers of people moving off benefits) without comparative data. Glenys and colleague's study did have comparator sites for each demonstration site, although one of them obtained IAPT funding during the period of the evaluation. At four month follow up, the IAPT cohort and the comparison cohort had improved on all the patient-reported outcome measures with a similar degree of improvement. At eight months there were no statistically significant differences between the cohorts. 

By contrast, a research study comparing face-to-face (FTF) with over-the-telephone (OTT) delivery of low intensity cognitive behavioural therapy has been received enthusiastically by the IAPT programme. The study found that the two methods of delivery were just as effective and it was cheaper to use the phone. I suppose if IAPT doesn't really have much effect, then doing it over the phone isn't going to make it worse and it's better not to waste too much money on the programme.

I agree with Rosemary Rizq that this is a perversion of care (also see her paper -  IAPT, anxiety  and envy). IAPT is turning away from the realities of managing distressed people. Of course, this isn't new for mental health services, but it's particularly blatant with IAPT.

Turning neuroscientists into psychosocial psychiatrists

Interesting paper on Adolf Meyer, about whom I have published, linking his psychobiological ideas with critical psychiatry (eg. see article and edited book).

Having had an elite training in Zurich, Paris, London, Edinburgh, Berlin, and Vienna, Meyer emigrated from Switzerland to USA in 1892 and his first job was at the Illinois Eastern Hospital for the Insane at Kankakee as a pathologist. Disgusted at being seen as the 'ominous crow' who was summoned when a patient's death seemed imminent, he started visiting the wards with another physician discussing possible causes, diagnoses, and treatments at the bedside in the presence of the patient and staff. He fetched patients from the ward and escorted them to the staff residence where his colleagues were occupied with leisure activities and examined them at length. He said he gained the confidence of the patients, found out points overlooked in the ward and roused the interest of the physicians.

Thereafter he threw himself into the clinical field. When he moved to the Worcester Hospital for the Insane in Massachusetts, he standardized procedures for examination, history taking, and ongoing clinical observation; encouraged discussion and collaboration among the staff regarding cases; and integrated the data collected at the bedside with those observed at autopsy. He emulated Kraepelin, whom he had spent a summer on sabbatical with in 1896, by creating a catalogue of detailed case histories, handwritten on index cards.

As the director of the Pathological Institute established by the New York State Commission in Lunacy, he spent a week at every state asylum in New York, leading case conferences, teaching clinics, and ward rounds and demonstrating satisfactory examination and history taking procedures to the staff. He then became the first psychiatrist-in-chief at Johns Hopkins, gaining a reputation as the "Dean of American Psychiatry" before he retired in 1941.

Maybe modern neuroscientists can learn from Meyer's experience of changing from neuropathologist to focusing on the patient as a person. Trouble is too many are attracted to neuroscience as it avoids the need to be centred on patients.

IAPT propaganda truly impressive

The chief executive of the NHS in a foreword to a report on the 3 year review of Improving Access to Psychological Therapies (IAPT) (see my previous comments about this programme eg. Is mental illness curable by CBT?) thinks that the progress made has been "truly impressive". The Care Services minister emphasises that by the end of March 2012 "more than 1 million people have used the new services, recovery rates are in excess of 45% and 45,000 people have moved off benefits".

What isn't spelt out from the figures in the report is that only 60% of the people using the service complete a course of treatment. The percentage of people completing a course of treatment has decreased as the service has grown.

Rccovery is no longer defined in a report of this sort. Maybe we are just supposed to assume we all know what recovery means. To be considered cases at the start of treatment patients are required to score above 9 on the PHQ-9 and/or above 7 on the GAD-7 at assessment. They are said to have recovered if their score goes below these cut-off levels at the end of treatment. The higher patients’ initial PHQ-9 and GAD-7 scores are, the less likely they are, therefore, to recover. Recovery rates have steadily improved from 17% to over 45% over the first three years of the programme, which the report boldly states shows that services are becoming more effective. However, no data is given about whether there have been changes in baseline scores. Is the apparent increase in effectiveness due to milder cases being taken on?

Nor are the so-called economic gains controlled. How many of the 45,000 said to have moved off benefits would have done so without IAPT? Depression and anxiety get better with time without treatment. How many would have recovered without IAPT? The programme cannot make claims about effectiveness as it is not a controlled clinical trial.

This is political exploitation of psychological quackery. The programme now seems to be making a case for more funding to deal with its growing waiting list. Let's have a proper evaluation first.

Psychiatry in dissent

I have mentioned the book Psychiatry in dissent in a previous entry. Vivek Datta echoes this book in the title of  his eletter posted in response to the article about psychiatry beyond the current paradigm that I mentioned in the previous post. He makes clear that the motivation for a remedicalised psychiatry is the fear that psychiatrists will be made redundant in the current financial pressures on health systems (see another previous post).

He misses the point that medicine in general needs to be more patient-centred. Psychiatry could, and in theory should, lead the way on this. Patients should be suspect of a remedicalised psychiatry that clearly is primarily about the interests of psychiatrists, not patients.

Psychiatry beyond the current paradigm

Special article, with my name (see my book chapter on need for paradigm shift in psychiatry) as one of the 29 authors (first author Pat Bracken - see previous post), has been published in the British Journal of Psychiatry. An accompanying editorial by Arthur Kleinman, who I have mentioned in previous posts (eg. see entry), argues that academic psychiatry has been too biomedical. Perhaps it's easier for Kleinman to say this in a British journal, rather than in the USA where NIMH has dominated research (eg. see previous blog entry).

Congratulations to the BJPsych editor for encouraging this debate. I have said previously that I have been surprised by some of his comments from the editor's desk (eg. see post). He has made his position clearer in his current commentary. He seems worried that psychiatry may be no more than quackery. I'm not saying this to encourage a civil war in psychiatry, but his position could encourage neuromania (eg. see previous post). We need to move on from this.

Defining psychiatry

Recent article in The Lancet makes reference to an article that I commented on in a previous post. It suggests that in some ways psychiatry is a "speciality only beginning to define itself". 

Wonder why it's taken so long to do that! Perhaps the article is trying to dissociate itself from psychiatry's history (see my chapter in Mental health ethics). If it's following the previous article, this means believing that psychiatry needs to "realign itself as a key biomedical specialty at the heart of mental health".  That's always been the hope of psychiatry that it will find the biological basis of mental illness. And, what's that got to do with being a "branch of medicine that seeks to support some of the most marginalised members of society", which is what the article says psychiatry is? 

The latter characterisation of psychiatry may even raise questions. The article favourably references The Lancet's Global Mental Health Series, which I have commented on in a previous post. However, social factors, such as poverty and injustice, are not necessarily at the centre of the understanding of mental health problems in modern psychiatric practice. 

The article also mentions the  Schizophrenia Commission's recent report, but doesn't mention the Inquiry into the schizophrenia label (ISL) (see previous post).  Suman Fernando, one of the ISL co-ordinating group, has commented on the report. Psychiatry should be about treating people with mental health problems as persons, but this isn't always the case. A helpful feature of the Schizophrenia Commission's report is its recognition that too many people with a diagnosis of schizophrenia are in secure psychiatric provision.

Overdiagnosing bipolar disorder

An article in Acta Psychiatrica Scandinavica, of which one of the authors is Nassir Ghaemi (whom I have mentioned before eg. see post), says that the claim of overdiagnosis of bipolar disorder is mistaken. True, the paper which is commonly quoted to substantiate this point also found considerable underdiagnosis. Of 145 patients who reported they had had a previous diagnosis of bipolar disorder, only 63 were diagnosed as such using the Structured Clinical Interview for DSM-IV (SCID). But there were also another 27 patients picked up on SCID that had not had that diagnosis.

The article uses these figures to argue that bipolar disorder is mainly underdiagnosed. This is motivated by the authors' belief that antidepressants are not very effective in bipolar depression and these people would do better on mood stabilisers. However, the dispute about the significance of the figures misses the main point about the validity of bipolar II disorder. Has the diagnosis of bipolar disorder been extended too far to include people who would not necessarily have been seen on that spectrum (see previous post)?

Is it critical to use the term 'schizophrenic patient'?

A comment on my previous post (as does a tweet from Jacqui Dillon) takes me to task for using the term 'schizophrenic patient'. But, is it such a crime? I am a doctor and I do see patients. I don't think the term 'patient' should be monopolised by biomedicine.

Patients may also be diagnosed as schizophrenic. Of course there is an issue about what this means. The point I was making in the post is that schizophrenia cannot be diagnosed from a brain scan, and even the most biomedical of psychiatrists, such as E Fuller Torrey and Stephen Stahl (see previous post) agree with that. This message needs to be understood more widely. Public perception is often that schizophrenia can be diagnosed from a scan.

It is not possible to diagnose anosognosia in schizophrenic patients on brain scan

As I mentioned in my previous post there has been a clash between Sandra Steingard and E Fuller Torrey about anosognosia in schizophrenia. Where they are both agreed is that it is not possible to use a brain scan to diagnose this condition or even schizophrenia itself. However, it may be difficult to realise this from the brain scan image above taken from the Treatment Advocacy Center's  backgrounder webpage on pictures of anosognosia, which implies that anosognosia is due to decreased blood flow in the precuneus region of the brain. Sandra Steingard is right to object to this misleading brain overclaim, which is very common in the literature (see eg. previous post).

Despite Fuller Torrey's accusation, I am aware of the evidence that he cites for brain volume reduction in schizophrenia. However, I do object to his interpretation of this data as evidence of schizophrenia being a brain disease as such and his apparent unwillingness to debate his speculation. Any differences in brain volume are modest and there is an overlap with the normal population. The result is also non-specific as similar findings are found in other psychiatric conditions. Confounding variables such as nutrition and hydration also affect brain volumes. An association does not necessarily imply a causal link, as Fuller Torrey knows, and he should be more cautious in interpreting the data. 

E Fuller Torrey attacks "The new antipsychiatry"

E Fuller Torrey has upset Robert Whitaker (see Dear Dr Torrey: Please stop the lies) because of his response to a post by Sandra Steingard on the Mad in America blog (to which she has also replied). Fuller Torrey says that the Mad in America blog has become "one of the new antipsychiatry centers". I've said in a previous post that I get irked sometimes if I'm seen as an anti-psychiatrist.

I mentioned Fuller Torrey in my Critical psychiatry book (see relevant passage). In 1974 he wrote a book  called The death of psychiatry, which agreed with Thomas Szsaz, who unfortunately recently died (see previous post and Guardian obituary), by opposing involuntary psychiatric interventions and the insanity defense. Fuller Torrey subsequently changed his mind and now advocates for forced treatment through being founder of the Treatment Advocacy Center and executive director of the Stanley Medical Research Institute. He doesn't mention The death of psychiatry in his list of books on his "about" webpage on the Treatment Advocacy Center website. I did a critical review of The invisible plague, a book which is on the list.

I don't think I'm as ignorant as Fuller Torrey says I am by questioning what it means to say that schizophrenia is a brain disease. As I keep saying, please do not misunderstand me. Of course, schizophrenia is a brain disease in the sense that mental health problems, just like our normal and everyday behaviour, thoughts and emotions, are due to the brain. That's mere tautology. But Fuller Torrey is claiming more than this. He's suggesting there's brain pathology, and the evidence for this is lacking.

As for anosognosia, which started this spat off, I think it's stretching a point to regard lack of insight in schizophrenia as the same as anosognosia caused by brain injury or stroke. But I doubt whether there's anything to be gained by arguing with Fuller Torrey about it. He's too stuck in his reaction formed from giving up his Szaszian views from the past. His worldview means too much to him (see previous post about this point in relation to Robert Whitaker) to give it up. 

Stronger conflict of interest policies needed

Article analyses five cases exposed by Senator Chuck Grassley of eight psychiatrists under-reporting pharmaceutical company earnings to their academic medical centers and the National Institute of Health. The concern is that these conflicts of interest affect promotion of a drug and are not taken into account when research funding is allocated.

It is difficult to know how generalisable these cases are or whether psychiatry is more problematic than other specialities. The article questions whether transparency in physician-industry exchanges is sufficient. Apart from the emotional consequences, the psychiatrists in these cases escaped largely unscathed. Only one academic medical center had its research funding affected. The NIH seems reluctant to intervene and the head of NIMH helped one of the worst violators avoid serious consequences, for which he later apologised (see The Chronicle of Higher Education article). The problem is endemic in the system.

The majority of psychiatrists think adult ADHD is an example of the over-medicalisation of everyday life

I have just attended the second day of the annual conference of the General and Community Faculty of the Royal College of Psychiatrists. There was a debate today on the motion that adult ADHD is an example of the over-medicalisation of everyday life. Perhaps surprisingly, the majority present voted in favour of the motion.

When I trained, adult ADHD was never mentioned - it's a relatively new concept, gaining popularity in the 1990s. Many psychiatrists don't feel happy diagnosing a condition in adults that they were taught children generally grow out of. There may be problems with diagnosing children, mainly boys, as hyperactive (eg. see my eletter), but it is even more problematic to recognise ADHD later in life, the majority identified being females. Interestingly enough, the majority of British psychiatrists seem to share these concerns. The diagnosis of adult ADHD has been led by the Americans, and it has been said that it is the most common undiagnosed chronic psychiatric disorder in adults (see my BMJ article). British psychiatrists are following their lead in diagnosing it more commonly.

The point I'm making is that psychiatry doesn't seem to be in control of this development. The majority of psychiatrists, at least British ones, have reservations, but they don't seem to express them. There is a problem with voicing concerns about such trends for fear of being labelled as anti-psychiatry (see eg. previous post). We need to encourage a more open debate on issues within psychiatry.

Driving the development of mental health services by rhetoric

West Australian Labor MP Martin Whitely has given a speech in the Legislative Assembly, Parliament of Western Australia, a transcript of which he has posted on his Speed Up & Sit Still website. He is critical of Patrick McGorry, who I have mentioned in a previous post. McGorry's ideas are affecting the development of youth mental health services in the UK. 

What does it mean to say that antidepressants are not addictive?

The Royal College of Psychiatrists has published a leaflet with the results of a survey about coming off antidepressants, which I mentioned in a previous post. Generally, I think this is a helpful leaflet. However, it ends with a throw-away remark, "We would like to reassure readers that despite some people having symptoms of withdrawal when stopping antidepressants, antidepressants are not addictive".

I think what is meant is that there is no evidence that the body gets addicted with antidepressants. However, people can get psychologically addicted and it seems confusing to restrict the use of the term 'addiction' to physical addiction. GlaxoSmithKline, the makers of paroxetine, eventually dropped its insistence that paroxetine is not addictive, I think at least partly because of this confusion (see Guardian article).

Helpfully, the survey confirms that the primary symptom of antidepressant discontinuation is anxiety. This would fit with my argument that antidepressant discontinuation problems are due to psychological dependence (see my Antidepressant discontinuation reactions webpage and my book chapter Why were doctors so slow to recognise antidepressant discontinuation problems?)

Restricting the critique of psychiatry

One of Thomas Szasz's last papers (see previous post) was the write-up of an invited address, presented at the Annual Meeting of the International Society for Ethical Psychology and Psychiatry (ISEPP), Los Angeles, California, 28 October 2011. Szasz wanted to monopolise psychiatric criticism, restricting it merely to the abolition of psychiatric coercion. In my view, to do so undermines the critique of psychiatry.

The primary problem with modern psychiatry is its reduction of mental illness to bodily dysfunction. Objectification of those identified as mentally ill, by insisting on the somatic nature of their illness, may apparently simplify matters and help protect those trying to provide care from the pain experienced by those needing support. But psychiatric assessment too often fails to appreciate personal and social precursors of mental illness by avoiding or not taking account of such psychosocial considerations (see previous post). Mainstream psychiatry acts on the somatic hypothesis of mental illness to the detriment of understanding people's problems.

Szasz was correct that he first made this argument in The myth of mental illness but its impact was undermined by his insistence on the abolition of the Mental Health Act. 

Inaugural meeting of London Asylum Group

Dave Harper has called the inaugural meeting of the London Asylum Group at:

6.30-7.30pm
Thursday 18 October
Studio 2 (first floor), Oxford House, Derbyshire Street, Bethnal Green, London E2 6HG.

Oxford House is 5-10 mins walk from Bethnal Green tube.

Following the lead of other local groups like the one in Manchester, the aim of the group is to support the work of the Asylum: The magazine for democratic psychiatry.

Asylum needs volunteers to help raise the magazine's profile: to increase subscriptions (so that it can continue to grow) and to let people know it is a place for them to send and read interesting articles, poems and artwork.

The main item on the agenda will be staffing a stall Dave is booking at the London Anarchist Bookfair which runs from 10am-7pm on Saturday 27 October and is held at Queen Mary, University of London, Mile End Road, London, E1 4NS. If you can’t attend the meeting on 18 October but would like to help staff the stall on 27 October do get in touch with Dave.

The bookfair is the kind of place where we might interest new subscribers. At the meeting on 18/10 we can also spend some time thinking about other events where we might sell the magazine.

I know you're all really busy but hopefully it will be both fun and productive. Drop Dave a line if you're interested.

Dave organised the Critical Mental Health Forum that met in London over several years.

No use for brain scan in assessing psychiatric patients

Stephen Stahl, who I've mentioned in a previous post, in an editorial in Acta Psychiatrica Scandinavica, talks about psychiatrists becoming 'disease scene investigators'. He anticipates psychiatrists being able to combine what he calls the art of good clinical judgement with the scientific results from a structural brain scan, functional brain images from psychiatric stress tests and genetic information to decide on appropriate medication.

He admits that, "We are still, however, a long way from getting brain scans of patients to diagnose their schizophrenia or to monitor their course illness over time." He goes on, "In fact, it is beginning to look like no structural, functional or genetic test will ever diagnose schizophrenia or tell us what drug to use or avoid. It is not likely to be that simple."

He further tempers his wishful thinking with a cautionary comment that "at the forefront, things can get a bit turbulent and slip too far ahead of long-term evidence-based practice standards". Why not just stick to psychiatric formulation (see previous post)?

Defender of individual responsibility and freedom dies

Death notice for Thomas Szasz who died at the weekend. He contributed to critical psychiatry in the sense that he regarded the biological basis for mental illness as a myth.

He expressed himself forthrightly and clearly. As far as he was concerned, society shouldn't incarcerate people on the basis of so-called mental illness. I have been critical of the way his trenchant position could be said to have actually detracted from the cultural critique of medicine and psychiatry (eg. see my review of Pharmacracy). As he said to me in an e-mail a couple of years ago, "you and I draw the line at very different places: you at conceptual issues, I at coercion-noncoercion (and psychiatric excuses vs no excuses)."

Nonetheless, we will miss his contribution to the debate about psychiatry (eg. see a positive perspective on his legacy from Phil and Poppy Barker). He was still active into his 90s and I attended a seminar he gave on the fiftieth anniversary of The myth of mental illness (see previous post). Despite his protests, he will always be associated with the history of anti-psychiatry (see my Historical perspectives on anti-psychiatry).

Profile of a postpsychiatrist

Profile of Pat Bracken in Irish Times. Pat wrote Postpsychiatry with Phil Thomas. Postpsychiatry is one form of critical psychiatry.

I've always said that critical psychiatry can be understood without postmodernism. The split between biomedical and biopsychological approaches goes back to before the 1960s. The theoretical views of Adolf Meyer about the nature of mental illness are no different from those of critical psychiatry (eg. see my article).

My attempt to gain a profile for critical psychiatry was published in THES.

Formulating psychiatric diagnosis

This post is prompted by a comment on a previous post suggesting that psychiatric diagnosis is unscientific and that formulation is a better alternative. I've nothing against formulation. As I indicated in a previous post, it's remarkable how a full assessment in psychiatry is too often seen as almost out-of-date. When I did my membership examination for the Royal College of Psychiatrists, I was asked what my formulation of a clinical case was. This was because it was recognised that assessment was about more than formal psychiatric diagnosis.

So, I do agree that formulation is better than unscientific psychiatric diagnosis that sees diagnosis as an entity or "thing" of some sort. But I have a wider understanding of diagnosis (see eg. my article). And I do see it as scientific to do a full assessment.

I recommend the book edited by Lucy Johnstone and Rudi Dallos on formulation on my book recommendations page. It's also worth looking at Lucy's Users and abusers of psychiatry  (see my review).

Has the psychopharmacological revolution come to an end?

I don't know what to make of Peter Tyrer, the editor of the British Journal of Psychiatry, saying in his latest 'From the Editor's desk' that "The time has come to call an end to the psychopharmacological revolution of 1952". I pointed out in a previous post that he seemed to be agreeing with me about so-called 'remedicalised psychiatry' (eg. see another previous post). But surely this isn't an indication that critical psychiatry's time has come, is it?!

Actually I don't think the psychopharmacological revolution is over. Biomedical psychiatry continues to reign supreme. For example, the British Journal of Psychiatry still publishes uncritical neuroscience editorials (see previous post).

What has inspired Peter Tyrer is an editorial suggesting that the risk-benefit ratio of antipsychotics needs to be re-evaluated to facilitate informed choice and decision-making. It even suggests reappraising whether anti-psychotic medication must always be first line of treatment for people with psychosis. 

I'm sure proposals like this will be watered down. For example, I have already commented on a paper (see previous post) that the editorial references that its authors say found "a smaller antipsychotic drug-placebo difference than we had intuitively expected". Those authors went on to publish a subsequent paper which they interpreted as showing that psychiatric drugs were just as effective as other medical drugs. They even seemed to label as anti-psychiatry attempts to interpret trial data in a critical way.

I welcome any indication that mainstream psychiatry is open to critical approaches, but I think we just need to be aware of the power of the biomedical myth (see previous post). Let's see where Peter Tyrer leads the British Journal of Psychiatry in what I guess must be coming up to his retirement as editor.

The mind of a psychopath

The latest What's New Online from the BMJ editor draws attention to the poll on bmj.com, which asks "Is fanaticism a form of madness?" This is linked to two published articles that debate whether Anders Breivik is sane .

The argument in the Breivik trial is about whether he is psychotic (see previous post in which I suggest there is little doubt that he is not psychotic). That is not to say that he is not psychopathic (mentioned in neither of the BMJ articles). Psychopathy is distinguished from psychosis, although it was originally named "moral insanity". Psychopathic people are not deluded.

And being deluded is not just about whether fanatical ideas are shared by others, which is the argument used by Taylor in his BMJ article for regarding Breivik as insane. What matters is whether the thinking process that led to the ideas is abnormal - in Karl Jaspers words whether the ideas are "of morbid origin". Jaspers regarded delusional ideas as "ununderstandable", because even putting oneself in the deluded person's position and seeing the world from their point of view, one is still unable to understand how they could hold such a belief with delusional intensity. Obviously there may be a metaphorical sense in which one could understand the thoughts but delusional ideas are believed literally.

Interestingly, the Mental Health Act in England and Wales was amended in 2008 to abolish the distinction between mental illness and psychopathy in terms of the way in which the conditions are regarded under the Act. Because of Breivik's determination not to go to a psychiatric hospital, it could be argued that he is not detainable in psychiatric hospital because he is not treatable (under the old Act) or because there is no appropriate medical treatment available to him (under the amended Act).

Aubrey Lewis (who I've mentioned in another previous post) wrote a Lancet editorial in 1940 on the mind of Hitler. Hitler wasn't deluded. Lewis quoting Oswald Bumke points to the extent to which cold, unfeeling, ruthless, apparently conscienceless, violent, cruel people attain their ends and "how great a role fanatics and other psychopaths play in history and especially the history of revolution". Martyrdom, eg. suicide bombing, may be one outcome of fanaticism. But others, such as Breivik develop the "unshakeable conviction that they are in the right" and end up in a law court. Others play their part on a larger stage, such as Hitler or more modern tyrants.

The real problem with Breivik and Hitler is their personality not mental illness as such. They represent the uglier side of human nature. It is important to recognise this rather than trying to distance ourselves from them by labelling them as insane.

I'm not an anti-psychiatrist, or am I?

It irks me sometimes when I'm seen as an anti-psychiatrist, rather than a critical psychiatrist. After all, I make my living from being a psychiatrist. My critique of practice is merely intended to make it better. I'm not against psychiatry as such, just how it's put into effect sometimes.

I've been thinking why I'm viewed in this way. The critical psychiatry website that I set up years ago (before the Critical Psychiatry Network was formed) was originally called the anti-psychiatry website, but I changed the name because of the confusion it caused (see THES article). But I suppose there is a sense in which I am against what is happening in modern psychiatry. It's difficult to get the right balance about how oppositional to be.

And I've always encouraged critical psychiatry to be seen as a broad church ( eg. see previous post). There are people in the critical psychiatry movement who want to abolish psychiatry and think we do not need a Mental Health Act. But I'm not one of them.

The problem is the degree to which modern psychiatry is a faith believing that mental illness is a brain disease (see eg. previous post). If I'm not a believer then I guess there's a tendency to see me as an anti-psychiatrist. What needs to happen is for this situation to be made more transparent. Psychiatric practice should not be dependent on taking a step of faith.

By the way, a chapter of my edited book, Critical psychiatry, was on the history of anti-psychiatry. It is important to understand this context, but it's about time we moved on.

On the validity of psychiatric diagnosis

Witness, on BBC World Service, last month broadcast about the Rosenhan experiment (listen to podcast). Rosenhan died earlier this year (see Stanford Law School news). There's also an earlier, longer radio programme by Claudia Hammond in the Mind Changers series.

I do think Rosenhan's 1973 paper in Science, On being sane in insane places, is still relevant. It very much contributed to the crisis in psychiatric diagnosis that led to DSM-III trying to tighten up the definition of the different syndromes by operationalising them. We're still struggling trying to revise DSM on this basis (see previous blog entry).

We need a different reaction to Rosenhan. Psychiatry need not have been so defensive about his experiment. Of course psychiatric diagnosis is arbitrary to some extent. Trying to put a patient's psychiatric presentation into a single word isn't going to be sufficient, nor is it always going to be very helpful. I'm not against trying to classify psychiatric disorders, but the limitations need to be recognised. They're idealised descriptions which do not describe entities as such. The extent to which psychiatric diagnosis is subjective is not a sign of scientific deficiency but of its meaningful nature.

Neuroscience needs to be more critical

Suparna Choudhury & Jan Slaby have published an edited collection entitled Critical neuroscience (see website). This is a response by a group, which began meeting in Berlin, to what they call the “neuromania in the natural and human sciences”. They describe the “shared sense of irritation about the hubris of neuroscience and the reverberations of ‘brain overclaim’ in areas of everyday life far beyond the lab”.

Such ‘brain overclaim’ is apparent in an editorial by Mary Phillips from the latest edition of the British Journal of Psychiatry. Although she acknowledges that there are limitations to neuroimaging studies in psychiatry, she holds out the hope that they will differentiate individuals with unipolar v. bipolar depression; identify those at future risk of developing psychiatric illness; and find those who are most likely to respond to a specific drug. She even suggests neuroimaging might be more accurate than clinical assessment.

At least Phillips has committed herself to outcomes that we can look back on and see that she has not achieved. But I doubt this will curb her wish-fullfilling phantasies. And why does the British Journal of Psychiatry publish such speculation, implying it could be fact? We need to admit, like Choudhury & Slaby, that neuroscience is misguided inasmuch as it seems that its aim is to solve the mind-body problem, which it won't do.

Is mental illness curable by CBT?

The report from The Centre for Economic Performance (mentioned in my last post) boldly states that mental illness is curable. To support this claim it references three papers – Layard et al (2007), Clark (2011) and Gyani et al (2011).

Layard et al (2007) calculated the expected improvement in employment rates from CBT treatment, and estimated this to be on average about one month for each person in 2 years. They emphasise that they are not claiming huge effects and go on to give estimates of the reduction in numbers of people on benefits from the introduction of IAPT, saying that the programme will easily pay for itself. I'm not sure if they'll get the opportunity to show whether the programme has met these targets.

Clark (2011) describes the national programme for IAPT including the results from the two pilot demonstration sites. He emphasises that the demonstration sites were not set up as randomised controlled trials. It is therefore not possible to exclude the possibility that improvements may have been due to natural recovery and self-fulfilling expectancy effects. 

Gyani et al (2011) analyses data from the first year of the IAPT programme. They note that people can get worse in treatment as well as better. Considerable between site variability  in overall recovery rate between 27 and 58% was found  (median 42% - approaching target of 50%). "Recovered" does not equal symptom free. Nor is it clear that any apparent benefits can be maintained over the longer term.

In reality, this literature is insufficient to substantiate the statement about the curability of mental illness as such. As I said in my last post, I’m not wanting to undermine optimism in treatment, but we do need to be realistic about the evidence. Otherwise, scientific expertise is merely being exploited for political ends. 

Of course people do recover from mental illness, but this might be a difficult, slow, costly, painful and sometimes incomplete process. Promoting CBT as a panacea is no different from pharmaceutical quackery. 

Need to be realistic about value and effectiveness of psychological therapy

David Clark's comment in the Guardian is headlined to say that psychological therapies are highly effective and save money. Steady on! As with medication, we all want a simple, quick, cheap, painless and complete cure of mental health problems. It's important to be hopeful about the outcome of treatment, but we also need to be realistic (eg. see previous blog entry How easy is it to treat depression?).

What Clark doesn't mention is the difficulty of measuring the effectiveness of psychological therapy. Expectancies affect the outcome of clinical trials and can't be controlled by double-blinding, as subjects know whether they receive the active treatment or are in the control group. There is a real issue about the adequacy of control groups (eg. see my BMJ letter).

His claim about saving money relates to the report from the Centre for Economic Performance. Lord Layard has been very influential in getting the Improving Access to Psychological Therapies (IAPT) initiative introduced into the NHS. We need evidence that IAPT has helped the economy before making such a claim.

Psychiatry is a medical speciality

I've been thinking about the motivation for the move to a remedicalised psychiatry, which I've mentioned several times previously (eg. see previous post). What psychiatrists are worried about is that their job seems to be being taken over by non-medical professionals.

I gave up my medical training for 8 years because I found it difficult to see the need for medical training in psychiatry. However confused this decision was, it does mean I am speaking from experience on this matter.

We should welcome other professionals taking on consultant roles, including being responsible clinicians under the Mental Health Act. However limited in practice this development has been so far, it is happening in other areas of medicine besides psychiatry. It offers more choice to a patient to be able to see a consultant from another profession, such as nursing or clinical psychology. Other professions should be encouraged to take on the responsibility which has traditionally been undertaken by the doctor.

Other professionals have always had a central role in managing patients in hospital. This continues to be the case with care co-ordination in the community.

None of this means that medical training is not of value for psychiatry. This is because many physical complaints have a psychogenic origin. In fact, as argued by Bill Fulford and others, psychiatry could be seen as the pre-eminent medical speciality because practice is so obviously determined by values. This may be more hidden in the rest of medicine but a focus on the person is inevitably central.

In particular , none of this justifies retreat into a biomedical psychiatry. In fact, it was the disease-centred nature of biomedicine that put me off understanding the medical nature of psychiatry when I was younger.

The editor of British Journal of Psychiatry agrees with me

The editor of the British Journal of Psychiatry, in his latest "From the editor's desk", has said he would not have contemplated becoming a psychiatrist if psychiatry had been a branch of neurology, which is relevant to a previous post. He has recently been at a conference in Belgrade "where speaker after speaker predicted the demise of our profession or its absorption into neurology or some other discipline, as the funding for mental illness and respect for psychiatrists gets progressively less". This is again relevant to another previous post. 

Like me he's disturbed by these trends. Let's hope he's right to be optimistic nonetheless.

Phil Barker on front cover of British Journal of Psychiatry

Considering his views about psychiatry, who would believe Phil Barker has his self-portrait on the front cover of the British Journal of Psychiatry, albeit under his painter's pseudonym of Phil McLoughlin? I have mentioned Phil in a previous post and contributed a chapter to his edited book Mental health ethics. He spoke at the first Critical Psychiatry Network conference I organised in Sheffield in 2001.

Not surprising that premature babies have higher psychiatric risk

The authors of an article in Archives in General Psychiatry, linking prematurity and admission to psychiatric hospital, are reported by Reuters as saying that the "increased risk may be down to small but important differences in brain development". Just finding an association does not mean that there is necessarily a causal link. The association may be related to a third factor. For example, prematurity is associated with social class, as is psychiatric admission. Social class may be more of a causal factor producing both prematurity and psychiatric admission. 

Of course the researchers know this. In their paper, they say "the association between preterm birth and psychiatric outcomes may be confounded by risk factors, including unmeasured sociodemographic and lifestyle factors (including ethnicity and socioeconomic status) ...". However, the bias to place a biomedical, rather than social, interpretation on such results is illustrated by this example. The finding of an increase in psychiatric admissions in those with premature birth should not be surprising because of the link through social deprivation.

The mind is indivisible from the brain

Peter White et al in an article in the BMJ propose that classifications of neurological and psychiatric disorders should be merged together into a single category of disorders of the nervous system. They justify this because of what they call the “revolution in the clinical science of the mind, as the techniques of basic neuroscience are successfully applied in mental health”.

This success is apparently demonstrated in brain scans that they say show structural brain abnormalities in various mental health disorders. However, they then don't say what these abnormalities are; nor do they note the dynamic nature of the appearance of the brain on scans; or discuss whether findings are specific. They also make a lot of the results of functional brain imaging showing brain activation but don’t say how it’s helped our understanding of brain function. For example, we already knew before brain scans that the limbic system is involved in supporting a variety of functions such as emotion. 

Of course the mind is indivisible from the brain, as they say. As such, a statement of this sort is tautologous, but White et al are saying more than this. Essentially, they believe that a sharp distinction between organic and functional disorders is unhelpful (an issue I’ve commented on in a previous post). In fact, they don’t seem to realise that DSM-IV has already tried to get rid of this distinction.

The arguments they use about the advantages of a more medicalised psychiatry do not really stand up. They suggest it helps stigma but as I have pointed out previously (see post), it could in fact increase stigma, as people do not really feel understood. Similarly, they think it might help recruitment to psychiatry but as I’ve again pointed out previously (eg see post), it may put people off.

I’m not against psychiatrists getting training in neurology and vice versa, but I do think it’s important that psychiatrists are well trained and they may well get the wrong idea if White et al’s proposal is taken up. Psychiatry, unlike neurology, is not based on treating a physical lesion.

Conflict in psychiatry

Pleased to see that psychiatric trainees are still interested in controversies in psychiatry. The Frontier psychiatrist blog has a post about Anthony Clare's Psychiatry in dissent. I commented in an eletter on an article about this book before Clare died in 2007.

Perhaps Frontier Psychiatrist is right that we need a "contemporary critique of psychiatry aimed at the layman". For the moment maybe my Critical psychiatry is a start.

Different perspectives in psychiatry

George Dawson in a comment on my previous blog entry mentioned an article by McHugh & Slavney, which has just come out in NEJM (not sure how George seemed to know about it before it was published). I agree with the analysis of this paper. A full psychiatric assessment of a patient in terms of family and personal history is too often regarded as almost 'out of date' and unnecessary in psychiatric training these days.

I don't agree, however, with McHugh and Slavney's proposed solution. They say "No replacement of the criterion-driven diagnoses of the DSM would be acceptable". That's just the point and why the DSM system should be abandoned to help psychiatry to realise that full psychiatric assessment is essential to practice. They are also right in a way that "much turns on causation" but then I think this is where they get it wrong by including schizophrenia and panic disorder as brain diseases with delirium. 

Why would psychiatry be better off without a psychiatric classificatory system such as DSM?

I thought it might be helpful to explain a little more why I think DSM-5 shouldn't go ahead. As I've said previously (eg. see earlier post), I am supporting the campaign to abolish psychiatric diagnostic systems. This campaign 'No more psychiatric labels' gives its rationale on its website.

The World Health Organisation started classifying the causes of death in the International Classification of Diseases (ICD). In the sixth revision it extended its classification to causes of morbidity as well as mortality and a chapter was added for psychiatric disorders (which don't cause death as such). The americans have always run a parallel DSM system. ICD-9 and DSM-II were essentially the same.

Criticism of psychiatric diagnosis led to the DSM-III revision, which attempted to define psychiatric disorders using operational criteria. Although it may have been technically atheoretical in its approach, it encouraged a biological understanding of mental illness as due to brain disorder. The misguided hope has been that reliable diagnoses will equate with standardised biological tests developed by advancing neuroscience (eg. see blog by Allen Frances, who has also been critical of DSM-5 because of its potential expansion of the boundaries of psychiatric diagnoses). DSM-IV abolished the distinction between organic and functional disorders as they are all seen as brain disorders (see previous post).

There were of course diagnostic systems before ICD-6 and DSM-I, but it is the authority attached to diagnostic descriptions since DSM-III that causes problems. However important classification may be for scientific communication, it is also essential to realise that diagnosis is also about the reasons why a person has developed problems. Focusing on a single word entity distracts diagnosis from obtaining this personal understanding.

Idealised diagnostic descriptions are not entities as such. This truth has been lost in the pursuit of DSM-5, which should be abandoned. There are alternative ideas about comprehensive diagnosis which could be developed (eg. see World Psychiatric Association (WPA) conference report). Allen Francis has recently suggested in NYTimes that a new organisation is needed to take over from the American Psychiatric Association, but I'm not quite sure why he doesn't consider WPA.