Misguided medical training in psychiatry

Niall Boyce has clarified in a tweet what he means in a Lancet Psychiatry editorial about the critique of the biomedical model in psychiatry. He thinks the critique is "worth considering". But he is relaxed about it because he knows neuroscientific findings will eventually affect practice. Actually the point of the critique is that this is a myth. Psychiatry has always had this wish and it's about time that it realised that this is "pie in the sky".

And, as Anne Cooke points out in a tweet in response, Niall has conflated his arguments in his rebuttal by promoting a medical training for mental health practice. I've always said that there are advantages to a medical training (eg. see previous post). However, there are disadvantages as well in that it encourages a biomedical approach, which Niall obviously finds difficult to give up.

Reducing psychotropic medication prescribing

Peter Gøtzsche, who I have mentioned before (eg. see previous post), has caused controversy at a Maudsley debate and in a BMJ Head to head by suggesting that psychotropic medication should be reduced to 2% of its current level of prescribing. As far as he is concerned, it "should almost exclusively be used in acute situations and always with a firm plan for tapering off, which can be difficult for many patients".

His argument is that the results of clinical trials are biased by unblinding and what he calls the 'cold turkey' effect of the washout period. Any remaining benefit, if there is any, is not justified by the mortality caused by medication.

Whether psychotropic medication increases mortality is controversial. I have mentioned before (see eg. previous post) that it may create a vulnerability to relapse. People may actually do better if they manage to work through their problems without medication. Peter Gøtzsche's stark presentation of the issue at least encourages this debate, even if it risks overstatement.

Renewing mental health practice

I have been re-reading the final chapter of my edited book Critical psychiatry: The limits of madness. Next year will be 10 years since the book was published. The first chapter outlines the various chapters written by the contributors. The book came out of three conferences held in Sheffield, Birmingham and London in 2001-3.

It's also 16 years since the Critical Psychiatry Network was first formed. I've mused before about the impact of critical psychiatry (see previous post), maybe, as I said, because I am approaching full pension. How should critical psychiatry be taken forward?

Psychiatric research folly

A perspective in Science by Thomas Insel & Bruce Cuthbert should make american psychiatry fearful about the scientific credibility of its NIMH director. He's gone completely 'over the top' in his speculation about RDoC and precision medicine (see previous post). He thinks there's been a "tectonic shift" to now considering mental disorders as brain disorders. Following his lead, this folie à plusieurs has apparently led to "nearly 1000 papers addressing various aspects of RDoC over the past year". 

I've made fun of Daniel Amen suggesting there are 7 types of ADD (see previous post). However, Insel believes three subtypes of ADHD have been discovered with different responses to stimulant medication. He suggests biologically meaningful subgroups of psychotic or mood disorders are being discovered. He does admit these are "preliminary reports" and the "results will need replication". RDoC domains are supposed to be better at predicting length of hospital stay or hospital readmission than symptom-based diagnoses. 

Even though Insel accepts that "many challenges must be faced", I'm sorry but I'm not part of what he calls the "emerging consensus that such new approaches are necessary to move the field forward". Psychiatry's going 'off beam'. People may appear to be going along with Insel because he holds the research funding purse strings. His speculation builds on his 'brain circuitry disorders' concept of mental illness (see previous post). Science demeans its name by publishing such phantasy.

Being explicit about the nature of mental illness

I am not sure why Ketan Jethwa has moved to a core training post in medicine from an academic psychiatry training post. Could it reflect his disillusionment with psychiatry or is he wanting to ensure  an adequate medical foundation for his psychiatric career? I don't want to undermine him because he has written a good quality article for BJPsych Advances. However, I think his piece does require comment.

He suggests psychiatry has an identity crisis because of the nature of mental illness. I'm not sure if I would call it an 'identity crisis', but I agree that how the nature of mental illness is understood does matter. Jethwa argues for psychiatry being a clinical neuroscience and suggests, following Bullmore et al (2009) (see previous post), that British psychiatry over recent years has taken an increasing 'neurophobic' position. He goes on, "It is imperative that the scientific underpinnings of psychiatry are explicit within mental health services and in interactions with patients and the public in general". The trouble is that he hasn't been explicit about the neuroscientific basis of psychiatry. He seems disappointed that psychiatry can't be more explicit. I have said before (eg. see previous post) that modern psychiatry is setting itself up to disillusion trainees by promoting neuroscience as the solution to mental illness in the way Jethwa hopes it can be. I fear that it may have lost another good quality trainee in his case. I hope I'm wrong!

Bipolar craziness

Much of Edward Shorter's recent book, What psychiatry left out of the DSM-5: Historical mental disorders today, is, to my mind, speculative nonsense. However, there is a chapter on 'Bipolar craziness', which I think has some useful references. I've mentioned before (eg. see previous post) how the concept of bipolar spectrum has extended during my working lifetime to a notion whose meaning must be questioned. As Shorter says at the end of his chapter:-

Unlike in previous editions, when DSM- 5 was launched in 2013 the discussion of bipolar disorder was no longer merely a section of an "affective disorders" chapter but had a chapter of its own, as though the previous hundred years of world psychiatry had never existed.

Unipolar and bipolar disorders are now seen as separate disorders whereas they used to be seen as two subcategories of manic-depressive illness. I am not necessarily saying that the previous way of looking at this diagnostic issue was better, but it is clear that at least some of the motivation for the change has been to promote mood stabilisers for bipolar disorder (see eg. previous post).

It's suggested antidepressants should be avoided in treating patients with bipolar disorder in favour of mood stabilisers. However, I've also mentioned before that the risk of manic switch when using antidepressants has been exaggerated. NIMH has endorsed the use of the diagnosis bipolar disorder not otherwise specified to categorise bipolar disorder as on a spectrum (see press release). It affirmed that such patients were being inappropriately treated by giving antidepressants or other psychotropic medication in the absence of mood stabilisers. However, systematic reviews have not found evidence that switching to mania is a complication of antidepressant treatment (Gijsman et al 2004, Visser & Van Der Mast 2005). In a placebo-controlled trial, use of adjunctive, standard antidepressant medication, as compared with the use of mood stabilisers, was not associated with an increased risk of treatment-emergent affective switch (Sachs et al 2007). Moreover, there was no difference in efficacy.

The limitation of medication, whether antidepressants or mood stabilisers, needs to be recognised. Just because antidepressants are not always effective does not necessarily mean that even mood stabilisers will be helpful in so-called bipolar spectrum.