Critical psychiatry

Could psychiatrists become extinct?

2012-01-29T14:44:00.000Z

Paul Harrison (who I've mentioned in a previous post), Ed Bullmore (again, who I've mentioned in another previous post) and others have posted an eletter in response to a BJPsych editorial entitled "The future of psychiatry". They argue for what they call a "remedicalised psychiatry". By this they mean that psychiatrists should concentrate on "what doctors do best" and challenge their "involvement in activities or services which are not of this kind". They suggest that without change psychiatrists will be left like "the apothecaries 300 years ago: in decline, mental health care increasingly left to a poorly coordinated coalition of other health professionals".

What these authors are at least partly reacting against are the reforms, such as so-called New Ways of Working, influenced by the previous National Director of Mental Health, Louis Appleby. In a recent interview, Appleby said "I get uneasy if it starts to sound as if doctors have a natural entitlement to a unique place in mental health care".

There were problems with New Ways of Working, such as not paying enough attention to the continuity between the new services created and a lack of proper emphasis on the expertise of mental health staff, not just medical staff. Department of Health policy has now moved on. However, I too, like Appleby, have concerns about Harrison, Bullmore et al's stance.

The danger is that their position could be seen as saying that psychiatrists are not concerned with the personal dimension, which is actually the primary element of mental health practice. It doesn't actually matter that, for example, non-psychiatrists prescribe medication or become approved clinicians under the Mental Health Act, as long as they are properly trained to do so. This is where the debate should focus.

By the way, before completing my university medical degrees, I first practiced medicine as a licentiate in medicine and surgery of the Society of Apothecaries, which could approve medical training in the UK until 2003. I had been sceptical about the value of medical training for mental health practice and gave up my medical training for 8 years before returning to complete it (see eg. a talk I gave some years ago). A patient-centred medical training is indispensible in modern mental health practice. The problem is that medical training is not always as patient-centred as it should be.

Critical rationality in psychiatry still required

2012-01-14T12:40:00.003Z

Another book by Arthur Kleinman has made the BMJ medical classics list (see previous post about the other book) - this time The illness narratives - see review.

Kleinman edited a book with Theo Manschreck in 1977 called Renewal in psychiatry in which they defined critical rationality as a:-

commitment to rational evaluation and derivation of knowledge. It encompasses the critical scrutiny of prevalent beliefs and practices; and refers to the use of explicit values and rigorous methods, clear concepts and argument, precision in thinking, and supportive evidence to help us harness the creativity of imagination and intuition in the discovery of new knowledge. It promotes exacting standards for the process of inquiry, regardless of its object; and it is self-critical. It therefore qualifies as an indispensable standard governing clinical discourse, teaching and research.

Good to see that someone who could be said to have been involved in the origination of critical psychiatry is getting such recognition.

Champion of mental health awareness dies

2012-01-11T18:23:00.002Z

Article in Irish Times announcing John McCarthy's death. Read his "Comparing a diagnosis of cancer and psychiatric disorder".

Have fun with drugs

2011-11-21T21:48:00.001Z

Looks beautiful in Colorado Springs where the 2011 NEI GlobalPsychopharmacolgy Congress has just been held. Not sure about the congress opener though. I'm still waiting for Stephen Stahl to post about the RSM meeting on pharmaceutical sponsorship of psychiatry research (see previous post).

What if the drugs don't work?

2011-11-06T21:15:00.015Z

Article in the Independent with this title. It mentions a debate between Ian Anderson (see previous blog entry) and Irving Kirsch (see another previous blog entry) with the motion "Antidepressants are useful in the treatment of depression" coming up at the 4th International Congress on Psychopharmacology of the Turkish Association for Psychopharmacology.

There's also a quote from Daniel Carlat (who blogs at The Carlat Psychiatry blog), who admits that, "When I find myself using phrases like 'chemical imbalance' and 'serotonin deficiency', it is usually because I'm trying to convince a reluctant patient to take a medication. Using these words makes their illness seem more biological, taking some of the stigma away." As I wrote in a BJPsych eletter, patients are able to understand that the chemical imbalance theory is only a theory. What they find more difficult to appreciate is why they are told that the theory has been proven when this is clearly not the case (see another previous blog entry).

Pleased also to see that Irving Kirsch is talking more about the nocebo effect from coming off antidepressants, as I have for some time (eg. summarised in my chapter in recent book Demedicalizing misery) . To quote from the Independent article, "If you expect to feel bad when you come off antidepressants, you will, because 'we tend to notice random small negative changes and interpret them as evidence that we are in fact getting worse', Kirsch says".

Psychiatrists should know what they're doing with medication

2011-10-16T21:43:00.001+01:00

An editorial this month in the British Journal of Psychiatry is entitled 'No psychiatry without psychopharmacology'. It suggests there is insufficient prioritisation of psychopharmacology in psychiatric training. It asks for psychopharmacology to be affirmed as an integral and significant component of psychiatry, and a consequent expectation of a commensurately high level of knowledge and practice.

As I mentioned in my previous post, I've just come back from a conference in Newcastle. Paul Harrison, the main author of the editorial, gave a presentation at the meeting with the same title as the editorial. He thought that the low priority apparently given to psychopharmacology may be related to what he called the 'anti-pharmacological lobby'. I suppose I would be seen as part of this lobby, but, despite what Harrison implies, I agree that psychiatrists should be well trained in psychopharmacology.

What I didn't hear in his talk, but is mentioned twice in the editorial, is unquestioned belief in the efficacy of psychiatric medication. To quote from the editorial, research shows that "contemporary psychotropic medications are effective". Again, it says that "the evidence that psychotropic drugs are beneficial when used in the right way and for the correct indications is unequivocal".

Good psychopharmacological training will highlight the weaknesses and bias of randomised controlled trials (eg. see my Bias in controlled trials webpage). The trouble with much prescribing is that it is beyond the evidence (and not even conforming to guidelines such as those produced by NICE). Psychiatrists are insufficiently critical of the evidence base for medication.

Are antidepressants really placebos?

2011-10-16T19:06:00.000+01:00

I've just come back from Newcastle, where the Faculty of General and Community Psychiatry of the Royal College of Psychiatrists has been holding its Annual General Meeting (see programme). One of the talks was by Professor Ian Anderson entitled 'Are antidepressants really placebos?' As he himself said, as might be expected, his answer was no.

I'm not sure if the talk really had much more in it than a letter he had published in the British Journal of Psychiatry several years ago. Anderson makes a lot of the fact that continuation studies show high relapse rates. Following the results of the meta-analysis by Geddes et al (2003), the average rate of relapse on placebo is 41% compared with 18% on active treatment. In other words, continuing treatment with antidepressants reduces the odds of relapse by 70%. Anderson doesn't think this could possibly be a placebo effect.

Doctors have always underestimated the difficulties of discontinuing antidepressants (see my Antidepressant discontinuation reactions website). If patients are significantly unblinded in discontinuation studies, the negative placebo (nocebo) response could explain these results because of how reliant people have become on their medication. Any change threatens an equilibrium related to a complex set of meanings that their medication has acquired.

No more psychiatric labels

2011-09-19T08:03:00.002+01:00

I have joined the campaign to abolish psychiatric diagnostic systems like DSM called "No more psychiatric labels". There is an overemphasis on biomedical diagnosis in psychiatry (eg. see my article with this title). Psychiatry does need to recognise diagnosis for what it is (eg. see presentation from a talk of mine).

Even Allen Francis, Chair of the DSM-IV taskforce, is critical of the approval of new fad diagnoses in DSM-5 (eg. It's not too late to save 'normal' and a more recent Psychiatric Times article). I think we'd be better off without any psychiatric diagnostic system at all for a while rather than go along with DSM-5.

Are the chinese really taking over drug companies?

2011-08-30T12:39:00.001+01:00

Stephen Stahl, whose Essential psychopharmacology book now has his name in the title, has a post on his NEI (Neuroscience Education Institute) blog about drug company research. He mentions a crisis meeting at the Royal Society of Medicine this month, which he says he will report on when he gets back. I look forward to hearing more.

He regrets that "Nobody likes drug companies these days". I don't think he's helping their press by seeming to support drug company sponsorship of medical education and illegal marketing of their drugs. At least he admits that half of prescribing in psychiatry is "off label".

Nor is his case helped by misrepresentation of those who express concern about these practices as believers in psychiatric illnesses being "pure inventions of Pharma". As I've pointed out in a previous post, there's no need to be defensive if pharmaceutical companies really are pulling out of psychiatric research.

(With thanks to a post on Carlat Psychiatry Blog).

Unthinkable? R.D. Laing in Guardian editorial

2011-08-29T11:44:00.001+01:00

Not sure what prompted an editorial in the Guardian about R.D. Laing in its Unthinkable? series. The editorial makes reference to a production of Knots at the King's Head Theatre. It suggests it is time for a reassessment of Laing in "an era of big pharma and proliferating diagnoses". Samantha Bark in her response says she was thrilled to see the editorial and makes reference to her PhD thesis on Laing, which I have added as a link on my articles critical of psychiatry webpage.

Critical psychiatry has never hidden its origins in the work of R.D. Laing (see my book chapter Historical perspectives on anti-psychiatry). There were excesses in 'anti-psychiatry'. Critical psychiatry aims to avoid the marginalisation experienced by R.D. Laing and others like him designated as 'anti-psychiatrists'.

Mental illness not same as focal brain lesions

2011-08-14T10:23:00.005+01:00

Thomas Insel in his NIMH Director's Blog asks whether a neurological approach to mental illness is helpful. He admits it is an "NIMH mantra" to describe mental disorders as brain disorders. I have previously mentioned his view that mental illnesses are disorders of brain circuits.

He suggests mental illnesses are analogous to heart arrhythmias which may not have a demonstable lesion in the heart. He holds out the hope that mapping patterns of cortical function will find abnormal brain circuitry. The example he gives is of apparent delayed cortical maturation in ADHD. Well, let's see - is this conclusion based on one study ie. Shaw et al (2007), which hasn't been replicated? He also speculates that neuroimaging could allow early detection of so-called circuit disorders.

Insel goes on to state that neuroimaging is beginning to yield biomarkers, but then doesn't say what the biomarkers are. He suggests that deep brain stimulation is demonstrating how changing the activity of specific circuits leads to a remission of refractory depression, but doesn't say what circuits are being changed.

Finally, he at least concedes that, "In truth, we still do not know how to define a circuit". He also concludes that "One thing we can say ... is that earlier notions of mental disorders as chemical imbalances or as social constructs are beginning to look antiquated." Not sure why he includes 'social constructs' in this broadbrush remark, as he's not considered this possibility. His faith in the value of neuroscience to help people recover from mental disorders has been the wish-fulfilling phantasy of modern psychiatry since the 19th century.

NHS treatment of eating disorders

2011-08-13T21:42:00.003+01:00

I have already mentioned Bryan Lask in a previous post about eating disorders. He has responded to a Guardian leader about specialist treatment for anorexic children. He believes that eating disorders are "highly complex genetically determined, brain-based disorders". However, he doesn't explain why he thinks this.

He expresses concern about the reduction in the number of young people admitted to specialist inpatient units and suggests that they are being admitted to paediatric units instead. I'm not sure where he gets his figures from. He argues that the motivation for closure of specialist units is financial.

I presume he means that NHS savings mean that the number of referrals to private units has decreased. He is no longer medical advisor to the Huntercombe group which runs three such units. Maybe he's worried they'll be forced to close. Current reforms of the NHS (see my personal blog) may well eventually open up the market for the management of eating disorders, but it's not necessarily always been the best use of money to ship difficult to manage patients out of the NHS (again, see another personal blog entry).

Think about investing in intercultural mental health

2011-07-24T11:19:00.004+01:00

My previous entry implied that the 'Grand challenges in global mental health' initiative is a thinly veiled attempt to obtain funding from the Gates Foundation for mental health research. I'm not sure if this is right, as the Gates Foundation Global Health Strategy has "chosen not to focus on research in mental health, even though it is a serious health problem in developing countries, in part because of the very large contributions already being made by the U.S. National Institutes of Health, the pharmaceutical industry, and other funders".

I guess the initiative must be directed at other funders, or maybe it's hoping the Gates Foundation will change its mind. Anyway, well done to the Gates Foundation for not supporting such a project.

Thought needs to be given to the conceptual foundation of any investment in intercultural mental health. 'Grand challenges in global mental health' tied itself to the academic concept of 'global mental health' linked to a past series of Lancet articles. However, there are problems with the validity of the knowledge base for this approach (see Derek Summerfield's BMJ article). The best book in the field of transcultural psychiatry (I prefer the term intercultural - see David Ingleby's chapter from my Critical psychiatry book) is Suman Fernando's Mental health, race and culture.

How to get money for global mental health research

2011-07-21T21:47:00.003+01:00

The Grand challenges in global mental health initiative reckons it has identified priorities for research in mental, neurological and substance-use (MNS) disorders (see Nature article). Similar initiatives in global health in general and in chronic non-communicable diseases have led to the commitment of significant new programmes of funding from the Bill and Melinda Gates Foundation amongst other research funders.

The term 'mental health' is seen as a convenient label for MNS disorders, excluding conditions with a vascular or infectious aetiology because these were covered by previous initiatives. This brain disorder bias seems to reflected in the identified priorities. Such priorities obviously also reflect the biases of the assembled international panel. They don't seem particularly interested in what people with mental health problems themselves in different parts of the world want.

Drug companies losing interest in psychiatry is great news

2011-07-16T23:35:00.001+01:00

Letter from Sami Timimi in response to BMJ news article about drug companies pulling out of neuroscience research. I've mentioned in a previous post that I'm not sure if this is really the case. But if it is, as Sami points out, that's a good thing - we shouldn't be defensive about it. Psychiatry research has for too long been dependent on drug company sponsorship. The biomedical myth has been used as the justification for too much psychiatry research in general.

Could antidepressants really be a hoax, a mistake or a concept gone wrong?

2011-07-12T07:47:00.001+01:00

The New York Times Sunday review has an article by Peter Kramer 'In defense of antidepressants'. He finds it worrisome that antidepressants may be merely placebos with side effects (see previous blog entry).

He suggests that the way pharmaceutical companies produce data submitted to the FDA to obtain a licence for antidepressants is "sloppy" because subjects who don't really have depression are included. He argues that this recruitment bias of an "odd bunch" of people increases the placebo response rate for so-called mild depression, but he doesn't explain why this complication should necessarily change the finding of a small statistical difference between active and placebo groups.

He thinks studies done in specific disorders, such as depression in neurological conditions, eg. stroke, multiple sclerosis and epilepsy; depression caused by interferon; and anxiety disorders in children, have greater external validity. Furthermore, he suggests that results in chronic and recurrent mild depression, such as dysthmia, are more trustworthy, but doesn't give a reference.

He goes on, "Scattered studies suggest that antidepressants bolster confidence or diminish emotional vulnerability — for people with depression but also for healthy people." It was this aspect that was perhaps most questionable about his book Listening to Prozac. He seems to think the placebo effect is a good thing, without realising that what he is describing is a placebo response.

Nor does his argument on maintenance studies wash. He suggests that withdrawing placebo shouldn't have any effect. Again, this does not seem to demonstrate much understanding of the placebo effect. Withdrawing a substance which is believed to have improved mood inevitably will produce a nocebo effect.

Kramer is also critical of a JAMA study picked up by a USA Today piece 'Study: Antidepressant lift may be all in your head'. He suggests the selectivity of the study made it one that "could not quite meet the scientific standard for a firm conclusion". He thinks the media should not embrace what he calls "debunking studies".

He concludes that "it is dangerous for the press to hammer away at the theme that antidepressants are placebos. They’re not. To give the impression that they are is to cause needless suffering." I guess that it's just too difficult to accept that antidepressants could "really be a hoax, a mistake or a concept gone wrong".

Speak out against psychiatry

2011-06-29T20:58:00.007+01:00

I like to think of critical psychiatry as a broad church. For example, the last Critical Psychiatry Network conference I organised in Norwich in 2009 was called 'Promoting the critical mental health movement'. As I wrote in the blurb:-

The critical mental health movement is comprised of various perspectives developing a critique of the current psychiatric system. These range from reform to revolution. Although there may be debate about how much can be achieved within psychiatry, the movement is held together by recognition of the need for fundamental change.

Speak Out Against Psychiatry is organising an event at the Royal College of Psychiatrists in London on 27 July. This is a group of people who have either used, or have been in close contact with people who have used, psychiatric services. A lot of the people they have spoken to have had a very negative experience of psychiatry, and many feel they have not been treated like human beings - that they are labeled as “ill” and given drugs rather than being listened to and offered support. The experiences are particularly painful for people who have been detained under the Mental Health Act. When detained in hospital, people can be forced to take medication, and often feel that anything they say is dismissed as a symptom of their “illness” rather than their genuine fears and frustrations of being imprisoned in what can be a terrifying environment.

Speak Out Against Psychiatry wants to give these people the chance to come together and speak about their experiences, and are going to be doing this outside the Royal College of Psychiatrists on the 27th of July between 4pm and 6pm. They also want to give people the opportunity to discuss alternative, humane ways of helping people in distress.

I have always said that the root problem in modern psychiatry is the belief that mental illness is a brain disorder. My personal view is that psychiatry can be practised without the justification of postulating brain pathology as the basis for mental illness. This position should not be misunderstood as implying that mind and brain are separate. Perhaps a way to express what I am saying is that mental disorders must show through the brain but not always in the brain.

I think it is important that there is a forum for debate both within critical psychiatry and between critical and mainstream psychiatry. I have suggested setting up an International Critical Mental Health Movement (see previous blog entry).

Although the manifesto of Speak Out may be more radical than I would express myself, I do think it is important that psychiatry engages in this debate. In this sense, mental health services would be truly centred on users of services. The views of critical psychiatry are not marginal to the present situation in modern mental health services.

Survey about stopping antidepressants

2011-06-27T08:20:00.001+01:00

The Royal College of Psychiatrists is doing a survey to look at people's experience of stopping antidepressants. This is to help produce a 'Stopping antidepressants' leaflet. The problems produced by discontinuing antidepressants are seen as an area of disagreement.

Some time ago I set up my Antidepressant discontination reactions website. This was following a letter (at the bottom of the letters on this link) I had published in the BMJ. Psychiatrists were slow to recognise antidepressant discontinuation problems (see powerpoint from a talk).

Psychiatric classic

2011-06-09T21:20:00.002+01:00

Nice to see that the BMJ in its Views & Reviews series regards Arthur Kleinman's Rethinking psychiatry as a medical classic. I include it my critical psychiatry website book recommendations page.

A focus on culture arises out of the combination of anthropology and psychiatry. Indigenous healing systems worldwide use nonspecific symbolic techniques to counteract demoralisation. Kleinman promotes a paradigm shift in medical and psychiatric practice to create a robust relationship between psychiatry and the social sciences.

The review was written by a junior doctor (in anaesthetics) who says he was left "uninspired by the basic sociology taught at university". Rethinking psychiatry invigorated a renewed interest for him. This confirms what I said in a previous post about what might attract young doctors into psychiatry.

Psychiatrists do not believe that psychotropic drugs fix chemical imbalances in the brain

2011-06-08T22:01:00.005+01:00

A book review of Anatomy of an epidemic is critical of Robert Whitaker for "settling for a simple but crude interpretation: those drugs messed you up". There may be some validity in pointing to the "totalising argument" and the "expansive sweep" of his interpretation. Actually, as I've noted before, I think the value of Whitaker's books is the way he describes the evidence for the vulnerability created by taking medication.

Perhaps surprisingly, the reviewer deflects Whitaker's argument by suggesting he knows of "no serious psychiatrist who believes that psychotropic drugs 'ﬁx chemical imbalances in the brains' of their patients". That's good, because as a recent article in Philosophy, Psychiatry and Psychology points out, theories, such as the dopamine hypothesis of schizophrenia, have "held the status of a scientific paradigm defended by some with great avidity". The article suggests the psychiatric field "needs to become more self-critical about the validity of its theories". There is a sense in which chemical imbalance theories have persisted despite the contrary evidence. Many patients believe them because they think that's what psychiatrists believe.

Attracting people into psychiatry

2011-06-05T21:19:00.002+01:00

Thomas Insel, in his NIMH Director's blog, views clinical neuroscience as the answer to psychiatry's recruitment problem. The dean of the Royal College of Psychiatrists, Rob Howard, has also said that recruitment into psychiatry is at a crisis point (see his May 2009 newsletter). Solutions were discussed at a London division academic day (see Frontier Psychiatrist blog).

The problem with Insel's remedy is that too many young psychiatrists, if they believe him, will become disillusioned. He makes reference to an NIMH Neuroscience and Psychiatry module Translating neural circuits into novel therapeutics, which suggests that impaired GABA neurotransmission in chandelier neurons in the dorsolateral prefrontal cortex contributes to cognitive impairments in schizophrenia, which may be corrected by an agonist for GABA_A alpha 2 subunit receptors. The module mentions a small RCT using such a drug, MK-0777, which seemed to find evidence of improved performance on memory tasks, but doesn't mention a larger scale study which failed to show any improvement in cognition.

Putting on one side that cognitive impairment in schizophrenia may well be functional, the complexity of speculation is supposed to excite people into understanding the pathological basis of psychiatry so that they can develop so-called rational treatments that then undergo rigorous testing. But are hypothetical, wishfulling phantasies really going to attract a new batch of recruits?

Personally, I suspect we need to remind ourselves of the interest in psychiatry which Aubrey Lewis stimulated at the Maudsley Hospital Medical School after he was appointed Professor of Psychiatry in 1948. For him, postgraduate psychiatry should be for "ardent, critical, lively, disputatious and reflective, eager minds". He encouraged a sceptical approach to psychiatry. He had little patience for imprecision or poorly thought-out ideas.

As Michael Shepherd pointed out in a BJPsych article, "Throughout his professional life Sir Aubrey was at all times an educator who was much concerned with the problems of recruitment into psychiatry, more especially with quality rather than quantity." Doctors with open minds, who are sceptical of psychiatric quackery, need to be attracted into psychiatry.

Whistling in the wind

2011-05-16T18:26:00.002+01:00

Edward Shorter, in his response to an article by Thomas Szasz, says there are solid biological findings in psychiatry. Shorter, who I've mentioned in a previous post, is the Hannah Professor of the History of Medicine at the University of Toronto. In 1996 he was cross-appointed to a professorship in psychiatry. As a non-clinician, has this professional association gone to his head?

The examples he gives of "obvious evidence" are the role of panicogens in triggering panic disorder; the response of catatonia to barbiturates and benzodiazepines; and what he calls the reliable accompanying of melancholic depression by hypothalamic-pituitary-adrenal dysregulation, as reflected in high levels of serum cortisol, a positive dexametasone suppression test (DST) and a shortened rapid eye movement sleep latency.

The reference Shorter gives for the importance of panicogens is from the proceedings of the 32nd annual meeting of the American Society of Clinical Investigation held in Atlantic City on 6 May 1940. In this study, patients with anxiety neurosis were found to increase sighing respiration more than controls when exposed to carbon dioxide and rebreathing. The feelings that they had during this rebreathing tended to resemble or be identical to their panic attacks. Shorter suggests that studies such as this were marginalised because of the influence of psychoanalysis. He doesn't make any mention of the controversy in the literature about the mechanism of action of lactate, which has been seen as the common pathway for the mechanism of action of carbon dioxide and several other panicogens.

The reference he gives for the evidence of the organicity of catatonia was a study of 4 cases, which were actually thought to be neuroleptic-induced, which responded to intravenous lorazepam. Shorter also mentions the response of catatonia to barbiturates. William Bleckwenn's use of intravenous amobarbital to produce lucid intervals in catatonic patients quickly led to the development of the so-called "truth serum". How's this proved the organic basis of catatonia?

The reference Shorter gives for the biological basis of melancholic depression is his own recent book, written with Max Fink, entitled Endocrine Psychiatry. Fink has been an advocate of ECT over the years. I need to read the book. The DST was rejected as a biological marker because it was insufficiently sensitive and specific. I know that Fink thinks it shouldn't have been rejected, but this does seem to be a very idiosyncratic view. I'll come back to this when I've read the book.

Shorter seems to be using his historical expertise to suggest that modern psychiatry has overlooked evidence of its biological basis. As I have repeatedly said, please do not misunderstand me. Of course mental illness has a biological basis, as does our "normal" behaviour. But to be suggesting that biological markers have been established, or even overlooked in history, is whistling in the wind. This is what Shorter accuses Szasz of doing by claiming the opposite. As Szasz makes clear in his article, what he is stating is what he calls an "analytic truth", not dependent on scientific research.

Furthermore, Shorter suggests views such as those of Szsaz (he actually says the makers of the movie One flew over the cuckoo's nest) have led to many people committing suicide because they've avoided treatment. Not surprisingly, he doesn't give any reference for this opinion. As I've commented in a previous post, it's a pity debates such as this get so polarised.

And I'm not saying this because I totally agree with Szasz (eg. see my book review). But on the point on which Shorter has attacked him, he's correct. Shorter may be right that mainstream psychiatry now acknowledges a neurological basis for much psychiatric illness, whereas when Szasz was first writing psychoanalysis was more influential (see my article). But it's just as wrong to take a biomedical view now as it was then.

Where should first meeting of International Critical Mental Health Movement be held?

2011-05-14T10:43:00.001+01:00

In a previous post I mentioned the idea of setting up an International Critical Mental Health Movement. Is there any momentum for this? I'm happy to help organise the first conference. Where should it be held?

Why did the balance between the genders for psychiatric detention switch?

2011-05-13T20:57:00.002+01:00

Kate Millett, the feminist and survivor of mental health services, at a seminar organised by Anthony Stadlen that I attended last Sunday, said that more women than men are detained in psychiatric hospital. My thought, although I did not have the figures, was that in fact more men, particularly young men, are detained because of their violence.

It seems we were both right in a way. Up to 1994-5, when Kate Millett was surviving mental health services, more women than men were formally admitted under civil procedures using the Mental Health Act in the UK. After that time more men were detained (Audini and Lelliott, 2002). And it is particularly younger men where there is the imbalance (see figure). And once admitted they tend to stay in hospital longer, as the ratio of men to women resident in hospital at any one time is even higher (see table).

There does not seem to have been much comment about this switch. Women's disadvantaged social status is commonly seen as a factor generating mental health problems, but this doesn't explain the rise in men being detained. Maybe the emphasis over recent years on risk management and accountability is responsible. Ideas please and I'd also be interested in any references in the literature as I can't easily find them.

There should be concern if children are being prescribed medication as a quick fix.

2011-05-08T22:41:00.010+01:00

As I mentioned in a previous post, reviewers have been critical of Richard Bentall's book Doctoring the mind for taking aim at child psychiatrists. They also suggest that he characterises psychologists as better educated and trained than psychiatrists to "understand people and the human experience and to provide healing therapy".

I'm not sure if this is the case, but I do know that psychiatrists are more likely to take a biomedical rather than biopsychological approach. I'm a member of both the Royal College of Psychiatrists and the British Psychological Society (see my talk Psychiatrists can have understanding too).

And, it's the British Psychological Society that has supported a call for a national review of the use of medication to treat children’s behavioural issues (see Treating children's behaviour). Peter Kinderman, Chair of the Division of Clinical Psychology, seems confident that psychiatry colleagues would be equally concerned if there is evidence of inappropriate use of drugs or medication.

I don't know how much these sort of reviews achieve. A previous technical report for MPs is a bit out of date now. Still Richard Bentall is concerned that there is inappropriate use of medication, whereas it seems Peter Kinderman would only be concerned if there was. Perhaps we do need an authorative view to let us know. And the reviewers criticised Richard for not providing a reference to back up his view, so he would at least then have one.

Facts about NAMI funding

2011-05-06T10:09:00.001+01:00

In my previous post, I noted that reviewers of Richard Bentall's book Doctoring the mind, which I recommend on my Critical Psychiatry website book recommendations page, criticised him, amongst other reasons, for indicating that the National Alliance on Mental Illness (NAMI) is funded primarily by Big Pharma. According to an article in the NewYork Times, "drug makers from 2006 to 2008 contributed nearly $23 million to the alliance, about three-quarters of its donations".

NAMI now lists on a quarterly basis in its website registry all major corporate and foundation grants and contributions above $5,000. What NAMI emphasises is that, as a matter of policy, it does not endorse any specific treatment or service.

NAMI-Vermont has recently decided to diverge from national policy and no longer accept direct corporate contributions from pharmaceutical companies (see message to the membership). On their website, NAMI-Vermont Board President Ellen Vaut of South Burlington explains: “Though NAMI-Vermont has only received between three and seven percent of its total revenues from pharmaceutical companies in each of the past six years and none during the past fiscal year, we voted to dispel any concerns or public perception that our programs and/or organizational practices are influenced by pharmaceutical company money.”

I guess that the national organsiation will find it difficult to follow this lead because of the higher proportion of pharmaceutical funding. Still, quite why the reviewers of Richard's book criticise him for stating the truth is not clear. Perhaps the truth is "incendiary and divisive".

More heat in the debate about psychiatry

2011-05-05T10:54:00.006+01:00

A review in Psychiatric Services is reluctant to recommend Richard Bentall's book Doctoring the Mind because it is said to be "incendiary and devisive". The reviewers are frightened that the book exaggerates issues for service users.

I'm not sure who's doing the exaggerating. Richard is said to suggest that there is a long-standing battle for supremacy between psychologists, "who are educated and trained to understand people and the human experience and to provide healing therapy", and psychiatrists, who are "indoctrinated with the medical model, have unwittingly carried Nazi-era notions of the genetic origins of psychosis into the present and are intent on pumping people full of as much useless, dangerous medicine as possible while simultaneously avoiding any conversation".

Richard is also criticised for saying that as many as 50% of psychotic patients would be better off without taking drugs, for claiming that the term "schizophrenia spectrum disorder" was introduced to get the results wanted in genetic research and for indicating that the National Alliance on Mental Illness is funded primarily by Big Pharma. Furthermore, he is said to provide no reference for his suggestion that child psychiatrists do not seem to be troubled by the as yet unknown long-term impact of psychotropic drugs on the developing brain and for his impression that medications are often prescribed by child psychiatrists without any serious attempt to understand or remedy the awful social circumstances in which psychologically disturbed children often live.

It's unfortunate that Richard's argument noted by the reviewers that "the case for a genetic cause of mental illness has been overstated by psychiatrists and that symptoms are much more the result of psychosocial stressors" including behaviour by families, gets lost in this polarisation of the debate. As I've indicated in a previous post, there seems to be some difficulty in having a calm discussion of these matters.

There were even some flames about my own Critical Psychiatry book (see another previous post), although I never managed to get a review in a mainstream psychiatric journal. Still there was a reasonably generous BMJ review. So maybe we should be grateful that books such as Richard's are at least being considered, even if dismissed, by mainstream psychiatry..

Is deep brain stimulation promising?

2011-05-02T20:38:00.004+01:00

Deep brain stimulation (DBS) involves placing one or two thin wires into specific locations deep within the brain and then connecting the wires to a battery situated just beneath the skin. A recent article in the American Journal of Psychiatry reports on the follow-up of 20 patients who received DBS for treatment-resistant depression.

Unfortunately two of these 20 patients died from suicide and one died from colonic cancer. As I said in my psychiatric update for Openmind, there is no clinical trial data about the effectiveness of DBS. I'm sure case reports, such as the latest article, will be used to justify continuing experimentation with it, however limited. I just wish that psychiatry could focus its efforts on providing more hope and effective treatment than DBS.

What should alternative to biomedical model be called?

2011-04-21T11:03:00.000+01:00

Tim Thornton has posted a chapter on his In the Space of Reasons blog entitled "The recovery model, values and narrative understanding ". He points to the confusion about the meaning of recovery, and even more so about what a recovery model might be.

As I wrote in my paper "Redressing the chemical imbalance", the concept of recovery is inherently critical of the biomedical model, and Tim Thornton seems to agree with me. I think the problem is its acceptance into official policy and nullification of its impact by interpretation within the biomedical context.

The use of the term 'recovery model' is unlikely to help fully define an alternative psychosocial paradigm. Nor, despite its merits, do I think the notion of 'narrative' will either. I've always said that the origin of the psychosocial approach was with Ernst von Feuchtersleben's The principles of medical psychology, first published in german in 1845 (see my article).

An optimisitic moralism, such as an emphasis on recovery, has always had its moments, perhaps particularly identified in the progressive outlook before the First World war. This can be contrasted with the materialism of an emphasis on structural pathology, producing a therapeutic pessimism, minimising the potential of people to change. It is important to give people hope in mental health services. This strand is one of the sources for a psychosocial alternative to the biomedical model, but I think it's unlikely to define the whole paradigm.

Has the concept of bipolar spectrum been broadened too far?

2011-04-15T17:56:00.005+01:00

Catherine Zeta-Jones booked herself into a clinic for 5 days for treatment of her bipolar II disorder (see Guardian story). I don't want to underestimate the emotional impact of dealing with her husband's throat cancer. She has been praised for raising the profile of mental health issues.

One issue that might be worth commenting on further is the way in which the concept of bipolar disorder has been expanded since it became the new name for manic-depressive illness (see my book review for some background). I'm not saying that Catherine Zeta-Jones doesn't have bipolar II disorder, but it might be worth understanding what this diagnosis means.

The expansion in the concept of bipolar spectrum is not dissimilar to what happened to schizophrenia in the 1960s and 70s, particularly in USA, leading to the American Diagnostic and Statistical Manual in its third revision tightening up the definition, so that it was more reliably applied. People may find it helpful to put a label to their mental health problems, but I do have concerns that the diagnosis of bipolar spectrum has become so variable that its validity must be in question.

I've been dismissed as "postmodern" for this sort of questioning of the nosological basis of bipolar depression (see comments following another book review, also previous blog entry). What I am clear about is the need to avoid reification of psychiatric diagnosis. There's always a danger that we tend to assume that a diagnostic concept implies an entity of some kind. But a diagnosis is not a "thing". It's merely an abstract device which is useful for thinking about mental health issues.

I just have concerns that bipolar depression is not as useful as some people make out. And I don't think the argument can be dismissed that one of the reasons people have found the new concept useful is because of the development of so-called mood stabilising medication. There's even been a marketing ploy to develop medication specifically for bipolar depression (see previous blog entry).

Don't get too heated in the debate about psychiatry

2011-04-06T10:09:00.003+01:00

Two reviews in Psychiatric Services recommend reading Robert Whitaker's book Anatomy of an Epidemic even if it makes you angry and you want to dismiss him as an anti-psychiatric activist. It's apparently good to read biased, flawed books like this to be able to marshall a response to defend psychiatry. Let's please have this debate. It's not really dealing with the issues by just expressing disappointment that Whitaker blames biomedical psychiatry and suggesting he's illogical to connect the taking of medication with poor outcomes.

Actually, I think all he's asking for is a debate about how drugs increase the risk that people will become chronically ill (see previous post).

Challenging myths about psychiatry

2011-03-27T20:10:00.001+01:00

Nada Stotland was the 2008-9 President of the American Psychiatric Association. She writes on Huffpost Health challenging "myths about psychiatry". The trouble is she has promoted just such a myth. She writes, "Using brain scans ... we now can distinguish between the brain of a person with depression and a person who is not depressed". Evidence please. And perhaps she could explain what the "many, many other such observations" are.

Political nature of psychiatry

2011-03-20T12:41:00.000Z

Interesting seminar last week, which I attended, organised by Tony Stadlen, invited Vladimir Bukovsky, the anti-communist, to talk about his experiences of being detained in psychiatric hospital in the Soviet Union. Luckily for him, he was never given psychiatric medication and there was a dispute amongst psychiatrists about his diagnosis.

His case nonetheless highlights, which Bukovsky himself did, the political nature of psychiatric diagnosis and its potential for misuse. In Soviet psychiatry, the particular problem was the development of diagnoses such as sluggish or creeping schizophrenia and paranoid development of the personality, and the Soviets withdrew from the World Psychiatric Association for a while because of criticisms of their political abuse of psychiatry. People who do not fit into society are at risk of being regarded as mentally ill and such a mechanism can be exploited by the state.

Many factors affect the number of antidepressant prescriptions dispensed in particular areas

2011-03-05T23:24:00.002Z

The Guardian has published a map of GP antidepressant prescribing. Its article based on the data makes a lot of the finding that it tends to be Northern parts of England with higher numbers of prescriptions.

However, as the care services minister commented, "There are many factors that affect the number of antidepressant prescriptions dispensed in one particular area". For a start the Guardian data is not age standardised. There are significant differences between GP practices in the same area, which can be greater than the average differences between areas. The article doesn't mention the high rates in Norfolk and Waveney where I work.

Deprivation is likely to be a factor in prescribing as mental health need is correlated with deprivation. Pharmaceutical company marketing influences cannot be ignored.

Rank order of antipsychotics for producing weight gain

2011-02-20T12:21:00.001Z

A review in the Archives of General Psychiatry looks at the evidence for weight gain and changes in other cardiovascular risk factors caused by antipsychotic treatment. It has produced a rank order of the different drugs with olanzapine noted to cause more weight gain than all other second-generation antipsychotics except clozapine. Clozapine causes more weight gain than risperidone, risperidone more than amisulpride, and sertindole more than risperidone. The average weight gain after 6 to 8 weeks taking olanzapine was found to be 5 to 6 kg, which was significantly higher than the average weight gained while taking risperidone (4 kg) or haloperidol (3 kg).

Antipsychotic medication does seem to reduce brain volume

2011-02-07T23:10:00.004Z

I have mentioned a study in a previous blog entry that seemed to show that antipsychotic medication reduces brain volume. This study was referred to in an interview with Nancy Andreasen. The point I was making in the previous entry was that the research had been "sat on" for fear it may lead to people stopping their medication.

The study has now been published in the Archives of General Psychiatry. The authors mention, as I did in my previous blog entry, that an association does not necessarily mean a causal connection. However, the evidence is quite strong considering that illness severity and substance misuse had minimal or no effects and data from animal studies also suggests brain tissue loss.

Of course we have known for some time from clinical evidence that antipsychotics cause brain damage in that tardive dyskinesia is not necessarily reversible when antipsychotic medication is discontinued. This is reflected in the finding of a specific increase in size in the putamen in the present study. We don't know that brain changes are necessarily "bad" for patients, but, as the study itself concludes, we have to entertain the possibility that antipsychotics may have potentially undesirable effects of brain tissue volume reduction.

Understanding psychosis

2011-01-31T23:00:00.005Z

This post has the same title as the latest post from the Healthy Minds. Health Lives blog, my favourite for commenting on because it is published under the auspices of the American Psychiatric Association (APA) (see previous post). The APA blogger suggests that it helps to understand psychosis by recognising its connection with the brain. Does it really? It's merely tautologous. Of course it's something to do with the brain. So what? Knowledge of the brain doesn't give any understanding about personal and social factors.

Actually understanding the irrational may require more than being logical. What makes us think that someone is mentally ill may be that what they are saying is difficult to follow and understand. It makes us think there is something wrong mentally. It doesn't help to wishfully speculate about brain processes when what is required is considerable effort to understand why someone may have crazy experiences and express themselves in a mad way. We don't live in the real world for all sorts of reasons, including our own convenience about understanding the world. And it suits the APA blogger to have her biomedical belief about psychosis.

Menacing cloud hovering near prospective patients

2011-01-14T20:30:00.014Z

Seroquel is the best-selling psychiatric medication in the US and, as pointed out in a feature in Medical Marketing and Media (MM&M), its patent is due to expire in 2012. Its manufacturers, AstraZeneca, last year reached an agreement to settle US product liability litigation over Seroquel for about $198 million (see Wall Street Journal article). Earlier in the year it also paid $520 million to resolve allegations that it marketed regular Seroquel for off-label uses between 2001 and 2006.

However, this doesn't seem to matter to Astrazeneca financially with global Seroquel sales of $4.9 billion in 2009. And it is MM&M's Large Pharma Marketing Team of the Year. It has approval for an XR formulation which extends the use of the drug under patent. This formulation has been approved as an add-on to antidepressants for the treatment of major depressive disorder.

There's a full page advert for it on the back of this week's BMA News, which does not use the cloud as in the US campaign. The image of the depressed woman curled up in her kitchen unable to do her washing, which is used to advertise seroquel XL (it's called XL, not XR, in the UK) to UK doctors, for some reason seems to be different from that used for direct-to-consumer US advertising.

Off-label use of atypical antipsychotics

2011-01-13T12:31:00.001Z

A Reuters report based on an article in Pharmacoepidemiology and Drug Safety suggests atypical antipsychotics are overused. The article looked at trends in outpatient prescribing in the US. Antipsychotic use for indications without FDA approval increased between 1995 and 2008 with an estimated cost associated with off-label use in 2008 of US$6.0 billion. Atypical use has grown far beyond substitution for the now infrequently used typical agents.

(With thanks to Vince Boehm)

Opportunities and threats for psychiatry

2011-01-08T16:04:00.005Z

In an e-interview in The Psychiatrist, John G. Csernansky was asked what he saw as the most promising opportunity facing the psychiatric profession and what he saw as the greatest threat. He said the most promising opportunity was the introduction of new knowledge about neuroscience into the practice of psychiatry. The greatest threat was that the public has become impatient with the lack of progress of biomedical research and may begin to withdraw its support for it.

Psychiatry has seen itself on the verge of neuroscientific breakthrough ever since its modern origins over 150 years ago. We are no nearer being "finally on the threshold of knowing enough to develop reasonable models of the pathophysiology of neuropsychiatric diseases and how to treat them", as Csernansky believes, than we were then. It's not so much that the public has become impatient with the lack of progress but that there needs to be a conceptual shift in understanding. The reason progress hasn't been made in biomedical research is that it is "barking up the wrong tree". The sorts of neurobiological processes underlying mental disorder may be no different from the basis of our "normal" thinking, feelings and behaviour.

By the way, when Csernansky was asked what single change would substantially improve quality of care, he said simplification of how we pay for mental healthcare. This is just at the time when the UK government is reforming health care (eg. see my personal blog entry), which will lead to the introduction of a mental health tariff based on clusters of patients which people don't, at least currently, understand. Still, it will be possible to undercut the national tariff, so maybe the new clustering system will never get off the ground. Anyway, the introduction of a tariff complicates block contract arrangements which we have got used to in the NHS and there is a lack of evidence that this change will lead to an improvement in services.

A cute little video about a visit to a psychiatrist

2011-01-04T20:52:00.000Z

(With thanks to Adinah's post on ICSPP Discussion Group giving the link. See also her comment on another blog.)

Does it really take several weeks for antidepressants to work?

2010-12-30T15:00:00.003Z

In my previous post, I have gone on about the errors about the treatment of depression in the latest blog entry on the APA's Healthy Minds. Health Lives. There's another mistake about how long it takes for antidepressants to work. Patients are commonly told, as they are in the blog entry, that antidepressants can take up to 4 to 6 weeks to have an effect.

What the blogger should have said is that it commonly takes 4-6 weeks for a statistically significant difference between active and placebo treatment to be detected in clinical trials. But this is an artefact of the way in which statistical significance is measured. Larger size clinical trials will detect a statistical difference earlier than trials with smaller numbers of subjects.

Actually, the largest improvement per unit time produced by antidepressants occurs within the first 2 weeks of treatment (Mitchell, 2006). Recovery from depression fits an exponential model (Priest et al, 1996). The false 'delay' hypothesis has been used to call for research into better antidepressants that act more quickly. Maybe it would be better just to be honest and accurate with patients about the limitations of antidepressants.

How easy is it to treat depression?

2010-12-30T12:44:00.004Z

The latest blog entry from APA's Healthy. Healthy Lives., besides making the misleading statement that antidepressants work by increasing the amount of serotonin between nerve cells, also gives the wrong impression that depression can be readily treated. The blog makes out that there are lots of options to try, so if you just keep making changes of medication everything will be alright.

I don't want to appear pessimistic about the outcome of treatment for depression. However, the reality is not as simple as the blogger makes out. Some people fail to respond to treatment and some relapse after responding. Over 6 months, maybe, about half of people do quite well, a third have a fluctuating course and 1 in 9 remain unwell (Mulder et al, 2006). Of those who are doing quite well at 6 months, maybe about half relapse in the following year (but a third of those depressed at 6 months recover) (Mulder et al, 2009).

Over the long-term, recurrence is high. Figures in studies vary from 40-85%. If about a quarter of people are improved by treatment, there's a quarter of people who do not have good outcomes (Hughes & Cohen, 2009). Even if there's a clinical improvement, this does not necessarily mean there's been a social recovery (Kennedy et al, 2007). Many patients still report residual symptoms despite apparently successful treatment (Fava et al, 2007).

Outcomes for non-drug treated samples are not necessarily any worse over the long-term (Hughes & Cohen, 2009). Doctors do not generally tell patients about the small effect size and substantial non-response rate of antidepressants for fear of undermining the effectiveness of medication. The serotonin imbalance theory is used as a means of encouraging patients to take their medication, which is why the Healthy Minds. Health Lives. blog mentions it.

The role of psychiatry is to give hope to depressed people. It is also to be honest with them about the cause of their problems and the appropriate treatment. Patients are able to understand that the 'chemical imbalance theory' is only a theory. What they find more difficult to appreciate is why they are told that this theory has been proven, when this is clearly not the case. They may also struggle when antidepressants may not give the simple and easy answer they have been led to expect.

Are pharmaceutical companies really moving away from psychiatric drug development?

2010-12-29T16:10:00.003Z

In my previous post, I mentioned that Thomas Insel, Director of NIMH, had noted that pharmaceutical companies are moving away from psychiatric research. He elaborated on this further in a previous post on his blog, when he expressed concern about GlaxoSmithKline and AstraZeneca apparently terminating their psychiatric medication development programmes. Jeffrey Lieberman discussed this issue further in a Medscape broadcast.

However, PhRMA reported earlier in the year that a record 313 new medicines to treat patients suffering from mental health disorders are being developed by America’s pharmaceutical research and biotechnology companies (see press release with link to full report). Doesn't sound like a lack of investment to me, even if there are no drugs working by new mechanisms. As has always been the case, the motivation for research is to fulfill the wish for medication that will provide the cure we've been hoping for.

A report from NIMH takes the issue of cure further to prevention and emphasises the importance of so-called personalization and preemption as the foundations for new treatments. As the report itself notes, psychiatric genetics has not yielded a single validated target for any mental disorder. The causes of mental disorders and their mechanisms are unknown making the development of so-called personalized psychiatry a risk for the pharmaceutical industry, which it understandably may not wish to take (see News and Notes from Psychiatric Services).

Mental health breakthroughs in 2010

2010-12-24T11:49:00.005Z

Thomas Insel, Director of NIMH, who I have mentioned in a previous post, has listed his top 10 research events and advances of 2010 on his blog. I'm not quite as convinced as he is that these represent advances for psychiatry and I think we do need to question whether we are really getting value for money from NIMH (see previous post).

Insel concentrates on genetic research. I'm not saying this research doesn't need to be done, but would question its value for psychiatry. For example, whole genome sequencing has demonstrated the surprising number of variants in normals - as he says each child shows "50 – 100 new mutations not present in his or her parents". But it's speculation to correlate rare “structural” variations in the genome with autism, schizophrenia and other neurodevelopmental disorders. Parental imprinting is an interesting phenomenon and we need to understand it further, but it's unlikely to change the way we approach mental disorders. Epigenomics does need to be developed as a basic science but it's unlikely to provide us with a new way of understanding mental illness.

I don't think funding for genetic research should be obtained on the back of what is provided for psychiatry. Nor can I see induced pluripotent stem cells (iPSCs) cell technology, despite its interest and potential, contributing to psychiatry. Similarly, the Human Connectome Project may well produce basic scientific advances in the understanding of patterns of brain-function connections. It's the belief that this will uncover abnormal brain circuits that worries me. HIV/AIDS is also an important condition for research but so-called potential progress in its prevention isn't really going to help psychiatry. There was a thought that we could all take medication to prevent us developing mental illness, but this seems to have dropped off the horizon for the moment. I think we should also be sceptical about the value of expensive antiretroviral chemoprophylaxis for HIV/AIDS - shouldn't we be spending money more on prevention through condoms?

I'm not exactly sure why pharmaceutical companies have moved away from the development of psychiatric medication. Insel makes out that there are various basic science developments that they could pursue. In terms of the basic science hypotheses, I think the ones he mentions are just as likely to end up on the failed heap of neurobiological hypotheses of the basis of mental illness. Nor have we really made the advances this year in the understanding of the autistic brain that he implies. And surely it's scraping the barrel to screen for chemicals capable of enhancing neurone formation in the hippocampus of adult mice to develop them as antidepressants.

I hadn't realised that Nature had produced a whole issue on schizophrenia this year, which Insel classes as one of the events for psychiatry of 2010. I'll have to look at it further.

Is money well spent on mental health research?

2010-12-08T13:44:00.009Z

A New York Times article suggests that an entire psychiatric textbook was ghostwritten by a writing company funded by a drug company. Perhaps we shouldn't be too surprised by this. As another New York Times article points out, ghostwriting has not been that uncommon in medical journal articles.

Doctors are not always neutral agents in the marketing of pharmaceutical drugs. Understandably, maybe, they want to find effective medications for their patients. Their promotion of these medications may well be biased. However, patients do look to their doctors to provide a balanced assessment of the effectiveness of medication, even if they may wish for a simple, quick and complete cure.

Academic psychiatrists may see their presentation of material in a textbook as scientific knowledge. From their point of view, it therefore doesn't matter too much who writes the chapters. After all, they sign off the final copy. They accept responsibility for what has been written. A press release from the American Psychiatric Association (APA) admits that editorial assistance from a writing company has not been that uncommon and insists this isn't ghostwriting by a drug company. From their point of view, it's merely compiling and checking facts. The problem is that "facts" in psychopharmacology are usually open to interpretation. I suppose it depends how much of the "compiling" has been done by the writing company as to whether it should be seen as "ghostwriting". Actually, perhaps what the APA is more objecting to is that technically it wasn't the drug company doing the ghostwriting - which is what it says the original NYT article implied (it's been amended since) - it was a writing company paid by the drug company.

What the authors of the book don't mention is that they have been paid handsomely to put their name to such a book. The NYT article actually implies that they didn't tell their publisher about the writing company (but anyway, according to the APA press release, the publisher wouldn't have been too bothered if it had known). Nor is the book likely to have very high quality scientific content, in the sense of critically and independently examined and reviewed. It's these researchers that obtain large research grants, and have been shown up before for not disclosing their interests to their University (eg. see another NYT article).

The Project On Government Oversight (POGO) takes a keen interest in strengthening the integrity of federally funded science and has written to the National Institutes of Health (NIH) I think NIH are the right target here. The funding they put into mental health research and medical research in general is very significant. Such vested interests do encourage a biomedical bias (eg see my article) within psychiatry. Challenging the myth that a biological basis of mental illness will be elucidated by further research undermines the basis for these large NIH grants. Losing research funding is what biomedical psychiatry finds difficult to accept. Academic standing to obtain research grants can be improved by writing a textbook, and it's even easier if a writing company does it for you, and money can be made out of it.

(With thanks to posting on Mad in America blog)

Why no amplified placebo effect for reboxetine?

2010-11-15T23:21:00.005Z

A recent article in the BMJ has shown that the data on reboxetine has not proven its effectiveness. This evidence has at least partly been hidden because of publication bias.

However, the FDA never gave reboxetine a licence anyway. Intriguingly, in a rapid response to the BMJ article, the medical officer who reviewed the FDA application hints that we still haven't got all the relevant data. We still don't know why the FDA turned reboxetine down in 2001.

It's tempting to speculate, as GoozNews does, that somehow it was connected with David Healy's overinflated promotion of reboxetine at the time in terms of restoring social interaction. Reboxetine is a NARI rather than a SSRI, which means it is more specific for blocking the reuptake of noradrenaline, rather than serotonin. Serotonin specific reuptake inhibition (SSRI) was marketed as the mechanism of action of a whole new generation of antidepressants, such as fluoxetine. The competitor noradrenaline reuptake inhibition (NARI) hypothesis never really gained ground, not least because the FDA did not approve reboxetine.

So, it could be said there's always been a bias against reboxetine. I suppose this could explain why no amplified placebo effect has been found and therefore reboxetine is no better than placebo. If apparent antidepressant efficacy is due to an amplified placebo effect (see previous post) one might have expected the same to be found with reboxetine. As it hasn't, it is already being said (see post by Neuroskeptic) that the amplified placebo hypothesis must be wrong.

But there could be other explanations, such as the lower expectancy for reboxetine. In other words, the placebo effect was not amplified because there was a lack of belief in reboxetine. Also, in another rapid response to the BMJ article, it is pointed out that the BMJ meta-analysis may have been selective, certainly compared to the NICE analysis.

It'll be interesting to see what NICE make of the BMJ article. Hopefully, we can also find out what was behind the FDA decision in 2001.

.

How may antidepressants worsen the long-term outcome of depression?

2010-10-30T10:55:00.013+01:00

Robert Whitaker in his latest posting on his Mad in America blog (to which I have referred before) elaborates on the work of Giovanna Fava about the vulnerability to relapse created by taking antidepressants. Fava has produced a recent review in which he builds on his hypothesis that the neurobiological mechanism underlying the increased vulnerability is due to oppositional tolerance. By this he means that the effects of the drug are opposed or counteracted by homeostatic changes in the brain, and when drug treatment ends, these processes may operate unopposed.

I am cautious about calling the effect 'tolerance'. Unlike, for example, alcohol, there is no evidence of the need to increase the dose or concentration of antidepressants to produce the desired effect. Maybe what Fava means is a tolerance-like effect.

More fundamentally, I'm not convinced that looking for an underlying neurobiological explanation is the real way to look at the issue. Surely the problem is psychological dependence. As I've said in a previous post, doctors concentrate too much on the physiological explanation of drug effects. People form attachments to their medication more because of what they mean to them than what they do. It's an identity-altering experience taking antidepressants. Discontinuing them is going to cause all sorts of problems which take time to make sense of.

The official view about mental illness

2010-10-11T20:10:00.004+01:00

I was not intending to be personal about the bloggers on Healthy Minds. Heathy Lives. in two of my previous postings (see link to the first and to the second). The reason I've focussed on this blog is because it's published under the auspices of the American Psychiatric Association (APA). It therefore has the official backing of American psychiatry.

I've expressed concern before about the biomedical bias which has developed within the APA (see article). It's not so long ago that the APA was more pluralistic. Although I stand to be corrected, I think the Royal College of Psychiatrists in the UK would be more cautious about tying its ideological understanding of mental illness, at least in official statements, to a biomedical model.

Loren Mosher resigned from the APA in 1998 saying it had become the American Psychopharmacological Association rather than the American Psychiatric Association (see his resignation letter). Will the Healthy Minds. Healthy Lives. blog allow a debate about this situation? I doubt it, which I think is a cause for concern.

More on stigma of mental illness

2010-10-11T08:09:00.004+01:00

The psychiatrist, Gariane Phillips Gunter's, MD, latest blog on Healthy Minds. Healthy Lives. has a video of her in which she argues that mental illnesses are "not your fault" because they are “biological illnesses, just like having high blood pressure, diabetes or cancer". She believes her crown as Mrs United States 2008 gave "her a greater opportunity to be a voice across this great nation for patients with mental illness and their families".

Reducing stigma is welcome but should not be based on a speculative biological theory of mental illness. As mentioned in the previous post, such a theory could actually increase stigma, as it doesn't really promote understanding of mental illness. As I keep saying, please do not misunderstand me. Of course, our thoughts, behaviour and emotions have their origins in the brain, but if that's all that Dr Gunter's saying, it's merely tautologous. However, she's making a statement about how we understand the world and it's not right.

Genetic theory not cure for stigma of ADHD

2010-10-09T12:40:00.004+01:00

Ben Goldacre, in an article in his Guardian Bad Science column, comments on the Lancet ADHD study (as have I in a previous post). What he emphasises is that in fact a genetic theory of ADHD may actually potentially increase, not decrease, the stigma of the condition by encouraging a social distance from people identified as genetically damaged.

Can there be an open debate about biomedical psychiatry?

2010-10-09T11:37:00.011+01:00

Robert Whitaker, in a posting on his Mad in America blog, writes about how he sometimes loses the hope that "our society will ever be able to have a thoughtful, honest discussion about what is truly known about mental disorders, and about the merits of psychiatric medications". I understand the sentiment. However, we do need to remind ourselves that biomedical psychiatry is a cultural system. Like a religion, it expresses a view about the nature of the world that provides what Clifford Geertz called an 'aura of factuality'. This feeling of realness is not easy to upset. People don't want to have their worldview turned upside down.

Whitaker's books The Anatomy of an Epidemic and Mad in America are well worth reading. One of their main themes is the vulnerability created by taking psychotropic medication. Relapse rates when people stop medication are very high. There is also evidence of a loss of benefit emerging with long-term treatment and also on retreatment after discontinuation of treatment. People may actually do better over the long-term if they work through their problems without medication. This is a legitimate scientific hypothesis (eg. Can long-term treatment with antidepressant drugs worsen the course of depression?).

(with thanks to News and Alerts from Mind Freedom International)

Psychosocial theory of ADHD does not blame parents

2010-09-30T15:18:00.007+01:00

Sarah Boseley's report in the Guardian about the Lancet genetic study of ADHD, which concludes in the paper that ADHD is not purely a social construct, quotes Professor Anita Thapar, the senior author of the study, as saying that she hopes "that these findings will help overcome the stigma associated with ADHD". She's confident that ADHD is a genetic condition, which, to her mind, shows she was right that ADHD should not be dismissed as being due to bad parenting or poor diet.

Avoiding blaming the parents is commonly used as an argument for a biomedical view of ADHD and other mental disorders, such as schizophrenia. However, it's a misunderstanding of the psychosocial perspective to take this as its implication. Trying to understand why a child becomes hyperactive is several steps away from blaming anyone. There's no suggestion that there's any conscious intention to cause harm and there is no one-to-one causal connection. Understanding reasons is not the same as causal connections.

Oh no, not another neurobiological theory of depression

2010-09-29T18:55:00.006+01:00

When I initially read Scicurious' posting on the Guardian Science blog, I wondered whether it was a spoof. But no, there are some references in the literature to antidepressants increasing neurogenesis in animals. Scicurious wonders whether this may be the mechanism of action of antidepressants, as she's given up on the low serotonin theory of depression.

Scicurious blogs at Neurotic Physiology. She makes clear her view on her About Scicurious page that "we have [now] discovered that all “neuroses” and psychiatric disorders have a physiological basis". I don't want to undermine her faith, but she should make it clear she's just promoting her belief and not call it science.

She notes that "antidepressants do work in some patients". As I've said in a previous post, the way in which they work may be merely as amplified placebos.

Adult executive brain dysfunction

2010-09-26T17:56:00.008+01:00

Felicia Wong, in a posting on the Healthy Minds. Healthy Lives. blog (the American Psychiatric Association’s online resource for mental health issues), refers favourably to a Wall Street Journal article on adult ADHD. As the article says, ADHD is "thought to be an imbalance in neurotransmitters, the chemical messengers that relay signals in the brain, particularly in the frontal cortex that governs planning and impulse control." Ivan K. Goldberg, a psychiatrist in New York City, who co-developed a commonly used screening test, is quoted as saying "What it really is is a disturbance of the executive functions of the brain".

Dr Wong recommends that those who suspect they have ADHD should have a thorough evaluation with a psychologist or psychiatrist. How do psychologists or psychiatrists know if there is an executive brain dysfunction? It's an hypothesis but how do we know whether it's true? Using the screening test co-developed by Dr Goldberg is not a diagnostic test, although there are rating scales used for diagnosing ADHD. But they're not measuring executive brain dysfunction. So what is being diagnosed when a diagnosis of adult ADHD is made and why link it to speculation about executive brain dysfunction? It's just a convenient way of viewing the world, isn't it?.

Does it matter whether biomedical psychiatry is true or not?

2010-09-23T18:04:00.006+01:00

Lesson 5 of the NIMH course curriculum on mental illness, mentioned in a previous post, looks at the problem from the diagnosed children's perspective. Like any other kid is a video in three parts.

Regarding their problem as caused by a brain disorder has helped to make sense of their situation for these young people. Biomedical psychiatry can provide a genuine order to the world. Does it matter whether it's true or not?

Misleading children about mental illness

2010-09-21T17:51:00.006+01:00

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.

Mental illness as faulty circuits in the brain

2010-09-19T12:10:00.008+01:00

Research in mental health has moved on from chemical imbalances as the cause of mental illness to circuitry dysfunction in the prefrontal cortex, at least according to Thomas Insel, Director of NIMH. For example, in his article Disruptive insights in psychiatry: Transforming a clinical discipline, he says aspects of schizophrenia can be mapped onto dysfunction of dorsolateral prefrontal circuits that mediate executive function; depression appears to involve dysfunction in a region of the midline infragenual prefrontal cortex important for regulation of mood; OCD (obsessive-compulsive disorder) involves dysfunction in the orbitofrontal prefrontal cortex via its role in perseverative behaviours; and posttraumatic stress disorder (PTSD) can now be mapped to dysfunction in prefrontal circuits required for the extinction of fear.

There is of course some localisation of function in the brain but dynamic interactions between multiple regions produce thought, emotion and behaviour. It's a long step to mapping specific mental illnesses to dysfunction of brain circuits. Insel himself concedes that more research is needed.

Moreover, Insel clearly juxtaposes his concept of mental illness as brain disorder with psychological disorders caused by psychic trauma or conflict. He says we need to rethink our approaches to diagnosis, treatment, and professional training. So he's happy for his approach to encourage psychosurgery and intracranial brain stimulation.

He got an airing of his views in an article, Faulty circuits, for the popular Scientic American. His claim that neuroscience will revolutionise psychiatry is no different from the one made by modern psychiatry since its origins with the asylums. How many more blind alleys will psychiatric research lead us down? Faulty brain circuits in mental illness are as much of a myth as biochemical imbalances.

Psychiatrists rarely think about the impact of medication on anything other than brain chemicals

2010-08-25T09:39:00.007+01:00

David Karp in his book Is it me or my meds?: Living with antidepressants talks about how one's view of oneself is at stake in taking antidepressants. In an earlier paper, he described the initial resistance to drug taking; negotiating the terms of treatment; adopting new rhetorics about the cause of depression, such as "chemical imbalance"; experiencing a conversion to medical realities; and becoming disenchanted with the value of medication for solving personal problems. Adopting the view that one suffers from a biochemically based emotional illness is an identity-altering view of reality.

The obvious effects of antidepressants

2010-07-31T13:23:00.020+01:00

Edward Shorter, in his book, Before Prozac, rues the fact that there has been no progress in the pharmacological treatment of mood disorders, since imipramine was introduced in the 1950s. He quotes from Ronald Kuhn, who discovered imipramine, and who "never used 'controlled double-blind studies' with 'placebo', 'standardised rating scales' or the statistical treatment of large numbers of patients". Instead, what Kuhn noticed was an "obvious effect" in improving vital depression in psychiatric patients that he tried it on. To use a quote, again from Kuhn in Shorter (2009), "The patients become generally livelier, their depressive whisper voices become louder, the patients appear more social, the yammering and crying come to an end."

As I pointed out in a previous post, how do we know that antidepressants aren't just placebos with side effects? What Kuhn may have "discovered" was merely the placebo effect.

Shorter thinks we may have "lost something" because today "Kuhn would be kicked out of the door at the FDA", by which he means imipramine would never have come onto the market without controlled trials to support it. As he says, what we've got at the moment is a "mesh of patent-protected remedies". I agree this isn't progress, but Kuhn may have merely sent us down the route of the wish-fullfilling phantasy of the chemical cure of depression.

Academic freedom for critical psychiatry

2010-07-20T18:27:00.012+01:00

As a follow-up to my post on Why haven't professors of psychiatry used their tenure to go up against the system that we’re in?, I suppose Thomas Szasz is the exception that makes the rule. There's a tweet that agrees with me. I guess Szasz has been lucky to have tenure.

The best article that explained what happened to Szasz when his tenure was threatened is by Ronald Leifer. Perhaps I'm just jealous that I've had to carry on in the real world of psychiatric practice and not had the freedom of tenure like Szasz, still going aged 90.

Am I a bromide?

2010-07-20T10:39:00.008+01:00

Now Nassir Ghaemi has called me a "bromidic anti-biological critic". I have reviewed his book The rise and fall of the biopsychosocial model, which I mentioned in a previous post. He has replied to my review and I have responded to his comments.

I can understand him being upset about my views about his book. But I have gone on at length about the misunderstanding of saying that critical psychiatry is anti-biological (eg. see another previous post). By the way, bromides were used as sedatives in psychiatric hospitals in the past.

And I don't think critical psychiatry is bromidic in the sense of being conformist to majority opinion. Maybe I should be happy to be bromidic in the adapted words of the song from South Pacific:-

Wonderful critical psychiatry

I expect everyone
of my crowd to make fun
of my proud protestations for critical psychiatry.
And they'll say I'm naive
as a babe to believe
that the fables of psychiatry will be exposed.
Fearlessly, I'll face them and argue their doubts away.
Loudly, I'll sing about flowers in spring.
Flatly, I'll stand on my little flat feet and say....
Critical psychiatry... is a grand and a beautiful thing.
I'm not ashamed to reveal,
the world famous feeling I feel.
I'm as corny as Kansas in August,
I'm as normal as blueberry pie,
no more a smart little guy with no heart,
I have found me a wonderful cause.
I am in a conventional dither,
with a conventional star in my eye.
And you will note there's a lump in my throat,
when I speak of that wonderful cause.
I'm as trite and as gay as a daisy in May
a cliché coming true,
I'm bromidic and bright as a moon
happy night pouring light on the dew.
I'm as corny as Kansas in August,
high as the flag on the 4th of July.
If you'll excuse an expression I use...
I'm committed, I'm committed, I'm committed,
I'm committed, I'm committed, I'm committed to a wonderful cause!
(interlude)
I'm as trite and gay as a daisy in May
a cliche' coming true.
I'm bromidic and bright as a moon
happy night pouring light on the dew.
I'm as corny as Kansas in August,
high as the flag on the 4th of July.
If you'll excuse an expression I use...
I'm committed (13x) to a wonderful cause!

(To the music of "A wonderful guy" from South Pacific)

Why haven't professors of psychiatry used their tenure to go up against the system that we’re in?

2010-06-20T16:26:00.004+01:00

Profile of Leon Eisenberg who died last year. I've always found some of his articles seminal eg. The social construction of the human brain.

Arthur Kleinman's obituary comments are pertinent. Eisenberg "follows in the great footsteps of ... William James, because James argued powerfully for the broad range of normal experience, for our tolerance of multiple ways of being human." (WPA obituary). “He was a major voice in American medicine." (Boston Globe obituary)

Why have I been called a postmodernist?

2010-04-25T20:19:00.006+01:00

Nassir Ghaemi in his book The rise and fall of the biopsychosocial model says I am an "explicit proponent of applying postmodernism to psychiatry". His evidence for this is said to be my 2002 BMJ article.

In the article, I say that "Psychiatry needs to return to a biopsychological view to limit its excesses". True, I do go on to say that "Such an approach conforms to the new direction that has been called "postpsychiatry" and there is a box summarising the central tenets of postpsychiatry.

What I meant by this is that postpsychiatry is one form of critical psychiatry, which, as far as I am concerned is about 'returning to a biopsychological view'. Ghaemi has got it right that I am trying to rehabilitate the ideas of Adolf Meyer (whose perspective was called Psychobiology) (eg. see my article Adolf Meyer's psychobiology and the challenge for biomedicine).

I see postpsychiatry as one form of critical psychiatry (see my letter to Psychiatric Bulletin). Personally I take a more pragmatic view than postmodernism. In fact some would juxtapose critical psychiatry and postpsychiatry even more than I would eg. see entry for Critical Psychiatry on Wikipedia.

How do I get confused with Digby Tantam?

2010-03-21T12:24:00.006Z

Tom Szasz in his new book Antipsychiatry: Quackery squared quotes my critical psychiatry website page on 'What was antipsychiatry?' but attributes it to Digby Tantam, not me. What I wrote was, "A key understanding of 'anti-psychiatry' is that mental illness is a myth (Szasz 1972)." Szasz objects to this because he is not an anti-psychiatrist. However, unfortunately for him, it is true that he has been identified with anti-psychiatry, and the myth of mental illness is a key idea that is associated with it.

I don't feel too bad about Szasz's criticism as he calls RD Laing an anti-psychiatrist, and Laing disowned the term, like Szasz.

He also complains that I put the date of his The myth of mental illness book as 1972, because of course it was first published in 1961. I did this because I was referring to the Paladin edition, which was first published in 1972.

Antidepressants are placebos with side-effects

2010-02-23T21:27:00.012Z

Irving Kirsch's new book The Emperor's new drugs: Exploding the antidepressant myth makes the strongest case yet for antidepressants being merely amplified placebos. Irving does not make reference to a paper by Thomson (1982), which I think was the first to suggest this specific hypothesis. There were also previous references to the importance of the breaking of the blind in clinical trials.

I have always been sceptical about the value of antidepressants and psychotropic medication in general (eg. Limitations of double-blind trials) and share this lack of evidence with patients in my clinical practice. However, I have always felt it has been very difficult to get away from the notion that, however small the difference is between active and placebo groups in clinical trials, there is still a statistically significant difference. If patients have wanted an antidepressant I have felt I have had no choice but to prescribe.

Irving is more confident in his presentation of the case than I have been that this statistical difference is an artefact. Perhaps he has been more definitive because he started from a belief in antidepressants, which he no longer has, whereas, having always been sceptical, I have tended to qualify my position eg. Why is the effect size so small?.

Irving's evidence is summarised on page 21 of his book:-

The final piece of evidence to which he makes reference ie. a paper by Barbui et al is still to appear in print entitled 'Is the paroxetine-placebo efficacy separation mediated by adverse events?' As Irving says, the evidence "may not be conclusive proof, but it is strong". It'll be interesting to see the impact of this more confident case.

Critical psychiatry is not neurophobic

2010-01-04T22:41:00.011Z

An article by Bullmore et al entitled Why psychiatry can't afford to be neurophobic followed up Craddock et al's article mentioned in my last post. It suggested that "there seems to be a deep-seated reluctance to embrace the theoretical and therapeutic potential of neuroscience for psychiatry".

I don't think this reluctance comes from critical psychiatry as such. It has always emphasised the integration of mind and brain. It's a mistake to think that mental symptoms are not based on a neural substrate. Critical psychiatrists can understand the wish, as much as anyone else, that neuroscience could solve the theoretical and therapeutic problems of psychiatry.

The problem is that fulfilling that wish is "intellectually bold" in Bullmore et al's own words. They are fearful that psychiatry will be cast "adrift from the core principles of medicine". They can't understand why anyone would want to prescribe psychotropic medication without thinking that symptoms were "somehow related to abnormal synaptic signalling between nerve cells".

Correspondence in reply (eg. by Andrew Blewett) sees through this argument. Neurohawkishness seems to be on the defensive.

Is there a debate about the future of psychiatry?

2010-01-03T19:33:00.009Z

All in the Mind broadcast a programme that included a debate between Nick Craddock and Pat Bracken. It suggested there was a fierce debate within psychiatry about the very future of the profession.

I think the origin of this so-called debate is supposed to be an article by Craddock et al entitled "A wake-up call for British psychiatry". It has been portrayed as a biomedical reaction to the policy of New Ways of Working.

I think the issues are more complex (see my e-letter). There has been a deprofessionalisation of services in the sense of an undermining of professional expertise. New Ways of Working encouraged a fragmentation of services and, in fact, Department of Health policy now seems to have moved on to focusing on the "creative, capable workforce" and not so much about the structure of services.

The question is whether there is really a debate about the conceptual basis of psychiatry. Pat has always tended to argue that postpsychiatry is not another model (eg. see Openmind article). I may have misunderstood the implication of Pat's point but I do think there should be a debate about whether psychiatry has a biomedical or truly biopsychosocial foundation. "Biopsychosocial" may not be the best term as it has been used to mean an eclectic, atheoretical position. But I think critical psychiatry is clear that psychiatry can be practiced without postulating brain pathology as the basis for mental illness. That is a debate worth having but I haven't seen much engagement in it.

It may be illegal to discriminate against critical psychiatrists

2009-11-09T07:59:00.006Z

It may now be illegal to discrimate against critical psychiatrists following a ruling that environmentalism is a belief system (see Guardian report). If green beliefs can come under employment regulations on discrimination (although not in the sense of merely belonging to the Green party), then it may well be illegal to discriminate against a critical psychiatrist (although not just because they are a member of the Critical Psychiatry Network or some other group).

Critical psychiatry seems to fit the 5 tests set by Mr Justice Burton:-

 The belief must be genuinely held
 It must be a belief and not an opinion or view based on the present state of information available
 It must be a belief as to a weighty and substantial aspect of life
 It must attain a certain level of cogency, seriousness, cohesion and importance
 It must be worthy of respect in a democratic society, not incompatible with human dignity and not conflict with the fundamental right of others.

Critical psychiatrists have been discriminated against. Trainees are worried that if they express an interest in critical psychiatry, their careers will be affected. Somehow this perception has got to change. A few legal challenges may help.

More advice on long-term prescribing of antidepressants needed

2009-10-23T18:44:00.006+01:00

Study in the BMJ looking at why antidepressant prescribing has increased suggests it may well be due to people staying on antidepressants long-term. It only needs a small number to stay on them long-term to increase the total number of prescriptions dramatically.

The problem is that doctors get guidance about starting people on antidepressants but not much about when and how to take them off.

What's wrong with the pharmaceutical industry going bust?

2009-08-29T13:49:00.006+01:00

Sarah Boseley has written a Guardian article about a Compass report "A bitter pill to swallow". The subtitle of the report is "Drugs for people, not just for profit".

The report tends to blame the neo-liberal market economics of Thatcher and Reagan for "why the drug companies are getting away with it". There are political changes that could be made, such as that all phase 3 trials be carried out independent from the industry. As the report says, this could be funded through an industry levy as initially put forward by John Abraham and Helen Lawton Smith in their book Regulation of the Pharmaceutical Industry. Doctors' education needs to be through public funding rather than relying on the pharmaceutical industry.

However, things won't really change until it's recognised how much doctors are merely agents of the pharmaceutical industry, rather than independent practitioners in the interests of patients.

International Critical Mental Health Movement

2009-08-24T16:03:00.004+01:00

Following the last Critical Psychiatry Network conference held in Norwich (conference website) there has been talk about setting up an International Critical Mental Health Movement. This is not an initiative of the Critical Psychiatry Network, which is a group of psychiatrists, mostly from the UK. It is important that the International Movement is widely based and inclusive.

Please post your comments. Expressions of interest and ideas about how to develop the movement would be welcome. It is envisaged that the International Movement would be open both to individuals and groups, so comments on behalf of organisations will be particularly welcome.

Please circulate interested people and organisations about this posting, so that they can also add their comments.

Critical psychiatry should not be dismissed as anti-psychiatry

2009-07-03T10:07:00.005+01:00

At least Pat Bracken and Phil Thomas, advocates of postpsychiatry, have managed to get some response from mainstream psychiatry. They have an editorial in the Psychiatric Bulletin this month, which has an invited commentary from Frank Holloway to which they write an authors' response.

The problem is the way in which critical psychiatry/postpsychiatry gets dismissed as anti-psychiatry. It's not really clear what Frank Holloway means when he says the postpsychiatry project is strikingly similar to the anti-psychiatry of the 1970s. What he implies is that it doesn't really need to be considered. It'll end up in the same dead-end as anti-psychiatry, which was over the top anyway.

It is true there were excesses in anti-psychiatry (see my Historical perspectives on anti-psychiatry). However, the rotten reputation of anti-psychiatry should not be used to hide mainstream's psychiatry's defensiveness about the challenge of critical psychiatry, with which it does need to engage.

Pharmaceutical industry sponsorship of psychiatry conferences

2009-06-19T21:01:00.012+01:00

The prospectus for industry sponsorship and exhibition at the 18th European Congress of Psychiatry in Munich in 2010 invites applications for different levels of benefits ranging from platinum to just an ordinary contributor. To obtain platinum, more than 75,000 euros (+VAT) needs to be paid out to be allowed to set up events such as official satellite symposia and "Meet the Professor" sessions. I doubt that the Congress Scientific Committee fails to approve many of these applications, perhaps particularly because the conference would lose the sponsorship money if it did. Full page colour adverts in the conference final programme are allowed by the best sponsors and there are other opportunities for advertising in the conference material. Educational grants in support of particular sessions can be acknowledged in the final programme.

Other options include buying congress bags and the notepads and pens and umbrellas to go in them, sponsoring the presidential dinner and contributing to the Young Psychiatrists' fund. Companies can advertise their logo on computer equipment in the cyber centre, in the facilities for young psychiatrists to review their presentations, in the Speakers' Ready Rooms, on the Congress webcast, and have their name attached to research prizes and scholarship programme winners awards. Just doing a straightforward exhibition also costs money.

I suppose the conference would not run without this sponsorship. Perhaps it's not really an educational event - more a marketing event.

Educational links between drug companies and medical education should cease, as several reports have suggested (eg. recent Royal College of Physicians report Innovating for health: Patients, physicians, the pharmaceutical industry and the NHS see BMJ news report). This means governments being prepared to meet their responsibilities by proper funding for medical education - it should be an element of Barack Obama's healthcare reforms, giving a lead to the rest of the world.

(With thanks to Pat Bracken)

Pseudoneurobiology of addiction

2009-05-14T19:36:00.008+01:00

According to an article in Journal of the American Medical Association (JAMA), "During the past 20 years, fundamental advances in the neurobiology of addiction have been made. Molecular and imaging studies have revealed addiction as a brain disorder with a strong genetic component, and this has galvanized research on new pharmacological treatments." This is said without reference.

In a follow-up letter, the authors clarify that they used the term addiction instead of dependence to avoid confusion with physical dependence. "Physical dependence results in withdrawal symptoms when drugs such as alcohol and heroin are discontinued, but the neuroadaptations responsible for these effects are different from those that underlie addiction (compulsive drug-taking condition with loss of control over the intense urges to take the drug even at the expense of adverse consequences)."

Brain mechanisms associated with reward are presumed to be disrupted. Of course, addiction or dependence, whatever you call it, is something to do with the brain. And it's also a habit that may be difficult to break, not least if it's associated with physical withdrawal symptoms. But it's sheer neurologising tautology (as Adolf Meyer used to call it) to think that anything has been explained by calling psychological dependence a brain disorder/disease. It doesn't make sense to say that psychological addiction is caused by a structural brain abnormality, rather than being a functional problem. If specific brain abnormalites have been found in addiction, we'd know what they are.

"I wanted to do something as important as the discovery of penicillin"

2009-05-04T13:05:00.009+01:00

A New York Times interview with Nancy Andreasen, author of books, such as The broken brain. She reports what she calls the "big finding" that people with schizophrenia are losing brain tissue at a more rapid rate than healthy people of comparable age. Some are said to be losing as much as 1% per year. This data comes from an unpublished study following up schizophrenics. Andreasen seems to suggest the finding may be due to prefrontal cortical atrophy caused by antipsychotic drugs.

Andreasen says she "sat on" the findings because she didn't want people who need the drugs to stop taking them. Actually, there may be other non-specific reasons why people given antipsychotics have less brain tissue. Any drug effect on brain tissue also may not be of much consequence. But, the problem is the lack of debate. Andreasen is so wedded to the biomedical hypothesis that any potential negative repercussions of her views are suppressed.

How many people need to die each day for it to be an indictment of mental health services?

2009-04-15T16:11:00.010+01:00

The Observer, the Liberal Democrats and Rethink argue that four people dying each day in contact with mental health services (Front page news story) shows that psychiatric help is inadequate. The data comes from incidents reported to the National Reporting and Learning Service (Quarterly data summary Feb 2009) resulting in death in mental health settings (most of which will have been suicides).

Actually this data isn't new. The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness found 1367 cases of suicide (including open verdicts) of people in 2005 who had been in touch with mental health services within the last year, which is more than the number of NPSA incidents leading to death.

About 27% of people in England and Wales who commit suicide have been in touch with mental health services in the last year before their death. Suicide rates vary by country (see WHO data). Suicide is quite common, certainly in terms defined by the politics of mental health that it reaches the front page of a Sunday newspaper. What suicide rate is it reasonable for a country to have without blaming its mental health services?

Jonathan Leo's not a nobody and a nothing

2009-03-29T23:29:00.006+01:00

Jammed by JAMA. Jonathan Leo used to be co-editor of the Ethical Human Psychology and Psychiatry journal. Even if the JAMA editor thinks he's a nobody and a nothing, he isn't. Even a Washington Post editorial talks about JAMA's hush-up.

(With thanks to Vince)

Eating disorders 2009

2009-03-29T18:03:00.003+01:00

Dr Ian Frampton has got a busy week coming up at the 9th London International Eating Disorders conference 2009, which explains how he's quoted in a story in the Observer Anorexia risk 'could be prevented'. He reckons children could be screened aged 8 to detect a brain problem in the insular cortex that makes them liable to develop an eating disorder. He apparently comes to this conclusion from neuropsychological testing of people aged 12-25 with anorexia nervosa. 70% of these people are supposed to have neurotransmitter damage or subtle brain structure changes or both.

We'll have to see if the papers he's presenting live up to the hype. Looking at the programme for the conference, he's the lead in 4 sessions. The first's called an accessible introduction to the clinical implications of advances in the neuroscience of eating disorders All in the mind? I guess the point he's going to make is that it isn't all in the mind, and that there must be some brain vulnerability in the insular cortex that makes some people more liable to anorexia than others. We then have his presentation of a global neuropsychological assessment in eating disorders. These are the first findings from the Ravello Profile collaboration. In the same short papers sessions, he's also got to present the first findings on testing the insular hypothesis. He rounds up on the last day convening the neuroscience special interest group.

Frampton is one of the authors of a paper from last September The fault is not in her parents but in her insula--a neurobiological hypothesis of anorexia nervosa. This is the element that is picked up by the chief executive of beat, the working name of the charity Eating Disorders Association, based in Norwich where I am. She is quoted in the Observer article as saying "It could pave the way for the first drugs to be developed to treat eating disorders, similar to the way that anti-depressants help rebalance the brain of people with depression. And it will help parents understand that they aren't to blame. Parents always blame themselves when their child develops an eating disorder. But what we are learning more and more from research in this area is that some people are very vulnerable to anorexia and that is down to genetic factors and brain chemistry, and not them trying to look like celebrity models or suffering a major traumatic event early in their lives. This research is a key missing part of the jigsaw of our understanding of anorexia."

This argument has been used to justify biological explanations of other psychiatric disorders, such as schizophrenia or ADHD. It's a misunderstanding of the psychosocial paradigm to suggest that understanding the reasons for something happening is necessarily anything to do with cause, in the sense of a proof of direct one-to-one correspondence.

And should Dr Frampton be allowed to have this publicity before he's even presented his findings? He's gone to the press even before his papers have been put to peer review in a journal.

Oh, and the conference is supported by the Huntercombe group, who have three hospitals for adolescent and young adult eating disorders. One of the convenors of the conference, retired psychiatrist, Bryan Lask, is Medical Advisor and Research Director for the Group.

Is UK improving dementia care?

2009-03-13T11:43:00.001Z

I still haven't got round to reading the National Dementia Strategy as I said I would. Still the BMJ editorial about it is a good read. It agrees that the evidence for "a memory clinic in every town" is questionable. The French national plan for dementia sounds good.

The drug without the fatal flaw of clozapine

2009-02-22T17:39:00.003Z

Rolling Stone Bitter Pill story and behind the story.

Time for another hunger strike

2009-02-21T18:57:00.003Z

NIMH are still getting away with saying that depressive illnesses are disorders of the brain without quoting any evidence. So they're agreeing with the American Psychiatric Association (APA) as I pointed out in my article from a few years ago.

There are massive research interests in psychiatry. If depression is not a disorder of the brain, it would potentially undermine what is called research and development, but despite saying that there have been improved treatments over the last 5 years the APA did not make any effort to explain what these improvements have been in response to a hunger strike in 2003. Would NIMH respond to a hunger stike?

(With thanks to Deborah and Vince)

Don't get an orgasm by pulling a rat out of your mouth

2009-02-11T20:31:00.017Z

How can a cinema advert by Pfizer, the makers of Viagra, not mention the drug they make? By saying the real danger is counterfeit medicines. The European Alliance for Access to Safe Medicines, which has three out of seven Board Executives who are pharmaceutical representatives, has called the internet the Counterfeiting Superhighway.

And believe it or not, Pfizer has got support from the Medicines and Healthcare products Regulatory Agency (MHRA). But why should the Pfizer campaign focus on the UK which does not allow direct to consumer advertising (except through such campaigns?)?

Pfizer have produced a report Cracking Counterfeit which even pretends they are focusing on men because they're far less likely than women to visit or even be registered with a GP. Actually, as the company information says, Viagra is intended for use only by men. The senior chemist at Pfizer Counterfeit Lab is quoted as saying that rat poison has been found in a counterfeit blood pressure lowering treatment, but doesn't say which drug and doesn't say it's Viagra. By the way, Viagra does reduce blood pressure.

The MRHA makes reference to a brochure Counterfeit drugs kill produced by IMPACT. WHO says it has responded to the challenge of counterfeit medical products by creating a global coalition of stakeholders called IMPACT (International Medical Products Anti-Counterfeiting Taskforce), a partnership comprised of all the major anti-counterfeiting players, including: international organizations, non-governmental organizations, enforcement agencies, pharmaceutical manufacturers associations and drug and regulatory authorities. Why do they need pharmaceutical manufacturers organisations? Do they want them to run for them?

The IMPACT brochure says fake medicines led to a trail of death in Argentina in 2004. A woman was given 7 out of a course of 10 of what the Argentinian medicines authority called "highly toxic counterfeit injections" of an iron-based compound for anaemia, before she died of liver failure. Four people were prosecuted. A second woman injected with the same counterfeit drug gave birth to a 26 week premature baby. No other examples are given of counterfeit drugs causing a "trail of death".

The IMPACT report does point out that some internet pharmacies are completely legal operations. Pfizer uses the IMPACT brochure to say that substandard and counterfeit medicines can lead to death, as well as therapeutic failure and drug resistance.

Survey data found that 67% of men purchasing prescription erectile dysfunction medicine without prescription use the internet. Pfizer helpfully tell you that the legitimate sites that sell precriptions can be found listed at the Royal Pharmaceutical Society of Great Britain (RPSGB) www.rpsgb.org. They presumably get their cut from this site but not from the illegal ones.

Pfizer estimate that over £10 million pounds is potentially being poured into the counterfeit market in the UK. They quote the Centre for Medicine in the Public Interest as predicting that counterfeit medicine sales will reach approx 55.5 billion euros globally by 2010. The Wikipedia entry on this centre says it is "a non-profit medical issues research group which is partially funded by the pharmaceutical industry". Where's the public interest?

The suggestion is that men buy Viagra on the internet because it's cheaper and less embarassing. And they think it is like an over-the-counter drug. Could Pfizer make Viagra more cheaply? Is it too dangerous (watch out for the lowering of blood pressure and Pfizer give warning for cardiac risk of sexual activity in patients with preexisting cardiovascular disease) to be over-the-counter? Does it work?

By the way Pfizer is the world's largest pharmaceutical company. Who are the counterfeiters? Are the regulators doing their job?

And finally, Pfizer have even got Dr Mark Porter supporting them in the campaign. Is there a conflict of interest with his BBC job, presenting Case Notes on radio 4 amongst other activities?

State of mind on radio 4

2009-02-09T12:12:00.002Z

Good series has just finished. Listen again, I would say, particularly to episode 2 Altered states and episode 5
Which way now?

Has Terry Prachett got dementia?

2009-02-07T13:03:00.001Z

Terry Pratchett: Living with Alzheimer's 4 & 11 February, BBC Two 9pm. Alzheimer's Disease Society discussion at Talking Point. If he hasn't this backs up the concern about encouraging people to come forward early by the National Dementia Strategy. Who's advising the Alzheimer's Disease Society?

2009-02-06T11:09:00.004Z

BMJ publishes five commentaries on Doctors, patients and the drug industry. Copy of editor's choice page from print journal.

The critical mental health movement is made up of reformers and revolutionaries

2009-02-05T23:00:00.004Z

Phil Barker's review of my edited book Critical Psychiatry has provoked me to reply. Comments please.

Improving NHS dementia care

2009-02-04T23:42:00.007Z

Emma Dent from HSJ's version of dementia strategy. Good to point out that programme of support and counselling at diagnosis can be helpful, although have to be a bit careful about using reduction in institutional care as outcome. The point of the strategy shouldn't just be about reducing number of beds. Relatives may well need respite and even permanent residential and nursing care for demented person considering the burden of care.

How much do care homes make? Are there any figures on this? The government had a choice years ago whether to develop its own provision and chose instead using the profit motive to get enough provision. There's no going back here, but some care owners seem to do quite well out of it. Perhaps they should, but elderly care is not about exploitation.

And I wouldn't like people just to concentrate on information. Looking after someone with dementia has a physical side which must not be ignored. Input is not just about information but also practical help if it's asked for. Dementia care isn't just about advice. Calling people advisors means they may say that's all they can do. What's wrong with calling them consultants? - oh, that's monopolised by the doctors.

Sube Banerjee is right that people do worry they are becoming demented, if that's what he is saying. But it's not just because they really are becoming demented. Information can increase as well as decrease fear, particularly if the problem is incorrectly assessed.

I'm not totally convinced about the resources argument. We have seen a pretty dramatic increase in provision. OK, but so has the rest of medicine as well. As with any mental health care, so much depends on how well it is organised and how good the staff are at understanding what's going on.

I'm not against drop in services. We're supposed to be having them in every local NHS anyway. Are the memory clinics supposed to be part of that set-up? This is getting a bit muddled. I will get to the actual strategy publication soon.

(To be continued)

Dementia strategy published

2009-02-04T23:15:00.004Z

Health Service Journal version. Are clinics the best way forward? Shouldn't people with dementia be seen at home? Isn't this the history of the development of old age psychiatry in this country? Perhaps history is being reversed.

Good that there's a clinical lead. Problem is that it must remain clinical, not some manager or governance person. There's too much of a divide between managers and professionals in the NHS in general, but maybe having a clinical lead for dementia will help resolve this conflict. But then why just for dementia?

As mentioned previously people with dementia, as opposed to people worrying they have dementia, may not be very good at self-refering. Where's the evidence that early intervention makes any difference? As for psychosis, just because people do worse the later you pick it up, does not necessarily mean that intervening earlier would really make any difference.

I'm not convinced by the strong leadership from the Department of Health idea. They're bureaucrats, aren't they? When did they last see a demented patient? Listen to the professionals.

(To be continued)

Maybe the drug companies really are in trouble

2009-02-01T20:48:00.004Z

GlaxoSmithKline to slash 6,000 jobs. Competition from generic manufacturers and doubts about company pipelines are posing a serious threat to the sector and ING analysts warned of an "intellectual property meltdown" as top-selling products come off patent and sales slow dramatically.

I wasn't so sure about this in my book review of Marcia Angell's The truth about drug companies: How they deceive us and what to do about it but maybe she was right.

Don't forget to look at the national dementia strategy this week

2009-02-01T20:20:00.007Z

Health secretary Alan Johnson will unveil the national dementia strategy this week. The government's aim is to raise the profile of dementia, increase early diagnosis and improve the quality of treatment.

There may be a problem with encouraging people to seek early diagnosis. People are not very good at recognising they are dementing. This means dementia may be misdiagnosed when it is really benign forgetfullness or depression.

The drug companies must be laughing about the encouragement of mind-enhancing drugs. These are the same drugs which when I was training were said to be ineffective. Academic old age psychiatrists opposed their introduction then, but now seem to be encouraging the government strategy. Check out any conflict of interest.

Nor do I think there are any intervention studies for changes to diet and lifestyle. Just because there may be associations does not mean they are causal.

Thank goodness for better support for carers but what does it mean?

(To be continued)

Campaign for animals treated with antidepressants

2009-01-26T15:50:00.002Z

An offshoot blog has been created.

Where did depressed, unpredictable dog bite Jacques Chirac?

2009-01-23T09:04:00.009Z

Another story about an animal (this time a dog) being treated for depression. This time the problem is unpredictable depression that caused the dog to bite Jacques Chirac, the ex-French president. As I said in the last post, the only licensed indication is for use in separation anxiety associated with behavioural training. It's not clear that the Chirac's dog has separation anxiety - he's living with them, not separated from them, as far as I know. Nor is there any mention of any other loss in the story. No-one seems to have asked why the dog bit Jacques. Nor does anyone seem very interested in where it bit him. The incident does seem serious though as the story describes it as a mauling and the ex-President was rushed to hospital. Should the depression be allowed to excuse the dog's behaviour?

Dogs are being given pills without the evidence. The story doesn't say what antidepressant Chirac's dog has been given. Presumably it's Clomicalm. This blog is prepared to start a campaign for animals being treated with antidepressants. Maybe it will be listened to more than one about humans.

Maybe as a first step someone needs to ask Novartis, the manufacturers of Clomicalm, how much they are making out of the drug. Help please. Join the campaign.

(With thanks again to Cornishcynders. Where do the stories come from?)

Number of tropical birds that require antidepressants is growing

2009-01-16T16:20:00.005Z

Telegraph story - Parrot is taking Prozac for depression following the death of its owner. Actually it's not Prozac (fluoxetine), probably the most well-known of the newer antidepressants - well, newer in the sense it first went on the UK market in 1989 - but Clomicalm (clomipramine), a traditional tricyclic antidepressant. Most prescribing of psychotropic medication in veterinary medicine is outside licensed indications. According to a recent veterinary psychopharmacology textbook the only label uses in the US for the treatment of behaviour problems are Clomicalm for separation anxiety in dogs and deprenyl for cognitive dysfunction in elderly dogs. So Clomicalm for parrots is unlicensed.

The company product information says Clomicalm was tested in clinical trials involving client-owned dogs. When used in conjunction with behavioural training, Clomicalm accelerated both the time to improvement and the final result of separation anxiety therapy compared to behavioural training alone. So behaviour training is a necessary component of therapy with Clomicalm. Perhaps it doesn't work on its own. The Telegraph story doesn't say whether it worked for the parrot.

(With thanks to Cornishcynders)

Inmates on suicide watch in prison need not be completely naked

2009-01-12T12:26:00.004Z

Guess who's registered the internet domain preventsuicide.com. It's Ferguson Safety Products. Aren't the models sterotypes? I guess the company must make money. Perhaps NICE should consider assessing the evidence for inclusion in its guideline.

(With thanks to Lou Pembroke)

RD Laing: A new film will tell his extraordinary story

2009-01-01T12:21:00.002Z

Story from the Independent - R D Laing: The celebrity shrink who put the psychedelia into psychiatry

Read Bob Mullan's biography

Recommended psychiatry blogspots

2008-12-31T16:17:00.002Z

Not this one but try:

The Carlat Psychiatry Blog

Clinical Psychology and Psychiatry: A Closer Look

Advances in the history of psychology

Pharmalot

New thread for blog

2006-01-20T17:56:00.001Z

I am starting a new thread for people that want to discuss critical psychiatry and engage with the issues.

Advertisments for SSRIs may be misleading

2005-11-17T19:01:00.000Z

Medscape medical news