Saturday, April 13, 2019

Surely enough money’s been made out of antidepressants

An editorial in Acta Psychiatrica Scandinavica asks whether the time has come to treat depression with anti-inflammatory medication. This is based on a meta-analysis which provides evidence that anti-inflammatory treatment can be beneficial. Throughout this blog (eg. see previous post), I have emphasised bias in clinical trials, so I’m not encouraging the use of anti-inflammatory medication to treat depression. Not least, the trials in the meta-analysis show a high risk of bias and tend to be done by using the anti-inflammatory drug as an add-on to antidepressant treatment, or in patients who have somatic disease, so an anti-inflammatory effect on somatic disease may be the reason for any improvement in depression scores, rather than a true antidepressant effect.

What I want to note is why anti-inflammatory medication, despite the apparent evidence for its benefit, has not managed to be included in guidelines for depression. To gain approval, a large scale trial would need to be done to show that anti-inflammatory medication offers the prospect of better treatment than current treatments, but would be very expensive. As the editorial says, only drugs with a high likelihood of generating future profit are put through such trials. The editorial goes on:-
In the case of the traditionally used, safe and tolerable anti-inflammatory agents that are already on the market, there is no financial incentive for the pharmaceutical industry to conduct these costly, large-scale RCTs. Rather, they are more likely to fund newly discovered immunotherapies with a poorly characterized safety profile, as such novel immunomodulatory treatments can be patented and monetized. 

Unlike the editorial, I am not suggesting government funding for such trials. As I indicated in my review of Ed Bullmore’s book (see previous post), it’s non-sensical to think that depression is a form of inflammation. Any apparent increase in inflammatory markers in depression is far less than inflammatory disease in general, and has non-specific causes rather than being a marker for depressive disease as such (see previous post).

The market for depression has been flooded. The pharmaceutical companies themselves seem to have realised this years ago (see previous post). If people want medication treatment, let’s at least keep it cheap. We should be suspicious of any attempt to make further money out of medication treatment for depression. Marketing and commercial, rather than scientific and therapeutic, interests have always determined which drugs are prescribed.

Thursday, April 04, 2019

The stigma of anti-psychiatry

As I said in my previous post, challenging the biomedical model of psychiatry is not anti-psychiatry. Another example of how the term 'anti-psychiatry' is being used by mainstream psychiatry is in a session at the International Congress of the Royal College of Psychiatrists in July this year (see full programme) entitled 'The new anti-psychiatry: Responding to novel critiques on the legitimacy of psychiatry'. The chair of the session is Rob Poole, who I have mentioned in a previous post. The speakers are Paul Salkovskis (again, see another previous post), Dariusz Galasiński (see his blog post about anti-psychiatry) and Linda Gask (see another previous post).

I'm presuming critical psychiatry is what the session calls the 'new anti-psychiatry'. I've argued in a previous post that the Power Threat Meaning Framework that Paul Salkovskis is critiquing is not anti-psychiatry. I'm not sure how new the critiques of critical psychiatry really are; nor that they challenge the legitimacy of psychiatry as such. But I guess this is what mainstream psychiatry thinks is the case, which is why they use the term 'anti-psychiatry in the title of the session. As I've said before, it's a pity mainstream psychiatry finds critical psychiatry so threatening (eg. see previous post and extract from chapter 1 of my edited book Critical Psychiatry). There were excesses in anti-psychiatry (see my book chapter) but critical psychiatry shouldn't continue to be tarnished by this rotten reputation.

My own proposal for the International Congress on 'Integrating critical approaches into the training of psychiatrists' was turned down. Jo Moncrieff was going to chair it and the three sessions were on (1) Integrating service user/survivor perspectives (2) Integrating transcultural psychiatry and global psychologies (see new book by Suman Fernando and Roy Moodley) and (3) Integrating critical psychiatry. Maybe the session wasn't accepted because it was seen as too anti-psychiatry. If so, perceptions do need to change about the value of critical psychiatry.

Challenging the biomedical model is not anti-psychiatry

Lisa Cosgove and Jon Jureidini have responded (see article) to a Debate article in the Australian & New Zealand Journal of Psychiatry (ANZJP) criticising the Report, which I have mentioned previously (eg. see previous post), of the United Nations Special Rapporteur on the right to health, Dainius Pūras. This report has also been criticised by the European Psychiatric Association (see previous post). The World Psychiatric Association has also criticised an associated report of Dainius on corruption and the right to health, with a special focus on mental health (see another previous post).

The Debate article is entitled 'Responding to the UN Special Rapporteur’s anti-psychiatry bias'. What it means by 'anti-psychiatry' is challenging the biomedical model and, rather remarkably, it includes the British Psychological Society (BPS) in the global anti-psychiatry movement. The Division of Clinical Psychology within the BPS has produced a valuable position statement on giving up the disease model of mental disorder (see previous post).

The Debate article usefully highlights the right to access to mental health care but seems to limit this right to access to pharmaceuticals. As Lisa and Jon point out, the article mistakenly quotes from Dainius' report saying that it "views inpatient psychiatric care as ‘inconsistent with the principle of doing no harm'" [emphasis in original]. What Dainius actually said was "Overreliance on ... in-patient treatment is inconsistent with the principle of doing no harm, as well as with human rights" [my emphasis]. Furthermore, by quoting Fountoulakis and Möller (2011),  the Debate article seems to think that it has undermined the Kirsch meta-analysis of the effectiveness of antidepressants, which is not the case (see previous post). I don't know what evidence the Debate article is referring to that leads to its conclusion "that many psychiatric presentations are effectively and quickly treated with purely biological treatments".

The term 'anti-psychiatry' has general been used by mainstream psychiatry rather than critics themselves. I don't think it's helpful to polarise debate too much but the Debate article should not use the term 'anti-psychiatry' in this sense. Challenging the biomedical model is legitimate within mainstream psychiatry (see previous post). Critical psychiatry is an advance over anti-psychiatry (see previous post) and anti-psychiatry should not be seen as having had no value (see another previous post). It's difficult to get the right balance about how oppositional to be (see previous post). Certainly dogmatic positions such as that taken by the Debate article need to be challenged.

I'm not sure where the apparent quote in the Debate article comes from about the "creeping devaluation of medicine in UK psychiatry ... [being] likened to ‘throwing the baby out with the bathwater’". As far as I know this isn't happening. In fact, although British psychiatry continues to marginalise critical psychiatry, the British Journal of Psychiatry did publish my editorial on 'Twenty years of the Critical Psychiatry Network'. Let's hope there might be more debate about critical psychiatry in Australia and New Zealand, as well as globally in general (eg. see previous post).

(With thanks to Mad in America post by Zenobia Morrill)

Sunday, March 31, 2019

Rising antidepressant prescriptions and primary care mental health

Antidepressant prescriptions dispensed in England have almost doubled since 2008 (see BBC News article). Helen Stokes-Lampard, Chair of the Royal College of GPs, has responded to this recent release of prescription data by NHS Digital (see press release). She is keen that the rising rate is not necessarily seen as a "bad thing, as research has shown they [antidepressants] can be very effective drugs when used appropriately". I'm not quite sure what she means about antidepressants being effective, as I keep emphasising in this blog that the evidence is still open to interpretation (eg. see previous post).

She suggests improvement in the identification and diagnosis of mental health conditions could help to explain the rise. GPs were traditionally found to fail to diagnose up to half of cases of depression or anxiety on initial presentation (Goldberg & Huxley, 1992). Over the longer term, this figure may not be as high or as clinically important as this initial impression may suggest. Some depressed patients are given a diagnosis at subsequent consultations or recover without a GP’s diagnosis. However, there is still a significant minority of patients (Kessler et al., 2002 found 14% in their study) with a diagnosis of persistent depression that is undetected  The failure of detection of depression is commonly presumed to arise because of a lack of psychological mindedness amongst doctors. In general, doctors value objective evidence of disease more than subjective experience. This tendency creates a bias towards the over-diagnosis of physical disease, rather than the detection of mental health problems.

Maybe GPs are now treating and referring more people with anxiety/depression to mental health services, perhaps partly encouraged by the opening up of services by the development of Improving Access to Psychological Therapies (IAPT) over the last 10 years (see graph of increasing numbers of people seen by IAPT) . The number of referrals to general adult mental health services has also increased and figures suggest the number of people seen has more than doubled since 2003, excluding IAPT referrals (see tweet).

Primary care is an essential element of the provision of mental health services and has always traditionally seen more patients with mental health problems than secondary care. Helen Stokes-Lampard complains that access to alternative treatments to medication, such as CBT and talking therapies, is " patchy across the country". She says this despite the introduction of IAPT which was supposed to bridge this gap.

I want to pick up, though, the way in which Helen Stokes-Lampard seems to dichotomise the treatment of mental health problems between medication and talking therapies. In fact, most people seen by secondary mental health services do not receive psychological therapy as such. Even within IAPT, many people do not even receive short-term therapy but instead guided self-help. Polarising treatment between medication and psychological therapy forgets that much mental health treatment is social intervention - helping people understand and recover from the problems with support and becoming as independent as they are able and capable of being. GPs used to do a lot of this work with patients, perhaps particularly when there was continuity of care in general practice. But maybe primary mental health care has become more difficult with the fragmentation and dysfunctionality within health services in general over recent years.

I'm not defending a rise in antidepressant prescribing as Helen Stokes-Lampard could be said to be doing, but I agree with her that these issues - including the role of primary care in mental health treatment - need to be discussed more widely.

Monday, March 11, 2019

Overstating the impact of psychiatric research

Medium has a new mental health publication - 'Inspire the Mind' - produced by the Stress, Psychiatry and Immunology (SPI) Lab at the Institute of Psychiatry, Psychology and Neuroscience at King’ College London led by Professor Carmine Pariante, who I have mentioned previously (eg. see previous post). It has reprinted 'Facts You Should Know About Psychiatry and Why It Is Helping the Person Next to You' from a HuffPost article, although it's dropped the reference to 29 facts we should know, I think because the booklet from the Royal College of Psychiatrists to which the original article refers no longer exists (if it was ever published). Maybe the College had second thoughts about making such 'scientific' claims (eg. see previous post).

It is important to encourage debate about the potential harm of recreational drugs and whether substitute prescribing of methadone leads to harm reduction, but Pariante seems to think it is clear that cannabis causes schizophrenia, which is not the case (see eg. previous post). Like him, I also agree the development of psychological therapies should be evidenced-based, but he doesn't describe the realities of the Improving Access to Psychological Therapies (IAPT) programme (see previous post), nor mention the evidence bias towards specific therapies, such as CBT, or even the problem of the adequacy of controls in evaluating psychological therapy (eg. see previous post). Nor am I sure where his apparently inflated figure of 80% recover for psychological therapy of panic disorder and social anxiety comes from. I doubt research is really needed to show that reducing the maximum pack size of over-the-counter sales of paracetamol, and limiting sale to one pack, reduces paracetamol overdoses (although has such research actually been done?). But Pariante needs to be more careful about making claims for the value of the National Confidential Inquiry into Suicide and Homicide in improving patient safety (eg. see previous post).

I do understand why Pariante wants to answer criticisms of psychiatry. He admits himself that the article is a "little bit of PR". But his attempt to create a positive view of psychiatry shouldn't lead to him unscientifically overstating his case.

Monday, February 18, 2019

The realities of working in IAPT

Despite me saying (eg. see previous post) that people must be more realistic about the effectiveness of Improving Access to Psychological Therapies (IAPT) and stop saying that it is a "marvellous treatment", a recent self-congratulatory event (see programme) celebrating 10 years of IAPT led to a further bout of overhype for the programme (apparently to obtain further funding - note that the Chief Executive of the NHS and the Secretary of State for Health and Social Care were both speaking). For example, Claire Murdoch, NHS England's National Mental Health Director, in a tweet to me said that she was sad that I was dismissing the "brilliant IAPT work".

I'm actually not undermining the work of IAPT. I just want IAPT therapists more recognised for the difficult work they do. Helping people is not always as straightforward as following an IAPT protocol. Luckily the natural history and spontaneous improvement of anxiety and depression over the short-term is about 50% or above, which is what the IAPT programme calls its recovery rate (see previous post). But, particularly over the long-term, it's not always easy to help people deal with their suffering, dependency and vulnerability (see another previous post). IAPT is perverting care, as Rosemary Rizq said (see her article). It shouldn't be seen as a simple programme that people just need to follow and everything will be alright, which is how Claire Murdoch's comment could be interpreted. Politicians seem prepared to invest in IAPT further, maybe to meet the so-called 'parity of esteem' target required to treat mental health services at least as well as they do physical care, even though we don't hear much now about the original reason for the programme being agreed, which was because politicians were persuaded it would take people off benefits.

David Clark (who I have mentioned before, see eg. previous post) in his blog on IAPT at 10, seems to see the only challenge for the IAPT programme as being the need for further expansion. As I said in my talk, David Clark has said that his initial research interest was in psychotropic medication not psychotherapy. He has merely succeeded in encouraging the exploitation of the placebo effect with psychological therapy in the same way as for medication. Although people on average may well prefer talking therapy to medication, let's try and be more realistic about how we develop mental health services.

Monday, January 28, 2019

Progress in mental health research

The Wellcome Trust has said it believes "a radical new approach is needed [in mental health] to drive science forward and improve people’s lives" (see its webpage). I couldn't agree more. As it says, "some underlying problems need to be addressed before the field can make significant progress ... We want to bring ... [a] sense of common purpose to mental health, with different disciplines working together to collaborate in a new super-discipline of mental health science.“

As I have said throughout this blog, the underlying problems that need to be addressed are more conceptual than empirical. There's no point (eg. see previous post) pursuing the reductionist agenda that has come to a halt (eg. see previous post). We need an organismic rather than mechanistic perspective. Psychiatric research has become too focused on speculative neurobiological notions which produce studies plagued by inconsistencies and confounders (see my BJPsych editorial). Would Wellcome be interested in funding the Institute of Critical Psychiatry?

Sunday, January 27, 2019

Critical psychiatry is not Cartesian (nor vitalist)

I want to pick up on the way people who take a reductionist view on psychiatry, such as Ed Bullmore (see previous post), accuse their critics, such as myself, of being Cartesian. René Descartes (1596-1650) was the first to apply a natural scientific mechanistic approach to life (see previous post). Animate and inanimate matter were understood by the same mechanistic principles. Animals are therefore machines; and human physiology is also mechanistic. Descartes stopped short, though, of including the human mind in this mechanistic framework. The soul was denied any influence in physiology. Descartes, thereby, avoided the materialistic implication that man himself is a machine. The split he created between mind and brain is what is referred to as Cartesianism.

One of the first to challenge this perspective was Georg Ernst Stahl (1659-1734). Living beings, including humans, have a purposiveness which cannot be derived from mere physical-chemical processes. For Stahl, the anima or soul provides what he regarded as the key element of movement to matter within the living body (motus tonicus vitalis). However limited this concept may have been by the understanding of mechanics and physiology at the time, Stahl’s dualistic notion was different from Descartes, in that he differentiated organic life from the inorganic, not the soul from the body. Unlike Descartes, the soul and body were not separate but integrated in the organism. Stahl originated an organismic perspective in the life and human sciences. I have several times (eg. see previous post) emphasised how critical psychiatry integrates mind and brain. It is not Cartesian. This perspective formed the basis for Stahl having an emphasis on psychosomatic medicine, and a focus on clinical medicine rather than the physical sciences. 

Yet, Stahl took a mistakenly conceived vitalist position that reductionists deride as much as Cartesianism. Vitalism is the claim that living things possess something else - a vital entity - that is neither physical or chemical in nature. In fact, Stahl's anima was a force within the body, an explanatory agent within physiology, rather than a religious transcendent soul. But, still, Stahl conceptualised the soul as an immaterial ordering principle of movement. Despite this erroneous element in Stahl's thinking, we do need to build on his organismic perspective. 

Those that suggest that life cannot be explained in mechanical terms, as Stahl did and I do (eg. see previous post), may seem to be open to the charge of vitalism. But I'm not anti-physicalist. Biological wholes do not literally cause their parts. Nor am I suggesting that living matter has a level of organisation above the physicochemical level that makes it different ontologically. Biological processes do not have causes (such as a vital entity) outside of physicochemical terms.

Neither am I saying that living processes cannot be studied mechanically. The mechanistic conception of nature, however, fails to provide a complete characterisation of living systems (see previous post). Understanding the meaning of human action is a different kind of explanation from mechanical explanation. We explain the parts of biological wholes in functional not structural terms. Non-organic mental illness, for example, is a functional disorder and cannot be explained structurally as brain pathology (eg. see previous post)

Reductionists of course do appreciate there is a mind-body philosophical problem (eg. see previous post). They think, though, that this problem will eventually be solved (see previous post). I take the same view as Kant that the irreducibility of biology to physics is permanent. Our knowledge is limited. We conceptualise organic matter in a different way to inorganic matter. Our understanding is discursive and how living wholes cause their parts is unknowable to us. In fact, it's the discursive nature of our understanding that creates the possibility of mental illness (eg. see previous post). Summarising Kant's Critique of Judgement, we can never have theoretical knowledge that anything in nature is teleological, but such judgment is nonetheless necessary and beneficial for us. We have to accept this enigma to practise psychiatry (eg. see previous post).