Thursday, September 19, 2019

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.

Saturday, September 07, 2019

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.

Wednesday, August 21, 2019

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 Nicolson 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 process 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 and disease, particularly since the development of anatomoclinical methods in the 19thcentury (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 paper 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 Nicolson, 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 paper 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)

Wednesday, August 07, 2019

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.

Sunday, July 28, 2019

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).

Saturday, July 27, 2019

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.

Saturday, July 13, 2019

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 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.

Wednesday, July 10, 2019

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.

Friday, July 05, 2019

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.

Saturday, June 29, 2019

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 uncover reports at Whorlton Hill 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?

Sunday, June 02, 2019

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".

Friday, May 31, 2019

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.

Saturday, May 25, 2019

Critical psychiatry is reformist

Bonnie Burstow's chapter entitled 'From 'bed-push' to book activism: Anti/Critical psychiatry activism' in the Routledge handbook of political activism (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.

Thursday, May 16, 2019

Schizophrenia is not a chronic brain disorder

I've been asked how the American Psychiatric Association (APA) is allowed to call schizophrenia a "chronic brain disorder" on its information webpage about 'What is schizophrenia?'. The answer is that professional bodies, including the Royal College of Psychiatrists (see eg. previous post), can't be relied on for information about psychiatry. There was a time when American psychiatry would have been more cautious about making such a claim. For example, neurobiology was only represented in a few sections of the 1959 American Handbook of Psychiatry (see my book chapter). Any influence of psychoanalysis and Meyerian psychiatry is now difficult to find in modern American psychiatry (see eg. another book chapter).

I'm reminded of the hunger strike on the 16 August 2003 by six "psychiatric survivors" to challenge the APA for evidence to support common claims that major mental illnesses are "proven biological diseases of the brain" and that emotional distress results from "chemical imbalances" in the brain (see Fast for Freedom information webpage). I wrote an article about this situation. It’s still the case that the APA needs to take a more balanced view of the evidence about the neurobiological basis of mental illness. 

Tuesday, May 07, 2019

People made dependent on psychotropic medication have not abused or misused the drugs

Twitter conversation this morning (see thread leading to my tweet) has made me realise that it may be misleading to say that people who have experienced antidepressant discontinuation problems have become addicted to antidepressants. I'm certainly not wanting to imply that people made dependent on antidepressants have abused or misused the drugs. There is confusion in the nomenclature (see eg. previous post and my Antidepressant Discontinuation Reactions webpage) and I don't want to add to it.

Friday, May 03, 2019

Integrating critical psychiatry into the mainstream

Although the Critical Psychiatry Network was formed over twenty years ago (see my editorial), critical psychiatry remains marginal to mainstream practice. This may be because of its association with so-called antipsychiatry (eg. see previous post).

Critical psychiatry’s challenge to the ‘disease model’ of mental illness is legitimate (eg. see previous post and my Lancet Psychiatry letter). As I've pointed out in this blog before (eg. see previous post), its point of view has actually always been present historically and philosophically since the origins of modern psychiatry. It is not just a new fad, and grapples with the same conceptual issues that were present with the origin of modern psychiatry. It's always been a minority perspective.

For example, present day psychiatry tends to see itself as ‘biopsychosocial’ (eg. see previous post). It is not only concerned with biological but also psychological and social aspects of disease. Anthony Clare articulated this perspective as the outcome of the anti-psychiatry debate (eg. see previous post). He encouraged the avoidance of doctrinaire devotion to ideology in psychiatry. This ill-defined basis for practice may create theoretical inconsistency, such as viewing more minor psychological disorder as psychosocial, whereas more severe mental illness is identified as biological in origin. It may also lead to the combination of psychotherapy and biological treatments without any systematic theory to support such a strategy ( see my book chapter).

Nassir Ghaemi is critical of such eclecticism, although he incorrectly blames George Engel and Adolf Meyer for this situation (see my review of Ghaemi's book and responses). Both Engel and Meyer had an integrated mind-brain understanding, as does critical psychiatry. Engel’s biopsychosocial model promoted a holistic psychiatry and, like critical psychiatry, is a challenge to biomedical dogmatism (see eg. previous post). True, Meyer’s embracing of the uncertainty of psychiatric practice led to him being prepared to compromise with opposing opinions. He failed to challenge biomedical excesses, complaining that the research evidence was lacking (see another previous post and my article). But Meyer’s Psychobiology, which dominated American psychiatry in the first half of the twentieth century, is a legitimate theoretical framework for the more recent critical psychiatry movement.

The fundamental issue of the relation of mind and body creates the context for conceptual conflict in psychiatry. The first to apply a mechanistic approach to life was René Descartes (1596-1650) (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 referred to as Cartesianism. However, living beings, including humans, have a purposiveness that cannot be derived from mere physical-chemical processes. Organic life needs to be distinguished from the inorganic, not the soul from the body. Despite Descartes, the soul and body are not separate but integrated in the organism. Critical psychiatry takes an organismic, rather than mechanistic, perspective in the life and human sciences and is not Cartesian.

In the second half of the eighteenth century, reacting against Cartesianism, anthropology established itself as an independent discipline, concerned with the study of man as a psychophysical individual. In this context, medical psychology had its origin with two major variants of anthropological thinking (Verwey, 1985). A medically-orientated anthropology represented by Ernst Platner, among others, was one version. The other was Immanuel Kant’s pragmatic anthropology. Kant, like critical psychiatry, was clear that it is futile to expect to be able to understand and explain life in terms of merely mechanical principles of nature (Zumbach, 1984).

In the same year, 1845, that saw the publication in German of the book that gave Wilhelm Griesinger his reputation in psychiatry, Ernst von Feuchtersleben produced his psychiatric textbook based on Kantian principles (see previous post). Griesinger was dedicated to the idea of the pathology and therapy of mental diseases as a mechanical natural science, although he remained aware of the gap between this ideal and reality. Nonetheless he set the trend for this positivist biomedical understanding that has dominated psychiatry since the middle of the nineteenth century. Such a positivist reduction of mental illness to brain disease is what causes such concern for critical psychiatry. Feuchtersleben, by contrast, like critical psychiatry, recognised that the mind-brain problem is an enigma that can never be solved. He has been called a ‘forgotten psychiatrist’, but should be remembered as creating a framework for critical psychiatry based on Kant’s philosophy.

Critical psychiatry has foundations that go back to the origin of modern psychiatry. It is integral to its history and it is, therefore, a mistake for psychiatry to marginalise it from the mainstream. Critical psychiatry can be understood as a truly biopsychosocial, neo-Meyerian approach to psychiatry based on Kant’s critical philosophy.

Thursday, May 02, 2019

Anti-reductionism and critical psychiatry

Immanual Kant in the section on the ‘Critique of Teleological Judgement’ in his Critique of Judgement (1790) said:-
For it is quite certain that we can never adequately come to know the organized beings [living things] and their internal possibility in accordance with merely mechanical principles of nature, let alone explain them; and indeed this is so certain that we can boldly say that it would be absurd for humans even to make such an attempt or to hope that there may yet arise a Newton who could make comprehensible even the generation of a blade of grass according to natural laws that no intention has ordered; rather, we must absolutely deny this insight to human beings.   

What did Kant mean by this and what is its application to psychiatry? As a critical psychiatrist I think I am applying Kant’s critical philosophy to psychiatry.

What Kant was saying is that a mechanistic psychology is impossible. Not that people cannot be studied in a mechanical way, particularly parts of themselves - and as far as psychology is concerned this is the brain - nor that we cannot produce descriptions of thoughts, emotions and behaviour. But a mechanistic conception of nature fails to provide a complete characterisation of living systems.

Why is this? Living things are different from inanimate objects. They have functional and goal-directed characteristics. They have designed and designer-like aspects. They seem to be intended for a definite purpose and they have the ability to form their parts. Living things are purposiveness systems, or to use Kant’s words, teleological systems. A machine is different. It does not serve its own interests but the interests of its maker or user. Organisms, unlike machines, are self-organising and self-reproducing systems.

We therefore need different modes of explanation for teleological and mechanical points of views. For example, understanding the meaning of human action is a different kind of explanation from mechanical explanation. The mechanistic conception of causality fails to provide a complete understanding of human and living systems in general.

In fact, Kant goes further than this. What he says is that how living wholes cause their parts is unknowable to us. We just have to accept that our knowledge is limited because we conceptualise organic matter in a different way to inorganic matter. Life and human sciences are doomed to a kind of pre-scientific descriptivism rather than becoming a natural science.

We can never have theoretical knowledge that anything in nature is teleological, but such judgment is nonetheless necessary and beneficial for us. Which is why we attempt to understand human and living behaviour in mechanical terms. We may well wish we could explain life in mechanistic scientific terms and so-called science has often embarked on what Kant called a “daring adventure of reason”. Despite Kant recognising the wish to have a physical understanding of life and human behaviour, nonetheless he argued that it is absurd and futile to expect to be able to explain mental processes in physical terms.

I want to try and apply this kind of thinking to psychiatry. Mental illness is commonly perceived to be due to brain pathology. This is standard understanding. People may even be told by doctors that their mental health problems are due to a chemical imbalance in the brain or some other biological disease. You may even have heard or read something like this yourself. But critical psychiatry is saying you are being misled by perspectives like this.

Of course acute brain disorders can present as a toxic confusional state. More chronically they can lead to a dementia. But most mental health problems are functional in the sense that they are not structurally represented in the brain.

I don’t want to be misunderstood. Of course I’m not saying that mental health problems have nothing to do with the brain. The mind is clearly enabled by the brain. But what I’m saying is that mental health problems should not be reduced to the brain. And, like Kant, this is primarily a statement about how one explains mental health problems. I’m not saying that mind and brain are different substances. I’m not anti-materialist in this sense. Nor am I saying that it’s not important to use scientific methods. In fact, a lot of what passes for science, certainly in mental health, is more to do with speculation than the real world. Considering the amount of money that’s been spent on mental health research, one might hope that progress would have been made. But essentially results are so clouded by inconsistencies and confounders that it’s not been possible to say anything definitive about the biological basis of mental illness.

You may be surprised by me taking such a position as this. And, you may well not be alone. I am taking a minority view within psychiatry. In fact, psychiatry is more like a faith that doctors are expected to believe in rather than a science as such. If I don’t follow the faith of believing that mental illness is a brain disease, then I’m seen as unorthodox. I do, however, have a few other psychiatrists who agree with me. Twenty years ago we formed the Critical Psychiatry Network. If you’re interested in finding out more, there’s an editorial in February's British Journal of Psychiatry entitled ‘Twenty years of the Critical Psychiatry Network’.

(Adaptation of talk given to Cambridge University Psychology Society, 21 February 2019)

Wednesday, May 01, 2019

Who's going to take responsibility for promoting the chemical imbalance theory of mental Illness?

I reviewed Ronald Pies' book Psychiatry on the Edge a few years ago (see review and previous post). A recent Psychiatric Times article picks up his theme of debunking the chemical imbalance myths of depression and schizophrenia. I think I do understand his view that these notions were never really taken seriously by most well-informed psychiatrists (see previous post). He does admit, though, that it's not surprising the theory has "taken hold in the minds of so many in the general public". It worries me, though, that he may be seen to be blaming Laura Delano (whose New Yorker article led to his response) for her view, as a patient, "that [her] depression was caused by a precisely defined chemical imbalance, which her medications were designed to recalibrate". I hope he's not.

I'm not quite sure what's achieved by arguing that "there was never a unified, concerted effort within American psychiatry to promote a 'chemical imbalance theory' of mental illness in general", if that's the impression that's been created in Laura Delano and the public in general. Whose fault was it then? Certainly patients are given this professional opinion by psychiatrists (whether they really believe it or not) (see previous post). As I said in my review, Pies thinks that:-
Doctors know it’s an oversimplification ... but use it so patients don’t feel so blameworthy. He does agree this is “a little lazy” ... on the doctors’ part and doesn’t excuse their behavior, but says they are very pressed for time with so many patients to see.

I also agree with Pies that most psychiatrists are more eclectic than just biological (eg. see previous post). In fact, Pies is quite biological in his approach to psychiatry and admits for example that he's enamoured of the idea that depression is a form of inflammation, even though I think this hypothesis is nonsense (eg. see last post). I think Pies is just trying to say that psychiatrists are not simplistic in their biological (which doesn't omit psychosocial aspects) theories of mental illness. That's as may be and it's good he admits the chemical imbalance theory is bogus. But, if he doesn't attribute the chemical imbalance theory to psychiatrists, who take a much more complex view about the nature of mental illness, then who's been responsible for its promotion? Surely he doesn't think it's the silly patients who’ve believed it.

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 and 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.