Support the development of the Institute of Critical Psychiatry

I've mentioned the idea of the Institute of Critical Psychiatry before on my personal blog (see post). I have partially organised an inaugural conference but this has stalled for lack of funding. I've therefore set up a crowdfunding initiative and am looking for support and donations (see project).

People need to think critically and independently about psychiatry. Even the Wellcome Trust thinks a radical new approach is needed for mental health research (see previous post).

Abandoning CPA policy

David Kingdon in his BJPsych Bulletin editorial questions whether we need the Care Programme Approach (CPA). Its implementation went wrong right from its beginning in 1991 (Simpson et al, 2009).

In the context of a service that has become bureaucratised by managerialism and deprofessionalisation, it's about time mental health services abandoned CPA as a policy. The principles of CPA: high quality and complete assessment; continuity of care; care plan agreed with service user; and identified lead for those who have input from more than one professional (including inpatient and crisis and home treatment (CRHT) services) should be retained. However, professionals need to take responsibility for their implementation and the policy itself should be abandoned.

Stopping antidepressants may cause more problems than it’s worth

Vasco M Barreto defends antidepressants in his Aeon essay. Although he may have some doubts about the serotonin theory of depression, he still believes in the neuronal basis of depression and antidepressant effects, and has no doubt antidepressants work better than placebo, even though clinical trials may be biased. I’m not convinced he’s right (see eg. previous post) and do not see depression as a neuronal disease.

I can't prove it, and I guess Barreto will never believe me, but I think any apparent antidepressant effect may be due to placebo. I'm not saying that antidepressants are inert, but if they help depression, this may be because of the placebo effect. Despite what Barreto says, I'm also sceptical about the claimed benefits of aspirin (see BMJ eletter).

Barreto describes his own history of depression, which returned on stopping  antidepressants, and led to him making the decision to persist with treatment. I agree people should not be shamed for taking antidepressants (see previous post). Discontinuing antidepressants may well cause more problems than it's worth. All the more reason why guidelines should be followed to warn people, when they first start antidepressants, of the risk of discontinuation problems. Stopping antidepressants, if only because of withdrawal symptoms (see previous post), may cause more problems than it's worth.

Reclaiming the term 'illness'

Twitter conversation has highlighted that the reason some people object to the term 'mental illness' is because they think the term implies biological abnormality. I don't think this is necessarily the case.

Relating symptoms to their underlying physical pathology was a major advance for medicine from the first half of the nineteenth century (see previous post). We've always needed ways to understand illness even before the development of modern pathology (see another previous post). For example, for many years humoral theory was a model for the working of the body. Both mental and physical illness were understood as an imbalance of the four humors. Such a theory was intended to help make sense of symptoms for people and provide a rationale for doctors’ interventions. Assuming mental illness is a brain abnormality can do exactly the same for modern patients and psychiatrists.

However, I agree with the critics of the term 'mental illness' that there is a gap between the reality and apparent ideal of psychiatry as a physical science (see eg. previous post). The trouble is that we can't understand functional mental illness in physical terms. More generally, we can't understand life in terms of merely mechanical principles of nature. So for example, mental illness can't be reduced to brain disease. I can understand why people don't want to use the term 'mental illness' if it implies brain disease, because to do so is misleading people by making claims that we have biological understanding that we do not.

But, the term 'illness' has always been used wider than our modern definition of physical disease. Technically a distinction has been made in the scientific literature (see my Lancet Psychiatry letter) between illness, which is the personal experience of symptoms and suffering, whereas disease is the underlying biological pathology. Disease is something an organ has; illness is something a person has.

In this sense, mental illness is a perfectly valid concept. I've no objection to using the term 'mental health problems' instead of 'mental illness'. But, functional psychosis, for example, can be seen as an illness. By attempting to reclaim the term 'illness' for such mentally abnormal presentations, I'm not doing so to imply that I think there is an underlying biological disorder for psychosis (see previous post). I don't! But because people do seem to think the term 'mental illness' implies biological abnormality, there is room for confusion. I'm just trying to help clarify what I mean.

How should psychiatry respond to criticism?

Twitter conversation about the session yesterday at the Royal College of Psychiatrists (RCPsych) International Congress 2019 entitled 'The new anti-psychiatry: Responding to novel critiques on the legitimacy of psychiatry' (see previous post) has clarified for me that even though the session had a provocative title, there is a genuine issue about how psychiatry should respond to criticism. We shouldn't be surprised that psychiatry is controversial. The power to detain people against their will on the basis of their health or safety or for the protection of other people because of a mental disorder - criteria which may be open to interpretation - is bound to be challengeable, and safeguards are written into the legislation itself. So there will be people that argue for the total abolition of psychiatry (see eg. previous post).

Abolitionists may be the most extreme critics that psychiatry has to deal with. The nature of mental disorder itself is an issue. I have always argued that critical psychiatry arises out of mainstream psychiatry's tendency to reduce mental illness to brain disease. These are not new issues for psychiatry and were made particularly pertinent when disease was defined by physical pathology from the middle of the nineteenth century. We need more recognition that mental illness does not fit this model. The organiser and speakers in the RCPsych Congress session at least need to be thanked for getting this matter onto the RCPsych agenda, even if the title of the session may suggest a defensiveness, rather than the embracing of criticism.