Analysing the evidence about antidepressants and other psychiatric medication

Editorial in The Lancet Psychiatry helpfully calls for a “dispassionate analysis of the evidence” about psychiatric medication. It seems to be particularly concerned about what it calls “Hooked on happy pills” headlines that have appeared in British newspapers over recent years (see one example). 

By criticising these articles without dealing with the issues, the editorial could be taken as another example of minimising the significance of antidepressant discontinuation problems (see previous post). This issue does need to be taken seriously. 

Why doesn’t The Lancet Psychiatry commission a review of the evidence? Or more generally, why doesn’t it commission an analysis of the placebo amplification hypothesis of antidepressant efficacy (see previous post). Rather than platitudes in an editorial, it should be doing its job of analysing the evidence. There are too many issues about psychiatric medication that are being fought out in the press rather than psychiatric journals dealing with these matters scientifically.

The wish for a biological basis for mental illness will never go away

James Davies in his book Cracked (see my review), was surprised when Robert Spitzer, chair of the DSM-III task force, said no biological markers had been identified for functional mental illness (see recent @ClinpsychLucy tweet). DSM-III understood that organic mental illness is different from functional mental illness. It was DSM-IV, led by Allen Frances, that abolished the distinction. This was a mistake (eg. see previous post).

I have mentioned in a previous post how Sami Timimi couldn’t understand why he was indoctrinated in his psychiatric training. Similarly, I remember the discussions I had with Alec Jenner, my professor of psychiatry in Sheffield (see previous post), about why people believed what they did about psychiatry. The problem is that the belief in the biological basis of functional mental illness will never go away (see my tweet in response to @ClinpsychLucy). I’m not one who expects that a radical, new psychiatry will replace biomedical psychiatry. But we do need to break the dominance of the biomedical model and recreate a more pluralistic psychiatry. This situation is not helped by dissolving the distinction between functional and organic mental illness, which needs to be reinstated.

Running amok in American society

The New England Journal of Medicine (NEJM) has an article about how to stop mass shootings (see article). I've written before on this situation in the USA (see Psychiatry shooting itself in the foot and The omnipotence of the mental health system).

It isn't just in the USA where people have run amok (see medical definition of amok from Merriam-Webster). The NEJM article says that such US tragedies are "entirely preventable" by the implementation of policies requiring that firearm sales involve background checks on purchasers and also allowing courts to have firearms removed temporarily from people who pose an imminent hazard to others or themselves but are not members of a prohibited class. These policies may well reduce such incidents, but the article doesn't provide any evidence to suggest that their implementation will prevent mass shootings entirely. And there must be questions about whether they really go far enough.

Amok episodes normally end with the attacker being killed or committing suicide. Murders which are followed by suicide are most likely to be committed in anger by aggrieved people blaming others as well as themselves. Although amok was traditionally seen as a syndrome bound to cultures such as Malaysia and Indonesia, all societies, including American society, can subtly sanction such mass shootings (and perhaps also not so subtly sanction them - eg. How does NEJM publish an article like this that doesn’t properly consider removing guns from civilian possession). The American government and people need to understand the ways in which they themselves are doing this. Amok isn't just happening in other parts of the world.

Institutional corruption within the Royal College of Psychiatrists

I’ve commented before on institutional corruption within psychiatry (eg. see previous post). I’ve also pointed out how the Royal College of Psychiatrists can’t be relied on for its information about psychiatry (eg. see another previous post).

The College does need to do more to deal with institutional corruption within its own ranks. The American Psychiatric Association may be more blatantly corrupt (eg. see previous post), in that there doesn’t seem to be much attempt to hide commercial influence. However, this doesn’t mean there aren’t problems within the Royal College as well.

The College does prevent pharmaceutical company influence within College meetings. But many of the speakers have a conflict of interest. Declaring conflict of interests, even if it does make matters more transparent and honest, is insufficient to deal with the issue of conflict of interests (see previous post). If one thinks about it, declaring conflict of interests doesn’t purify the content of College meetings. In fact it does the reverse.

Peter Gordon’s campaign to make disclosing of payments from drug companies mandatory may help (see BMJ news item), but ultimately it’s up to the Royal College of Psychiatrists to deal with institutional corruption within its own organisation. The problem is that I don’t think the College agrees that conflict of interests compromises the work of its representatives.

We are all mad here

Peter Kinderman is giving a lecture at Salomons Centre in Tunbridge Wells this week entitled 'Our turbulent minds: why we’re all crazy, but none of us is ill'. I've mentioned Peter several times in this blog previously. For example, I’ve said he can express the essence of critical psychiatry better than me (see previous post), as he points out that explaining mental disorder in terms of the brain is no different from explaining all other behaviour and emotions in terms of the brain.

Despite all my agreement with Peter, I have been critical of some aspects of his book A prescription for psychiatry (eg. see previous post with links from that post). Obviously I don’t know exactly what Peter’s going to say in his Salomon’s talk. He might start with a quote from Lewis Carrol in Alice in Wonderland (see tweet):-

“But I don’t want to go among mad people," Alice remarked.  

"Oh, you can’t help that," said the Cat: "we’re all mad here. I’m mad. You’re mad." 

"How do you know I’m mad?" said Alice. 

"You must be," said the Cat, "or you wouldn’t have come here.”

Of course we’re all crazy in this sense. We believe all sorts of things which it might be very difficult to justify. Our very existence relies on having a worldview that protects our viability as human beings. It’s particularly difficult to give up these kind of beliefs. For example, it was quite traumatic when in my late teens I gave up my belief in God. Similarly psychiatrists find it very difficult to give up the biomedical model. They may feel that their very existence as psychiatrists may fall apart if they do.

Yet I worry that Peter may mislead by going on to say that no one is ill. I do understand what he means. Illness since the nineteenth century (although not really before) has been understood as having a bodily tissue pathological basis. I agree with Peter that functional mental disorder does not have a physical basis in this sense. For example, no physical pathology has been established for psychotic disorders, such as schizophrenia or bipolar disorder. True, with the amount of psychiatric research that is done, many people assume that a physical basis has been established for these conditions, but this is wrong.

However, this does not mean that psychosis does not exist. It’s not surprising Alice may not have wanted to go amongst psychotic people who are out of their minds. We all have the potential to lose touch with reality and this is different from believing our normal everyday crazy ideas which sustain our worldview. Of course, the psychotic person’s delusions and hallucinations are sustaining their worldview in this way, but it’s idiosyncratic and the rest of us find it very difficult to understand why they’re out of their mind.

Personally I’m happy to see mental disorders as ‘illness’, as the 19th century anatomoclinical understanding of disease in terms of physical pathology has never incorporated functional mental illness. We’ve been misled by defining illness so narrowly. That definition allowed Thomas Szasz to say that mental illness is a myth.

But we need more historical undestanding of the origin of psychiatry. Of course mentally ill people were looked after by the state in poor law arrangements. And it was once the state started to intervene in this way that it identified there was a group of people that were mentally ill. They weren’t necessarily responsible for their poverty, as they were mentally ill and needed treatment. Psychiatry developed the role of identifying this group. What psychiatrists now call phenomenology is the process of identifying psychological abnormalities. Peter’s right that there may well be disagreement about what counts as an abnormality. But the fact that people were prepared to question the beliefs that they had led to psychiatry having the role of identifying insanity. They were alienists, identifying mental alienation.

This proto-psychiatry existed before the introduction of anatomoclinical thinking in medicine. Much of the thinking about the origins of mental illness was in fact very physically based. For example, there were ideas about the brain being oppressed by blood and several early psychiatrists were phrenologists. Yet incorporating the anatomoclinical way of understanding disease into psychiatry has eclipsed a more psychological understanding. This is why we need a critical psychiatry to point out that psychiatry can be practiced without believing that mental illness is due to brain disease.