Misguided medical training in psychiatry

Niall Boyce has clarified in a tweet what he means in a Lancet Psychiatry editorial about the critique of the biomedical model in psychiatry. He thinks the critique is "worth considering". But he is relaxed about it because he knows neuroscientific findings will eventually affect practice. Actually the point of the critique is that this is a myth. Psychiatry has always had this wish and it's about time that it realised that this is "pie in the sky".

And, as Anne Cooke points out in a tweet in response, Niall has conflated his arguments in his rebuttal by promoting a medical training for mental health practice. I've always said that there are advantages to a medical training (eg. see previous post). However, there are disadvantages as well in that it encourages a biomedical approach, which Niall obviously finds difficult to give up.

Reducing psychotropic medication prescribing

Peter Gøtzsche, who I have mentioned before (eg. see previous post), has caused controversy at a Maudsley debate and in a BMJ Head to head by suggesting that psychotropic medication should be reduced to 2% of its current level of prescribing. As far as he is concerned, it "should almost exclusively be used in acute situations and always with a firm plan for tapering off, which can be difficult for many patients".

His argument is that the results of clinical trials are biased by unblinding and what he calls the 'cold turkey' effect of the washout period. Any remaining benefit, if there is any, is not justified by the mortality caused by medication.

Whether psychotropic medication increases mortality is controversial. I have mentioned before (see eg. previous post) that it may create a vulnerability to relapse. People may actually do better if they manage to work through their problems without medication. Peter Gøtzsche's stark presentation of the issue at least encourages this debate, even if it risks overstatement.

Renewing mental health practice

I have been re-reading the final chapter of my edited book Critical psychiatry: The limits of madness. Next year will be 10 years since the book was published. The first chapter outlines the various chapters written by the contributors. The book came out of three conferences held in Sheffield, Birmingham and London in 2001-3.

It's also 16 years since the Critical Psychiatry Network was first formed. I've mused before about the impact of critical psychiatry (see previous post), maybe, as I said, because I am approaching full pension. How should critical psychiatry be taken forward?

Psychiatric research folly

A perspective in Science by Thomas Insel & Bruce Cuthbert should make american psychiatry fearful about the scientific credibility of its NIMH director. He's gone completely 'over the top' in his speculation about RDoC and precision medicine (see previous post). He thinks there's been a "tectonic shift" to now considering mental disorders as brain disorders. Following his lead, this folie à plusieurs has apparently led to "nearly 1000 papers addressing various aspects of RDoC over the past year". 

I've made fun of Daniel Amen suggesting there are 7 types of ADD (see previous post). However, Insel believes three subtypes of ADHD have been discovered with different responses to stimulant medication. He suggests biologically meaningful subgroups of psychotic or mood disorders are being discovered. He does admit these are "preliminary reports" and the "results will need replication". RDoC domains are supposed to be better at predicting length of hospital stay or hospital readmission than symptom-based diagnoses. 

Even though Insel accepts that "many challenges must be faced", I'm sorry but I'm not part of what he calls the "emerging consensus that such new approaches are necessary to move the field forward". Psychiatry's going 'off beam'. People may appear to be going along with Insel because he holds the research funding purse strings. His speculation builds on his 'brain circuitry disorders' concept of mental illness (see previous post). Science demeans its name by publishing such phantasy.

Being explicit about the nature of mental illness

I am not sure why Ketan Jethwa has moved to a core training post in medicine from an academic psychiatry training post. Could it reflect his disillusionment with psychiatry or is he wanting to ensure  an adequate medical foundation for his psychiatric career? I don't want to undermine him because he has written a good quality article for BJPsych Advances. However, I think his piece does require comment.

He suggests psychiatry has an identity crisis because of the nature of mental illness. I'm not sure if I would call it an 'identity crisis', but I agree that how the nature of mental illness is understood does matter. Jethwa argues for psychiatry being a clinical neuroscience and suggests, following Bullmore et al (2009) (see previous post), that British psychiatry over recent years has taken an increasing 'neurophobic' position. He goes on, "It is imperative that the scientific underpinnings of psychiatry are explicit within mental health services and in interactions with patients and the public in general". The trouble is that he hasn't been explicit about the neuroscientific basis of psychiatry. He seems disappointed that psychiatry can't be more explicit. I have said before (eg. see previous post) that modern psychiatry is setting itself up to disillusion trainees by promoting neuroscience as the solution to mental illness in the way Jethwa hopes it can be. I fear that it may have lost another good quality trainee in his case. I hope I'm wrong!

Bipolar craziness

Much of Edward Shorter's recent book, What psychiatry left out of the DSM-5: Historical mental disorders today, is, to my mind, speculative nonsense. However, there is a chapter on 'Bipolar craziness', which I think has some useful references. I've mentioned before (eg. see previous post) how the concept of bipolar spectrum has extended during my working lifetime to a notion whose meaning must be questioned. As Shorter says at the end of his chapter:-

Unlike in previous editions, when DSM- 5 was launched in 2013 the discussion of bipolar disorder was no longer merely a section of an "affective disorders" chapter but had a chapter of its own, as though the previous hundred years of world psychiatry had never existed.

Unipolar and bipolar disorders are now seen as separate disorders whereas they used to be seen as two subcategories of manic-depressive illness. I am not necessarily saying that the previous way of looking at this diagnostic issue was better, but it is clear that at least some of the motivation for the change has been to promote mood stabilisers for bipolar disorder (see eg. previous post).

It's suggested antidepressants should be avoided in treating patients with bipolar disorder in favour of mood stabilisers. However, I've also mentioned before that the risk of manic switch when using antidepressants has been exaggerated. NIMH has endorsed the use of the diagnosis bipolar disorder not otherwise specified to categorise bipolar disorder as on a spectrum (see press release). It affirmed that such patients were being inappropriately treated by giving antidepressants or other psychotropic medication in the absence of mood stabilisers. However, systematic reviews have not found evidence that switching to mania is a complication of antidepressant treatment (Gijsman et al 2004, Visser & Van Der Mast 2005). In a placebo-controlled trial, use of adjunctive, standard antidepressant medication, as compared with the use of mood stabilisers, was not associated with an increased risk of treatment-emergent affective switch (Sachs et al 2007). Moreover, there was no difference in efficacy.

The limitation of medication, whether antidepressants or mood stabilisers, needs to be recognised. Just because antidepressants are not always effective does not necessarily mean that even mood stabilisers will be helpful in so-called bipolar spectrum.

Madness in civilisation

I'm not sure if it really works, as I did in my previous post, collecting together tweets of quotes or amended quotes from a book which I've sent when I'm reading it. Another book I've recently read is Andrew Scull's Madness in civilization: A cultural history of insanity from the Bible to Freud, from the madhouse to modern medicine. It has been reviewed by Phil Thomas on Madness in America. I don't think the book is as good as some of Scull's previous books, such as Madhouse (see my BMJ review). It's trying to provide a wide-ranging survey of the history of madness over the last 3000 years. 

What I tweeted about from Scull's new book was the way that we seem to need myths to understand madness and illness in general. For example, the theory of the four humours - blood, phlegm, black bile and yellow bile - remained a major influence in understanding the working of the body until well into the 1800s. But we haven't really advanced:-

DBDouble Biomedical hypothesis justifies modern psychiatric practice in same way as humoral theory justified bleeding, purging and use of emetics 29/03/2015 10:56

DBDouble Humoral theory of disease was immensely powerful, making sense of symptoms and pointing the way towards remedies for what had gone wrong. 28/03/2015 20:22

DBDouble Humoral theory provided reassurance to the patient and an elaborate rationale for the interventions of the physician 28/03/2015 20:24

This wasn't the only theory:-

DBDouble Religious and secular, supernatural and what purported to be naturalistic explanations of illness persisted down the centuries 28/03/2015 20:27

DBDouble Notion that madness might sometimes be a means to truth (divine madness, as some would have it) would resurface repeatedly 28/03/2015 20:27

Furthermore:-

DBDouble Anti-phlogistic physicians saw disease as fundamentally a problem of inflammation and fever. 28/03/2015 20:29

DBDouble Bleeding, purging and making use of emetics, all designed to counteract and to deplete the over-active, over-heated body 28/03/2015 20:30

DBDouble Religious and spiritual interventions might be tried alongside the bleeding, purging and emetics of the anti-phlogistic physicians 28/03/2015 20:31

So, the notion of chemical imbalance in the brain (eg. see previous post) even though it's wrong, like humoral theory, persists because it provides an 'aura of factuality' (see previous post). The historical perspective provided by books like Madness in civilisation helps us to realise that modern claims about brain dysfunction in mental illness are not really facts but part of a myth, even delusion, to suggest an understanding of mental illness and justification for its treatment.

Pathologist of the mind

As I have been reading it, I have been tweeting quotes or amended quotes from Pathologist of the mind: Adolf Meyer and the origins of American psychiatry by Susan Lamb (who I have already quoted in a previous post). I thought I would bring some of these tweets together to try and explain the importance of Adolf Meyer's work.

Susan's book (see her website) is a scholarly account that the literature has needed. Meyer himself failed to be explicit in getting across his theory of psychiatry, which was called Psychobiology (eg. see my article). Susan includes clinical material from his archives which also helps to relate his theory to his practice.

As Susan says in her conclusion, one of the key insights is that:-

DBDouble Meyer viewed mental activity and brain activity as a single biological response 24/04/2015 13:12

She goes on, "to overlook this principle is to risk misconstruing Meyer's thinking, practice, and teaching". Or, as she says in another tweet:-

DBDouble The tendency to equate the descriptor 'biological' with 'physical, bodily or somatic' can render anything Meyer said or did unintelligible 08/03/2015 20:15

The second key insight is "to appreciate the essentially medical orientation of Meyer's thinking, practice, and teaching". For Meyer:-

DBDouble Mental dysfunction, as much as brain disease, is a medical condition resulting from pathological processes 08/03/2015 17:34

This meant that:-

DBDouble Meyer framed prevalent forms of mental illness not as distinct brain diseases, as did majority of his peers, but as failed adaptation 08/03/2015 17:37

This is why I have emphasised the views of Adolf Meyer in discussions of psychiatric diagnosis on this blog (eg. see previous post). Meyer was also clear that:-

DBDouble Brain research is comparative neurology not psychiatry 08/03/2015 20:58

In other words, Meyer warned against going beyond statements about the person to wishful 'neurologising tautology' about the brain. Even though:-

DBDouble Kraepelin was part of first wave in the generational backlash against the hegemony of brain mythology in the late 19th century 26/03/2015 16:59

DBDouble Meyer lamented the Kraepelinian craze to diagnose, classify and to generate statistics 26/03/2015 17:11

Meyer took over the Huxleyan notion of science as being organised common sense. 

DBDouble Science is defined by application of rigour to observing, documenting, comparing and ordering data 08/03/2015 22:01

DBDouble Science is not defined by principles of physics or chemistry, nor by experimental techniques 08/03/2015 22:00

In summary:-

DBDouble Psychobiology provided basis to liberate psychiatry from dogma that explained mental activity in reductive, dualistic or deterministic terms 24/04/2015 13:09

To emphasise, Meyer was primarily interested in the implication of these ideas for clinical practice. 

DBDouble Meyer was no philosopher. He was a pathologist on a mission 17/03/2015 08:59

Susan also agrees with me in my spat with Nasser Ghaemi (see previous post) that:-

DBDouble The pluralism of psychobiology was neither arbitrary nor uncritical 17/03/2015 09:00

No one should believe the chemical imbalance theory

A post on Slate Star Codex argues that the idea that "depression is a drop-dead simple serotonin deficiency was never taken seriously by mainstream psychiatry". There may be some truth in this view, but there's no doubt that many people have been taken in by the theory (see eg. previous post). They're surprised that the theory hasn't been proven. They may even have been told by a psychiatrist that their depression is due to a chemical imbalance.

And there's no doubt that drug companies have taken advantage of these beliefs as shown in the Zoloft (sertraline) advertisement above. True, the commercial does say that the cause of depression is unknown. But it then goes on to suggest that sertraline corrects a chemical imbalance to which depression may be related. And Slate Star Codex doesn't want to totally abandon the idea that "it's very likely it [depression] will involve chemicals in some way".

Actually, the 'chemicals in depression' may not be much different from those that create normal feelings. It may not make much sense to view depression as a neurochemical disorder. The kinds of processes that underlie mental illness at the biochemical level may be no different from those that produce thoughts, feelings and behaviour amongst the 'normal'. We tend to assume that there must be a neuropathological basis for mental illness, as there is a pathological basis for physical illness. But 'mental illness' is very different from physical illness, if only because of the mind-body philosophical problem.

And, the sertraline advert is also misleading in that it says that sertraline "is not habit forming". Antidepressant discontinuation problems do occur with SSRI antidepressants, like sertraline (eg. see previous post). It's not surprising that people may get psychologically dependent on a drug which they think has improved their mood (see my book chapter).

Psychiatrists do believe psychosis is a brain disease

Ronald Pies (whose recent book I have reviewed) has criticised the BPS report on psychosis (see previous post) in a Psychiatric Times article for underestimating the potential seriousness of psychosis and misconceiving its nature by focusing on hearing "voices". I agree that the report, for example, does not try and distinguish psychosis from dissociative identity disorder, in which people may also hear voices.

Pies also says that the report's argument against descriptive diagnosis is "historically ill-informed and medically naive" for suggesting psychiatric diagnosis should provide an explanation of people's problems. Again, I agree that psychiatric diagnosis is primarily phenomenological, in that it involves assessment of a person's mental state. Nor, as Pies says, is the "existence of societal prejudice and discrimination" a valid argument against psychiatric diagnosis, as inevitably the implication of a psychiatric diagnosis is that something has 'gone wrong' with the person's psychosocial functioning.

As I have explained in my book review, where I do have a problem with Pies is that I do not think he sufficiently knowledges that minds are not reducible to brains. For example, in another Psychiatric Times article on the BPS report, he says that "schizophrenia is often associated with neuropathology". He deliberately highlights the word "associated" because he does not want to imply causation necessarily. However, he tends to imply just that and it's difficult to see that he means otherwise. Psychiatrists do believe schizophrenia and psychosis are brain diseases and I think Ronald Pies does as well.


(With thanks to Around The Web post on Mad in America)

The psychogenic legacy of Adolf Meyer

Useful paper by Jordan Devylder on Adolf Meyer's psychogenic model of schizophrenia (dementia praecox), relevant to a previous post, summarises what I have been trying to say about Meyer. The article describes the development of Meyer's psychogenic theory in the context of related work in the period from Kraepelin to Bleuler. It reminds us that Kraepelin provided a "provisional and very indefinite" hypothesis that the biological cause of dementia praecox was intoxication from the sex glands causing a poisoning of the brain during puberty. As Meyer said, this was a theory that was "so vague as to demand consideration only if actual facts can be adduced and other facts should fail".

The article argues that we are beginning to see a revival of Meyerian psychiatry. I'm not convinced by Devylder's attempt to link this with the stress-vulnerability model, which is essentially still biomedical. However, as he says, "Meyer's legacy ... is the psychogenic perspective" (see my chapter The biopsychological approach in psychiatry: The Meyerian legacy in my edited book Critical psychiatry: The limits of madness).

The importance of antidepressant discontinuation problems

Giovanni Fava (who I have mentioned in a previous post) et al (2015) have produced what seems to be the first systematic review of clinical aspects of the discontinuation of serotonin specific reuptake inhibitor (SSRI) antidepressants. As they point out, the limited attention to this topic is surprising, considering its importance as SSRIs are widely used in practice.

Discontinuation symptoms may occur with any type of SSRI but seem to be more frequent with paroxetine. Gradual tapering does not eliminate the risk. The syndrome typically occurs within a few days and lasts a few weeks but many variations are possible, including late onset and/or longer persistence. A wide range of psychological and physical symptoms may occur. As I mentioned in a previous post, a survey has confirmed that the primary symptom is anxiety. In my book chapter, Why were doctors so slow to recognise antidepressant discontinuation problems?, I made reference to the paper by Schatzberg et al (1997), which described the core psychological symptoms as anxiety/agitation, crying spells and irritability. That paper also divided the physical symptoms into five clusters: disequilibrium, gastrointestinal, flu-like, sensory and sleep disturbances. There are many similarities with the withdrawal symptoms from benzodiazepines and other antidepressants. Discontinuation symptoms may easily be misidentified as signs of impending relapse.

As Fava et al point out, the use of the term 'discontinuation syndrome', rather than 'withdrawal syndrome' was heavily supported by the pharmaceutical industry to emphasise that SSRIs do not cause addiction or dependence. I have always emphasised the psychological dependence caused by SSRIs since my letter to the BMJ and my Antidepressant discontinuation reactions website. This vulnerability should not be minimised.

The miracle of psychiatry

Like Robert Whitaker (see previous post), I bought Shrinks: The Untold Story of Psychiatry by Jeffrey Lieberman (see eg. another previous post) because I intended to blog on it, but after reading it, I initially thought I wouldn't bother (see Robert's blog post).  Lieberman makes claims about brain abnormalities associated with mental illness, which need challenging. However, it's difficult to do so, because there are no references in the book, although there is a list of sources and additional reading at the end. I'm also not sure what has been untold about his story of psychiatry, because there doesn't seem to be much new in the book. Perhaps he thinks that what he calls anti-psychiatry has the dominant narrative in the history of psychiatry and he needs to replace it with his own.

Like Robert, what grated on me was the messianic nature of the book. Lieberman needs to be more circumspect about his claims for psychiatric treatment effectiveness. His tale of psychiatry, as he himself says, is of the "dramatic transformation from profession of shrinks to profession of pill-pushers". Although he is "under no illusion that the specters of psychiatry's past have vanished, or that my profession has freed itself from suspicion and scorn", he believes in the "mind-boggling effectiveness of medication". Steady on! He describes what he calls the "accidental discoveries of miracle medications". The introduction of psychiatric medications may well have been serendipitous but was it miraculous? When chlorpromazine was first introduced in state-funded mental institutions in America, as far as he is concerned, "the results were breathtaking". His enthusiasm for psychiatric medication extends to ECT. This is because he's seen "patients nearly comatose with depression joyfully bound off their cot within minutes of completing their ECT". As Robert Whitaker says, this is "a modern-day story of Jesus, curing the lame, who could now throw away their crutches and walk".

At the beginning of the book, Lieberman gives the history of a psychotic patient he calls Elena Conway, the daughter of a well-known celebrity. Three weeks treatment with risperidone, "a very effective antipsychotic medication", as far as he is concerned, and care in hospital led to a "dramatic improvement". The trouble is that he doesn't say what happened to Elena long-term, apart from suggesting that if she had carried on with aftercare treatment she would have had a "good recovery". Shouldn't we be told if she had a poor long-term outcome?

The combination of psychiatrists' belief in their treatments and patients' faith in psychiatrists may produce a powerful placebo remedy. Psychiatrists, like Lieberman, may be deluded into believing that their prescribing is having specific effects. Lieberman suggests that "instead of Daniel Amen's unproven claims for SPECT-based diagnosis of mental illness [see previous post], we will have scientifically proven methods of diagnosis [in the future] using brain-imaging procedures". But such simplistic and biologically reductionist accounts of mental illness are no different from those of Amen or some of the historical treatment excesses Lieberman describes in the book. Such faith and self-deception still sustains modern pharmacotherapy. The wish-fulfilling claims of modern psychiatry need to be shrunk to more realistic proportions.

"There are serious critics of psychiatric diagnosis and ... treatment ..."

Allen Frances, who I have mentioned in a previous post, has been attacked by Paula Caplan (see her article) for being very well paid by Johnson and Johnson (J&J) for producing guidelines which promoted the use of its drug, risperidone, as "first choice" in schizophrenia. Frances, in reply, argues that this is what he believed at the time, but admits it was unwise to have done this with drug industry funding. It suited both doctors and patients to believe that the atypical antipsychotics, like risperidone, were an advance in treatment (see my OpenMind column).

There has also been illegal over-marketing of risperidone. J&J pleaded guilty to a misdemeanor criminal charge of improperly marketing risperidone as a treatment for elderly dementia patients (see NYT article). It has also settled in cases where it has been accused of other "off-label" marketing, particularly in children, and of overstating the safety and effectiveness of the medication (eg. see report on Texas case).

Even some of the most biomedical of psychiatrists have expressed concern about unethical practice in psychiatry (eg. see my book review). The corruption of modern psychiatry does influence the academic debate about diagnosis and treatment (eg. see previous post).

Critical psychiatry position on schizophrenia

Joanna Moncrieff and Hugh Middleton, the co-chairs of the Critical Psychiatry Network, have produced a critical psychiatry perspective on schizophrenia (see article). They argue that the concept of 'schizophrenia' is neither valid, nor useful, and suggest replacing it with more generic concepts such as 'psychosis' or 'madness'. The replacement of the term 'schizophrenia' by 'psychosis' has already happened to some extent in everyday clinical practice, as reflected in the updating of NICE guidance, now called Psychosis and schizophrenia in adults: treatment and management, whereas previous editions just referred to schizophrenia. The recent BPS report was also entitled Understanding psychosis and schizophrenia (see previous post).

Psychosis, like schizophrenia, is of course not an absolute concept and there may well be clinical disagreement about whether mental symptoms should be seen as psychosis. Jo and Hugh argue against the suitability of seeing mental disorders as illness and disease. As I have said before (see eg. previous post mentioned above), I do not have a problem with the term 'mental illness'. As I see it, the critical psychiatry position is that mental illness, such as schizophrenia, is not a brain disease.

It is true, as Jo and Hugh note, that Emil Kraepelin formulated the concept of dementia praecox (which was renamed schizophrenia by Eugen Bleuler) "with the goal of delineating something whose biological origins could then be uncovered". What they don't mention is that Adolf Meyer argued at the time against the attempt to create disease entities in psychiatry (see eg. Meyer's 1906 paper). As expressed by Susan Lamb (whose paper I have mentioned in a previous post) in her book Pathologist of the mind (see her website):-

A patient did not contract a disease called schizophrenia any more than he or she became a schizophrenic, both of which implied that the disorder was an ontological entity distinct from the person. He [Meyer] urged that many prevalent forms of psychopathology were not the result of an attack on the organism (like syphilitic insanity, for example) but developed as part of its adaptive performance. "Every individual is capable of reacting to a very great variety of situations by [adopting] a limited number of reaction types," Meyer proposed in 1906, and he deemed this true of both healthy and pathological reactions. Schizophrenia ... described a particular type of maladaptation. Rather than a nosological term, then, he suggested a diagnostic adjective that would precede the term reaction-type. Instead of schizophrenia, he proposed "schizophrenic reaction-type."

Bleuler, like Kraepelin, also assumed that schizophrenia ultimately derived from an unknown organic cause. He nonetheless attempted to understand the psychological conflict that triggered the latent disease. Against Kraepelin, he disputed that schizophrenia was a degenerative condition. Schizophrenia has always been essentially a phenomenological diagnosis, even if the assumption is made that an underlying biological cause will be found. Jo and Hugh concede that "certain patterns might be recognised". The usefulness or validity of the term schizophrenia may depend on the identification of these patterns. Like Meyer, though, I agree the problem with any attempt at psychiatric classification is the reification of psychiatric concepts, such as schizophrenia. If the concept 'schizophrenia' is of value, it does not represent an entity or a thing. 

Psychiatric indignation

Jeffrey Lieberman (who I have mentioned in a previous post) is angry about Tanya Luhrmann's article in The New York Times (see his video post on Medscape Psychiatry). He's worried that people reading Luhrmann's article may think they don't have a mental illness when they do and, thereby, not get the treatment they need. He's also clear, despite what Luhrmann says, that antipsychotic drugs correct a biological abnormality. He must know that he can't say psychosis is due to dopamine hyperactivity, just because antipsychotics may block dopamine, so I don't understand what he means. I do agree with him, though, that it's stretching a point to align Thomas Insel's rejection of DSM-5 (see previous post) with the thesis of the BPS report on psychosis (see another previous post). Insel is still very much a biological psychiatrist (e.g. see another previous post).

Lieberman is indignant that he has to deal with an anthropologist, like Luhrmann, commenting on such a "disciplined, bound in evidence, and scientifically anchored" subject such as psychiatry. Luhrmann in fact studied psychiatry by participant observation in her excellent book Of two minds. What Lieberman finds difficult is any scepticism about the effectiveness of psychotropic medication. As he says, debate about this issue should be encouraged.

Is the insanity defence valid?

Peter Kinderman's latest post on the Salomons blog questions whether we need the idea of mental illness in criminal justice. He's not saying that the criminal justice system shouldn't take account of people's personal and social circumstances. But he is worried that courts may think that mental illness makes people commit crimes. In fact, as I've pointed out before in a previous post, he doesn't think there's a place for psychiatric diagnosis.

It does worry me that the critical mental health movement gets caught up in an apparent split about the validity of the insanity defence. Thomas Szasz, of course, famously argued against the insanity defence, as he did not believe in the notion of mental illness. Essentially, he thought there is no need for any specific mental health legislation (see eg. previous post). Whilst I agree that mental health services should not insist that people accept that their problems are symptoms of an underlying illness, Peter seems to be verging, at least, on rejecting the notion of mental illness altogether. We might benefit from more clarity about whether he thinks there should be a Mental Health Act.

The point is that what is designated as mental illness may lead to mental incapacity. People who are psychotic may not make the  most rational of decisions because of their mental illness. Crimes, including homicide, may be committed for psychotic reasons. It is generally accepted that it is wrong to punish a person deprived, even if only temporarily, of the capacity to form a necessary mental intent that the definition of crime requires. People should be presumed to have a sufficient degree of reason to be responsible for their crimes unless the contrary can be proved. But, in some cases people do appear to have acted irrationally because of mental disorder in committing their crime.

The legal test of criminal insanity in England was developed in the trial of Daniel McNaughton. On the 20th January 1843, Daniel McNaughton fired a pistol at point blank range into the back of Edward Drummond, the private secretary of the Prime Minister, Robert Peel. McNaughton may well have  thought he was shooting the prime minister. In the magistrates court the next day he said, "The Tories in my native city have compelled me to do this. They follow, persecute me wherever I go, and have entirely destroyed my peace of mind." Although the court did not examine whether there was any element of truth to his claim and it was not explained why he had a bank receipt for a large sum of money on him when arrested, both the prosecution and defence agreed he suffered from delusions of persecution. No medical evidence was offered to say he was not deluded and the jury returned a verdict of not guilty by reason of insanity. McNaughton was admitted to Bethlem hospital and transferred to Broadmoor when it opened, where he died in 1865. His diminished responsibility for the homicide was accepted on the basis of his mental illness.

In practice, courts may well be sceptical of psychiatrists' assessment of mental illness. For example, see my post about the case of Anders Breivik. I do understand what Peter means when he asks whether we really need the notion of mental illness to determine a Court adjudication. He seems happier with the notion of psychosis, so maybe we should use that term. Whatever we call it, mental dysfunction can diminish responsibility for a crime. Personally, I am happy to see such psychotic dysfunction as illness, in the same way as bodily dysfunction is illness. The real problem is seeing mental illness as brain disease (e.g. see another previous post).

Lowlights of Royal College of Psychiatrists' conference

Guess what events have been highlighted by the Royal College of Psychiatrists (RCPsych) in its publicity (sent to me by circular email) for its International Congress this year. Remember this conference is for psychiatrists and what their interests are. The top three are:-

(1) Neurostimulation: Current evidence for the management of depression. The evidence base for transcranial magnetic stimulation (rTMS) (see previous post), transcranial direct current stimulation (tDCS) and deep brain stimulation (DBS) will be described. rTMS uses a magnet to stimulate the brain, tDCS passes electrical current through two electrodes placed over the head, and in DBS a pair of electrodes is implanted in the brain and controlled by a generator placed in the chest. The idea seems to be that stimulation of the brain, however crude, will stop it causing depression. And, there's no need to cause an epileptic fit, as with ECT. Exciting stuff apparently!

(2) Disorders at the interface of neurology and psychiatry. A day course on neuropsychiatry - this must be proper medical psychiatry. Better learn about new disorders such as autoimmune encephalitis and c9orf72 gene mutation, in case they are relevant to mainstream psychiatry. Huntington's Disease features in a session and is probably only regarded historically as a psychiatric disorder, rather than neurological disorder, because some of these people ended up in asylums. I'm not quite sure why factitious disorder features so prominently in another session, as I would have thought whether symptoms are functional or feigned is a psychiatric rather than neurological problem. As I said in a previous post, "Psychiatry, unlike neurology, is not based on treating a physical lesion". Trouble is psychiatrists are attracted to neuropsychiatry because they want to believe there's no difference between neurological and psychiatric disorders. That's a specialist way of avoiding having to deal with mainstream psychiatric problems, and apparently popular and far more interesting.

(3) Immune pathogenesis of psychosis. Surely there's no evidence that schizophrenia is an immunological disorder. This sessions sets out to suggest otherwise. The MRC has even funded the PiPP study to look at the prevalence of neuronal cell surface antibodies in patients with psychotic illness. There is even a hypothesis that cytokine-mediated events are the key pathogenic event in schizophrenia. Immune based treatment studies are considered a realistic option. I suppose it's fun that such speculations are followed up, and it keeps researchers in a job. I guess they just shrug off their disillusion when they don't make progress.

Academic psychiatry seems to have been well and truly remedicalised, in the sense that it focuses on what it thinks is the expertise of psychiatrists as medical doctors. I find it sad that psychiatry has so narrowed itself to a physicalist perspective and now presents this as an exciting advance.

Critical psychiatry doesn't get any space in RCPsych congresses. In fact, submitted proposals have been turned down. It's a shame that mainstream psychiatry can't be more broadminded.

The future of psychiatry depends on not being reductionist

I wanted to follow up the comment on my previous post by Allan Seltzer. As he says, "Mind cannot be reduced to brain". To be clear, mind is enabled but not reducible to brain. Psychiatry hasn't always been as clear about this as it should have been. In fact, it has always hankered after a simple reductionist solution to the issue of mental illness. It tends to think the problem must be a brain disorder, but this is an illusion. We're surprised when this is pointed out and it seems to leave us with too complex a clinical situation to manage. So we naturally shy away from it.

Is it realistic to think that psychiatry's future may be non-reductionistic? Probably not! Psychiatry hasn't changed much since its modern inception with the introduction of the successful anatomoclinical way of viewing disease. It's understandable that mental illness has been expected to follow the path of physical illness, which is seen as being caused by bodily pathology. The trouble is that it doesn't. I agree with Allan that psychiatry should become non-reductionistic. But there are too many entrenched interests to be overcome, not least that much of research is based on hoping for the physical clue to mental illness. People will continue to wish for a simple, quick, cheap, painless and complete cure for their mental health problems. It's easier if the solution's in the brain.

The myth of brain abnormality causing mental illness

It may seem surprising, but modern psychiatry is based on the myth of biochemical imbalance in the brain causing mental illness. Some psychiatrists may protest that their perspective is broader than this. Of course they take into account the personal views of patients and the situation in which patients find themselves. But, in the end, psychiatrists have a belief that what has caused patients' mental health problems are brain abnormalities. That's why medication is needed to correct these abnormalities.

I was struck by a comment made to me by Anne Cooke, who edited the British Psychological Society's recent report on psychosis (see previous post). When doing the rounds of media interviews to promote the report, she said that what journalists found surprising was that she was saying that psychosis may not be a brain condition. Our cultural perspective has become so imbued with this notion that to challenge it seems out of order. But, it does need to be challenged. It's wrong! What's of concern is that modern psychiatry is based on this myth.

The Gorizian experiment

There will be a book launch and discussion of John Foot's new book on Franco Basaglia: La "repubblica dei matti". Franco Basaglia e la psichiatria radicale in Italia, 1961-1978 (Feltrinelli, 2014) at 5.30 pm on Wednesday 4th February 2015 at Bloomsbury Room G35, Institute of Historical Research (IHR), Senate House (Malet St, London, WC1E 7HU). Discussants: Howard Caygill and Barbara Taylor. Chair: Ilaria Favretto. For updated information see event details at IHR. 

An English edition The man who closed the asylums will be available in August 2015. To quote from the blurb:-

Asylums incarcerate the "mad" and exclude them from society. Gorizia, a grim mental asylum, right on the edge of Italy, miles from anywhere, was no exception. Yet, when a new director was appointed in 1961, everything changed. Drawing on the writings of Erving Goffman and Michel Foucault, interested in experimental "therapeutic communities" in the UK, the work of Frantz Fanon, and the ideas linked to radical psychiatrists like Felix Guattari, Franco Basaglia was convinced that the entire asylum system was morally bankrupt. So he decided to abolish it. This is the first comprehensive account of Basaglia's revolutionary approach to psychiatry and mental health. The book is a gripping account of one of the most influential psychiatrists of the twentieth century.

Basaglia's influence has not always been assessed positively in the literature in english, particularly as he is seen as the architect of law 180, passed by the Italian parliament in May 1978. This law prevented new admissions to existing mental hospitals and decreed a shift of perspective from the asylum to treatment and rehabilitation in the community with diagnosis and treatment beds in general hospitals. The asylums actually started reducing in size in the UK and USA before Italy. Even though there has been controversy about Basaglia, the traditional asylums have come to be closed anyway as they became increasingly irrelevant to modern mental health practice. The historical perspective in the book on the origins of Basaglia's anti-institutional practice in Gorizia provides a corrective to some of the misunderstandings in the english literature.

PsychoPolitics in the Twenty First Century: Peter Sedgwick and radical movements in mental health

Call for papers for conference on Peter Sedgwick's Psychopolitics (see flyer). Proposals to sedgwickconf2015@hope.ac.uk by 27th February 2015. In the meantime, read Mark Cresswell & Helen Spandler (2009) on Sedgwick's legacy for the politics of mental health.

What does it mean to say psychotic experiences are symptoms of an illness?

I have been reading the report by the Division of Clinical Psychology Understanding psychosis and schizophrenia. The report states that calling experiences, such as hearing voices and feeling paranoid, symptoms of mental illness is "only one way of thinking about them, with advantages and disadvantages" (p. 6). It says that "not everyone agrees that there is an underlying illness" (p. 7). It goes on, "The idea that they [experiences such as hearing voices] are symptoms of illness, perhaps caused by some sort of chemical imbalance or other problem, is just one of the theories. There is no objective biological test such as a blood test or scan for diagnosing mental illness" (p. 17).

In the section on the advantages of seeing such experiences as mental illness, Laura Lee, one of the contributors to the report, is quoted as saying, "If the concept of illness was extended from biology to include our emotional/spiritual/thinking and meaning-making faculties we would have a holistic approach which would offer more" (p. 25). I agree with Laura (although may not make as much of the spiritual reference). I think the rest of the report could have been clearer on this point. There's nothing intrinsically wrong with using the term 'mental illness'. Although the terms illness and disease are used interchangeably, there are specific meanings. To quote from Eric Cassell in The Healer's Art, "Disease is something an organ has; illness is something a ... [person] has". The error is to think mental illness is a brain disease.

Psychiatric orthodoxy

I've just taken the Amen Clinic ADD type questionnaire. I didn't know that Daniel Amen had suggested there are 7 types of ADD: classic, inattentive, overfocused, temporal lobe, limbic, ring of fire and anxious; and that this matters for treatment. For today's special price of $77, I could have started healing my ADD, but I decided not to go ahead, despite the marketed attractive benefits of "improving attention and focus, boosting positive behaviour, and reclaiming my mental edge".

A Washington Post article called Daniel Amen the most popular psychiatrist in America. I doubt whether Amen likes critical psychiatry, which doesn't have that much of a following. I'm obviously not making enough outlandish claims (eg. see previous post). Amen recommends a SPECT brain scan as part of psychiatric assessment, when it isn't indicated. As the Washington Post article says, Amen's "claims are no more than myth and poppycock, buffaloing an unsuspecting public". In a Telegraph interview, he defends himself by saying, "If I'm defrauding them [patients] how would I stay in business for decades ... ?". The answer is that regulation of his practice is poor. As the Washington Post article, again, says "the man has grown fabulously wealthy — he lives in a $4.8 million mansion overlooking the Pacific Ocean — by selling patients a high-priced service that has little scientific validity, yet no regulatory body has made a move to stop him".

Gina Pera, who recently called Peter Kinderman a 'nincompoop' (see his Mad in America blog post), was influenced by Amen. I've said before (see previous post) that Peter can express the essence of critical psychiatry better than me, although I don't totally agree with his views. To take a quote from his Scientific American blog:-

It’s all too easy to assume that mental health problems — especially the more severe ones that attract diagnoses like bipolar disorder or schizophrenia — must be mystery biological illnesses, random and essentially unconnected to a person’s life. But when we start asking questions about this traditional disease-model way of thinking, those assumptions start to crumble.

Amen and Pera may have taken the biomedical assumption to extreme, but it's still the same biomedical assumption. Trouble is that Peter and I are more likely to be seen as unorthodox than them.

Global human rights violations in mental health

Following up my previous post about global mental health, I understand the motivation of #FundaMentalSDG to include mental health as one of the UN sustainable development goals post-2015 (see their blog post). I don't think we should look away from mentally ill people being neglected and abused, including being "tied to beds, kept in isolation in psychiatric institutions, being chained and caged in small cells, and being physically abused by ‘traditional’ healing practices" (see Guardian documentary).

However, I worry about saying that mental illness affects 1 in 4 in the world, as though it is almost normal. And, by saying that mental illness is treatable, implying that the simple answer is psychotropic medication. Management of mental illness may not just be a problem in low and middle income countries. The madwoman in the attic in Jane Eyre may not be that much different from the practice of pasung in Indonesia (see ABC News item on documentary "Breaking the chains"). The commitment of the Indonesian government to eradicate the practice is to be welcomed. Further measures need to be taken to protect the human rights of the mentally ill worldwide.

Important developments in psychiatry

From a survey of mental health experts, Mark Micale has produced a list of the 12 most important changes in American psychiatry since World War II (see article).

1. The ‘psychopharmacology revolution’ of the 1950s.
   
2. Deinstitutionalization, or the movement of massive numbers of psychiatric patients out of state asylums into community health care facilities.
3. The ‘decline and fall’ of psychoanalysis.
4. Shifts in the practice of psychotherapy from psychiatrists to non-medical professionals, especially clinical psychologists and clinical social workers.
5. The rise of a vast scientific research programme, including massive institutional and financial resources, for studying the neurochemistry and neurobiology of mental illness.
6. The introduction and widespread adoption since the 1980s of a new generation of antianxiety and anti-depressant compounds, especially the so-called SSRIs such as Prozac (fluoxetine).
7. A steady increase in the influence of the pharmacology industry throughout the psychiatric profession (e.g. ‘big pharma’).
8. The growth in influence of the Diagnostic and Statistical Manual of Mental Disorders.
9. The multiplication of ‘new’ diagnoses.
10. The de-pathologizing of homosexuality
11. The emergence or expansion of particular subfields of psychiatry, most notably geriatric psychiatry and child psychiatry
12. The changing role of the mental health insurance industry and the coming of a managed care model of health services
    

Heh, critical psychiatry, or even anti-psychiatry, isn't important! And, young people mention mental health blogging, which doesn't feature in the main list. So, perhaps I should go on with this blog.

Outlandish claim about chemical deficiency in depression

Juliette Jowit makes a case in a Guardian comment that parity of esteem in mental health services is a scientific necessity rather than a gracious concession. She rightly indicates that Freud may well have thought that psychoanalysis would be replaced by psychopharmacology. However, she's been badly misled by Tim Cantopher in his book Depressive illness. The curse of the strong. She correctly quotes from Cantopher:-

If I were to perform a lumbar puncture on my patients (which, new patients of mine will be pleased to hear, I don't) I would be able to demonstrate in the chemical analysis of the cerebrospinal-spinal fluid (the fluid around the brain and spine) a deficiency of two chemicals.

Piffle! Cantopher doesn't just not do a lumbar puncture on his patients because it's an unpleasant investigation. It wouldn't show what he suggests. He might be 'struck off' by the GMC for doing an inappropriate investigation. Jowit rightly surmises that Cantopher means serotonin and noradrenaline as the 'two chemicals'. I presume Cantopher believes what he wrote but there are no references in the book, so it's difficult to know where he got the idea from. How does he get away with misleading journalists, let alone patients?

Just to be clear, I'm not advocating mental health problems being dealt with separately in the NHS. Jowit does note that "some psychiatrists have been driven to an obsession with biology". Perhaps she needs to investigate further why the public is being misled about mental illness being a physical illness. As I keep reiterating, do not misunderstand me. Of course mental illness is due to the brain - that's mere tautology. But, to make the claim that Cantopher makes in the quote above is outlandish.

DSM needs to return to its origins

Following my previous post, I just wanted to be clearer about why I am not advocating totally abandoning psychiatric diagnosis. My position may seem surprising as essentially I agree with the critics of psychiatric diagnosis. Biomedical diagnosis has failed in the sense that mental disorder is not due to brain abnormalities. Symptoms and signs in psychiatric assessment are about mental, not bodily functioning. Psychiatric diagnosis and biomedical assessment act as a means of avoiding the uncertainty and pain of people's life stories.

Yet, I'm not the only psychiatrist that has given a priority to personal assessment rather than psychiatric diagnosis. Nor am I the only one that does not see mental illness as a brain disease. There has always been this conflict in modern psychiatry, since the origins of the asylums and the introduction of the anatomoclinical understanding of disease in medicine in general. Particularly in American psychiatry, the biomedical assumption was undermined by the views of Adolf Meyer (eg. see previous post). As Erwin Stengel (see my mention of him in another previous post) wrote in his review of psychiatric classification in 1959:-

Recently, the attitude of many psychiatrists towards the conventional type of classification has become one of ambivalence, if not of cynicism. This attitude derives partly from a low estimation of diagnosis, which in large areas of psychiatry has remained imprecise and has proved a poor guide to prognosis and therapy. Also, the concept of mental disorder, which in Kraepelin's view closely approximated that of physical disease, has changed in such a way that a conventional medical diagnosis no longer seems applicable. In many schools, especially in America, mental disorders are viewed as reactions of the personality to known or unknown pathogenic factors (Stengel, 1959).

In other words, there was a time when psychiatrists were much more aware of the limitations and problems of psychiatric diagnosis. DSM-I used the term 'reaction' throughout the manual, influenced by the ideas of Meyer. For example, functional disorders were called "disorders of psychogenic origin or without clearly defined physical cause or structural change in the brain" and this included manic depressive and schizophrenic reactions. There was no pretence that mental disorder is due to brain abnormalities.

Now that it is apparent that DSM-5 has failed (eg. see previous post), we need to undo each of the steps taken along the way. DSM-IV dropped the functional-organic distinction, which needs to be reinstated (see previous post). DSM-III encouraged a biological view of mental illness and introduced operational criteria, but did not improve diagnostic validity. DSM-II was not too different from DSM-I, but dropped the term 'reaction'. Conceptually the DSM process has been totally misguided, and we need to rethink and return to basic principles if there is ever going to be a DSM-6.

Is community mental health care really worse in USA?

Allen Frances asks "How do we create a compassionate, cost effective mental health system?" and Psychiatric Times collects some answers in a blog post. There seems to be general agreement that the US mental health system needs fixing. Francis explains that, "Sixty years ago, community psychiatry was the big new idea". He thinks, "The dream worked well in many countries, but turned into a bitter nightmare in the US".

I'm not so sure that community care is the problem. Nor that the situation is much worse in the USA. Providing personalised mental health care worldwide is not easy and is not necessarily any better in the community than it was in the asylums.

Cigarette use associated with psychotic episodes

Cannabis use and cigarette use at age 16 were both associated, to a similar degree, with psychotic episodes at age 18 in a cohort study published in Psychological Medicine. I report this because it is commonly assumed cannabis can cause psychosis, but as the authors of the article say, there is no evidence that tobacco has a causal effect in psychosis. Of course, cannabis intoxication can cause transient psychotic-like experiences, but what is less clear is whether cannabis can cause psychosis not related to intoxification effects.

As I said in my BMJ letter, "Cannabis use is likely to be a proxy measure for poor premorbid adjustment associated with psychosis." I went on, "I am not saying that cannabis does not cause emotional problems; nor that people do not use it to deal with their emotional problems." The degree of correlation between the use of cannabis and cigarette smoking means it is difficult to disentangle independent effects. However, the likelihood is that cannabis use and cigarette smoking are both markers for socioeconomic and environmental factors associated with psychosis. It's illogical to interpret the association between cannabis and psychosis as causal, as it is to do the same for cigarette smoking.