What does it mean to be diagnosed with ADHD?

Owen Jones is a succesful Guardian journalist. He was central to the Jeremy Corbyn movement. He feels as though he has been held back by his ADHD, and obtained this diagnosis over a year ago (see his YouTube video). The charity ADHD UK was founded in 2020. It aims to help people like Owen Jones navigate their life with ADHD, and wants to reduce the stigma that some people attach to those with ADHD, build awareness, and undertake or fund research that will have a meaningful positive impact on those with ADHD. 

I’ve never sought a psychiatric diagnosis to explain my inadequacies or failures, or medication to treat them, although I did have twice-weekly psychotherapy for 3 years until my therapist retired. I do think psychiatry can be beneficial, although it can also cause harms. It worries me that people are being misled about the nature of ADHD (see eg. previous post). 

I’m not sure what Jones now thinks of his ADHD diagnosis and treatment after a year. Psychiatry has moved on from its modern origins in diagnosing madness (see eg. previous post). Incorporating neurodivergence over recent years has broadened its remit. Whether this has always been beneficial is at least an open question.

Psychiatry needs to be more thoughtful

Linda Gask, who I have mentioned before (see eg. previous post), has reviewed Conversations in critical psychiatry (2024) edited by Awais Aftab (see her review and eg. my comment about the book in a previous post). As she says, reading the book reminds her of when she first tried to make sense of psychiatry in her training. Such an experience of trying to make sense of psychiatry in the wake of the so-called anti-psychiatry of the time was common for our generation of psychiatrists (see eg. my MIA radio interview). For example, I've mentioned before (see eg. previous post and my article) Simon Wessely's description of how he went through this process  and was rescued by the book Psychiatry in dissent (1976) by Anthony Clare. As I said in my comment about Awais's edited book, there is a sense in which his book is trying to rescue psychiatry from the more recent critical psychiatry movement, in the same way as Clare did with anti-psychiatry.

As Linda says, she has "never identified with the British version of ‘critical psychiatry’, finding it rather like having to adopt a complete ideology that will only consider hypotheses that are self-confirmatory". I'm not exactly sure what she means by this. If critical psychiatry's ideology is so self-confirmatory, why don't more psychiatrists and people in general go along with it? As I've said several times (eg. see previous post), critical psychiatry has found it very difficult to get its message across. Nonetheless I agree with Linda's conclusion to her review that:-

We need to encourage those training to be psychiatrists to not only be more thoughtful but listen to as many patients’ stories as they can and read widely, even the work of those they are convinced they will disagree with. 

Is psychiatric diagnosis of any value?

I responded (follow my Twitter thread) to Justin Garson’s (mentioned in previous post) tweet . What he said was:-

I can’t fathom how a psychiatric diagnosis would ever be useful to anyone except as a tool to get accommodations or drugs. As far as understanding myself – who I am, why I act and think as I do – it contributes nothing.

I do understand what he means (see eg. previous post). As I said in response, I agree there is no value in the ‘one person, one disease’ view of psychiatric diagnosis. However, I worry that his critique goes too far and can only polarise debate and alienate mainstream psychiatry which does need to change its views about psychiatric diagnosis.

What needs to happen is that psychiatry should recognise psychiatric diagnosis for what it is rather than completely abandon it, as Justin would like. Diagnosis is justified as a means of communication. It is a way of trying to manage clinical complexity. But the boundaries of any diagnosis are fuzzy and there is no point of rarity between different syndromes. These are not absolute terms. Most psychiatric presentations are not natural kinds with an identifiable brain abnormality. 

The problem is that it is too easy to assume a diagnostic concept is an entity of some kind, which then acts as a justification for treatment. In fact a psychiatric diagnosis is an unobservable, hypothetical construct. It is more an idealised description of those aspects of psychiatric presentation that are of interest. Diagnostic concepts are therefore justified by their clinical utility. Diagnosis is not only about identifying disease but also about the reasons for mental health problems.

Where psychiatry went wrong over recent years was in response to the so-called anti-psychiatry critique. In a way, Justin could be said to be resurrecting aspects of that critique. But psychiatry needs to move on from the polarisation between pro-psychiatry and anti-psychiatry. For example, Thomas Szasz became famous for his view that mental illness is a myth. He was correct that psychiatry has misled too many people that their mental health problems are due to their brain. Of course the brain mediates what we think, feel and do, including when we are mentally ill. But that does not mean necessarily that there is an underlying brain abnormality causing the problems. Szasz was right that the supposed brain disease behind functional mental illness is a myth. But Szasz wanted to go further by abandoning psychiatric diagnosis altogether because he did not think psychiatric detention could ever be justified.

Mainstream psychiatry’s response to so-called anti-psychiatry has merely reinforced its belief that functional mental illness is due to brain disease. It tends not to take a hardline position on this issue by saying that functional mental illness is completely caused by brain abnormality. However, it wants to say that there must be brain abnormality as a factor in most psychiatric presentations. This is not necessarily the case. It’s wrong to reduce people to their brains. Personal and social explanations of why we do what we do can improve our understanding of the reasons for our actions but cannot provide a complete causal explanation, certainly not in biological terms.

As I keep saying, too many people are being misled by psychiatry that their mental health problems are due to their brain (see eg. previous post). This includes misleading children who are being given a neurodivergent diagnosis to justify their sense of difference from others. This blog is called “Thinking differently about mental health”. Being different does not necessarily need to be justified by a psychiatric diagnosis. I know the neurodivergence movement does not want to pathologise a neurodivergent diagnosis. But overvaluing the diagnosis, including implying that any personal difference is due to brain differences, is not really helping children, including people in general. Here Justin does have a point. Psychiatry needs to undo the way in which it is itself benefitting  from encouraging a psychiatric label as “the answer” to people’s mental health problems.

Work needs to be undertaken now as part of the process towards complete reform of mental health legislation

I was hoping the new government would revisit the Parliamentary Scrutiny Committee’s report on the last government’s draft Mental Health Bill. This would have also given an opportunity to produce a new Bill taking into account the recent WHO/OHCHR guidance to countries on mental health legislation (see previous post). Instead the new government has produced a Bill not that dissimilar to the draft Mental Health Bill of the last government (see eg. blog post from DHSC Media Centre and version of amended Mental Health Act (MHA) 1983 as if amended by the Bill prepared by Alex Ruck Keane). 

Homicide by psychiatric patients is a political issue which still seems to be preventing proper human rights MHA reform (see eg. previous post about case of Valdo Calocane as an example). Such reform will now almost certainly need to take place over time, maybe in the context of the also necessary reform of the Mental Capacity Act (MCA). In my view, the last government should have been more ambitious looking to replace both the MHA and MCA. There also needs to be a cultural shift of attitude within mental health services to make them more person-centred. As Mind said in its initial reaction to the new Bill:-

[T]here is more to do and questions to ask about whether this [Bill] will go far enough to fix the broken system as we know it. The mental health emergency we are facing will need much more than a reformed Act.

Work needs to be undertaken now as part of the process towards complete reform of mental health legislation. Mere amendment of the 1983 Act as will be enacted by the new Bill is not sufficient. This work (see eg. previous post) should include: reform of the Mental Health Tribunal to make it more rights-based; improving mental health advocacy by creating an integrated service of Independent Mental Health Advocates (IMHAs), mental health lawyers and independent experts; and further reducing the commissioning of secure placements, leading to the prevention of all civil detentions to secure facilities, apart from to short-term Intensive Care Units. The latter development needs to be supported by a renewed focus on improving the quality of acute psychiatric inpatient and crisis resolution and home treatment services. Work could also be undertaken on creating a new Mental Health Commissioner for England. The mental health reviewer and Second Opinion Approved Doctor (SOAD) functions of the Care Quality Commission will also have a role in monitoring the implementation of the new S56 treatment provisions for Approved Clinicians to follow a clinical checklist and the introduction of statutory care and treatment plans.

Blaming the brain is out of control in psychiatry

I've said before it's been difficult to get the message of critical/relational psychiatry accepted (see eg. previous post). People are being encouraged to see themselves as their brains. It's almost become heretical to suggest otherwise. Of course the belief that what we think, feel and do are caused by our brains is plausible. This assumption must not be questioned, though.

After all there are brain scans that prove this, aren't there? We've probably all seen pretty coloured scans that show areas of the brain lighting up when they are said to show connections to various human activities. But we’ve forgotten what our forefathers learnt in the late 19th/ early 20th centuries that human activity is not as well localised in the brain as we might have expected or hoped. They appreciated that the brain, indeed the complete human body, generally acts as a whole. People are also alive and cannot be explained in mechanistic terms. 

Elliot Vallenstein's book Blaming the brain was first published in 1998. It described how theories of chemical imbalance in the brain had replaced previous ideas that early experience in the family were the cause of mental disorders. As the publishers website says (see webpage), the book sounded a “clarion call throughout our culture of quick-fix pharmacology and our increasing reliance on drugs as a cure-all for mental illness”. This situation has in fact in many ways only got worse since despite the warning. For example, over recent years, the neurodivergence movement has promoted the idea that our differences from each other are due to our brains. No wonder there is therefore a burgeoning demand for a neurodivergent diagnosis. If it’s believed that the reason why we’ve seen ourselves as different from each other all these years is because of our brain, then the sooner we get a diagnosis the better.

We need a serious rethink about the nature of mental disorder. It may have suited psychiatry to go along with the idea that mental illness is due to the brain. Of course brain abnormalities can cause mental symptoms. But most of the presentations to psychiatrists are not caused by a brain abnormality, however much psychiatrists may have misled people that they are.

The untruths of psychiatry

I’ve said several times (see eg. previous post) that biomedical psychiatry wishfully thinks that primary mental illness will be shown to be caused by brain abnormality in some way. It even commonly acts as though that has already been proven. People are encouraged to think that there is something wrong with the brains of people who are mentally ill. That there must be something wrong may seem plausible but people are not just their brains. Of course what they think, feel and do is mediated by the brain. However, people are not completely driven by their brains. Their environment and circumstances, for example, have some influence. How people lead their life means that in a way people are also forming themselves. There may well be reasons why people become mentally ill but there is a sense in which we can never prove why they have.

People generally find this conclusion too difficult to accept. If they did there would be too much uncertainty in life and psychiatry in particular (see eg. previous post). They therefore embark on pseudoscientific speculations about the biological nature of mental illness believing them to be true (see eg. last post). These speculations can be repeated in the media misleading the public about the evidence. 

Peter Gøtzsche, who I've mentioned before (see eg. previous post), writes on Mad in America (see blog post) about the claim on Danish national TV that patients with an ADHD diagnosis die 5 years earlier if they are not treated with drugs. Peter managed to obtain a correction from Danish TV that there is no evidence for making such an unequivocal statement. The trouble is that such statements about ADHD (see eg. previous post) and neurodiversity in general (see eg. another previous post) are widely propagated in the media. Peter talks about the “pervasive lies of psychiatry” and there is a legitimate question about how much people are being misled about the role of the brain in mental illness and life in general. Mistakes and wishful thinking can become outright falsehoods in psychiatry that it should make more effort to avoid.

Biomedical psychiatry is a pseudoscience

Scientific knowledge is seen as the most respectable form of knowledge (see eg. last post). It is based on the scientific method of reasoning about observations to develop hypotheses which can be tested. Biomedical psychiatry claims primary mental illness is brain disease, or at least that brain abnormalities are a factor in its cause. Mental illness of course shows through the brain. That’s mere tautology. But biomedical psychiatry wants to claim that primary mental illness will be demonstrated to be located in the brain in some way.

Even eminently plausible and widely held beliefs, such as psychiatry’s mainstream belief that something is wrong in the brain in primary mental illness, can be pseudoscience. The value of scientific theories depends on their objective support. Psychiatrists as scientists want their theories to be respectable and provide genuine knowledge. Like all scientists, their aim is to prove their scientific theory beyond doubt, even though that may be an impossibly ideal dream. However, there still isn’t any proof that primary mental illness is brain disease, despite the vast research programme directed towards fulfilling that aim (see eg. previous post). When evidence accumulates against or fails to confirm the latest hypothesis, then attention is turned to another line of inquiry or some adaptation is made to the theory to accommodate the lack of evidence to rescue the original hypothesis. The underlying fundamental belief that progress is being made in discovering the cause of mental illness is therefore maintained. How psychiatry will change from its fundamental belief that brain pathology is at least an element in the causation of mental illness is unclear (see eg. previous post).

Psychiatry stuck in Newtonian physics

As I’ve said before, psychiatry tends to treat people as machines (see eg. previous post). Newtonian physics sees existence in terms of cause and effect rather than meaning. Modern science is based on experiment and has a comprehensive, mechanical, rational approach to nature. External observation is seen as the basis of worthwhile, definite knowledge. However, since Einstein, even our understanding of the physical world needs to be supplemented by quantum mechanics and the theory of relativity. Moreover, some kinds of knowledge are unknowable to us in terms of Newtonian physics, as we have beliefs and opinions which are not directly observable (see eg. another previous post). Our reality is social constructed by active shifting of moving and multiple points of view reinforced by social perspective-taking (see eg. yet another previous post). This does not mean that anything we think is true but that we need to think carefully about the way in which the external world impinges on our sense of reality. 

Psychiatry does not seem to realise that the mechanistic ambition of Newton’s laws has failed, at least beyond the physical world. The way in which the so-called human machine is constructed as viewed by natural science does not completely control and constrain human behaviour. Human beings have some freedom within those limitations. Human nature and life in general cannot be completely accounted for within the same laws and principles as the natural world. The body is both alive and lived. Biology cannot be a sufficient explanation of mental illness or human life in general. The brain mediates mental illness but cannot be its locus (see eg. previous post).

Expectancy effects in antidepressant withdrawal studies

Zhang et al (2024) have published a systematic review and meta-analysis of the incidence of antidepressant withdrawal symptoms. More than 40% experienced such effects. This figure is higher than the 15% estimate from another recent systematic review (see previous post). As I pointed out in that previous post, so-called withdrawal symptoms also occur in the continuation arm of randomised controlled trials (RCTs), when such withdrawal symptoms wouldn't necessarily be expected in this group as participants are still taking their antidepressant. This could be said to demonstrate how expectation can influence the experience of antidepressant withdrawal, as participants may have expected adverse reactions on withdrawal, thinking they were being withdrawn from antidepressant even though they were in the blinded control group. Zhang et al report that the incidence in the discontinuation group is significantly higher than the continuation group. What I want to challenge is their claim that this significant difference therefore necessarily excludes such expectancy, or nocebo, effects as an at least partial, if not complete, explanation of antidepressant withdrawal symptoms.

I want to emphasise that I'm not saying such nocebo effects are not real. They are felt and experienced as true medication effects. It may well be difficult for people who experience withdrawal effects to understand that they could be nocebo effects. However, in my experience, people do generally appreciate that people may become dependent on antidepressant medication. It was the basis for me writing my BMJ letter that led to my special interest in antidepressant withdrawal (see eg. my book chapter). A drug that is thought to improve mood may well be expected to be difficult to give up because of, for example, a fear of relapse. Psychological dependence with antidepressant medication is not surprising (see eg. previous post). What people find difficult to accept is that such nocebo effects can be so powerful that they can cause the severe and longlasting effects that they do. But, again for example, if the taking of antidepressants is associated with the belief that the medication is correcting a brain problem, even though this is the wrong way of understanding how mental health problems are corrected, then it's not surprising that it may take some time to come to terms with managing without the drug because of the complex set of meanings that the medication has acquired. Undoing these beliefs is not easy, particularly perhaps if the experience of taking antidepressants initially seemed to help.

Of course using placebos in clinical trials of efficacy is designed to exclude placebo effects. In the same way in discontinuation trials, having a control group which continues antidepressant is designed to control for nocebo effects. How effective these control methods are in preventing placebo/nocebo effects depends on how well blinded the participants are from knowing to which group they have been allocated. There is considerable evidence that people are not completely blinded in antidepressant efficacy trials (see eg. previous post). As far as I know, there has been no attempt to measure unblinding in an antidepressant withdrawal study. If unblinding occurs in antidepressant efficacy studies, I think it is also likely to occur in antidepressant withdrawal studies. As the blind can be broken in antidepressant efficacy trials, it cannot be said that expectancy effects have been eliminated.  So my case is that it cannot be said that expectancy effects have been eliminated from antidepressant discontinuation RCTs, because I think there is also likely to be significant unblinding in these withdrawal studies as well.

Habituation to antidepressants is to be expected (see eg. previous post). It helps to explain why people take them for such long periods of time. Psychological mechanisms causing antidepressant withdrawal symptoms should not be dismissed. I have considerable doubts about antidepressants being more than placebo in their antidepressant effect (see eg. previous post). Those that argue that antidepressants cause organic physical dependence tend to say that the sense that antidepressants have stopped working, which can occur, sometimes colloquially called the "poop-out" effect, is evidence that there is tolerance with antidepressants. As I don't think antidepressants are "effective" in the sense of being more than placebo, this explanation doesn't make sense to me. I am at least consistent in my scepticism about the effects of antidepressants, which for their apparent benefit I put down to placebo, and for their withdrawal effects I am inclined to think could be due to nocebo. To emphasise again, this does not mean I am saying any experienced benefit for antidepressants is not real. Nor am I saying that the experience of antidepressant withdrawal is unreal. What brought me into the area of antidepressant withdrawal years ago was my critique of mainstream psychiatry for denying the reality of such symptoms. I just don't think that there's necessarily been much progress since in understanding the mechanisms of such withdrawal effects, and it worries me that psychological mechanisms seem to be being ignored, even within the Critical Psychiatry Network (see previous post). 

Thinking differently about mental health

I’ve changed the name of this blog before (see eg. previous post). I’m not convinced it’s really made much impact in terms of attracting more readers (see eg. another previous post). I’m making another attempt to see if expressing what this blog is about in more everyday langauage, avoiding the use of the term ‘psychiatry’, makes a difference. As mentioned in another previous post, ‘mental health’ has come to mean the conditions and practices that maintain mental health. There is general acceptance that mental health needs to be rethought (see eg. yet another previous post).

Psychiatry struggles to cope with its inherent uncertainty

Terry Lynch, who wrote a chapter for my Critical Psychiatry edited book, has posted a video asking why doctors pay so little attention to trauma in the lives of people with psychiatric diagnosis. As Terry says, Robert Spitzer, Chair of the DSM-III taskforce (see eg. previous post), when asked in an interview whether psychiatric diagnosis shouldn't always take into account a person's life circumstances replied "If we did that then the whole system falls apart".

As I've said before (eg. see previous post), psychiatry is a cultural system. The belief that primary mental illness is brain disease clothes psychiatry with an aura of factuality, even though that belief is incorrect. As I also keep saying, biomedical psychiatry is more like a faith than a science (see eg. previous post). That includes what's often called the biopsychosocial approach to psychiatry, which can be more of an eclectic mix of biological, psychological and social in psychiatric assessment, regarding these aspects as more or less equally relevant in all cases and at all times. This understanding of ‘biopsychosocial’ makes psychiatry merely a weakened, ill-defined form of the biomedical model (see eg. another previous post), rather than truly anti-reductionistic in the way originated by George Engel (see eg. yet another previous post).

Psychiatry is sustained by its professional institutions, such as the American Psychiatric Association (see eg. previous post) and the Royal College of Psychiatrists (see eg. previous post). These professional bodies can’t always be relied on for information (see eg. another previous post). In fact, they are biased and do not take a pluralistic and integrated position to psychiatry, despite claims that they do (see eg. previous post). They tend to think that primary mental illness is brain disease or at least is caused by biological factors to some extent, whereas it is not a structural brain but functional personal problem. The American Psychiatric Association is responsible for the Diagnostic and Statistical Manual (DSM) which has resulted in a dead-end in its 5th version (see eg. previous post), building on the direction started by Spitzer.

The biomedical model gives a sense of direction and purpose to psychiatry. The trouble is it induces certain dispositions and ways of understanding in psychiatrists that can lead to them treating patients more as objects than people. It provides a worldview that, if psychiatrists did not accept and believe in it, would make their practice too uncertain for most. I think that’s what Spitzer meant. He was so panicked that psychiatric diagnosis may be unreliable that he initiated the process of taking psychiatry, particularly American psychiatry down the DSM route to its dead end in DSM-5 (see eg. previous post and my 2002 article). 

Mad studies and critical/relational psychiatry

I’ve mentioned before the chapter written by key members involved in the foundation of the Critical Psychiatry Network (see previous post). The book for which it was written has now been published: Mad Studies Reader, edited by Brad Lewis (who has written a guest post for this blog) et al. My chapter with Ameil Joseph in Mat Savelli et al’s edited book highlights how mad studies, critical psychiatry, anti-psychiatry, and decolonizing activism contribute to mental health education and transformation.

Do antidepressants cause emotional numbing?

George Dawson (mentioned eg. in a previous post) and Ronald Pies (also mentioned eg. in another previous post) argue in a Psychiatric Times article that antidepressants do not work by numbing emotions. They wrote the article to counter the claim by Joanna Moncrieff and Mark Horowitz, members of the Critical Psychiatry Network (CPN), that one of the pharmacological actions of antidepressants is emotional numbness and that is how they “work”. This hypothesis builds on Jo’s differentiation of a disease-centred and drug-centred understanding of the mechanism of drug action (see previous post). Psychiatric drugs do not necessarily work because they are correcting a disease process (disease-centred model) but because they have drug effects that may be useful in managing the illness (drug-centred model). Emotional numbing is hypothesised to be of benefit when using antidepressants for depression. 

Also being a member of CPN, I have some concerns about Jo and Mark’s claim. I accept that emotional numbing is a common side effect of antidepressants, particularly in long-term use. I don’t think it’s usually a very immediate consequence of taking antidepressants, for example within the short-term (often about 6 weeks) clinical trials that are used to make claims about the effectiveness of antidepressants. So, I don't quite see how emotional numbing can explain any significant difference between antidepressant and placebo demonstrated in these trials over the short-term. 

But over the longer-term, people often complain that antidepressants seem to have stopped them really dealing with their problems and complain of a flattening of emotional responses which includes 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 see themselves (see previous post). If antidepressants have seemed to help, even if more because of a placebo effect than true antidepressant action, then it's not surprising that people may feel that a physical rather than psychosocial approach to their depression has not really helped. They may express that as emotional numbness and not being in touch with their feelings. They might even still have the same underlying personal and social reasons that led to their depression, which haven't really been dealt with, as such, by mere taking of an antidepressant.

The trouble is that there is only a limited literature about emotional numbing caused by antidepressants that does not allow proper assessment of its significance and mechanism. One study that is commonly quoted is Goodwin at al (2017). They found that emotional blunting is reported by about half of people on antidepressants and is correlated with their depression score ie. a poorer quality of remission is associated with more blunting. However, the screening method used a leading question ‘To what extent have you been experien­cing emotional effects of your antidepressant?’, and followed this up with an explanation that ‘emotional effects vary, but may include, for example, feeling emotionally "numbed" or "blunted" in some way; lacking positive emotions or negative emotions; feeling detached from the world around you; or "just not caring" about things that you used to care about’. Those that gave a positive response were asked to complete a fuller questionnaire about emotional blunting. 

As the paper admits, the data is very much affected by subjective factors. People were guided by the methods used in the study into essentially having a wide understanding of the meaning of emotional numbness or blunting. I tend to think what's meant by emotional numbing is more to do with people feeling antidepressants are masking the real problem and thereby preventing them having their full range of experiences, rather than a direct physiological effect of the drug. Jo and Mark disagree with me about this, but I'm not convinced they've got the evidence for their view. People commonly, at least initially and maybe over time if they can sustain having stopped the antidepressant despite withdrawal symptoms, say that they feel more alive and in touch with their feelings after stopping the drug. That may not be surprising, as there must be relief, at least, that they do not have to take the antidepressant. There must also be a sense that emotions are no longer being controlled by the antidepressant. Trouble is that it's not always very easy stopping antidepressants, perhaps particularly if they were started when there didn't seem to be much alternative and the person has been misled into thinking that there must have been something wrong with their brain. This means that they get stuck in a vicious cycle of wanting to stop antidepressants but fear relapse and withdrawal symptoms if they've previously experienced them. Withdrawal symptoms are very common (see eg. previous post).

It worries me how the notion that antidepressants work by emotional numbing seems to be catching on, perhaps particularly with patients. As I've said, I'm not convinced there's the evidence for the hypothesis. As I've commonly said, I tend to think antidepressants are no better than placebo (see eg. previous post). That doesn't mean that I think they're inert. In fact, the reason I think antidepressants are no better than placebo is because I think the significant difference between antidepressant and placebo found in short term trials may be a methodological artefact. This arises, for example, because trials are not as double-blind as is commonly assumed. Trial participants may well be able to break the blind in randomised controlled trials because of side effects, so I'm not saying antidepressants are inert.

But I do worry that critics of biomedical psychiatry may be creating another myth, like the serotonin hypothesis, that antidepressants work by emotional numbing. In fact, because I don't think antidepressants probably work any better than placebo, in a way I'm saying they don't "work". There's no need, therefore, to even have an explanation of how they "work"! That's not meant to undermine the people that feel that antidepressants have helped (see eg. another previous post) but the limitations of medication do need to be acknowledged. The trouble is that mainstream psychiatry is committed to supporting the use of antidepressants because they are seen as effective.

Fearless speaking about psychiatry

John Heaton has been mentioned in this blog before (eg. in a guest post by Miles Clapham). John wrote a chapter in my edited Critical psychiatry book. He used the Greek notion of parrhesia from Foucault to help explain that critical psychiatry is a practice that states frankly what one thinks about the nature of persons and psychiatry. 

In the Fall Term of 1983, Foucault gave 6 lectures in English at the University of California in Berkeley as part of a seminar entitled ‘Discourse and Truth’ devoted to the study of parrhesia. These were taped recorded and edited by Joseph Pearson and published as Fearless Speech (2001). The general objective of the seminar was to construct a genealogy of the critical attitude in Western philosophy. 

The parrhesiates is someone who uses parrhesia and opens their heart and mind completely to other people through their discourse. The parrhestiastes makes clear they are expressing their own opinion by using the most direct words and expression they can find to express what they actually believe. In a positive sense, they are telling the truth because they know it is true. They are saying something dangerous because it is different from what the majority believe. They expose themselves to harm as the truth may cause hurt or anger but they prefer to be a truth-teller rather than being false to themselves. Parrhesia is therefore a form of criticism from a less powerful position than the one with whom the parrhestiastes speak. 

Parrhesia may become a problem of truth if it is seen as mere frankness in speaking when everyone is equally entitled to give their own opinion. It actually has a relation to knowledge and education. Bad, immoral or ignorant speakers may endanger democratic organisations. Saying what people want to hear avoids the necessity of being critical and the need to attempt to change people’s understanding and will. Parrhesia, in the positive sense, is, therefore, a virtuous personal attitude and quality to speak the truth boldly. 

I’ve commonly said that psychiatry is more like a faith than a science (eg. see previous post). That implies it is not true that primary mental illness is brain disease. Challenging the claim that primary mental illness is brain disease, as does critical/relational psychiatry, is not denying the reality of mental illness. It is a necessary challenge to the power of psychiatry speaking from the position of the parrhesiastes (see recent post ‘Truth-telling in psychiatry’ on my personal blog).

The definition of critical psychiatry

I mentioned before my interview with Awais Aftab (see previous post), which has now been published as a chapter in his edited book Conversations in critical psychiatry. Awais has added an introductory chapter to the interviews he has collected in the book. In that chapter he quotes my comment that “critical psychiatry may be difficult to define precisely” and suggests that the most specific use of the term is merely to make reference to psychiatrists, such as myself, associated with the Critical Psychiatry Network (CPN) (see eg. previous post). This suggestion fails to take account of my further comment that CPN takes an ideological position that primary mental illness cannot be reduced to brain disease. There is a range of views within CPN, true, but it coalesces round a systematic collection of ideas (see eg. previous post) and seeks to move on from the reductionism and positivism of much of modern psychiatry. 

Awais tries to be open to critical perspectives in psychiatry (eg. see previous post), but he is not as explicitly ideological in his position as CPN. The trouble is that he is inclined to see what he calls the integrative tradition as continuous with the critical. He wants to see integrative and critical pluralism as a variant of critical psychiatry. I’m very much in favour of an integrative and pluralistic perspective in psychiatry but this is based on CPN’s ideological position about the nature of psychiatry and the uncertainty in the field, rather than wanting to hold on to the possibility of biomedical perspectives, as does Awais.

As Robin Murray says in his foreword to the book, Awais suggests critical and integrative pluralism as a corrective to what he calls the lack of self-criticism of critical psychiatry. I’m not so convinced that critical psychiatry is lacking in self-criticism. It's more Awais saying he can't accept at least part of its critique. True, there are those within the critical psychiatry movement that want to abolish psychiatry but actually, as Awais acknowledges, members of CPN are psychiatrists themselves. As he says, “They fundamentally see critical psychiatry as a form of psychiatry”. They are open to different perspectives and take a reflexive position in their critique.

Awais is correct that “The folk judgements of 'something has gone wrong’ [in mental illness] might or might not be indicative of failure of a psychological or neurobiological mechanism to perform its ‘natural’ function”. But Awais suggests critical psychiatry creates “various binaries that sort psychiatric conditions into diseases versus problems of living, biologically caused vs representing self-directed behaviours, and illnesses vs understandable reactions to circumstances”. I agree with him that there is a form of critical psychiatry that does that. But it need not, nor do I, as a member of the Critical Psychiatry Network, so therefore representing 'critical psychiatry', at least part of it, in his sense. Those that do, as Awais notes, can be called neo-Szaszian critical psychiatrists.  Critical psychiatry does not need to be neo-Szaszian. I have always emphasised how it needs to be integrated with the mainstream (see eg. previous post). Awais should take on board, as I say in my interview, that "most presentations to psychiatrists do not have an underlying physical cause, even if that is presumed still to be discovered". Psychiatry came out of its previous phase of brain mythology in the 19th century by recognising the structural/functional distinction of mental illness at the beginning of the 20th century (see eg. previous post). Over recent years this distinction has been fudged, if not obliterated (see eg. another previous post). The point is though that psychiatry must stop reducing people to their brains (see eg. yet another previous post).

Awais is clear that he thinks it is plausible that psychiatric medications “act on mechanisms that produce, sustain, and modify symptoms”. I agree with his emphasis on outcome-based prescribing (see eg. previous post). But he is not sufficiently critical of the notion of whether medication “works” (see eg. previous post). He speculates that it “is likely that psychiatric medications act on symptom mechanisms while also producing global psychoactive effects”. He doesn’t want to consider that any effect of psychiatric medication may be primarily due to the placebo effect (see eg. previous post). 

In the same way that Anthony Clare did for a previous generation by emphasising psychiatry's eclecticism against anti-psychiatry (see eg. previous post), mainstream psychiatry seems to be defending itself against the message of critical/relational psychiatry by promoting integrative and critical pluralism. The publication of Awais' book is welcome. The trouble is that although it engages with the critique of psychiatry, it does not properly take its message on board because psychiatry does not want to change. However difficult it may be to hear the critique of critical/relational psychiatry, it does need to be stated boldly in the interests of patients (see eg. another previous post). Otherwise, psychiatry will merely continue to defend and maintain its biologism.

Do antidepressants cause manic switch?

As I said in a previous post, some critics of psychotropic medication do not always seem to apply the same rigorous scepticism to side effects as they do to treatment effects of medication. For example, in my review of Peter Breggin's (2001) The Anti-Depressant Fact Book: What Your Doctor Won't Tell You About Prozac, Zoloft, Paxil, Celexa, and Luvox, I expressed concern that people were being misled about the side effects of antidepressants. One of these controversial areas was whether antidepressants can cause people to shift to manic symptoms, potentially leading to a diagnostic transition from unipolar depression to bipolar disorder. 

Ironically, mainstream psychiatry also tends to believe in a causal relationship between antidepressants and manic switch (see eg. previous post). Current guidelines do not recommend using antidepressants in first-line treatment for acute bipolar depression, at last partly because of the risk of manic switch (see recent American Journal of Psychiatry editorial). Even so, generally the evidence for antidepressant induced mania has been seen as uncertain.

Rhode et al (2024) used data from a Danish health register to compare the occurrence of mania and bipolar depression in the year after discharge from a psychiatric ward of bipolar depressed patients who either received antidepressants or did not. There was no statistically significant association between treatment with an antidepressant and the risk of mania in the full sample, nor in the subsample concomitantly treated with a mood-stabilizing agent, nor in the subsample not treated with a mood-stabilizing agent. Neither was there any statistically significant association between treatment with an antidepressant and bipolar depression recurrence. This study may add to those questioning whether the risk of manic switch is overblown.

Another recent study (Tondo et al, 2024) found that about 6.7% of patients initially diagnosed as unipolar depression followed over a period of a mean of 12.7 years had their diagnosis changed to bipolar disorder, mostly type II (76.7%) rather than type I. This conversion rate may not be as high as expected, considering the fears of manic switch. 

Moreover the way in which the concept of bipolar disorder has expanded over recent years (see eg. previous post), in association with the introduction of mood-stabilising medication (see eg. another previous post), highlights how malleable psychiatric diagnosis is. There is a legitimate issue about what bipolarity means when it has become such an all embracing term, essentially amounting to mood instability, which of course is very common and not always necessarily best described as a mental disorder (see eg. yet another previous post). The mechanism of manic switch is unclear, and psychogenic, rather than physiological factors, may be significant. A sceptical approach to interpreting the inconsistent evidence is required. Manic switch is a risk in the use of antidepressants but how significant this is and whether it is physically caused remains uncertain.

Do people want to hear the message of critical/relational psychiatry?

I said in a previous post that mainstream psychiatry ignores critical psychiatry and I seem to have been wasting my time trying to get my message across in this blog. I have subsequently changed the name of this blog from critical psychiatry to relational psychiatry (see another previous post), partly in case the term 'critical', which tends to have negative connotations, is what puts people off. But it does seem to be the content of the message that people do not want to hear, rather than necessarily the way it's expressed. I'm not convinced psychiatry is really interested in relational psychiatry either. Why is that?

People not wanting to hear the message of critical/relational psychiatry may seem surprising to some, because isn't psychiatry primarily about relationships with people, as the term ‘relational psychiatry’ implies? Surely it's about trying to support them with their difficulties in their personal situation and relationships with others through an independent professional relationship. Is psychiatry then not really about helping people?

Well, yes and no seems to be the answer! Psychiatry does think it is helping people but not apparently necessarily through relationships with them. The focus tends to be on treating their brain problem. Psychiatry believes people's psychosocial difficulties may well be correctable by some physical intervention, such as prescribing medication, or by a simple, brief psychological course of therapy. The person will then be alright, or at least better with that treatment. Is there any more to it?

That’s the positive component to psychiatry's answer, is it? But what about the negative? What's wrong with just accepting this mainstream psychiatric view? However much of a caricature of psychiatry I'm presenting, it does seem to describe the essence of what people think psychiatry is expecting them to believe. No need to wrap it up in an academic critique of psychiatry called critical/relational psychiatry. Just express it in plain terms. That's not to deny that mainstream psychiatry certainly seems to suit some people. If that's all that's needed, all well and good. Keep things simple. That's fine for them at least, maybe!

But is that generally what people want from mental health services? Most people know their problems are more complex. They might hope they can be made simple and corrected easily. But generally, when they think about it, they may well be prepared to admit to themselves that might be wishful thinking. It might well take time and effort to recover from personal difficulties. And anyway, by reducing people's complex emotional difficulties and personal situation to a brain problem, hasn't the essence been lost of trying to understand why they are thinking, feeling and behaving in the unhealthy way they are? Ok, there might be a brain problem behind it. But for the vast majority of presentations to mental health health services, that is not the case.

So, what’s the point of encouraging people to believe that there is a brain problem? There are several reasons for this. As I’ve already said, it’s simpler to reduce the complexity of mental illness to brain disease. Understanding the relationship between mind and brain is difficult. For example, do we think and feel and do things because of our brains? We certainly need a brain to be alive. When we’re dead, it’s definitely not working! But then neither are our other bodily organs. We need a body to be alive. The brain is certainly an important part of that body to create the people we are. To some extent our human functioning is localised in specific parts of the brain, but actually not as well localised as people often think. The brain functions very much as a whole, despite all the attempts in research over the years to localise mental illness within it. Certainly mental illness shows through the brain but not necessarily in particular places within it. Nonetheless it’s attractive to think that mental illness may be localisable within the brain. We then don’t need to bother about what it means to be alive and can avoid having to deal with difficult abstract concepts like the nature of mental illness. Troublesome ethical debates about what psychiatry needs to do to manage such problems can then be short-circuited.

Another advantage of reducing mental illness to brain disease is that it makes mental illness more like physical illness. We can then follow the same kind of physical approach as the rest of medicine, which seems to have been remarkably successful in finding treatments for our various illnesses. Although, in practice, we may often overestimate how successful medical treatments are, it’s seductive to think that psychological medicine may be able to utilise the same scientific principles as the rest of medicine. Any differences between mental illness and other illnesses can, therefore, be minimised, if not obliterated. All well and good! As well as simplifying the conceptual issues, we now have a technological solution to mental illness following the same methods in psychiatry as the rest of medicine.  However much people may be fearful of mental illness, and want to exclude disturbed people from society, psychiatry has provided a way to give itself professional respectability in its dealings with them by making it more like the rest of medicine.

By adopting the same principles as the rest of medicine, psychiatry then creates another apparent advantage. It now needs a massive research industry, with considerable funding behind it, to find the so-called 'answer' to mental illness. It doesn’t matter that people are being reduced to their brains by seeing their mental health problems as being in the brain. It’s anyway more commonsensical, surely after all, to think that people are driven by their brains. There must be a need for neurobiological research to understand what’s gone wrong when people become mentally ill. Psychiatry's now avoided complex conceptual issues, found that it can follow medical methods and technologies, and just needs to invest more in research to make progress.  Psychiatry has created a firm edifice and foundation to provide care for mentally ill people, or has it? The problem is that it may suit us to think solutions are just round the corner but meanwhile there are still a significant number of people with mental health problems that need help, and we’re being distracted from dealing with what matters by seeking unattainable solutions in the future.

Biomedical psychiatry has, therefore, created a remarkably successful economic model. No wonder people don’t want to give it up and feel threatened when it is challenged. The problem is that taking this approach to psychiatry means that it has become more like a faith than a science. It has certain tenets which need to be believed. As we have outlined, these are: firstly, that mental illness will be shown to be due to brain disease and that there’s subsequently no need to get bogged down in complicated conceptual issues about the relationship between mind and brain; secondly, as mental illness has a material basis as do physical illnesses in general, it follows that psychiatry is not that different from the rest of medicine, so psychiatry can follow the same methods and technologies as the rest of medicine; and thirdly, that the scientific ambition of psychiatry and its associated research programme is to uncover the neuroscientific causes of mental illness and great progress has already been made in this aim. These fundamental tenets must not be questioned, otherwise the edifice of modern psychiatry may come tumbling down.

That's fine, maybe, but psychiatry has considerable legal powers, such as being able to detain mentally disordered people in hospital, subject to certain criteria within the Mental Health Act. It may well think it needs a firm foundation to be able to exercise that authority. It can’t really have people undermining its conceptual foundations, when it has such important social responsibilities. However, it is perhaps particularly because of the power that psychiatry has over people with mental health problems, that it's important to be honest about the state of its practice. Psychiatry may not want to listen to any candid criticisms, but it should. We're now back to where we started this post. If psychiatry is primarily about relationships with people, then it does need to accept this reality. However successful psychiatry may be in marginalising any critique, people do feel obliged to speak openly and fearlessly about how psychiatry needs to change. Otherwise, it may just continue to be designed more for its own interests than the people it purports to serve.

Misleading the public about mental health

Matthew Parris’s Times article entitled ‘Mental health industry is cheating the public’ led to some overdefensive responses from mainstream psychiatry (see Letters). Parris may have overstated his case but, for example, the diagnosis of neurodivergence is out of control (see eg. previous post). It’s legitimate to question whether psychiatry is a science, considering the pseudoscientific claims made by biomedical psychiatry (see eg. another previous post). There have been serious problems with the application of Personal Independence Payments (PIP) since it replaced Disability Living Allowance (see post on my personal blog). Although the economically inactive may not be choosing not to work, as ineptly expressed by Parris, why so many people are not working is a legitimate social question. Mental health problems are definitely being overmedicalised (see eg. yet another previous post) and people do not want to hear that message. 

Will the mistakes of the past be repeated in Mental Health Act reform?

The government has been reported (see Guardian article) as being prepared to slow down Mental Health Act (MHA) reform following the Care Quality Commission (CQC) review of the homicides by Valdo Calocane. Wes Streeting, Secretary of State for Health and Social Care, has been quoted (see another Guardian article) as saying that “three innocent people might still be alive” if the NHS had “done its job” in treating Calocane. As I said in a previous post, it has been a mistake for mental health services no longer to be prioritising assertive outreach (AO) for people with serious mental health problems, like Calocane. This does not necessarily mean reintroducing separate AO teams as previously, but the AO function needs to be restored and prioritised in an integrated, functioning community mental health service.

I welcome time being taken to give proper consideration to the issues of MHA reform, as they do need to be got right and we need to learn from mistakes made following similar tragedies in the past. For example, a 2006 Observer article was written by the father of a man with a 17 year history of schizophrenia who, even though the father accepted that his son’s illness was difficult to treat, wanted to know why the mental health system, of which he was very critical, could not cope. The article appeared in the week following publication of a report into the care of John Barrett, who killed a stranger in Richmond Park, and which was said to reveal a litany of failures in his care. Homicide inquiries all tend to have the same findings that there is a need for improvement in risk assessment, communication, care planning and interagency working. These factors need to be improved in all mental health cases, not just those that lead to homicide. To focus on enforced treatment in the community (Community Treatment Orders (CTOs)) has been a distraction from the need to provide consistent, high quality community care by improving these aspects for all mental health care.

The more recent Guardian articles above show we are still facing similar problems in mental health services today to 2006 before CTOs were introduced. Part of the answer of the patient’s father then was that services were not sufficiently realistic about the lack of insight of people with schizophrenia and did not do enough to provide ongoing, consistent rehabilitative care, including accommodation for his son. Unfortunately services are still not always prioritising and providing high quality care for those with severe mental illness. This is where the focus for improvement should be.

The article was written before the last Labour government amended the MHA in 2007 to introduce community treatment orders (CTOs) amongst other changes. An Observer editorial accompanied this article and several letters were published in response. A Mental Health Bill, which led to the 2007 amendments to the Act, had already been introduced. Rosie Winterton, Minister of State for Mental Health at the time, in one of the published letters, argued that MHA reform was necessary to introduce CTOs to deal with the situation described by the father of the man diagnosed with schizophrenia. She seems to have seen CTOs as the answer to the then failing mental health system.

If services are still so dysfunctional and fragmented, why did CTOs not work? I posted then that CTOs “could well make the culture of mental health services worse by making them more custodial and less therapeutic”, suggesting that CTOs were “not the correct response to the bureaucratic, defensive failings of mental health services” described in the article. Mental health services need to be supported in providing high quality care, rather than being made fearful they will be attacked when something goes wrong. Mental health services have unfortunately become more fearful about what might go wrong in mental health services, rather than concentrating on the task of improving things for people with mental health problems.

The Critical Psychiatry Network (CPN), of which I am a founding member produced a position statement on CTOs in 2007. It argued that it was unethical to apply the MHA to force people to take treatment in the community when they are functioning well enough to be living in the community and have capacity to decide about their treatment. The use of force to remove someone from their home and take them to a "clinical setting" to force them to take medication cannot be justified and exacerbates stigma. CTOs can also frighten people away from psychiatric services, when these are just the people that need to be encouraged to keep in touch with services through informal assertive outreach. The temptation is just to continue CTOs once they are in place, because it is difficult to prove the negative that the person is well enough to be discharged once a decision has been made in the first place that they are justified. Having CTOs as an option, even expectation for some, means that the use of S17 leave and informal community care follow-up is not explored as much as it should be. These informal arrangements could lead to just as good, if not better outcomes (see eg. previous post). The number of people detained under CTOs has been far more than anticipated and they are discriminatory in their application (see eg. another previous post). The years since CTOs were implemented have just confirmed all the fears expressed in the 2007 CPN position statement.

This blog has consistently argued that psychiatry needs to move on from an outdated belief in mental illness as brain disease (see eg. previous post). Mental health practice does need to be rethought (see eg. another previous post). A new 10-year plan for mental health is required. This includes reform of the MHA following recommendations from the Parliamentary Scrutiny Commitee and WHO/OHCHR guidelines (see eg. yet another previous post).

I would go further than working towards abolishing CTOs for civil detentions (see eg. previous post). The Mental Health Tribunal needs to become the Mental Health Rights Tribunal with a single judge hearing appeals on both treatment and detention decisions (see eg. another previous post). Tribunals need to provide robust and objective accountability and effective protection for people with mental health problems. Medical evidence can come from the RC and an independent expert from a new integrated advocacy service of mental health lawyers, IMHAs and independent experts (see eg. yet another previous post). Advocacy services need to help detained patients exercise their rights by assisting patients to access legal advice and support at Tribunal hearings. Second Opinion Approved Doctors (SOADs) could then be abolished. If any hiatus in MHA reform leads to all these issues being taken forward, then all well and good from my point of view.

Pro-psychiatry and psychiatric diagnosis

I've mentioned before Andrew Scull's (2023) article which claims that David Rosenhan's (1973) 'On being sane in insane places' is a "spectacularly successful case of scientific fraud" (see previous post). I agree the evidence suggests Rosenhan at least exaggerated his finding that people could gain admission to psychiatric hospital and mislead psychiatrists into diagnosing schizophrenia to reinforce his belief that psychiatric diagnosis is subjective and does not reflect inherent patient characteristics.

What I want to emphasise, though, is the importance of Rosenhan's study in reinforcing the split between so-called anti-psychiatry and pro-psychiatry. Generally I don't like people using the term 'anti-psychiatry' because it's used as a way of marginalising even legitimate critique of psychiatry (see eg. recent post). 

However, there is a sense in which we need to accept that 'anti-psychiatry' as used by mainstream psychiatry has stuck (see eg. previous post). It's seen as a passing phase in the history of psychiatry from the 1960/70s from which psychiatry has now recovered. In other words, we're now in the period of pro-psychiatry. Tom Burns suggests that four revolutionary books first published in 1960/1 by R.D. Laing, Michel Foucault, Erving Goffman and Thomas Szasz started off this period of anti-psychiatry (see another previous post).

The term 'anti-psychiatry' itself was not really introduced until 1967 by David Cooper in his books Psychiatry and anti-psychiatry (1967) and The dialectics of liberation (1968). The anti-psychiatry movement was taken up by the counter-culture to free itself from what it saw as the oppressive nature of society, which included psychiatry suppressing our true potentialities. With the waning of the counter-culture, anti-psychiatry is also seen as having faded away in significance.

However, the anti-authoritarian, popular, even romantic, attack on psychiatrists' use of diagnosis, drug and ECT treatment and involuntary hospitalisation caused a crisis for mainstream psychiatry. Rosenhan's (1973) paper on psychiatric diagnosis added to that crisis. In particular, Robert Spitzer, as Chair of the Task Force, was so panicked that psychiatric diagnosis may be unreliable that he introduced operational criteria for the definitions of psychiatric disorders in DSM-III, building on work with the Research Diagnostic Criteria (RDC) (see eg. my article). This provided a way for psychiatry to move on from the criticisms of anti-psychiatry, including Rosenhan. 

So, even if it suits pro-psychiatry to discover that Rosenhan's study was fraudulent or at least exaggerated, it still has to deal with the fact that DSM-III was seen as necessary to counter anti-psychiatry. Although Spitzer always insisted DSM-III was atheoretical, it was associated with a resurgence of biomedical thinking in psychiatry, sometimes called neo-Kraepelinian (see eg. previous post). This is now seen as the pro-psychiatry position and any criticism may still be labelled as anti-psychiatry. 

Actually, what psychiatry needs to do is move on from this polarisation between pro-psychiatry and anti-psychiatry, which it’s still not yet done. There are legitimate critiques of the biomedical perspective in psychiatry. Although the biomedical perspective may always have been dominant, psychiatry has been more open-minded in the past and needs to return to being more open and therapeutic in its approach, rather than defending an outdated biological view of primary mental illness (see eg. my article).

Specialist clinics for deprescribing psychotropic medication

I’ve been cautious about being too prescriptive in withdrawing people from antidepressants (see eg. previous post). There should be more monitoring by doctors of people taking antidepressants (see another previous post). The full importance of antidepressant withdrawal is not yet appreciated by the medical profession in my view (see yet another previous post). 

Still, tapering is generally the best way to stop antidepressants, although some people do seem to be able to stop more easily, particularly if they have not been taking antidepressants for too long. An article in Medical Republic highlights that the Royal Australian College of GPs (RACGP) (see its press release) has made the Maudsley Deprescribing Guidlelines freely available for up to 500 members with an interest in psychology or addiction medicine. Mark Horowitz, one of the co-authors of the guidelines, is quoted in the article as saying that too many doctors recommend going back onto antidepressants when patients have withdrawal difficulties, rather than doing what they really should do is say that the drug should be stopped more carefully. I think in my clinical practice, perhaps because of the time needed to support people in withdrawal, I too easily allowed people to go back onto medication (see previous post). I support the development of more specialist clinics for deprescribing.