Shameless exploitation of antidepressant placebo effect

I wasn’t going to blog about Carmine Pariante’s recent New Humanist article, as it just repeats what he has already published. But he has been promoting it as a balanced view on antidepressants (see eg. his tweet), which it isn’t.

I’ve questioned Carmine’s scientific credibility before (see previous post). I think the Royal College of Psychiatrists may even have appreciated that he overstates his case (see another previous post). For example, he wrongly sees critical/relational psychiatry, which has produced the critique of antidepressants he rebuffs, as dualist (see yet another previous post).

Carmine does need to take the critique of antidepressant efficacy more seriously (see previous post). I told him this several years ago (see another previous post). No one’s disputing what he says that many people report benefit with antidepressants. But the question is whether that means that antidepressants work (see yet another previous post), which he says it does. Actually, people’s experience of antidepressants is more complex than mere benefit (see even another previous post). 

Carmine will not like my sceptical argument about the overstatement of psychiatric medication efficacy because of biased clinical trial methodology (see previous post). He worries people are being shamed for taking antidepressants (see another previous post). But he seems to fail to realise that doctors have always exploited the placebo effect. Why he’s being so overdefensive could be because he fears that antidepressants may be another example. The overmedicalisation of society has created too much antidepressant prescribing (see yet another previous post). If psychiatry carries on in the way Carmine wants it to then I anticipate there are going to be serious problems (see last post).

The myth of massive psychiatric need

I want to start this post with a quote:-

There has been a massive growth in mental health services during the past 20 years as psychiatry has extended its boundaries to include an ever-widening array of human problems.

Don’t assume this is a recent quote, although it could be! It was actually written in 1988 in an article entitled ‘More and more is less and less: The myth of massive psychiatric need’.

The article goes on:-

Psychiatric manpower, facilities, and programmes have been vastly increased. However, as more resources are provided, more are perceived to be needed: more and more is less and less.

The article’s warning that the myth of massive psychiatric need was being used to justify additional resources for existing services, rather than solving current problems, has still not been heeded all these years later (see eg. recent post). That’s not to deny requirement for additional investment, but need for services should be prioritised rather than demand.

As supply of services increases, demand also continues to increase. Resources therefore fail to meet that demand. Merely increasing the numbers of professionals doesn’t solve the problem. If treatment is so effective at reducing need, then demand should decrease over time as that need is met, rather than increase. This situation is made even worse by broadening the boundaries of what counts as mental disorder over recent years (see my article referred to in this post).

As the article says, the problem with all this development is that resources are diverted from the most seriously mentally ill. The NHS, including mental health services, has become too fragmented and dysfunctional. We must stop  seeing mental health services as a panacea for society’s difficulties (eg. see previous post). We’re being oversimplistic about what psychiatry can achieve (see eg. another previous post).  Psychiatry, and health services in general, needs to redefine its role.

Preparing for Mental Health Act reforms

Wes Streeting, Shadow Secretary of State for Health and Social Care, has said that one of the first pieces of legislation he would bring forward in government would be on reforming the Mental Health Act (MHA) (see Guardian article). The current government did not include reform of the MHA in the King’s Speech for the current parliamentary session (see eg. Community Care article).

Reforms need to be taken forward in line with the Parliamentary Scrutiny Committee recommendations (see previous post) and recent WHO/OHCHR guidance (see another previous post). The Centre for Mental Health has produced a helpful document on A Mental Health Commissioner for England, a new role proposed by the Scrutiny Committee. I would like to see the opportunity taken, in the time available before legislation comes back again to parliament, to consider further:-

• prohibiting civil detentions to secure facilities
• improving advocacy by creating an integrated service of Independent Mental Health Advocates (IMHAs), mental health lawyers and independent experts 
• extending the role and powers of the Mental Health Tribunal (MHT) to treatment as well as detention decisions, thereby making the role of Second Opinion Approved Doctors (SOADs) redundant

See my submission to the Scrutiny Committee for further details.

Too much antidepressant prescribing reflects the overmedicalisation of society

As the BMJ reports (see article), a group of politicians, experts, and patient representatives has called for the UK government to reverse the rate of antidepressant prescribing. Their BMJ letter comments on both the increasing rates of prescribing (see previous post) and the increasing duration of time on antidepressant treatment (see another previous post). Long-term outcome for depression is not necessarily good (see yet another previous post). There is even evidence that treatment can create a vulnerability to relapse, meaning that people may do better over the long-term by working through their problems without medication (see previous post). The net ingredient cost of antidepressant drugs is not insignificant, and, in the 2022/3 financial year in England, it was over £235 million (see NHS Business Service Authority data).

This call to reduce antidepressant prescribing needs to be understood in the context of the overmedicalisation of society in general. Such overmedicalisation needs to be reversed in the interests of the country’s health as a whole, as the NHS has become unsustainable (see eg. previous post). The cultural process of creating panaceas for emotional and other mental health problems doesn’t always work and may create more problems than it is worth (see eg. another previous post). This may be particularly obvious with the ever increasing demand for mental healthcare for children and young people over recent years (see eg. yet another previous post).

The letter marks the launch of the Beyond Pills All Party Parliamentary Group (APPG) (see Guardian article), which joins the forces of the former APPG for Prescribed Drug Dependence (see eg. previous post) and the College of Medicine Beyond Pills Campaign (see previous post). A cultural change to reduce the reliance on medication and to support shared decision-making is needed, not least for mental health services. The BMJ itself has recently called for a reset in its campaign against too much medicine (see eg. post on my personal blog).

Misleading people that mental illness is brain disease

I’ve reposted a previous post from September 2010 about ‘Misleading children about mental illness’. The link to the NIH curriculum supplement on ‘The science of mental illness’, mentioned in that post, is dead. However, the section on the 2007 published “Information about mental illness and the brain’ from the NIH curriculum supplement series is available (see webpage).

That webpage states:-

As scientists continue to investigate the brains of people who have mental illnesses, they are learning that mental illness is associated with changes in the brain's structure, chemistry, and function and that mental illness does indeed have a biological basis.

This is not true. There is no evidence that functional mental illness is brain disease (see eg. previous post). The implication is that psychiatry needs to abandon its biomedical framework (see previous post). Although psychiatry ignores this critique, the complexity of the relation of biology with interpersonal, social and cultural factors does need to be acknowledged (see another previous post). As in the title of a previous post, psychiatry is too based on speculation rather than fact. For my whole career, I argued that psychiatry needed to incorporate a critical/relational perspective (see previous post). It’s about time that psychiatry became more open and therapeutic.

Misleading children about mental illness

(Originally published Sept 2010)

The NIH curriculum supplement for middle school (grades 6-8), The science of mental illness, aims to introduce students to what it calls the key concept that mental illnesses have a biological basis and are therefore not that different from other illnesses or diseases. It is important to get children to understand that the brain is the origin of thoughts, emotions and behaviour, and they do need to learn to challenge their negative prejudices and not be frightened of mental illness, but the way to do it is not to make the misleading and oversimplistic statement that mental diseases, such as depression, are diseases of the brain.

The curriculum is also keen to convey to students how science can help us make informed decisions. What it does in fact is demonstrate how knowledge is shaped and formed by our modern biomedical beliefs. The propagandist nature of the educational material needs to be made transparent.

Is antipsychotic prescribing justified in children and adolescents?

As I mentioned in my book chapter:-

Joseph Biederman, [was] professor of psychiatry at Harvard Medical School and chief of pediatric psychopharmacology at Harvard's Massachusetts General Hospital, …[and] influenced psychiatric practice to the extent that children as young as two years old … [were] diagnosed with bipolar disorder and treated with a cocktails of drugs, many of which are [still] prescribed ‘off licence’. Through Congressional investigations by Senator Charles Grassley, it … [was] disclosed that Biederman received $1.6 million in consulting and speaking fees between 2000 and 2007.

An obituary regarded him as the ‘father of paediatric psychopharmacology’. Johnson & Johnson gave more than $700,000 to a research center headed by Biederman (see NY Times article), which was involved in research on Risperdal, the company's antipsychotic drug, which is prescribed as a so-called mood stabiliser (see eg. previous post). 

Klau et al (2023) recently examined patterns of paediatric antipsychotic prescribing in Australian primary care services in 2011 and 2017. Antipsychotic prescribing increased in children and adolescents between these dates and most such prescribing was off-label, with an increasing proportion of off-label prescribing. Almost 70% of these patients prescribed antipsychotics were also co-prescribed other psychotropic medication. The most common diagnosis of children and adolescents prescribed antipsychotics was depression/anxiety, although international studies have found ADHD to be one of the most common diagnoses, and the proportion of ADHD diagnoses in this Australian sample doubled from 2011 to 2017. Antipsychotic prescribing for autism increased in those without the additional feature of behavioural problems, which is required for on-label use. Antipsychotic prescribing has also increased for those with eating disorder, even though off label, maybe because the weight gain is seen as potentially beneficial, particularly by olanzapine.

When I first trained in psychiatry, children and adolescents were seen as having emotional and behavioural problems but diagnosis of mental illness, as such, was uncommon. Medication had a very limited role in the context of family and behavioural therapies. As I wrote in my 2003 article:-

Historically, child and family studies … tended to take a more holistic approach to personal and social problems. The speciality of child psychiatry … served as a haven and opportunity for those who wanted to escape the reductionism of their colleagues in adult psychiatry. It … [is] a pity that the discipline has now been so invaded by the biomedical model.

Despite the efforts over the years of psychiatrists, such as Sami Timimi (see eg. previous post), this biomedicalisation has continued. As far as antipsychotics are concerned, there are potential harms such as weight gain. More fundamentally antipsychotics are at least overprescribed in children and adolescents outside licensed indications. Their use at least needs to be reduced and more critical debate is required about any benefit/harm ratio. Overmedicalisation of children’s mental health problems is not helpful (see eg. previous post). Young people need to be given correct information about mental illness (see eg. another previous post). The cultural process of seeking to create panaceas for emotional and other mental health problems of children and adolescents doesn’t always work and may be creating more problems than it is worth. 

The nature of psychiatry

I’ve mentioned Ivana Marková before (see previous post). She has an interesting article in History of Psychiatry in which she draws from Heidegger to explore the question of what psychiatry is. Psychiatry is a form of interpersonal interaction in which there is a specific reaching out of one Being to another. Through recognition of the other’s mental condition there is a corresponding sense that something should be done about it. She uses the word ‘distress’ for the condition being recognised, which is perhaps not ideal, and she may need to supplement her analysis with one about the nature of mental illness (see eg. previous post). 

As she says, meaning is created through interaction of clinician and person. The construction of distinctions and categories in diagnosis cannot be reified, or even necessarily reduced to brain abnormalities, and should not be viewed as always depicting absolute reality. We should not be surprised if we “struggle to fit clinical presentations into the conventional descriptions”. As she says, 

In the face of a psychiatry that is driven ever more by a neurobiological reductionism in research and by a mechanistic and algorithmic approach to the assessment and management of patients, it is increasingly important to rethink a formulation of psychiatry from within [her emphasis].

As she concludes, authentic engagement is required in the practice of psychiatry (see eg. previous post). Trouble is that modern psychiatry too often avoids it, even labelling it as anti-psychiatry (see another previous post).

Foundations of the Critical Psychiatry Network

I’ve mentioned before (eg. see previous post) my article on ‘Twenty years of the Critical Psychiatry Network’ (CPN). Key CPN members have written a chapter in a forthcoming book on ‘The emergence of the UK Critical Psychiatry Network’.

As the chapter says, the issues that brought CPN together still remain. To quote from it, “Psychiatry does not always make decisions in the best interests of patients, yet it presents itself as though it does, therefore avoiding necessary political and democratic scrutiny”.

Blood test for bipolar disorder will never be available

It worries me that organisations acting on behalf of service users and their representatives can be so taken in by biomedical psychiatry. For example, I have recently received an email from Bipolar UK about a JAMA Psychiatry brief report that there could be a simple blood test to diagnose bipolar disorder (see MailOnline report). Simon Kitchen, their CEO, is quoted as saying, such a blood test "would be immeasurably beneficial" for the bipolar community. He does qualify this by saying, “we would like to understand more about likely timescales and implementation. When will this blood test be available?" What concerns me, though, is that there is no questioning about whether this is even a realistic possibility.

I’ve always said the wish to find a physical basis for mental illness will never go away completely (see eg. previous post). The diagnosis of bipolar disorder, like any other psychiatric diagnosis, is not an exact science. There are even issues about whether bipolar disorder, certainly in the wider diagnostic sense it has come to be used over recent years, amounting, essentially, to seeing bipolar disorder as mood instability (see eg. another previous post), can be separated from major depressive disorder (see eg. yet another previous post). As I wrote in my book review:-

There was a time when psychiatry would not have made so much of the difference of whether depressed people also had manic episodes or not. With the development of mood stabilizing medication, this has come to matter more and the concept of bipolar disorder has even been broadened to make more people eligible for these new medications.

As I said in the title of a previous post, psychiatric practice is too based on speculation. It would be helpful if Bipolar UK did not encourage this. However trite it may be to say, people with a diagnosis of bipolar disorder need to be understood as people like everyone else, responding in an intelligible, maybe even reasonable way, to an unreasonable social situation. It may seem attractive to think there will be a blood test to detect the disorder but that’s pie in the sky, not science.

Misinformation about side effects of psychotropic medication

I”ve recently signed an open letter on ‘The Pseudoscience Crisis’, expressing concern about the lack of academic response to it. Our online world can generate misinformation, rather than fact, and psychiatry has also been affected in this way. By the way, I don’t see my relational psychiatry blog as pseudoscience and recognise how biased the academic literature is, which is why I blog (see eg. post on my personal blog). Brain overclaim is very common in academic psychiatry (see eg. previous  post). 

I have been worrying for some time, though, particularly about the misinformation on the internet about side effects of psychotropic medication. Some critics of psychiatry, such as Peter Breggin (see eg. my book review), do not seem to apply the same rigorous scepticism to side effects as they do to treatment effects of psychotropic medication. Don’t get me wrong! I have emphasised before (eg. see previous post) that psychiatry does not take seriously enough patients’ complaints about side effects. I was one of the first in the literature to point out the importance of antidepressant discontinuation problems (see my BMJ letter). Withdrawal symptoms are now accepted for antidepressants (see eg. previous post), as they should be for all psychotropic medication.

Biomedical websites contain misinformation about neurological effects in psychiatric conditions. For example, I’ve mentioned before (see previous post) that the Treatment Advocacy Center website misleads people about schizophrenia causing anosognosia. The background information page linked from that 2012 post has been updated (see pdf). This pdf makes clear that anosognosia is not the same as denial of illness. Whereas, another webpage from the same Center says that anosognosia is also known as lack of insight. Denial of illness and lack of insight in schizophrenia are the same thing. The apparent confusion on the website is not helped by the above mentioned pdf going on to say, “Approximately 50% of individuals with schizophrenia and 40% of individuals with bipolar disorder are estimated to have co-occurring anosognosia". That may well be the case for lack of insight or denial of illness, but not anosognosia. And, as I said in another previous post, "it's stretching a point to regard lack of insight in schizophrenia as the same as anosognosia caused by brain injury or stroke". In fact, it’s wrong! Lack of insight and denial of illness in schizophrenia are functional not structural.

Independent-minded psychiatrists, like me, do not need to be mavericks! Whereas, I have called Dr David Healy a maverick (see my book review). David has been very active on the internet, including his Rxisk website. I very much agree with the motto of that website that, “No one knows a prescription drug’s side effects like the person taking it". But then the role of the doctor in such situations is to discuss with the patient what the cause might be, and to evaluate the effects by taking into account their own medical expertise. As I’ve said before in yet another previous post,

What worries me about David's position is that he tends to take a physicalist approach to medication and not necessarily consider how people react to the taking of medication.

Let me use the example of whether antidepressants can cause akathisia as an example to explain my point. I don't think I ever saw an antidepressant cause akathisia in my professional career. Nonetheless, akathisia has been reported as an adverse event with antidepressants (eg. Madhusoodanan et al, 2010). That's also not to say that there can't be initial adverse reactions, which are not as widely recognised as they should be, when taking antidepressants, such as paradoxical initial worsening of depression and pendular euphoria (Fava & Ravanelli, 2019). But the paradoxical and pendular responses may not be so much due to a direct effect of the medication but to how the person has reacted to the taking of the antidepressant.

Similarly, there can be individual reactions that can be misinterpreted as akathisia. Akathisia is a extrapyramidal movement disorder caused by traditional neuroleptic/antipsychotic medication, such as chlorpromazine and haloperidol. Other extrapyramidal disorders caused by these kind of drugs are acute dystonia, parkinsonism and tardive dyskinesia. Atypical antipsychotic medication is associated with less diagnosis of akathisia than the first generation of antipsychotic medication. 

Even with antipsychotic medication, there can be misdiagnoses of akathisia that are, for example, really due to psychotic agitation itself. Akathisia is characterised by a subjective feeling of inner restlessness and an inability to sit still. Signs are repetitive movements, such as leg crossing, swinging or persistent shifting from one foot to another (eg. Salem et al, 2017). There are diagnoses of akathisia related to antidepressant use in case reports in the literature, which I think are at least suspect misdiagnoses. For example, Akagi & Kumar (2002) report three cases of akathisia because of symptoms such as behavioural disturbance, agitation, anxiety, restlessness, inability to sleep, pacing the house, sense of dread triggered by minor events, acute suicidal ideation and fear of being left alone because of suicidal urges. These functional symptoms don't necessarily sound like the neurological condition of akathisia to me in these reports, however unpleasant the experience of akathisia can be. Yet the paper is commonly referred to when people say that antidepressants can cause akathisia.

Similarly, the Rxisk website states that akathisia is an emotional state that causes suicidality, homicidality and other disturbances of behaviour. Hang on, where's that come from?! To be honest, I'm not exactly sure, but let me try and trace some of its origins. 

As I've said earlier, Peter Breggin, who wrote Toxic Psychiatry, has expressed concern about the apparent side effects of antidepressants. He included manic switch, akathisia, suicide and violence in this list as facts, whereas at least the mechanism of these said associations are controversial and I remain sceptical about them as direct effects of the medication. For example, I think the published data does suggest a small increase in suicidality with antidepressants, but probably not for completed suicide (see previous post). I'm still not convinced that the analyses have necessarily eliminated all bias (see eg. Kaminski & Bschor, 2020), but even so I don't think we should be surprised by any association (not necessarily cause anyway, as such, in terms of direct effect of the medication). Doctors do need to be cautious about prescribing antidepressants because of self-harm and suicide risk. That's already been in advice and guidelines to doctors for some time. 

The data suggests any increased risk is at least mainly in the first two weeks of treatment. To continue with the theme of this post, how people react to taking antidepressants does matter. For example, the person may feel that the doctor is trivialising or not understanding their problems by 'palming them off' with an antidepressant prescription. For instance, I think many practitioners will have had the experience of assessing someone for depression, not thinking they are at risk of suicide, maybe even discharging them and encouraging continuing antidepressant or other treatment, only to be surprised, even shocked, to hear later that they have killed themselves. Ok, they were probably at high risk of suicide, which was not detected or they covered up, but the point is that how the patient reacts to what the doctor has told them and done could be seen as a factor in the cause of suicide. To repeat, doctors do need to be cautious when starting antidepressants.

Peter Breggin has emphasised brain-disabling treatments in psychiatry, including in the title of another of his books. Tardive dyskinesia (TD), which as I mentioned above, is one of the four extrapyramidal symptoms of neuroleptic medication like akathisia, and such neuroleptic prescription can be seen as brain disabling treatment. If a neuroleptic drug causes TD then the symptoms may be permanent and even exacerbated, at least for a short-time, by discontinuing the medication. In other words, there does seem to be evidence that traditional neuroleptics can cause brain damage. As Peter has argued (see article):

If neuroleptics were used to treat anyone other than mental patients, they would have been banned a long time ago. If their use wasn't supported by powerful interest groups, such as the pharmaceutical industry and organized psychiatry, they would be rarely used at all. 

Atypical antipsychotics have now largely replaced neuroleptics on the market and, as I indicated above, these newer drugs are at least less likely to cause extrapyramidal symptoms, such as akathisia and TD. 

What I think happened is that Peter Breggin switched his concern about brain disabling treatment of psychotropic medication from antipsychotics to antidepressants and David Healy copied him. Their scope for dissemination of their ideas on the internet has helped. Antidepressed: A breakthrough examination of epidemic antidepressant harm and dependence, a successful literary publication to inform consumers and prescribers about antidepressants from the point of view of patient experience quotes extensively from Peter and David, maybe especially David. The internet has been a forum for service users/survivors, who have not felt understood by psychiatry. They can communicate with each other much more easily on social media. But as I have said, David’s a maverick, and people should be more cautious about quoting him.

To go back to akathisia, the Akathisia Alliance for Education and Research is a nonprofit organization formed by people who have experienced it. I'm not sure how much David is one of their advisors. They highlight a paper by Salem et al (2017), which does not quote David at all. I think this is a helpful paper. As I have been emphasising, this paper is clear that akathisia is particularly associated with antipsychotic medication, not necessarily antidepressants. Again, the Alliance highlight a Youtube video of Joseph Glenmullen talking about the 'torture of akathisia'. It can be very difficult to cope with the inner restlessness of akathisia. As the video says, this is different from the experience of depression. 

The Rxisk website says without reference that “Healthy volunteers commit suicide after a few days exposure to them [ie. drugs like clozapine, an antipsychotic]” (see webpage). This must sound terrifying to patients. However, I’ve no idea why (even whether) this happens to normal volunteers, when it doesn’t happen to patients on clozapine, at least the ones I saw, OK rarely started by me, if at all!

Scaring patients isn’t the way to get a balanced view of the benefits and risks of taking psychotropic medication. As I’ve always said, I’m sceptical about the value of psychotropic medication. I doubt whether antidepressants are effective but I can’t prove it (see eg. previous post). And as for their physical side effects, there can be misdiagnoses, particularly on the internet, which patients and other people increasingly use.

Mental health, human rights and legislation

In a previous post, I mentioned the opportunity to respond to a draft version of the WHO/OHCHR guidance and practice document on Mental health, human rights and legislation. The final version has now been published. The guidance aims to assist countries in adopting, amending, or implementing legislation related to mental health.

As the document says, “legislation on mental health has legitimized and, in some cases, facilitated … human rights violations”. As I also said in a previous post, “The fundamental problem with mental health legislation is that it is discriminatory and this must change". A further post of mine notes that, “Flawed use of mental capacity tests has led to the denial of the right to legal capacity [of disabled people]”. The use of coercion in mental health services may be more to do with a failure of treatment than treatment itself (see yet another previous post).

There should be no barriers to accessing good quality mental health services and support to those that need it. Keir Starmer committed the Labour Party to a similar position in his leader’s speech at the recent Party Conference (see tweet). As I said in my post about the review of the Mental Health Act in Scotland, “Significant harms to certain human rights … [should] be justifiable only exceptionally, on the basis of very significant advantages in the respect, protection and fulfilment of the person’s human rights overall”. 

Livestream of the launch event of the document is available. This video and the full document need to be disseminated widely.

UN community does not endorse biomedical psychiatry

I’ve mentioned before reports produced by professor Dainius Pūras, when he was Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, a position appointed by the UN Office of the High Commissioner on Human Rights (OHCHR). Oute & McPherson (2023) examine formal organisational responses to the reports he produced. He is a psychiatrist from Vilnius University in Lithuania and was appointed mandate holder for the period 2014–2020.

I have mentioned two of his reports previously. The first focused on the right of everyone to mental health (see post). The second was on corruption and the right to health, with a special focus on mental health (see post). These reports gained particular attention and I have commented on some of the adverse reaction in two further previous posts (see first and second). 

The UN Committee on the Rights of Persons with Disabilities has argued for even more radical reforms of mental health services than Dainius, for example, the abolition of capacity, detention and other practices that may violate human rights (see previous post). As noted by Oute & McPherson, there is a "discourse defending psychiatric practices within which critics ... [tend] to be categorised as ‘anti-psychiatry’", something which even happens to me (see eg. previous post)!

Oute & McMillan analysed 13 responses from medical or psychiatric organisations to the UN reports. Responses (and commentaries) from individually named authors were excluded from the analysis. They found two overarching themes: (1) Binary positions and contesting articulations of good mental health care and (2) Rejecting the UN reports in defence of psychiatry. The former had several sub themes: (i) psychiatric stakeholders have authority, (ii) the Special Rapporteur is unscientific and dangerous, (iii) abandoning biomedicine and long-term psychiatric care would be harmful, (iv) psychiatry is scientific and ethical, (v) psychiatry is a branch of medicine, (vi) psychiatric science always advances, (vii) critiques of the biomedical paradigm are wrong and (viii) psychiatric pluralism is common sense. All of these givens logically underpinned the second overarching theme, whose subthemes articulated reasons for rejecting the Special Rapporteurs's reports: (i) the report damages patient trust in psychiatrists, (ii) the report is offensive and unfair and (iii) failures in mental healthcare are located in society, governments and patients.

As Oute & McMillan discuss, medical and psychiatric organisational response to the Special Rapporteurs' reports has been largely or wholly negative and deploys a relatively homogeneous discourse "reflecting a number of firmly held assumptions underpinned by the depiction of a binary relationship between the ... [Special Rapporteur] and themselves". As I have said before (eg. see my interview). the arguments about anti-psychiatry that took place in the 1960/70s, subsequently polarised psychiatry between pro-psychiatry and anti-psychiatry. But that's missing the point that psychiatry needs to move on from the dominance of biomedical psychiatry (see eg. my book chapter). 

Oute & McMillan note that the responses they analysed did not include responses from national psychiatric organisations, such as the American Psychiatric Association. The organisational responses analysed are clearly acting in the interests of biomedical psychiatry. Although biomedical psychiatry may be dominant in national psychiatric organisations, such organisations may find it more difficult to reach a consensus view about the Special Rapporteur's reports and be more open to the criticisms it offers. There are diverse views both between and within national psychiatric organisations which may give hope for change to a more relational psychiatry (see previous post). 

The catastrophe of so-called anti-psychiatry

I’ve mentioned Aaron Esterson before (see previous post). As I said in that post, Esterson co-authored Sanity, madness and the family with R.D. Laing (see extract from my book chapter). It was

the result of five years of study of the families of schizophrenics. The aim was to establish the social intelligibility of the events in the family that prompted the diagnosis of schizophrenia in one of its members. … Esterson is an underrated figure in the history of anti-psychiatry, a term that he thought devalued the work he was doing. The research he was involved with could be said to have succeeded in making the apparently absurd symptoms of schizophrenia intelligible. Esterson was the lead author of a study that showed that the results of family orientated therapy with people diagnosed as schizophrenic compared favourably with those reported for other methods of treatment (Esterson et al, 1965). Esterson (1976) made clear in a letter in The New Review about anti-psychiatry that, as far as he was concerned, Sanity, madness and the family was not an anti-psychiatric text. In fact, he saw anti-psychiatry, by which he meant the writings of Cooper and also of Laing, to the extent that he went along with Cooper, as a movement that had done enormous damage to the struggle against coercive, traditional psychiatry.

Anthony Stadlen wrote an obituary of Esterson in Existential Analysis. To slightly paraphrase Esterson’s views about schizophrenia from Anthony's obituary, Esterson wrote:-

Some labelled schizophrenics are mad by any criterion. Yet, some are not, but have been mystified into believing they are. And some have been driven frantic as if they were mad. And even the mad ones are not necessarily mad in the way they are said to be by those who label them.

As Anthony says, Esterson failed his psychiatric examinations the first time, as he tried to write truthful answers. It was a mistake he did not repeat when he resat them. Esterson conducted all the interviews himself for Sanity, madness and the family and Laing sat in on one interview with each family. As Anthony says, Esterson came to regard both Laing and David Cooper as frivolous and destructive: exemplars of the romantic, 'charismatic', leadership he would criticise in Leaves of Spring, which was a subsequent book enriching the details of one of the families from Sanity, madness and the family.

Anthony recently conducted Inner Circle Seminar No. 286 (see info) on Aaron Esterson as the third in his series on existential therapists born in the 1920s. Anthony has also posted a posthumously published article from Esterson from Existential Analysis. 

In the article, Esterson contrasts the practice of psychiatry with what he calls existential phenomenological analysis. He notes how psychiatry can negate experience, which he defines as the indivisible unity of a person intentionally acting. Persons experience and, so, behaviour is a function of experience. Existential phenomenology, therefore, studies the experience of persons in respect of their way of being in the world with others and with nature, and social phenomenological analysis studies relationships directly.  It has to suspend judgement on the rationality or otherwise of even bizarre-seeming behaviour and experience, so that even the most mad-seeming actions and experience may be found to be an intelligible and even a reasonable response to an unreasonable social situation. Personally I think a strength of Esterson's work is that he allows the clinical material to stand for itself with little elaboration of theory.

By contrast, Esterson goes on, general psychiatry is primarily concerned with people’s conduct that deviates from the social norm, without being illegal, and with so-called aberrant experience. It therefore diagnoses madness without viewing the other in relevant interpersonal context. Furthermore, the presumed irrationality is regarded as indicating a disease of the mind, analogous to a disease of the body. The person's experience and actions are thereby invalidated, whereas social phenomenology can provide intelligibility. The commonsense view that people can be driven crazy by the actions of others needs to be accepted. Once a person has been diagnosed as mentally ill, the stigma means that ordinary human quirks can come to be seen as signs of a malignant internal process which confirms the prior diagnosis. Esterson highlights the power imbalance between the person diagnosed and the person doing the diagnosis in that the person diagnosed is not allowed to question the diagnoser. The person is, as it were, presumed guilty until proven innocent. 

Esterson's method involved observing the relationships of the members of the family in all their permutations. To emphasise, Esterson was not saying there is no such thing as madness. But there is no brain dysfunction. It is essentially a delusion for psychiatry to believe so.

The Simon Silverman Phenomenology Center of Duquesne University, Pittsburgh, Pennsylvania,  unfortunately did not benefit from this rich analysis at its symposium on Psychiatry and Phenomenology, on 6–7 March 1986. This was because Esterson withdrew the paper because he received a letter from the Director of the Center saying "I daresay your talk will be well received, having read it". As Anthony Stadlen says, he telephoned the Chair of the Phenomenology Center in 2000, who remembered well that Esterson had withdrawn the paper. The Center had apparently concluded Esterson was mad. Anthony also telephoned the director at the time that Esterson withdrew, who said he was mystified by Esterson's withdrawal. Anthony thinks Esterson had partially misunderstood the reply of the original director, who was a superb translator of Heidegger and would have been an" ideal reader of his paper", although there was clearly feeling against Esterson's paper from within the Center. Anthony calls this a "mis-meeting between two of the world’s finest phenomenologists". In 2013, when Anthony phoned that original director again, he still rated Esterson's paper as "Quintessential phenomenology".

The triumvirate of David Cooper (see egs. extract from my book chapter and previous post), R.D. Laing and Aaron Esterson were the core of what came to be called Laingian anti-psychiatry (see eg. previous post), although, as I said above, Esterson did not see himself as an anti-psychiatrist, as neither did Laing. Anthony Stadlen tells me that Esterson said the triumvirate failed, which Esterson called a castrophe. Esterson left Kingsley Hall (see previous post) and the Philadelphia Association (see egs. my book chapter extract, book review and previous post), of which he was a founding member, in the spring of 1967. Certainly Esterson failed to get his important message across. I'm hoping Anthony Stadlen and others might be able to help resurrect it.

The limits of psychiatry

I have recently re-read my 2002 BMJ article ‘The limits of psychiatry’. As I said in a post on my personal blog, the article was rushed through by the BMJ for a theme issue on the dangers of too much medicine. This article is still relevant to the current unsustainability of the NHS, including its mental health services. The overmedicalisation of society needs to be reduced in the interests of the country’s health (see another personal blog post). 

There were several errors made in publication of my BMJ article, which I was not given a chance to correct, and it may be worth spelling these out. Firstly, a picture of Alfred Meyer was used rather than Adolf Meyer. The quote given underneath that picture was also from Adolf, not Alfred, Meyer as the article wrongly states. Throughout this relational psychiatry blog and in other publications (see eg. my article), I have emphasised how relational psychiatry is built on the work of Adolf Meyer, who was the foremost American psychiatrist in the first half of the 20th century. Not that I’m suggesting a mere resurrection of Meyer’s ideas, as he tended to compromise too much with biomedical psychiatry.

Another error was in box 2 where I listed the assumptions of the biopsychological model. The publication process made the mistake of inserting Meyer’s name into the title of the box. I was meaning that these assumptions were not just of Meyer, but more generally of what I was calling the biopsychological model. More recently than Meyer (well, 1977), this model was reframed by George Engel, which he called the biopsychosocial model (see eg. previous post). The trouble is, as I have pointed out throughout this blog, modern psychiatry has come to see the biopsychosocial model in an eclectic rather than anti-reductionist way (see eg. my review of Nassir Ghaemi’s book The rise and fall of the biopsychosocial model).

A second error in box two was to transpose the last item in the list from box 3 to box 2. Box 3 was a summary of postpsychiatry (again, a hyphen was wrongly inserted into postpsychiatry, but that may have been my mistake rather than the editors, but, as I said, I wasn’t given a chance to correct the final version). That last item said, “Postmodernity provides doctors with an opportunity to redefine their roles and responsibilities”. This was the argument made by Pat Bracken and Phil Thomas, the originators of postpsychiatry (see eg. previous post). Their book entitled Postpsychiatry is one of what I have called the four essential texts of critical psychiatry (see another previous post). 

As I concluded in the BMJ article, The Critical Psychiatry Network (CPN), formed in 1999, was dedicated to establishing a constructive framework to renew psychiatric practice. As I said in my editorial twenty years later, CPN still seems marginal to mainstream psychiatry. This is despite its original dismay and outrage at the hegemony of biomedical psychiatry (see previous post).

Reasons for increasing rates of school refusal

The House of Commons Education Select Committee recently published its report on ‘Persistent absence and support for disadvantaged pupils’. It decided to investigate the causes and possible solutions to the growing numbers of children absent from school. 

Authorised absences was the main driver over unauthorised absences. Prior to the pandemic, absence and persistent absence had been gradually declining since 2010, but the Committee found no significant improvement in the speed and scale of rate reduction since the pandemic.

The department of education is planning to improve its data collection on school absences, but I have not seen any analysis of variation between schools. Technically, authorised absences are usually due to school refusal, an emotional problem, or other illnesses, and unauthorised absences to truancy, a conduct problem, in terms of the way this differentiation has traditionally been made in psychiatric classification. 

Such emotionally based conditions as school refusal are very much subject to social factors. For example, psychiatrists in the second world war working with units in the field became aware there were certain battalions in which individual breakdown was common and others in which it was rare. Tom Main, who after the war was the Medical Director at the Cassel Hospital in London, with others, tried to find out what made this difference. They recognised the ways in which the morale of battalions affected the mental health of the individuals who comprised them. The structure of battalions were by their nature the same and any difference seemed to be more intangibly due to human relations inside the social structure. In the same way, I’m sure that some schools manage school refusal better than others. 

I’ve mentioned before the apparent mental health crisis of young people (see previous post) with increasing numbers of referrals, of which increasing school refusal is part. As I said then, "The mental health system is clearly not functioning for young people”. Let’s hope the focus on reducing school refusal is on social measures to reduce it, such as improving morale in schools, rather than ploughing more money unnecessarily into expecting mental health services to have panaceas that can solve the problem.

The meaning of mental illness

Zsuzsanna Chappell has a rich article written in defence of the concept of mental illness. I have a previous post on the meaning of the concept of mental illness and various other previous posts on this blog relate to this topic. 

I agree with Zsuzsanna's argument that mental illness can be a useful way of understanding for at least some people to have a liveable personal identity within contemporary Western social and political culture. As she says, "there is a phenomenon ... which is usefully described as [mental] illness-like within our culture".

I have commonly emphasised the technical distinctions between illness and disease (eg. see my Lancet Psychiatry letter). Zsuzsanna helpfully adds the technical distinction from sickness as the social response to illness and disease. As she says, 

Disease is a biomedical, theoretical construct that is identified by the medical gaze; illness is the subjective experience of lack of health; and sickness is the bundle of social responses and attitudes which are provided to someone who is diagnosed with a disease, or is experiencing illness.

In her article, Zsuzsanna has an interesting section on the culture of medicalisation, which I would prefer to call the culture of over-medicalisation (see previous post). As she says, "By requiring that there should be something illness-like at play, we could guard against over-medicalisation". As she also recognises, "The promotion of mental health awareness may have led to people overinterpreting their experiences of mental distress as an example of mental disorder" (see eg. another previous post). She even recognises that "Over-spiritualising mental distress can be just as problematic as over-medicalising it".

She also helpfully forays into theories of intersectionality. I strongly recommend reading the whole article.  As she concludes "Crucially, by identifying our experience of mental distress as an illness, we are putting forward a claim towards a particular caring, affective kind of relationship with others”.

Themes from people’s experience of antidepressants

Many so-called treatment resistant depressed patients do not respond adequately to two antidepressant medications given one after another. The question of the efficacy of antidepressants is still an open issue in the scientific literature because of methodological problems with the clinical trials (see eg. previous post).

Crowe et al (2023) identified four themes from a meta-analysis of qualitative studies examining patients' experiences of antidepressant medication. These were:-

(1) The only option available. This was partly about the sense of ‘needing something’, often quite quickly. People were generally more accepting of taking antidepressants when in acute crisis but were more ambivalent about taking them outside this context. Some felt they had to take antidepressants because of what the doctor said and even felt bullied into taking them. Some said they got relief from their first prescription but over half in one study had a trial of more than one antidepressant before getting any relief. Not everyone took the medication as prescribed, with some deciding themselves when to take it and others choosing not to even take the prescription. Most participants described feeling that there was no other treatment option available and were desperate for relief.

(2) Stigma associated with ‘biochemical deficit’. Participants in 14 studies described how the medical construction of their experience as a biochemical abnormality was stigmatising. Participants may feel different or damaged and reliant on medical expertise. Having been positioned into a passive position with the doctor having control may have shamed some into taking medication. Just using medication itself was linked to the stigma by many. Most participants in this theme described being told they needed antidepressants for their ‘biochemical deficit’. For some the deficit was constructed as something that would require on-going treatment. The doctor may state as fact that the person was biologically flawed even though there was a lack of evidence for such a view. 

(3) Not myself. In weighing up the benefits and risks, participants in 6 studies, if they took medication, described it as helping their functioning, noticing improvement in mood and being given a sense of hope on starting. However, this was often offset by experiences in which they felt the medication was masking the real problem or altering their experiences of themselves and others. This was captured in one study where participants described unbearable side effects, undermining emotional authenticity, masking real problems and reducing the experience of control. Most people commonly experienced a flattening of emotional responses which included feelings of being ‘dulled’, ‘numbed’, ‘flattened’ or completely ‘blocked’, as well as descriptions of feeling ‘blank’ and ‘flat’, affecting their relationships with others and how they saw themselves. Some described how antidepressants made them feel worse than the original depression.

(4) A vicious cycle. Patients in 8 studies identified issues in relation to discontinuing antidepressants. They often described wanting to discontinue antidepressants but had a fear of relapse. Discontinuation was associated with withdrawal symptoms, ranging from mild to severe. Fear of relapse and the experience of withdrawal symptoms meant participants felt compelled to keep taking antidepressants when they no longer wanted to.

Disclosure of industry payments to the healthcare sector

I've mentioned Peter Gordon before (see previous post). He raised a petition for a Sunshine Act for Scotland in September 2013 to make it mandatory for healthcare workers (including academics and allied health professionals) to declare fully any payments from industry and commerce (see his blog post). 

The UK government has recently issued a consultation on disclosure of industry payments to the healthcare sector (see BMJ news report). This is based on a recommendation from the Cumberledge review that investigated the harm caused by the use of Primodos, sodium valproate and pelvic mesh (see BMJ news report). 

Peter argues that government proposals for disclosure need to go further (see his blog post). It will be interesting to see the Royal College of Psychiatrists' response to the consultation. Peter tells me that the College has given no response to the Cumberledge review. Still, two high profile media doctors have been persuaded to become conflict-free (see BMJ article). 

Updating psychiatry’s biology

I’ve mentioned John Dupré previously (see post). His book The metaphysics of biology: Elements in the philosophy of biology (2021) looks at four general philosophical perspectives on life: vitalism, materialism, mechanism and organicism. Vitalism is generally derided because it is seen as postulating a vital thing or substance that is unique to life. Materialism, in the sense of the non-existence of the immaterial, is obviously true but, in this sense, a narrow claim. It is often strongly associated with the thesis of mechanism that life can be explained as a machine. Organicism, like vitalism, asserts that different principles apply to living systems. As Dupre says, "The point of difference is that it is not that there are principles that don’t apply to matter, but that these principles apply only when matter is organised in a particular way.“

An organism exhibits a mode of organisation very different from a machine. It is more than the sum of its parts. Cells and bodies are not well-defined structures but actually stabilised processes (see eg. previous post). Vitalism attributes the wrong kind of specialness to life, but nonetheless, living beings have a purposiveness that cannot be derived from mere physical-chemical processes.

Psychiatry, therefore, needs to update its biology from mechanism to organicism. Mechanical explanations are insufficient for an account of the totality of human nature. Psychiatry's primary object is not the brain but the person living in relationships. This fundamental failure to appreciate this philosophical reality is damaging psychiatry.

Taking relational psychiatry forward

I completed two years in semi-retirement of a five year part-time PhD on ‘The foundations of critical psychiatry’ at the University Department of Psychology in Cambridge in 2017/9. My supervisor left after 4 terms and I couldn’t find a replacement! Still, I managed to write three articles in Royal College of Psychiatrists’ journals: (1) Twenty years of the Critical Psychiatry Network; (2) Critical psychiatry: An embarrassing hangover from the 1970s?; and (3) Toward a more relational psychiatry: A critical reflection. An interview with Awais Aftab expressing my views about critical/relational psychiatry is to be published in a forthcoming book. 

As I said in the interview, part of the reason I changed the name of my blog from critical psychiatry to relational psychiatry was to try to move on from debates about so-called anti-psychiatry and incorporate more recent perspectives from anti-cognitivist phenomenology and enactivism and the tradition from cultural psychiatry. Key contributions here would be: two books by Thomas Fuchs: Ecology of the brain: The phenomenology and biology of the embodied mind (2018) (see eg. previous post); and In defence of the human being: Foundational questions of an embodied anthropology (2021) (see eg. previous post); the book Enactive psychiatry by Sanneke de Haan (2020) (see eg. previous post); and the contributions over many years by Laurence Kirmayer (see eg. previous post) including the book Re-visioning psychiatry: Cultural phenomenology, critical neuroscience, and global mental health (2015), of which he was the first editor. 

Other initiatives include the Relational Practice Movement, which has developed out of the therapeutic community movement (see eg. previous post). It has produced a Relational Practice Manifesto. Russell Razzaque has also produced a Relational Psychiatry vlog. He is now the Presidential lead for compassionate and relational care at the Royal College of Psychiatrists. It would be nice to think that the College could help to bring all these strands together to make psychiatry more relational. 

Still against the grain to be against biomedical psychiatry

I've managed to find a Psychiatric Times article by David Kaiser (1996) 'Against biologic psychiatry' which I thought had been lost in the ether. Unfortunately I can't find his associated articles that featured in the MHi 'Against the Grain' series. My critical psychiatry webguide, which originally was published on the Royal College of Psychiatrists' website in 2001 featured these articles. Some of the other links on the webguide are also now dead.

Kaiser's articles were also some of the first I posted on my list of articles critical of psychiatry, which I collected over many years on my Critical Psychiatry website. Again, many of the links in the list and on the Critical Psychiatry website in general are now dead.

As I indicated in the webguide, an advantage of the internet in the early days was that it provided a forum for critiquing biomedical psychiatry. In the modern days of social media, we have become used to everyone being able to express their views online about many things, besides psychiatry. Still, two of my first posted comments in the list of articles (see first and second), critiquing 1999 psychiatric journal articles about the biological basis of schizophrenia stand as much now as they did then. I didn’t bother submitting them to the journals as letters because they wouldn’t have been published! But I could self-publish on the internet. Kaiser's expression of his "dismay and outrage [at] the rise and triumph of the hegemony known as biologic psychiatry" doesn't seem to have had as much impact as it should have done from within psychiatry.

On psychiatric diagnosis

A diagnosis is a name for an illness or a disease. Technically, illness is the experience of symptoms and suffering and disease is the underlying biological pathology. People can be ill without have a disease and primary mental illness is an example where there is no underlying brain abnormality.

So, having a psychiatric diagnosis does not necessarily mean there is something wrong with your brain. And anyway, people are not their brains or bodies.

Psychiatry needs to abandon its biomedical framework

Campolonghi & Orrù (2023) argue that psychiatry needs to abandon its biomedical framework (see Mad in America research news). As they say, treating functional mental illness as brain disease "constitutes an illegitimate epistemological leap” which “leads to pseudoscientific (and unethical) practices”. 

As they go on, “biological processes and the brain are [of course] involved in enabling and mediating cognitive, emotional, and behavioral functions and responses”. However, "the consistent and systematic search for biological and neurological causes of distress and problematic behaviors conducted over more than a century" has not provided "any evidence or support for the existence of 'mental disorders' as natural kinds”.

The problem is that “psychiatry is not built upon physical sciences (as medicine is) and yet adheres to a (neo)positive-empiricist tradition”. Psychiatry will not find it easy to abandon its biomedical framework but it needs to do so in the interests of patients.