Scottish Mental Health Law Review

The Scottish Mental Health Law Review (SMHLR) final report (see summaries and recommendations; also see previous post about interim report) is intended to shift mental health and capacity law from being too focussed on authorising and regulating actions which may limit a person’s autonomy, to one where a person’s rights are respected, protected, enabled and fulfilled. It recognises that the United Nations Convention on the Rights of People with Disabilities (UNCRPD) (see eg. previous post) has provided an impetus for a shift in how states respond to disability rights. UNCRPD was signed by the UK in 2007, came into force in 2008 and was formally ratified by the UK in 2009. The Scottish Review did not take an absolutist approach to UNCRPD, by which it meant "tearing down the whole house - pulling all our existing systems down and starting from scratch", which it did not see as yet possible or even necessarily desirable. 

UNCRPD and SMHLR both promote a supported decision making (SDM) approach rather than substitute decision making. This is included within what SMHLR calls its Human Rights Enablement (HRE) framework. The framework also includes an Autonomous Decision Making (ADM) test to allow for non–consensual intervention in situations when this is necessary to protect the person’s or others’ rights. 

Any authority for a deprivation of liberty should be granted only to the extent it is needed and only for as long as needed to achieve the protection required. The advantages against harms to human rights need to be assessed. Significant harms to certain human rights would be justifiable only exceptionally, on the basis of very significant advantages in the respect, protection and fulfilment of the person’s human rights overall. A court/tribunal may grant a Standard Order for Deprivation of Liberty in order to preserve the person’s overall human rights or an Urgent Order for Deprivation of Liberty in order to preserve life or health. 

The opinion of the Review was that law reform can help reduce coercion, although it is only part not the whole answer. Reduction of coercion does need to be a priority of services in general. The problem with the reforms in England and Wales is that, although motivated to reduce detention and inequalities, there was no wholesale reform as in Scotland to a Human Rights Enablement framework. It will be interesting to see how mental health law develops in Scotland compared to England and Wales. The Scrutiny Committee is taking its final oral evidence today (see event and previous post).

We have over-medicalised normal life and it's destroying the NHS

Even though she may overstate her case, Katie Musgrave has a helpful article in Pulse about the state of NHS mental health services. I've used the same title as her article for this post, although changing one word: 'medicalisation' to 'over-medicalisation'. As she says, "the system isn't functioning".

I think it's reasonable for a GP, for example, to be discussing a child's "tantrums and mood-swings" with parents. GPs need to deal with mental health as well as physical problems.

But I agree with Musgrave that hoping "an hour on the phone having CBT might solve issues from a difficult childhood, a broken marriage or long-standing financial stresses" oversimplifies people's problems. Addressing "our broken, disconnected communities" is not easy. The NHS has not got "the answer to all of life’s ills". 

I also agree that NHS leaders may not have "the courage to fix this". In fact I think NHS England has encouraged this oversimplification, based on a misguided understanding of the need for early intervention to prevent problems getting worse (see eg. previous post). I'm not wanting to stop people coming forward for help if they need it, but the NHS does need to become more realistic with people about what can be achieved (see eg. another previous post). 

Psychiatric training needs to incorporate a critical perspective

I have been re-reading my first published book chapter in This is madness too (2001). Psychiatry doesn’t seem to have changed much in over 20 years.

It was obvious then that the fantasy hope of a neurobiology that would uncover genetic and neurobiological abnormalities in functional mental illness was nonsense. That hope was said to be inspired by (1) the overwhelming evidence of the efficacy of pharmacologic treatments, (2) a growing appreciation of the heritability of psychiatric disorders, (3) the standard use of objective, criterion-based diagnoses, and (4) the ability to examine the structure and function of the brain directly. I challenged those claims then and my arguments still apply (see eg. last post).

What I then concluded is required is still the same: “The case for an extensive, national programme of training and supervision in order to disseminate a critical perspective on psychiatry is overwhelming.” Psychiatric training has still not incorporated a critical perspective (see previous post). It’s too enamoured of its wish-fulfilling speculations.

Hypothesis of depression as a brain disorder does not just depend on evidence

Bruce Levine (who I've mentioned in a previous post) highlights three reviews in his Counterpunch article that confirm that "there is no scientific evidence for what we have long been told by psychiatry — and the mainstream media — about the neurobiology of depression", ie. that depression is a brain disorder. As one of those reviews by Peter Sterling says, "if neuroscientists are unwilling to acknowledge that their hypothesis of depression as a brain disorder currently lacks evidence, they render it unfalsifiable — and thus 'just like' religion". 

As I've said several times (eg. see previous post), biomedical psychiatry is more like a faith than a science. It doesn't seem to matter that there's no evidence that depression is a brain disorder. There's always enough belief that the answer to mental illness is just round the corner and we merely need to keep looking for it. The brain-defect mythology of depression will therefore persist, as we do not want to admit to the limits of our knowledge about mental illness (see previous post).

But it's not just the lack of evidence for believing that mental illness is brain disease that's the problem. As I've also said before (eg. see another previous post), functional mental illness cannot be reduced to brain disease in principle. The hypothesis is not just an empirical matter. The subject matter of psychiatry is people as a whole, not their brains. Brain abnormality is not a sufficient explanation of depression in the same way as it is for organic mental illnesses, such as dementia. We need to understand the reasons for depression and these meanings are lost by looking for mechanistic explanations in the brain. There are conceptual as well as empirical reasons why depression should not be seen as a brain disorder.

Efficacy of lithium

MailOnline has an article discussing views about lithium for bipolar disorder. Years ago I created a webpage for 'Efficacy of lithium'. Not sure if the debate has progressed much since.

Like a lot of medication, lithium was introduced through a mistaken hypothesis (see webpage). I'm not convinced its efficacy has ever been satisfactorily demonstrated. Rapid withdrawal is associated with higher relapse than gradual withdrawal (see my eletter). Such a finding suggests that nonspecific factors are important in the interpretation of clinical trials (see another eletter). Unblinding can occur in clinical trials of lithium, compromising their results (see my BJPsych letter). Denial of the extent to which lithium may be a placebo effect in clinical practice does not necessarily serve the interests of the many patients who have been made reliant on this medication.