The true situation about antidepressant discontinuation problems

I’ve mentioned before (see previous post) that I signed a complaint to the Royal College of Psychiatrists about a statement made by Wendy Burns, the President, and David Baldwin, the Chair of the Psychopharmacology Committee, that discontinuation problems on stopping antidepressants resolve within two weeks for the vast majority of patients. I do not think this statement is evidenced-based. The complaint has been dismissed by the College as unfounded (listen to MIA Radio podcast)

Minimising the significance of antidepressant discontinuation problems doesn’t seem to matter to the College. I’m not convinced the College membership fully agrees with this unwillingness to engage with the evidence and I am ashamed as a member of the College about this apparent lack of concern. As I said in my previous post, there is a history of antidepressant discontinuation problems being minimised, even denied, and this situation just seems to be being perpetuated by the College.

On the other hand, I guess we shouldn't be too surprised that the College is unconcerned about the truth of a matter of this sort. It finds it difficult to acknowledge the political and ethical implications of psychiatric practice. However neutral and objective the College may like to think it is, it exists, actually, as an institutional structure to justify psychiatric treatment, such as antidepressant medication. So, it would want to minimise problems caused by medication, wouldn't it? More generally, the validity of what it promotes as science does need to be challenged (eg. see previous post). We should not assume that the College has full and absolute legitimacy in truth over psychiatric matters and this has been demonstrated by the way this complaint has been handled.

Let's hope Wendy Burns and David Baldwin are prepared to discuss these matters further now that the complaints procedure is over.

The origin of critical psychiatry

The origin of the term 'critical psychiatry' was probably in an edited book Critical psychiatry: The politics of mental health by David Ingleby (1980). My own edited book Critical psychiatry: The limits of madness (2006) deliberately echoed David's use of the term, and, of course, the name was adopted by the Critical Psychiatry Network (see previous post). David also contributed a chapter to my book.

In the preface to the second impression of his book (2004), David commented that "the notion of mental illness as a brain disease has become even more widely accepted than ever before" (p. 5). The essential position of critical psychiatry can be said to be the critique of this notion. Mental illness should not be reduced to brain disease (eg. see previous post). Even Thomas Szasz contributed to critical psychiatry in this respect, as he regarded the biological basis of mental illness as a myth (eg. see another previous post).

There are, of course, implications of taking this conceptual position. How critical psychiatry's essential understanding is taken forward does lead to differences within critical psychiatry (see previous post). In his introduction to the book, David suggested that, "One premise shared by all contributors to this book is that mental illness is, in fact, a political issue" [his emphasis] (p. 8). In fact, Franco Basaglia (eg. see previous post), one of the contributors to his book, tended to be less concerned about whether mental illness had an organic aetiology. His primary motivation was to abolish the asylum as, as far as he was concerned, its main purpose was to segregate the under-privileged (see extract from my book chapter).

David made it clear that "mental illnesses ... do exist" (p. 18). He, thereby, moved critical psychiatry on from Szasz's theme of 'the myth of mental illness', in the sense that Szsasz did not believe that the concept of mental illness is valid (see previous post). David also notes how some critical psychologists and others have questioned whether mental health problems "really have much to do with medicine in the first place" (p.8). However, he also quotes Peter Sedgwick, who argued that "mental illness was, after all, a medical problem" [his emphasis] (p. 9).

David juxtaposed 'positivist psychiatry', defining positivism as "the paradigm of studying human beings as if they were things' (p. 13), with 'interpretative' approaches, by which he meant "[u]nderstanding people's 'symptoms' in terms of their social situation" (p.52). Mental illnesses are "meaningful responses to difficult situations ... [but] in many conditions a 'residue' remains refractory to commonsense understanding" (p.13). Here he turned to psychoanalysis to interpret the 'residue' in terms of unconscious meanings.

David concludes his chapter by saying that “until the political component of our disagreements is brought out into the open, we will never go beyond the phoney synthesis of psychiatric ‘eclecticism’” (p.71). His book was written at the end of the period of conflict know as 'anti-psychiatry'. He does mention (on p.7) Anthony Clare's book Psychiatry in dissent, which, as I have said previously, many have seen as the compromise outcome of the anti-psychiatry debate. Clare reinforced an eclecticism in psychiatry by avoiding any clear conceptual basis for psychiatry (eg. see my Psychiatric Bulletin letter). Manschrek & Kleinman called this kind of position in psychiatry 'semi-critical' (see previous post). In many ways, psychiatry is still in this situation (see eg. previous post). The critique of psychiatry does need to go further. Critical psychiatry, in very much the sense originally used by David Ingleby, does need to be seen as a valid solution to the anti-psychiatry debate.

Mind-body relation

Further to my previous post in which I mentioned Charles Myers, I came across a lecture he gave in 1932 entitled ‘The absurdity of any mind-body relation’. (1) What he meant by this was that life has direction and is more than blind mechanism. And, “[c]onscious mind is essentially a specialization, a distillation of that directive activity” (p.8). So mental activity and living bodily activity are identical and it doesn’t make sense to talk about a mind-body relation.

Physical concepts of mechanism are incomplete for a total description of nature (see previous post). The primary distinction is between life and inanimate matter, not life and consciousness (see previous post). To quote from Myers’ lecture, “In no form of life is directive activity wholly absent.” (p.21) As Kant said in the Critique of Judgement,

there will never be a Newton of the blade of grass, because human science will never be able to explain how a living being can originate from inanimate matter

Directive activity is still inherent in plants, even though, as Myers said, “locomotion and plasticity are minimal” (p.25). This doesn’t mean that there can be no causal explanations for an account of the physical nature of organic matter. But, mechanistic explanations are insufficient for an account of the totality of human and living nature. As Myers concludes, “There is no separable mental or vital force: and the mental must be regarded as identical with the vital.” (p.26) Psychiatry needs to recognise its mistake in reducing mental illness to inanimate brain disease.

(1) Hobhouse memorial lectures 1930-1940 OUP: London

The roots of medical psychology

I’ve mentioned before (eg. see previous post) that I am doing a PhD in psychology at Cambridge University. It’s probably just as well that I’m in the psychology department rather than psychiatry, considering how critical I’ve been of some of the emphasis within the psychiatry department (eg. see previous post).

What may be of interest is that it was actually the psychology department that first started psychiatric training at Cambridge University with the setting up of a Diploma in Psychological Medicine (DPM) course in 1912. It only lasted until 1927 (although no students had enrolled on the course for two years before it was abolished - the lack of popularity due maybe partly to being able to avoid being examined in psychology and neurology by going elsewhere). But the intention had been to make Cambridge the “national centre for the education of psychiatrists” (Forrester & Cameron, 2017: 248).

One of the main driving forces was Charles Myers, who set up the Psychological Laboratory at Cambridge. After the war, he wanted to develop the medical, educational and industrial aspects of psychology. He left Cambridge in 1922, at least partly because of the lack of support for psychology within medicine, physiology and philosophy.

Cambridge psychology needs to be reminded of this root in medical psychology. The British Psychological Society closed the British Journal of Medical Psychology in 2001 and continued it as Psychology and Psychotherapy: Theory, Research and Practice the following year. The first editorial of the newly titled journal said that “the term ‘medical psychology’ is itself becoming anachronistic”. I’m not convinced psychology should be quite so dismissive of this aspect of its history.

Psychiatry should be more scientific

An advertisement article in the Guardian paid for by the Royal College of Psychiatrists uses Mary-Ellen Lynall (who I've mentioned in a previous post) to promote young doctors coming into psychiatry. I'm not sure if it really improves recruitment by speculating that "brain inflammation may be a cause of depression and in five or 10 years we could have a blood test to detect whether that inflammation is present", because this is merely misguided wishful thinking (eg. see previous post).

What worries me is that the apparent motivation for this campaign is that newly qualified doctors don't think psychiatry is very scientific. That's not surprising considering what's promoted as apparent advances in psychiatry, including seeing brain inflammation as the cause of mental illness (eg. see another previous post). Junior doctors are right to laugh at psychiatry if that's all that's on offer.

Psychiatry isn't just about physical disease, as the advertorial indicates. It's a human science, and not just focused on the brain. Nor is the rest of medicine just focused on the body and psychiatry needs to promote itself as a truly patient-centred scientific medical discipline (eg. see another previous post).