More research required on withdrawal from antidepressants

Fava & Balaise (2018) in a Psychotherapy and Psychosomatics editorial comment on a failed trial (see letter) of CBT to prevent relapse after withdrawal of antidepressants in remitted anxiety disorder. Despite guidance, only 36% of patients succeeded in discontinuing antidepressants over 16 months and only 28% did not have a recurrence and there were no differences between the CBT group and controls.

As Fava & Balaise say, the trial wasn't futile as it has confirmed that:-

Withdrawal symptoms and syndromes may occur during and despite slow tapering, do not magically vanish after a couple of weeks from discontinuation and may persist for a long time, leading to postwithdrawal syndromes.

As they also say:-

.. discontinuation that is performed without medical consultation and adequate psychotherapeutic support entails substantial risks for the patient and is often bound to fail

Fava and Balaise tend to emphasise their model of oppositional tolerance, which I have said before does not convince me (see previous post). Personally I have tended to argue for the importance of psychological dependence (eg. see previous post). This does get me into trouble with the 'prescribed harm' patient community, but despite what they may think, I am not minimising their problems, which mainstream psychiatry does (eg. see previous post). As Fava & Balaise conclude:-

The time has come to initiate research on withdrawal phenomena related to AD [antidepressants], and to redefine the use and indications of these medications

Repeal Mental Health and Mental Capacity Acts

The Independent Review of the Mental Health Act 1983 (see previous post) has produced its final report ‘Modernising the Mental Health Act: Increasing choice, reducing compulsion’. It is disappointing, as Suman Fernando says in his blog, although not surprisingly so. It gets the government ‘off the hook’ of having to do anything about the observations from the Committee on the Rights of People with Disabilities about the UK government’s response to the United Nations Convention on the Rights of Persons with Disabilities (CRPD). The proposals made for change are minimal and will do little to prevent the unacceptable, including racist and abusive, treatment of detained patients (eg. see another previous post). CRPD is being ignored by suggesting that it prevents involuntary detention, which I don’t think is the case and in fact the Independent Review concedes this. Instead current legislation should be repealed and replaced by new legislation to preserve the dignity and respect of detained patients.

Progress in psychiatry

Peter Tyrer (who I have mentioned before, eg. see previous post) has recognised the value of critical psychiatry, however grudgingly, in his commentary on a BJPsych Advances article by Hugh Middleton & Joanna Moncrieff (also previously mentioned eg. see post). However, Tyrer thinks critical psychiatry is Luddite by hindering progress in psychiatry. Psychiatry has always had the forlorn hope that it will discover the biological basis of mental illness, and I don’t think that Tyrer has given up this wishful thinking. The examples he gives of progress in psychiatry include lithium for bipolar disorder and methylphenidate for ADHD, and these must be suspect, and even CBT for traumatic stress disorders is questionable.

I actually agree with him that critical psychiatry should be constructive. I also agree critical psychiatry’s views on psychiatric diagnosis can appear confused, but this is because there are actually different views within the critical psychiatry movement about whether psychiatric diagnosis is valid and whether mental disorder should be seen as illness (eg. see point 3 in previous post). Critical psychologists within the critical psychiatry movement, such as David Pilgrim, who Tyrer quotes, tend to be against psychiatric diagnosis. Michel Foucault, who again Tyrer mentions, actually probably wasn’t against diagnosis as such. What he was against was the positivist reduction of mental illness to brain disease (see last post). Despite what Tyrer says, incorporating positivism into psychiatry has actually made it less scientific not more (see another previous post).

Psychiatry, as well as human and life sciences in general (see previous post), need to take Kant’s explanatory anti-reductionism seriously. Kant was clear that it is absurd to expect to understand goal-directed mental disorder in physical terms. Epistemologically it’s just not possible. Consciousness is a puzzle we’d like to be able to solve but we can’t (see previous post). That doesn’t mean that we can’t study part-functions such as the brain, but we need an organismic psychiatry to treat the whole person. Such a view was present in the origins of psychiatry, such as Ernst von Feuchtersleben’s Principles of Medical Psychology (see eg. point (1) on previous post). Psychiatry needs to go back to its roots to make progress. Critical psychiatry is arguing for a positive way forward by promoting an organismic psychiatry. Psychiatry has never really been able to achieve this because of its dominant biomedical positivism.