Reality of mental health problems

I’ve mentioned before several times (eg. see previous post) about the hope that neuroscience will explain mental illness. Psychiatry commonly assumes that there is an underlying hypothetical brain lesion, even if not yet discovered, causing mental health problems. But these are often mere conjectures (eg. see another previous post).

The problem with continually promising ourselves physical lesions is that we can tend to ignore psychosocial facts that are already available. As Adolf Meyer (1906) said, “it has become my conviction that the developments in some mental diseases are rather the results of peculiar mental tangles than the result of any coarsely appreciable and demonstrable brain lesion” (see previous posts about Meyer eg. Pathologist of the mind). This doesn’t mean ignoring organic factors when they exist. But, again following Meyer, “we had better use the facts at hand [psychosocial factors] for what they are worth” rather than “have to invent them [somatic factors] first in order to get anything to work with”.

Pragmatic treatment is about helping the person adapt and adjust. This may well not be easy, but it’s not a reason for avoiding trying to do so or deflecting the problem onto the brain.

The scope of psychotropic medication discontinuation problems

The stakeholder comments submission (see table) from the College of Mental Health Pharmacy about the Scope for the NICE guideline on Safe prescribing and withdrawal management of prescribed drugs associated with dependence and withdrawal is revealing about why antidepressant discontinuation problems are minimised (see eg. previous post). The College questions why antidepressants have been included within the Scope. What it's worried about is that patients might discontinue or not seek antidepressant treatment when they need it, if they know about antidepressant discontinuation problems.

Similarly, prescribers may use the chemical imbalance theory as a way of persuading patients to take antidepressants (see previous post). This is despite the fact that believing the theory may make patients more pessimistic about the prognosis of their depression and lower their perceived ability to regulate their mood (see previous post). More seriously as far as antidepressant discontinuation problems are concerned, believing the chemical imbalance theory may at least contribute to, if not cause, discontinuation problems (see previous post). Eveleigh et al (2019) found evidence from patients that the chemical imbalance theory was a prominent factor in creating fear of discontinuation.

Several stakeholders in the NICE consultation suggested including in the Scope other drugs, such as antipsychotics, which also cause discontinuation problems. NICE refused, saying that such guidance is included within the NICE guideline for psychosis and schizophrenia in adults, although I can't see any mention of discontinuation problems there. NICE only seems to have included antidepressants within the Scope because it was asked to by the Department of Health.

The Royal College of Psychiatrists usefully raises the issue of the psychological component of dependence but I'm not sure that NICE really takes this on board in its response. People who have antidepressant discontinuation problems often experience them very physically. It's good that NICE will presumably expand (although maybe by not very much) on its Depression guideline to produce more detailed advice for safe prescribing, monitoring and safe withdrawal of antidepressants. But people are being made dependent on psychotropic medication in general. The psychological element, at least, of antidepressant discontinuation problems cannot be denied (see previous post). It's understandable NICE may wish to sidestep this complex issue but these wider factors do need to be addressed.

Misdiagnosing dementia

When I first started this blog several years ago now, I indicated I would return to the issue of the National Dementia Strategy (see previous post). Times have moved on and the incentivisation of GPs in the NHS to diagnose dementia, which began in 2011, has been controversial. This is because of the increased number of referrals of people with cognitive complaints not due to dementia (Bell et al, 2015). Mistakes can be made about the diagnosis of dementia and doubts have been expressed about the security of diagnosis for at least some so-called dementia advocates (Howard, 2017) (see previous post).

A systematic review of functional cognitive disorders has just been published in Lancet Psychiatry. Current views of functional neurological disorders tend to emphasise excessive attention towards physical symptoms rather than psychological stress as such in the generation of symptoms. People with functional disorders are more likely to attend alone and be worried about their memory, providing a detailed account of personal history and memory failures more than patients with neurodegenerative disease. Those with functional cognitive disorder phenotypes are at risk of iatrogenic harm because of misdiagnosis or inaccurate prediction of future decline.

Are there no problems with psychiatry?

George Dawson (who I have mentioned previously - see post) has responded in a blog post to a NEJM article by Caleb Gardner and Arthur Kleinman entitled 'Medicine and the Mind — The Consequences of Psychiatry’s Identity Crisis'. As far as Dawson is concerned there is no identity crisis in psychiatry. The only problem he recognises is that:-

most psychiatrists are working in toxic practice environments that were designed by business administrators and politicians. As a result, psychiatrists are expected to see large numbers of patients for limited periods of time and spend additional hours performing tasks that are basically designed by business administrators and politicians and have no clinical value.

Dawson is a believer in psychopharmacology, ECT and transcranial magnetic stimulation and thinks the benefits of psychosocial treatments are significantly limited. He also believes neuroscience research is translating into benefits for clinical practice, but these seem to be more about possibilities for the future rather than now.

Gardner and Kleinman (2019) recommend reducing the amount of spending on biologic research in psychiatry to support only the highest quality such research. They suggest that academic psychiatry needs to be rebuilt by more recognition of the limits of biologic research. Dawson wonders why NEJM has accepted this article, and I agree it is surprising considering how biomedical the perspective of the journal has been about psychiatry. I wonder, though, whether, like Wellcome apparently (see previous post), NEJM has become more sceptical about whether psychiatry is really being advanced by neuroscience.

I'm not saying managed care doesn't create problems for psychiatry, but there are wider conceptual issues that do need to be addressed. I agree with Dawson this issue shouldn't just be decided by rhetoric.