Are mental illnesses really medical disorders?

Lucy Johnstone asks the question 'Does mental illness exist' in her IAI (Institute of Art and Ideas) article. Her answer leaves me with the question 'What is medical illness?'.

Lucy doesn't deny the reality of "suicidal despair, hearing hostile voices, crippling anxiety and mood swings". But she does not think these experiences should best be understood as mental illnesses/disorders. In fact she goes further and says that there's never been any evidence to support the idea that these "very real experiences" are best explained as medical disorders.

What she seems to mean by 'medical disorder' is a condition caused by physical pathology. Here, in a way, she follows Thomas Szasz, who thought mental illness is a myth. For Szasz, it was a misnomer to call mental illness an 'illness', because it's not an illness with physical lesions (see eg. previous post).

I agree with Lucy (and Szasz) that functional 'mental illnesses' are not "chemical imbalances, genetic flaws or other bodily malfunctions". Where I have difficulty with her (and Szasz's) view is that I think the best way to understand medicine is that it covers the treatment of both physical and mental illnesses (see eg. another previous post).

In fact, our modern idea of physical pathology only really developed from the mid-nineteenth century with the correlation of pathological, including histological, findings with clinical symptoms (see eg. previous post). The problem for psychiatry was that it did not completely fit with this development of anatomoclinical thinking, which was of such importance for the advancement of modern medicine in general (see eg. another previous post). Modern psychiatry's always hankered after this identification with the rest of medicine. Most psychiatric illness is functional and not organic, in the sense of not having an identifiable physical lesion in the brain (see eg. yet another post). Lucy's correct that much of modern psychiatry assumes that physical pathology will be found to underly what is called 'mental illness'. It's always tended to believe this, but, in my view, thereby avoids philosophical issues about the mind-body problem and the nature of life in general (see eg. previous post).

I also agree with Lucy that psychiatric assessment is about formulation. It's not commonly appreciated that the standardising of procedures for history taking and mental state examination in psychiatry at the beginning of the 20th century was about formulation (see eg. previous post). What should be important in psychiatric assessment is helping people understand their problems. Reducing people's problems to brain disease has the potential to be stigmatising by turning people into objects.

I, therefore, understand Lucy's concern about psychiatric classification. I agree with her critique, if the aim of psychiatric classification is to create a functional diagnostic system based on biological markers. This was the original intention of DSM-5 and it failed (see eg. previous post). But Lucy seems to think that psychiatry needs to have a reliable and valid classificatory system to be a science. Following Peter Breggin, she argues that psychiatry is undermined by not being able to treat mental illness as physical illness.

Here, again, I have difficulty with her view. Any psychiatric classificatory system is merely descriptive, not aetiological, certainly not biologically-based in the sense of brain abnormalities (see eg. previous post). It needs to be understood for what it is, and there may well be nothing to be gained, or even harm caused, by using psychiatric labels. But sometimes it can be helpful to use words to describe mental states. This was in fact how modern psychiatry first started from the end of the eighteenth century by attempting to reason about madness (see eg. previous post). There will be inevitable uncertainty about using these descriptions of the ways in which people react to the situation in which they find themselves (see eg. another previous post). Of course brain abnormalities can cause psychotic symptoms as part of delirium or dementia (see eg. previous post). However, for the vast majority of psychiatric presentations, which are functional, we have to rely on our ability to identify patterns of responses if we are going to create any validity for a psychiatric diagnostic system (see eg. previous post). We are profoundly limited in what we can achieve and too much should not be made of these limitations.

I just worry that Lucy is making too much of this situation. Mental health practice is interdisciplinary but that doesn't mean it's not medical. I just think it's potentially misleading to suggest that what's identified as 'mental illness' may not be a medical problem. Medicine includes both physical and mental aspects.

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.

How medical psychology became psychotherapy

A post on the British Psychological Society (BPS) History of Psychology Centre blog marks 100 years since the first BPS Member Networks were formed. The Medical Section was one of the first of the three sections formed in 1919 (the others being Educational and Industrial) and I've posted previously on 'The roots of medical psychology’. The Medical Section is now the Psychotherapy Section - name changed in 1988, having previously changed to Section of Medical Psychology and Psychotherapy in 1976 (see BPS history timeline). I'm not sure if the Psychotherapy Section is aware of this history.

Incorporation of the Society in October 1941 reflected the safeguarding of the professional interests of trained psychologists and instituted different classes of membership (Edgell, 1947). Membership had been opened in 1919 to anyone ‘interested in psychology’, not just recognised scholars or teachers. This deprofesionalisation led to an increase in membership from 98 at the end of 1918 to 427 at the close of 1919. A large proportion of these new members were in the Medical Section. Charles Myers used his First World War medical contacts (some treating shell shock; Myers probably being the first to recognise the essentially psychological nature of shell shock) to persuade them to join the Society (Jackson, 2019).

I'm sure there is a need to protect professional psychological expertise, but there are also advantages in extending general interest in psychology. Professional separation of medicine and psychology is not always helpful.

Creating a ketamine epidemic?

Ketamine has been claimed to be the first truly new pharmacological approach for treating depression in the past 50 years and promoted as the first of a new generation of rapid acting antidepressants (eg. see BMJ news report). US clinics increasingly offer IV infusions of ketamine off label. In March, esketamine, a nasal ketamine-based drug, was approved by the US Food and Drug Administration (FDA) for treatment-resistant depression. This is despite it performing better than placebo only in one out of three studies (see my tweet).

Concern about potential approval of esketamine by the Medicines and Healthcare products Regulatory Agency (MHRA) in the UK has led to discussion through responses to a BMJ article. The latest response by Mark Horowitz and Joanna Moncrieff expresses concern that "history is repeating: a known drug of abuse, associated with significant harm, with scant evidence of efficacy, is being submitted for licensing, without adequate long-term safety studies".

It's important not to forget the epidemic of amphetamine use that peaked round the end of the 1960s (see article). Ketamine has the ability to induce an acutely altered state of consciousness, reminiscent of indigenous medicines such as ayahuasca, peyote, and ibogaine, which have been used for centuries across many cultures (see another article). Amphetamines in general were prescribed readily and with insufficient thought in the past (see yet another article). Amphetamine was said to adjust hormonal balance in the central nervous system by creating or amplifying adrenergic stimulation so as to promote activity and extraversion. It was even said that true addiction to amphetamine probably did not occur.

However, evidence emerged after 1960 that amphetamine is truly addictive, instead of merely habituating. The introduction of monoamine oxidase inhibitor and tricyclic antidepressants from the end of the 1950s did not immediately lead to a significant decline in prescribing of amphetamines, but eventually the claim that the newer drugs were superior to amphetamines held sway. Amphetamines and barbituates had nonetheless seemed better to doctors than the bromides and nerve tonics that had been prescribed up to the 1950s. Psychiatrists used to complain that GPs, when they did use the newer tricyclic antidepressants, did not use them in sufficiently high enough therapeutic doses. This complaint was heard less when the SSRIs were introduced in the 1980s, perhaps partly because fluoxetine, maybe the most successful SSRI, was initially introduced at a single dose.

50 years may seem a long time not to have had any new pharmacological treatment for depression but it's important history isn't repeated. It actually wasn't that long ago that the epidemic of amphetamines was created by doctors. Do they really want to do the same with ketamine?

Neuroscience in psychiatric education

The Royal College of Psychiatrists (RCPsych) has published its first issue of PSynapse, the newsletter for its programme (that I've mentioned previously eg. see post), which has support from Gatsby and Wellcome, to transform UK psychiatric training by integrating modern neuroscience. The newsletter mentions that TrOn (the RCPsych online learning resource to support trainees preparing for its membership examinations) is looking for an additional specific neuroscience trainee editor in addition to its other trainee editors. It also mentions the third RCPsych neuroscience spring conference that marked the launch of the College neuroscience champions scheme, which creates a network of psychiatric trainees across the UK to ensure that neuroscience is properly integrated into their respective deaneries.

I’m not against trainees having a proper understanding of neuroscience. But I don’t think the College programme has incorporated critical neuroscience (see previous post). Wellcome has said it wants a radical new approach to mental health research (see previous post). Yet it’s also supporting the Psychiatry Consortium (mentioned in the PSynapse newsletter) of 6 drug companies, Alzheimer’s Research UK and MQ (mentioned in previous post), to accelerate innovative drug discovery in psychiatric diseases. The newsletter also has a report from the British Neuroscience Association festival of neuroscience in April 2019 which highlights ketamine as a potential antidepressant. The rest of the newsletter reports conversations with two of the leaders in the field of ketamine use for depression in the UK. But there’s no discussion of the potential risks of approving ketamine for antidepressant use (eg. see BMJ response by Mark Horowitz and Joanna Moncrieff).

There is a need for interdisciplinarity in mental health research (see previous post). I hope the College isn’t encouraging a neuro-turn in academic psychiatry (see another previous post). I’d like to see it also incorporating critical psychiatry into psychiatric training (see yet another previous post).


(With thanks to Frederico Magalhaes)

Psychiatry's reductionist tendencies

Rebecca Roache (who I’ve mentioned previously) has a useful PPP article which discusses the different forms of reductionism in relation to psychiatry. I’ve tried to make my view clear that critical psychiatry’s anti-reductionism is primarily explanatory (see eg. previous post).

Roache says that psychiatrists writing about the biopsychosocial model often contrast it with reductionism. Indeed I did so in my article (as did George Engel originally). I wish, though, that Roache had been clearer that Engel’s biopsychosocial model and Meyer’s Psychobiology are not eclectic (see eg. previous post).

Roache also seems to go along with Nassir Ghaemi that Roy Grinker originated the term 'biopsychosocial'. There is no use of the term in the reference she gives (viz. Grinker 1994), which she says was a 1954 lecture by Grinker. In fact, it's a paper that was first presented in October 1952. I'm grateful to an unpublished review of Ghaemi's The rise and fall of the biopsychosocial model by Neil Vickers that points out that Grinker used the near synonym ‘psycho-somatic-social’, not 'biopsychosocial' in this presentation. He first used the term ‘the biopsychosocial model’ in 1962, some eight years after Nathan Ackerman (1954). It was also used in two papers by F. A. Weiss in 1958. As Neil says, "In short, the case for Grinker’s priority is not credible." John Romano and George Engel had been talking about an integration of biological, psychological and social factors in psychosomatic medicine at least since 1945. True, Engel may well have had Grinker in mind when he linked the biopsychosocial model to systems theory, but I don't think his biopsychosocial model is dependent on systems theory as such.

I agree with Roache's critique of the confusion in the psychiatric academic literature about reductionism. There is widespread hope in psychiatry that neuroscience will explain mental illness. As I keep saying, critical psychiatry's challenge to this 'disease' model of mental illness is legitimate (see eg. previous post). I'd be interested to know if Rebecca Roache agrees with me.

Foundations of the biopsychosocial model

Derek Bolton is giving a series of colloquia on Engel's biopsychosocial model, based on his book with Grant Gillett (ebook freely available, and references below taken from it). Gillett and he recognise the need for the biopsychosocial model in the light of "historical prejudices against psychosocial causation deriving from physical reductionism and dualism" (loc 132). Nonetheless, they seem to accept criticism of the model by authors, such as Nassir Ghaemi in The rise and fall of the biopsychosocial model, that its eclecticism makes it "vague, useless and even incoherent" (loc 132).

I have myself reviewed Ghaemi's book (see review and response from Ghaemi and my reply). It critiques psychiatric eclecticism and in my view wrongly blames this on Engel's biopsychosocial model. Ghaemi is correct to note the contribution of Roy Grinker, who appreciated the relevance of general systems theory to psychiatry (see my article). Engel suggested that systems theory provided a suitable conceptual basis for his biopsychosocial model. Bolton & Gillett think this is "fundamentally the right way to go" (loc 563). But they seem unaware that Engel's biopsychosocial model is not responsible for the eclecticism in psychiatry.

As I've said before (see eg. previous post), the real origin of the eclectic view in psychiatry is Anthony Clare's response to anti-psychiatry. As Bolton & Gillett say:

The way Ghaemi tells the story ... [is that] the biopsychosocial model arose in the context of competing general views about illness, favouring one or other of the social, the psychological/psychoanalytic and the biological. ... Ghaemi interprets the biopsychosocial model as an elegant ... solution to these ideological conflicts ... [as] if all participants won, [as] if they were not really in opposition at all, but were in fact all true general accounts of illness and healthcare in all aspects. (loc 237)

This was what Clare argued, not Engel. Clare wanted to avoid the ideological conflict created by anti-psychiatry and proposed eclecticism as a way forward.

Bolton & Gillett do realise that "this line of thought [ie. eclecticism] is not apparent in Engel's main papers" (loc 237). In some of Engel's other papers, he does make the general comment that biological, psychological and social must all be taken into account. Misuse of this statement by Ghaemi to mean that all three are more or less equally relevant in all cases and at all times, seems to convince Bolton & Gillett that Ghaemi has a valid point.

As I’ve said (see eg. my editorial and previous post), Engel’s original paper was in fact written to counter Ludwig (1975), who recommended a retreat to a rigid biomedical model in the face of the onslaught of anti-psychiatry. In the same year as Engel, Manschrek & Kleinman (1977) similarly argued for a critical rationality to replace the hubris (dogmatic biomedical) and semi-critical (eclectic) positions in psychiatry (see previous post).

I'm not convinced that Bolton & Gillett have fully appreciated this context. Engel was aware of the success of biomedicine in explaining physical diseases. As a psychosomatic physician, he was also mindful that many presentations to doctors do not necessarily have an underlying physical disease. He wasn't retreating to vagueness, but accepting of the uncertainties of medicine and psychiatry. I, too, have reviewed the book on Biopsychosocial medicine edited by Peter White (see my review), which Bolton & Gillett reference by quoting from The Lancet review of that book by McManus (2005). As McManus notes, "the broader view [of biopsychosocial medicine] is seen by biomedicine as irredeemably soft, with no clear methodology, measurement, or experimental manipulation". This isn't a reason for dismissing the psychosocial nature of some patient complaints; nor for having a negative assessment of Engel's biopsychosocial model.

Bolton & Gillett try to meet the challenges to the biopsychosocial model by suggesting that it needs to be made "specific to particular health conditions" (loc 456). From their point of view, Engel's biopsychosocial model is not really a general model, and this explains its vagueness. I'm not against looking at examples and specifics, but I don't think this is an adequate reason for undermining the generality of Engel's model. Bolton & Gillett do recognise the connection between patient-centred medicine (see previous post) and the biopsychosocial model and the centrality of this element for Engel (loc 2707). An integrated understanding of the whole person is required for all medical conditions.

Bolton & Gillett suggest that the foundational theoretical constructs of the biopsychosocial model need rethinking and reconceptualising. Again, I'm not convinced this is necessary as such, although I recognise there is a need to develop the biopsychosocial model as a philosophical and scientific theory of health, disease and healthcare. This is the strength of Bolton & Gillett's book. For example, they argue that information processing theory has moved biology on from understanding causes as merely physico-chemical. There is some truth to this view and Bolton & Gillett are correct that psychiatry should not be dualist or vitalist (see previous post). However, the mechanistic perspective remains pervasive in biology. Biology still needs to move onto a processual, organismic philosophy (see previous post), in the same way as indicated by Engel.

Bolton & Gillett argue against physicalism. Persons do need to be understood as biological processes. An integrated biopsychosocial model studies people within the framework of biology. A mechanistic conception of nature fails to provide a complete characterisation of living systems (see previous post). We need a new organismic biological perspective to enrich the integrated mind-brain understanding promoted by Engel for medical and psychiatric practice.

Scientists think antidepressants work but is the evidence biased?

Gemma Lewis and Glyn Lewis popularise their PANDA study (published in The Lancet Psychiatry) in The Conversation. The headline of their piece is 'Antidepressants work, but just not how scientists thought they worked'.

Even though the PANDA study did not find a significant difference in depression scores at 6 weeks between sertraline and placebo groups, the authors still claim antidepressants work. This is because they found evidence of a significant difference for anxiety symptoms and suggest the benefit of antidepressants is more for anxiety than depression. I'm not sure if they're saying that antidepressants should be renamed anxiolytics.

As I've pointed out previously (eg. see post), despite antidepressant trials on average showing a statistically significant difference for active drug over placebo, the difference is small and there is a question about how clinically significant this difference is. Furthermore, methodological difficulties, such as unblinding, can bias the results, so it is possible that any statistically significant result is an artefact (see my Bias in controlled trials webpage). This is called the placebo amplification hypothesis of the apparent statistical advantage of antidepressants over placebo in clinical trials. It is difficult to prove and the debate about antidepressant efficacy is still open in the literature (see previous post), despite the Lewises apparently not being prepared to admit that their PANDA study may actually provide evidence that antidepressants are not effective.

Data is given on unblinding in the PANDA study, although the authors do not make very much of it. The authors knew of three incidents when participants opened the capsule to see if there was a tablet included, and these patients were withdrawn from the trial. The majority of participants did not think they were on active treatment, even though half of them were. More people on sertraline (46%) thought they were on active treatment than those on placebo (19%). People seem to have generally thought they were not on active treatment, and placebo patients were quite good at recognising this. Participants were able, therefore, for whatever reason, to distinguish sertraline from placebo, so it's misleading to say the PANDA trial was double-blind.

Despite what the authors seem to think, antidepressant trials are not adequately blinded (Even et al, 2000). The findings of the PANDA study may therefore merely reflect the authors bias (transmitted to the participants) that antidepressants are effective (although for some reason not detected at 6 weeks with depression scores). Antidepressants may merely be placebo panaceas for emotional problems.

The validity of the distinction between functional and organic mental illness

A tweet by Mohammed Rashed has intrigued me. He says the distinction between functional and organic mental illness is not valid, and suggests it's a false distinction based on a misunderstanding of the concept of illness. The brevity of communication on twitter leaves me not understanding what he means.

I have argued that critical psychiatry seeks to restore the functional/organic distinction (eg. see previous post). It was abolished by DSM-IV (see eg. previous post) but this was a mistake.

Mental and brain activity need to be understood as a single biological response. The problem is that we tend to have a mechanical view of biology, which can make it difficult for psychiatry to integrate mind and brain (see eg. previous post). Mental dysfunction ie. functional mental illness, as much as brain disease ie. organic illness, is a medical condition resulting from pathological process.

We have always needed myths to understand illness, including madness (see eg. previous post). Relating symptoms to their underlying physical pathology was a major advance for medicine in the first half of the nineteenth century and still underlies our modern understanding of disease (see eg. previous post). Applying this anatomoclinical method in psychiatry was not as successful because it was not always very easy to relate mental conditions to underlying brain pathology. In fact, it led to an overenthusiastic search for anatomical localisation of mental illness in the second half of the nineteenth creating a brain mythology that was unrelated to empirical findings. Acceptance of the organic/functional distinction helped psychiatry to move on from such fanciful notions.

Of course acute brain disease can cause delirium and chronic brain disease can cause dementia. The symptom patterns of brain disease are different from functional illness, with a prominent disturbance of cognitive function, such as orientation. Clinicians are trained to assess and detect whether a psychiatric presentation may have an underlying organic basis by testing cognitive function in particular. To suggest that the distinction between functional and organic mental illness is invalid does not seem to make sense to me clinically, let alone conceptually.

Nor am I sure what understanding of illness Mohammed thinks we should have that will make it apparent that the functional/organic distinction is invalid. Technically a distinction has been made in the scientific literature between illness, which is the personal experience of symptoms and suffering, whereas disease is the underlying biological pathology (see eg. previous post). Disease is something an organ has; illness is something a person has. It's commonly assumed that the organic basis of mental illness will be found (see eg. previous post). Could this be what Mohammed means? If so, my claim is that the functional/organic distinction is more fundamental and critical psychiatry is a legitimate challenge to the disease model of mental illness (see eg. previous post).

I'm hoping this blog may help to clarify what Mohammed meant by his tweet. Once I've understood, maybe this issue does need to be taken forward in debate in a scientific article. There does need to be further discussion about the validity of the functional/organic distinction of mental illness.

Reclaiming the term ‘biopsychosocial’

Joanna Moncrieff comments in a tweet on Niall McLaren’s Mad in America blog, saying that the biopsychosocial model is “just a phrase used to dress up biomedical reductionism”. I’ve commented before several times on the biopsychosocial model (eg. see previous post). I do understand what Jo means when she implies that psychiatrists who say they adopt a biopsychosocial model are really using a weaker version of biomedical reductionism (see eg. extract from my book chapter). And, as Niall indicates in his blog, despite Ronald Pies claim that psychiatry is biopsychosocial, Pies himself is quite biological in his approach to psychiatry (see previous post).

The definition of biopsychosocial has become quite confused and I have advocated using the term ‘sociopsychobiological’ (see previous post). But George Engel’s original biopsychosocial model was a deliberate challenge to biomedical reductionism and I think that critical psychiatry does take a biopsychosocial position (eg. see my article). What happened was that Anthony Clare (see previous post) deliberately avoided any ideological implications for psychiatry, encouraging an eclecticism as a way of dealing with the challenge of anti-psychiatry (see eg. my eletter [original layout has been lost on website upgrading]). We need to move on from this eclecticism (see eg. previous post). The original meaning of ‘biopsychosocial’ needs to be reclaimed by critical psychiatry.

The implications for psychiatry of a processual philosophy of biology

René Descartes was the first to apply the natural scientific mechanistic approach to life (although excluding the soul) (see previous post). This perspective has remained the most pervasive view within biology. Nonetheless there have been challenges that recognise that living beings have a purposiveness that cannot be derived from mere physical-chemical processes. For example, Georg Ernst Stahl differentiated organic life from the inorganic, integrating the soul and the body in the organism. This led to his erroneous claim that living things possess a vital entity. 

With the origin of enlightenment thinking in the second half of the eighteenth century, Immanuel Kant’s critical philosophy was clear that it is absurd and futile to expect to be able to understand and explain life in terms of merely mechanical principles of nature (see previous post). A mechanistic conception of nature fails to provide a complete characterisation of living systems. Organisms, unlike machines, are self-organising and self-reproducing systems. Different modes of explanation are therefore required for teleological and mechanical points of views. Although we can never have theoretical knowledge that anything in nature is teleological, such judgment is nonetheless necessary and beneficial for us and we commonly embark on a ‘daring adventure of reason’ to understand life in mechanical terms. 

American pragmatic philosophers, such as William James and John Dewey, in the context of Darwin’s theory of evolution, attempted to dissolve such metaphysical disputes by focusing on nature and experience and the centrality of the organism-environment interaction. Following the development of quantum mechanics in physics, a group of organicist biologists promoted life’s dynamic, systemic and purposive character as a way of moving on from physico-chemical reductionism (see previous post). For example, John Scott Haldane recognised the distinctiveness and irreducibility of living beings because of the continuous dynamic preservation of the internal environment. One of the most important principles of biology for Ludwig von Bertalanffy was the stream of life conception, that living forms are the expression of a perpetual stream of matter and energy.

More recently, Dupré and Nicholson (2018) have proposed a manifesto for a processual philosophy of biology to move on from explanation in terms of static unchanging entities. Their project promotes the metaphysical thesis that the living world is made up of processes not substances. Alfred North Whitehead articulated a comprehensive metaphysical system for process thinking, but Dupré and Nicholson distance themselves from its details. There needs to be more discussion about the underlying philosophical worldview and limitations of the mechanistic approach to biology and such processual thinking provides a valuable framework to take this debate forward. 

This perspective has implications for medicine in general, in particular in relation to the concepts of illness and disease. Illness disturbs a person’s functional equilibrium. Disease, particularly since the development of anatomoclinical methods in the 19^thcentury (see previous post), tends to be understood as structural biological pathology. Emphasising the disruption of dynamic processes as a way of understanding disease moves on from this simple contrast between organism as thing and its independent pathological process. 

This abstract focuses on the implication for psychiatry of processual thinking. The mind-body problem can be seen as a more specific form of the mechanistic-processual dilemma (see eg. previous post). Persons need to be understood as biological processes. There is a history in psychiatry of attempts to integrate somatic and psychosocial aspects, and this can be related to developments in processual thinking in biology (see previous post).

For example, George Engel proposed a new medical model, suggesting that the general systems theory of von Bertalanffy provided a suitable conceptual basis for his biopsychosocial model (see previous post). Perhaps in a similar way to Dupré and Nicholson, whose project does not specifically build on Whitehead’s overarching theory, an integrated biopsychosocial approach is not dependent on general systems theory as such. For example, Adolf Meyer’s Psychobiology was more related to American pragmatism. Meyer was clear that Psychobiology studies man as a person within the framework of biology (see previous post). 

Such integrated mind-brain understandings were also present in the origins of modern psychiatry. For example, Ernst von Feuchtersleben published his textbook influenced by Kantian critical philosophy in the same year, 1845, that saw the publication in German of the book in which Wilhelm Griesinger set the trend for understanding the pathology and therapy of mental diseases as a mechanical natural science. The argument of this abstract is that processual thinking in biology counters this dominant positivist tendency within current psychiatry. (see previous post).

(Abstract submitted to Peter Sowerby interdisciplinary workshop: Conceptual issues in biological psychiatry)

Advice to a young doctor considering a career in psychiatry

Dear trainee

Psychiatry needs doctors who are prepared to think critically. Unfortunately, it does not always make it easy for them to do so. Professor Sir Robin Murray, one of the most eminent UK psychiatrists over recent years, confessed to mistakes in an end of career mea culpa, wishing he had not adhered so “excessively to the prevailing orthodoxy" (see previous post) . As he says, there is an orthodoxy in psychiatry. You should, therefore, be prepared to be indoctrinated in your training (see previous post). This can be a confusing experience, and these comments are written to try and help you with that confusion.

Modern UK postgraduate psychiatry was developed at the Maudsley Hospital Medical School after Aubrey Lewis was appointed Professor of Psychiatry in 1948. He promoted the recruitment of high quality psychiatrists with "ardent, critical, lively, disputatious and reflective, eager minds" (see previous post). He encouraged a sceptical approach to psychiatry and had little patience for imprecision or poorly thought-out ideas. Building on these roots, it is still the case that doctors with open minds, who are sceptical of psychiatric quackery, need to be attracted into psychiatry.

The trouble is that you may have been encouraged to come into psychiatry because of clinical neuroscience (see previous post). There have been many exciting developments in basic neuroscience but what you may not have been told is that it is questionable whether these have any bearing on most of clinical psychiatry (see another previous post). The history of biological research in psychiatry is of speculations that have failed to be confirmed. Inconsistencies and confounders plague research studies, so that essentially it’s not been possible to say anything definitive about the neuroscientific basis of functional mental illness.

This may seem disappointing. But I wouldn’t want to encourage you to come into psychiatry if your only motivation is to uncover the biological basis of mental illness. You are bound to become disillusioned (see previous post). You may well have a successful career, like Robin Murray, but that may not be sufficient compensation for your personal scientific integrity (see another previous post).

However, maybe, after all, your primary attraction to psychiatry was more for philosophical and cultural reasons. You have trained as a doctor, so can appreciate how medical training is not always patient-centred (see previous post). However difficult it may be to have a whole-person approach to medical practice, this may well have been your initial motivation for choosing medicine. And, psychiatry, at least theoretically, should give you the opportunity to develop these interests further, although psychotherapy training is perhaps not always as readily available as part of psychiatric training as it used to be. Not that I am necessarily encouraging you to become a psychotherapist. Psychiatry itself has wider social concerns.

And, if you think about it, maybe you should not be so surprised that functional mental illness cannot be reduced to brain abnormalities. Biology itself raises philosophical issues about whether life can be understood as a machine. The fundamental issue of the relation of mind and body creates the context for stimulating conceptual debate and conflict in psychiatry. Despite Descartes, the soul and body are not separate but integrated in the organism. Psychiatry should take an organismic, processual, rather than mechanistic, perspective in the life and human sciences.

I would encourage you to take up the challenges of psychiatric practice. Clinical work is a privilege to share the traumas and sufferings of patients and help them understand and do something about their situation. Intellectual and academic rewards and fascinations are there for those that accept the limitations and uncertainty of practice. I wish you well in your application.

Let me know if I can do any more to help.

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.

Taking steps to reform the Mental Health Act

The film 55 Steps (see trailer) starts with Eleanor Riese (played by Helena Bonham-Carter) being injected with antipsychotic medication under restraint in a psychiatric hospital. Represented by her lawyers, Riese managed to convince the California State Court of Appeal that mental patients who are involuntarily committed to health facilities for short-term crisis care may refuse to take anti-psychotic medications, unless a judge determines that they are incapable of making an informed decision about their medical care (see NYTimes 1987 article). The ruling excluded those cases in which emergency intervention is needed to save the patient's life or prevent injury to the patient or others.

Similarly, the Alaska Supreme Court case has ruled that patients should not be given medication against their will without first proving by clear and convincing evidence that it is in their best interests and there is no less intrusive alternative available (see previous post). Nonetheless, forced medication under restraint is still common in psychiatric hospitals across the world.

Germany's Constitutional Court also found that the criteria under which coercive antipsychotic treatment is given were far too wide (see article). Because of legal challenges, for a brief time Germany was left without a law governing coercive treatment in psychiatry in all but life-threatening emergencies. A greater emphasis on consensual and less coercive treatment is required.

Essentially, the recent UK government's Independent Review of the Mental Health Act 1983 has failed to deal with this issue (see previous post), despite hearing considerable evidence of unacceptable, including abusive, treatment. Once detained, people essentially lose their rights and little account is taken of their will and preferences. This situation has been revealed by BBC Panorama in undercover reports at Whorlton Hall and Winterbourne View hospitals.

We need to move on from legislation based on substitute decision-making to offering support according to a person’s will and preferences, accepting that these may be unknown or distorted at times when people lose mental capacity. Nonetheless, the person's perspective still needs to be considered to give the best interpretation of their will, preferences and rights. For example, would patients want to be forcibly injected with medication if they become psychotic? The right to legal capacity needs to be protected (see WHO QualityRights training tool).

The problem is that assessments of capacity are not always very objective (see eg. Flynn, 2019). Although the Mental Capacity Act makes clear that a person should not be regarded as lacking the capacity to make a decision just because they make an unwise decision, in practice this can be the apparent criterion used. The person making the decision seems to need to make the case that they reach the standard of the ‘ability’ expected. If the explanation doesn't sound very persuasive then the person might be found to lack capacity. In short, substitute decision-making risks imposing disproportionate alternative perspectives to the person's own will and preferences.

To be clear, I do recognise that people lack mental capacity at times. I also accept the need for involuntary intervention at times. What I'm arguing for is a Mental Health Act that preserves the dignity and respect of detained patients. The Independent Review will not lead to sufficiently rights-based reform. Maybe the film 55 Steps can encourage further discussion by focusing debate on whether forced treatment with medication can ever be justified. Under what circumstances would you accept this if you became psychotic?

Being honest about antidepressants

Adrian James, Registrar at the Royal College of Psychiatrists, said in his recent Radio 4 interview (see transcript) that “we need to have an honest discussion about side effects” of antidepressants. This  should go without saying and it’s helpful the College is being explicit. But I worry that James’ interview demonstrates, as I have said previously (see post), that the College is not making a significant enough concession on antidepressant discontinuation problems.

The reason James and the College minimise antidepressant discontinuation problems is because they want people to take their antidepressants if needed. The College exists as an institution to justify psychiatric treatment, such as antidepressant medication (see previous post).

James therefore emphasises that any side effects from antidepressants may be mild and self-limiting. He may be talking about side effects on starting antidepressants, as it is true that antidepressants are usually reasonably well tolerated, although not always so (and, again, the College has not made enough of the small number of people that do have a severe adverse reaction to antidepressants). But discontinuation problems are not always mild and self-limiting. The College has recognised that people can have severe withdrawal symptoms over a long period of time, but James insists this is “a very small number”, which I’m not convinced is the case.

It’s possible that Rachel Kelly’s experience is more typical (see her Times article). She says coming off the drugs after two significant depressive episodes, which left her hospitalised, was "terrifying". Each time she did so, she "feared she would relapse". She goes on, "Indeed the resulting anxiety was so high that I had to use other drugs, chiefly tranquillisers, to ease the process." As I said over 20 years ago in a BMJ letter, the "general public might reasonably expect psychiatrists specialising in disorders of the mind to recognise psychological dependence, base their advice on clinical experience, and use their common sense".

Getting the right position on antidepressants

The Royal College of Psychiatrists (RCPsych) has been widely praised (eg. by the Council for Evidence-based Psychiatry (CEP) - see press release) for its call for NICE to update its guideline on antidepressant withdrawal (see RCPsych press release). This new statement follows a complaint made to RCPsych - which was wrongly dismissed without, as far as I know, any apology - about a claim, made by its President and Psychopharmacology Committee Chair, that discontinuation problems on stopping antidepressants resolve within two weeks for the vast majority of patients (see previous post).

Instead RCPsych now accepts that “there should be greater recognition of the potential in some people for severe and long-lasting withdrawal symptoms on and after stopping antidepressants”. This is a welcome development and I don’t want to seem negative about it. But I do have concerns overall about the recently released RCPsych position statement on antidepressants and depression.

For example, as far as discontinuation problems are concerned, the statement says “withdrawal symptoms ... are often mild and self-limiting”. I’m not sure this is right. They can be mild and self-limiting, but I’m not convinced they are often so. Nor do I find anywhere in the statement a proposal for research to establish the reason for these problems. This is particularly pertinent because, as the statement points out, there is a lack of evidence that antidepressants are physically addictive.

More generally, the statement overestimates the value of antidepressant treatment. For example, it makes several statements about how long people need to stay on antidepressants, without any references to support this advice. It also makes too much of what it calls the "partial understanding" of how antidepressants work, even assuming that they do work! Although it may indicate we need to move on from the chemical imbalance theory of depression (eg. see previous post), it still seems enamoured of biological theories of antidepressant action, such as neural plasticity. There's no way the RCPsych could consider that the placebo amplification hypothesis to explain trial data could possibly be valid, even though Cipriani et al (2018) (authors it praises) only say antidepressants "might work" (see previous post).

Rhiannon Lucy Cosslett in a Guardian article asks why it took so long for psychiatrists to listen to patients about antidepressant discontinuation problems. The answer is that they tend to focus on short-term fixes, they tend not to be psychologically-minded and they can be too quick to peddle medication (see my book chapter). RCPsych has got a long way to go to deal with these tendencies within its ranks.

Critical psychiatry is reformist

Bonnie Burstow's chapter entitled 'From 'bed-push' to book activism: Anti/Critical psychiatry activism' in the Routledge handbook of radical politics (2019) helpfully summarises her antipsychiatry position. She makes clear that "The chapter is written from an anarchist perspective". Antipsychiatry is distinguished by the fact that

... all antipsychiatry activists seek the total abolition of institutional psychiatry (and this distinction is crucial) not some just part of it and not the mere 'reform' of the institution. This, in practice, would mean that insofar as anything vaguely resembling psychiatry continued to exist, it would have no state powers, no state funding or promotion and no authoritative 'medical’ status [emphasis in original].

I've complained before about how the americanisation of critical psychiatry seems to be devaluing its meaning. For example, the Mad in America website reduces critical psychiatry to a general term for alternatives to the biomedical model in psychiatry (eg. see my book review). At places in her chapter, Bonnie Burstow seems to use the terms 'critical psychiatry' and 'antipsychiatry' interchangeably (as apparently, for example, in the subtitle of the chapter), but I'm not sure if this is intentional.

Rather than allowing the highjacking of the term 'critical psychiatry' by antipsychiatry, I think I need to make clear that critical psychiatry is a reformist movement. There are differences within the movement (see previous post) and although I'm more at the reformist end, I'm not against seeing critical psychiatry as a broad spectrum, which it is (eg. see previous post). But it's unrealistic to expect that the wish to find a physical basis for mental illness will ever go away completely. There's always been this wish, even before our modern understanding of medical psychology developed at the end of the 18th century. I've even argued that critical psychiatry was present in the origins of modern psychiatry (eg. see previous post). Critical psychiatry is certainly a medical enterprise (again, see eg. previous post).

I'm not against activism such as the 'Fast for Freedom' hunger strike in 2003 by six 'psychiatric survivors' (eg. see previous post). I attended an Occupy American Psychiatric Association meeting in the past (see previous post) and I do think there are particular issues about American psychiatry (see eg. previous post) that may require a more radical response. I also use social media as a form of activism, and some of the motivation for doing this is because of the difficulty in getting my perspective into mainstream psychiatric journals.

However, I'm not convinced that there really is what Bonnie Burstow calls "an unstoppable radical politic". But I do respect her position. and value her attempt to restate an antipsychiatry position. I originally called my Critical Psychiatry website the Anti-psychiatry website (see previous post), although it has became more defunct as it has now essentially been taken over by this blog. But I'm glad I changed the name because I never intended to promote anarchy. I'm sure that's what some people fear about critical psychiatry, but that's a misunderstanding.

I agree with Bonnie Burstow that "the mad and the antipsychiatry movements in themselves present challenges". I'm not against reconsidering my politics. But my ultimate aim is to make psychiatry more pluralistic, not to abolish it.