Tuesday, January 14, 2025
Psychiatry misleading the public about chemical imbalance in depression
Monday, January 13, 2025
Daring to argue that depression is not a physical disease
Sunday, January 12, 2025
The legitimacy of asking whether antidepressants work
Wednesday, December 18, 2024
Discovering what psychiatry’s really like
As I also say in my chapter, Foudraine wrote the best selling book Not made of wood (1974). To his surprise, this book became an immediate bestseller. More than 200,000 copies were sold and later the book appeared in seven translations. I have been re-reading a manuscript that Jan sent me - ‘The man who dropped out of his mind: Pointers from a rebellious mystic’.
It’s interesting looking back how popular anti-psychiatry, represented by Foudraine amongst others, was at the time (see eg. previous post). As Jan said in the presentation and manuscript, becoming a mega-seller made him into “some sort of Jesus Christ of psychiatry”. The same happened to R.D. Laing (see eg. previous post) after his books were republished by Penguin. Laing was taken up by the 1960s counterculture and always hankered to return and be accepted by mainstream psychiatry, but once he had become infamous this was not possible.
Jan admits in the manuscript that Not made of wood was “almost naive”. He said, “The experience of being a so-called famous ‘anti-psychiatrist’ led to much loneliness and despair”. This made him realise “the undeniable fact that this whole planet looked … very much like one big insane asylum”. He went into a personal crisis over several years with a sense of utter emptiness that the follow-up to his success had created. He was rescued from this mental state by his lightening-like realisation of the Truth. He read books and listened to audiotapes giving a discourse on Zen by Osho, as he became known, and went to Poona to “land right at the blessed feet” of his Guru. Foudraine published a book in 1979 entitled Original face, a journey home, although it was never translated from the Dutch, declaring his love for Osho, of whom he became his disciple. He described his mystical communion with Osho, who he thought was genuinely wise in his belief that “humanity is committing a collective suicide”.
Laing too went on retreat to Ceylon and India in 1971. As I wrote in my book chapter 'Historical perspectives on anti-psychiatry', this retreat could be said to have symbolised a lack of commitment to changing psychiatry. The difficulty in changing psychiatry is real and I have often commented in this blog about how hard it is to get the message of critical/relational psychiatry accepted (see eg. previous post). Overcoming the power of the prevailing biomedical structure in psychiatry, and medicine in general, is not easy. I have always argued that any critique of psychiatry needs to accept that there will not be a paradigm shift away from biomedical psychiatry, however much it may hope for one. Still, psychiatry can become, and needs to be, more open and therapeutic in its practice. But I think it is likely to remain a conflictual area of clinical practice.
So, rather that being deflected from the conflict involved in trying to change psychiatry to promoting personal authenticity, as were both Foudraine and Laing, the differences within mental health practice do need to be acknowledged and accepted. Foundraine's mystical solution to the dilemma of psychiatry does need to be respected, even if I don't personally accept it.
Friday, December 13, 2024
What does it mean to be diagnosed with ADHD?
Saturday, November 23, 2024
Psychiatry needs to be more thoughtful
As Linda says, she has "never identified with the British version of ‘critical psychiatry’, finding it rather like having to adopt a complete ideology that will only consider hypotheses that are self-confirmatory". I'm not exactly sure what she means by this. If critical psychiatry's ideology is so self-confirmatory, why don't more psychiatrists and people in general go along with it? As I've said several times (eg. see previous post), critical psychiatry has found it very difficult to get its message across. Nonetheless I agree with Linda's conclusion to her review that:-
We need to encourage those training to be psychiatrists to not only be more thoughtful but listen to as many patients’ stories as they can and read widely, even the work of those they are convinced they will disagree with.
Wednesday, November 13, 2024
Is psychiatric diagnosis of any value?
I can’t fathom how a psychiatric diagnosis would ever be useful to anyone except as a tool to get accommodations or drugs. As far as understanding myself – who I am, why I act and think as I do – it contributes nothing.
I do understand what he means (see eg. previous post). As I said in response, I agree there is no value in the ‘one person, one disease’ view of psychiatric diagnosis. However, I worry that his critique goes too far and can only polarise debate and alienate mainstream psychiatry which does need to change its views about psychiatric diagnosis.
What needs to happen is that psychiatry should recognise psychiatric diagnosis for what it is rather than completely abandon it, as Justin would like. Diagnosis is justified as a means of communication. It is a way of trying to manage clinical complexity. But the boundaries of any diagnosis are fuzzy and there is no point of rarity between different syndromes. These are not absolute terms. Most psychiatric presentations are not natural kinds with an identifiable brain abnormality.
The problem is that it is too easy to assume a diagnostic concept is an entity of some kind, which then acts as a justification for treatment. In fact a psychiatric diagnosis is an unobservable, hypothetical construct. It is more an idealised description of those aspects of psychiatric presentation that are of interest. Diagnostic concepts are therefore justified by their clinical utility. Diagnosis is not only about identifying disease but also about the reasons for mental health problems.
Where psychiatry went wrong over recent years was in response to the so-called anti-psychiatry critique. In a way, Justin could be said to be resurrecting aspects of that critique. But psychiatry needs to move on from the polarisation between pro-psychiatry and anti-psychiatry. For example, Thomas Szasz became famous for his view that mental illness is a myth. He was correct that psychiatry has misled too many people that their mental health problems are due to their brain. Of course the brain mediates what we think, feel and do, including when we are mentally ill. But that does not mean necessarily that there is an underlying brain abnormality causing the problems. Szasz was right that the supposed brain disease behind functional mental illness is a myth. But Szasz wanted to go further by abandoning psychiatric diagnosis altogether because he did not think psychiatric detention could ever be justified (see eg. previous post).
Mainstream psychiatry’s response to so-called anti-psychiatry has merely reinforced its belief that functional mental illness is due to brain disease. It tends not to take a hardline position on this issue by saying that functional mental illness is completely caused by brain abnormality. However, it wants to say that there must be brain abnormality as a factor in most psychiatric presentations. This is not necessarily the case. It’s wrong to reduce people to their brains. Personal and social explanations of why we do what we do can improve our understanding of the reasons for our actions but cannot provide a complete causal explanation, certainly not in biological terms.
As I keep saying, too many people are being misled by psychiatry that their mental health problems are due to their brain (see eg. previous post). This includes misleading children who are being given a neurodivergent diagnosis to justify their sense of difference from others. This blog is called “Thinking differently about mental health”. Being different does not necessarily need to be justified by a psychiatric diagnosis. I know the neurodivergence movement does not want to pathologise a neurodivergent diagnosis. But overvaluing the diagnosis, including implying that any personal difference is due to brain differences, is not really helping children, including people in general. Here Justin does have a point. Psychiatry needs to undo the way in which it is itself benefitting from encouraging a psychiatric label as “the answer” to people’s mental health problems.
Saturday, November 09, 2024
Work needs to be undertaken now as part of the process towards complete reform of mental health legislation
[T]here is more to do and questions to ask about whether this [Bill] will go far enough to fix the broken system as we know it. The mental health emergency we are facing will need much more than a reformed Act.
Work needs to be undertaken now as part of the process towards complete reform of mental health legislation. Mere amendment of the 1983 Act as will be enacted by the new Bill is not sufficient. This work (see eg. previous post) should include: reform of the Mental Health Tribunal to make it more rights-based; improving mental health advocacy by creating an integrated service of Independent Mental Health Advocates (IMHAs), mental health lawyers and independent experts; and further reducing the commissioning of secure placements, leading to the prevention of all civil detentions to secure facilities, apart from to short-term Intensive Care Units. The latter development needs to be supported by a renewed focus on improving the quality of acute psychiatric inpatient and crisis resolution and home treatment services. Work could also be undertaken on creating a new Mental Health Commissioner for England. The mental health reviewer and Second Opinion Approved Doctor (SOAD) functions of the Care Quality Commission will also have a role in monitoring the implementation of the new S56 treatment provisions for Approved Clinicians to follow a clinical checklist and the introduction of statutory care and treatment plans.
Monday, November 04, 2024
Blaming the brain is out of control in psychiatry
After all there are brain scans that prove this, aren't there? We've probably all seen pretty coloured scans that show areas of the brain lighting up when they are said to show connections to various human activities. But we’ve forgotten what our forefathers learnt in the late 19th/ early 20th centuries that human activity is not as well localised in the brain as we might have expected or hoped. They appreciated that the brain, indeed the complete human body, generally acts as a whole. People are also alive and cannot be explained in mechanistic terms.
Elliot Vallenstein's book Blaming the brain was first published in 1998. It described how theories of chemical imbalance in the brain had replaced previous ideas that early experience in the family were the cause of mental disorders. As the publishers website says (see webpage), the book sounded a “clarion call throughout our culture of quick-fix pharmacology and our increasing reliance on drugs as a cure-all for mental illness”. This situation has in fact in many ways only got worse since despite the warning. For example, over recent years, the neurodivergence movement has promoted the idea that our differences from each other are due to our brains. No wonder there is therefore a burgeoning demand for a neurodivergent diagnosis. If it’s believed that the reason why we’ve seen ourselves as different from each other all these years is because of our brain, then the sooner we get a diagnosis the better.
We need a serious rethink about the nature of mental disorder. It may have suited psychiatry to go along with the idea that mental illness is due to the brain. Of course brain abnormalities can cause mental symptoms. But most of the presentations to psychiatrists are not caused by a brain abnormality, however much psychiatrists may have misled people that they are.
Sunday, October 27, 2024
The untruths of psychiatry
Friday, October 25, 2024
Biomedical psychiatry is a pseudoscience
Even eminently plausible and widely held beliefs, such as psychiatry’s mainstream belief that something is wrong in the brain in primary mental illness, can be pseudoscience. The value of scientific theories depends on their objective support. Psychiatrists as scientists want their theories to be respectable and provide genuine knowledge. Like all scientists, their aim is to prove their scientific theory beyond doubt, even though that may be an impossibly ideal dream. However, there still isn’t any proof that primary mental illness is brain disease, despite the vast research programme directed towards fulfilling that aim (see eg. previous post). When evidence accumulates against or fails to confirm the latest hypothesis, then attention is turned to another line of inquiry or some adaptation is made to the theory to accommodate the lack of evidence to rescue the original hypothesis. The underlying fundamental belief that progress is being made in discovering the cause of mental illness is therefore maintained. How psychiatry will change from its fundamental belief that brain pathology is at least an element in the causation of mental illness is unclear (see eg. previous post).
Tuesday, October 22, 2024
Psychiatry stuck in Newtonian physics
Wednesday, October 16, 2024
Expectancy effects in antidepressant withdrawal studies
Of course using placebos in clinical trials of efficacy is designed to exclude placebo effects. In the same way in discontinuation trials, having a control group which continues antidepressant is designed to control for nocebo effects. How effective these control methods are in preventing placebo/nocebo effects depends on how well blinded the participants are from knowing to which group they have been allocated. There is considerable evidence that people are not completely blinded in antidepressant efficacy trials (see eg. previous post). As far as I know, there has been no attempt to measure unblinding in an antidepressant withdrawal study. If unblinding occurs in antidepressant efficacy studies, I think it is also likely to occur in antidepressant withdrawal studies. As the blind can be broken in antidepressant efficacy trials, it cannot be said that expectancy effects have been eliminated. So my case is that it cannot be said that expectancy effects have been eliminated from antidepressant discontinuation RCTs, because I think there is also likely to be significant unblinding in these withdrawal studies as well.
Habituation to antidepressants is to be expected (see eg. previous post). It helps to explain why people take them for such long periods of time. Psychological mechanisms causing antidepressant withdrawal symptoms should not be dismissed. I have considerable doubts about antidepressants being more than placebo in their antidepressant effect (see eg. previous post). Those that argue that antidepressants cause organic physical dependence tend to say that the sense that antidepressants have stopped working, which can occur, sometimes colloquially called the "poop-out" effect, is evidence that there is tolerance with antidepressants. As I don't think antidepressants are "effective" in the sense of being more than placebo, this explanation doesn't make sense to me. I am at least consistent in my scepticism about the effects of antidepressants, which for their apparent benefit I put down to placebo, and for their withdrawal effects I am inclined to think could be due to nocebo. To emphasise again, this does not mean I am saying any experienced benefit for antidepressants is not real. Nor am I saying that the experience of antidepressant withdrawal is unreal. What brought me into the area of antidepressant withdrawal years ago was my critique of mainstream psychiatry for denying the reality of such symptoms. I just don't think that there's necessarily been much progress since in understanding the mechanisms of such withdrawal effects, and it worries me that psychological mechanisms seem to be being ignored, even within the Critical Psychiatry Network (see previous post).
Tuesday, October 08, 2024
Thinking differently about mental health
Psychiatry struggles to cope with its inherent uncertainty
Thursday, October 03, 2024
Mad studies and critical/relational psychiatry
Wednesday, October 02, 2024
Do antidepressants cause emotional numbing?
Also being a member of CPN, I have some concerns about Jo and Mark’s claim. I accept that emotional numbing is a common side effect of antidepressants, particularly in long-term use. I don’t think it’s usually a very immediate consequence of taking antidepressants, for example within the short-term (often about 6 weeks) clinical trials that are used to make claims about the effectiveness of antidepressants. So, I don't quite see how emotional numbing can explain any significant difference between antidepressant and placebo demonstrated in these trials over the short-term.
But over the longer-term, people often complain that antidepressants seem to have stopped them really dealing with their problems and complain of a flattening of emotional responses which includes feelings of being ‘dulled’, ‘numbed’, ‘flattened’ or completely ‘blocked’, as well as descriptions of feeling ‘blank’ and ‘flat’, affecting their relationships with others and how they see themselves (see previous post). If antidepressants have seemed to help, even if more because of a placebo effect than true antidepressant action, then it's not surprising that people may feel that a physical rather than psychosocial approach to their depression has not really helped. They may express that as emotional numbness and not being in touch with their feelings. They might even still have the same underlying personal and social reasons that led to their depression, which haven't really been dealt with, as such, by mere taking of an antidepressant.
The trouble is that there is only a limited literature about emotional numbing caused by antidepressants that does not allow proper assessment of its significance and mechanism. One study that is commonly quoted is Goodwin at al (2017). They found that emotional blunting is reported by about half of people on antidepressants and is correlated with their depression score ie. a poorer quality of remission is associated with more blunting. However, the screening method used a leading question ‘To what extent have you been experiencing emotional effects of your antidepressant?’, and followed this up with an explanation that ‘emotional effects vary, but may include, for example, feeling emotionally "numbed" or "blunted" in some way; lacking positive emotions or negative emotions; feeling detached from the world around you; or "just not caring" about things that you used to care about’. Those that gave a positive response were asked to complete a fuller questionnaire about emotional blunting.
As the paper admits, the data is very much affected by subjective factors. People were guided by the methods used in the study into essentially having a wide understanding of the meaning of emotional numbness or blunting. I tend to think what's meant by emotional numbing is more to do with people feeling antidepressants are masking the real problem and thereby preventing them having their full range of experiences, rather than a direct physiological effect of the drug. Jo and Mark disagree with me about this, but I'm not convinced they've got the evidence for their view. People commonly, at least initially and maybe over time if they can sustain having stopped the antidepressant despite withdrawal symptoms, say that they feel more alive and in touch with their feelings after stopping the drug. That may not be surprising, as there must be relief, at least, that they do not have to take the antidepressant. There must also be a sense that emotions are no longer being controlled by the antidepressant. Trouble is that it's not always very easy stopping antidepressants, perhaps particularly if they were started when there didn't seem to be much alternative and the person has been misled into thinking that there must have been something wrong with their brain. This means that they get stuck in a vicious cycle of wanting to stop antidepressants but fear relapse and withdrawal symptoms if they've previously experienced them. Withdrawal symptoms are very common (see eg. previous post).
It worries me how the notion that antidepressants work by emotional numbing seems to be catching on, perhaps particularly with patients. As I've said, I'm not convinced there's the evidence for the hypothesis. As I've commonly said, I tend to think antidepressants are no better than placebo (see eg. previous post). That doesn't mean that I think they're inert. In fact, the reason I think antidepressants are no better than placebo is because I think the significant difference between antidepressant and placebo found in short term trials may be a methodological artefact. This arises, for example, because trials are not as double-blind as is commonly assumed. Trial participants may well be able to break the blind in randomised controlled trials because of side effects, so I'm not saying antidepressants are inert.
But I do worry that critics of biomedical psychiatry may be creating another myth, like the serotonin hypothesis, that antidepressants work by emotional numbing. In fact, because I don't think antidepressants probably work any better than placebo, in a way I'm saying they don't "work". There's no need, therefore, to even have an explanation of how they "work"! That's not meant to undermine the people that feel that antidepressants have helped (see eg. another previous post) but the limitations of medication do need to be acknowledged. The trouble is that mainstream psychiatry is committed to supporting the use of antidepressants because they are seen as effective.