Saturday, March 24, 2018

Tackling institutional racism in mental health services

I’ve posted before on Institutional racism and reform of the Mental Health Act. The Royal College of Psychiatrists has recently produced a position statement on ‘Racism and mental health’. Racial bias, of course, is not new in mental health services. There is also a history of attempting to tackle discrimination, which the College statement essentially ignores. True, it does make reference to the Blofeld report following the death of Rocky Bennett under restraint in my own NHS Trust. I worried at the time that the focus on institutional racism deflected from the other main issue about the dangers of restraint (see my BMJ response). Face down restraint should probably have been banned in mental health services (see previous post).

This history is relevant to the current reform of the Mental Health Act, because, in a way, its aim could be said to be to reverse the trend for increased coercion associated with the last reform. As Inside/Outside said, "[I]t is essential to place progressive community based mental health at the centre of service development and delivery". Services are failing to provide an appropriate and professional service to people because of their colour, culture and ethnic origin. This situation needs to be legislated for in any new Mental Health Bill, focusing on reducing coercion.  

Sunday, March 18, 2018

Effectiveness of antidepressants

The recent Lancet study, which was reported in the media as ending the debate about the effectiveness of antidepressants, has ironically led to more discussion about their effectiveness (see previous post) and a welcome focus on the nature of discontinuation problems (see another post). It has also led to a definitive summary in a BMJ editorial of the evidence for short-term treatment (less than 8 weeks).

To quote from the editorial:-
Importantly, these findings [the Lancet study] do not support the widespread calls in the popular press for more people to take antidepressants because the meta-analysis and underlying trials do not examine who or how many people should be treated.
And, despite the hope of the Lancet article, the BMJ editorial concludes:-
[T]he way many of the results were reported does not allow clinicians to extract clinically meaningful take home messages to inform conversations with patients.

This is partly because the Lancet study used odds ratios rather risk ratios. It did not provide evidence about the proportion of people that improved on placebo. The typical placebo response in other literature is 30-40%. Using the average odds ratio from the Lancet study means about 10-12% more people in the treatment group would benefit compared to placebo. So, roughly 8-10 people would need to be treated for one of them to benefit compared to placebo.

Patients need to know that roughly 40% of people in antidepressant trials improve with placebo and 50% in the treatment arm. As the BMJ editorial says:-
Knowing that roughly 80% of patients who get better did not improve because of the antidepressant underlines the importance of starting with low doses, systematically re-evaluating the need for treatment after a response is achieved, and not accepting any enduring adverse effects.
I would also add that it’s important to realise that a good proportion of people are not helped even in the clinical trials.

The BMJ editorial, therefore, usefully highlights the limited clinical scope of the Lancet study. We need at least to also focus on potential harms and long-term treatment. And, we need to ask whether the small statistically significant difference in clinical trials between active and placebo treatment could be an artefact due to placebo amplification (eg. see previous post).

Saturday, March 10, 2018

Minimising antidepressant discontinuation problems

Clare Gerada defended the Royal College of Psychiatrists on the Today programme this morning against a complaint (of which I was one of the signatories) that the College is minimising the significance of antidepressant discontinuation problems (see Council for Evidenced-based Psychiatry (CEP) press release). There doesn't seem to be a dispute that antidepressant discontinuation problems occur (eg. see previous post) - Clare Gerada said in about a third of patients - and can be prolonged (see another previous post), but the issue seems to be whether they resolve for the vast majority of patients within two weeks. I don't think the evidence supports that view.

There is a history of doctors thinking they know better about antidepressant discontinuation problems than the public (see my book chapter). The Defeat Depression campaign was a five-year national programme launched in January 1992 by the Royal College of Psychiatrists in association with the Royal College of General Practitioners. A door-to-door survey of public opinion was undertaken to obtain baseline data before the campaign started and most of the people questioned in the sample, that is 78%, thought that antidepressants were addictive. This finding caused some consternation amongst those running the campaign, because, as far as they were concerned, the public was misinformed on this issue. Part of the education programme, therefore, was to teach doctors that patients should be told clearly when antidepressants are first prescribed that discontinuing treatment in due course will not be a problem. Now they seem to be saying that it may be a problem but symptoms generally won't last long.

The first official recognition in the literature that SSRI antidepressants can cause discontinuation problems was in a BMJ editorial in 1998, which suggested they were preventable and simple to treat. The same authors only two years later acknowledged that discontinuation symptoms are common in a letter to the Lancet. I agree there is little evidence of physical addiction, in the sense that the body gets addicted to SSRIs, but commonsense understanding of the word also includes psychological dependence, and despite what the Defeat Depression campaign said, the public knew, even if doctors did not, that taking antidepressants can become a habit.

Doctors did not use their common sense to realise that discontinuing a drug that is thought to improve mood may cause problems - technically called a nocebo, or negative placebo, response. Antidepressants are likely to be habit forming, so however much the medical profession may declare that they are not primarily reinforcing like psychostimulants, the public has always understood that there may be difficulties in discontinuing antidepressants. The general public might reasonably have expected that psychiatrists, who are supposed to be specialists in disorders of the mind, would recognise psychological dependence, base their advice on clinical experience, and use their common sense.

I have always encouraged CEP to focus on psychological aspects of prescribed drug dependence (see eg. previous post). I was even critical of the RCPsych leaflet (see another previous post) that has caused such disquiet, not least because it's been taken down from the College website before it's been properly reviewed, even though I thought it was generally a helpful leaflet.

By the way, from the interview today, Clare Gerada, like her husband (see post), doesn't seem to believe in the placebo amplification hypothesis of apparent antidepressant efficacy, and I'm not sure why .

Tuesday, March 06, 2018

Commercialisation of precision psychiatry

I sent 7 tweets yesterday in response to a tweet from @PariantSPILab (who I have mentioned previously eg. see post) about a Financial Times article. Apart from several likes and a couple of retweets, I received only one answer from @Truthman30. Am I being marginalised?

The article at least says that "precision psychiatry remains largely in the research phases". But, it quotes Professor Leanne Williams as promoting Spring Health, which says it has a research group that has had several papers published in leading medical journals, starting with one in Lancet Psychiatry in 2016. A Lancet Psychiatry article, published in April 2017, has a lead author who declares that he holds equity in Spring Health. I'm not sure how much Spring Health charges employers for its services provided through health insurance plans.

I've commented before on an article by Leanne Williams (see post), which I think must be the 2016 article referred to by Spring Health. I've no idea what the evidence is referred to in the Financial Times article about venlafaxine only working for certain gene types. I'd never heard of Thalia Eley's attempts to develop "therapy genetics”.

I can understand Leanne Williams wanting more money to fund her research but it does need to be tempered with realism. She says it's "bordering on negligence to not be using a [precision approach to depression care] now". Actually, it's not justifiable clinically to say that everyone needs brains scans and DNA tests for mental health problems, which is how the article headline is framed.

What we need is a truly personalised medicine and psychiatry, not what's called individualised or precision medicine, which is actually commercialising mental health care not making it more personal (see previous post). Psychiatric research has lost its way (see another previous post). We need to accept the uncertainty of psychiatric practice and medicine in general, rather than promote "precision medicine" as the solution to mental disorders (see another post). Actually what we need is proper precision thinking in psychiatry, not the speculation being promoted (see post).

Monday, March 05, 2018

PTM Framework is not anti-psychiatry

I have blogged previously on the Power Threat Meaning (PTM) Framework (see post). Twitter is not always the best place to discuss these kind of issues, as people can act out their nastiness. I don't think people who have called the Framework 'anti-psychiatry' are necessarily "nasty". But it might be worth thinking about what it means to label someone, and even the PTM Framework, as 'anti-psychiatry' (eg. see previous post).

Even respectable psychiatrists recognise some value in what has been called anti-psychiatry (see another post). Critical psychiatry may have its roots in anti-psychiatry, but critical psychiatry also has its roots in mainstream psychiatry and in that sense is not anti-psychiatry (see another previous post). The term 'anti-psychiatry' has always been used as a way of psychiatry marginalising its critics. Anti-psychiatry has been called psychiatry's "nemesis" (eg. see another post), as other branches of medicine don't really have their own internal anti-movement.

I want to encourage people to view the PTM Framework positively. Lucy Johnstone, in a recent MIA podcast, has made clear that any attempt to describe patterns of responses need to be recognised as meaning-based differentiations, not absolute distinctions. I totally agree. I'm not suggesting returning to Meyer's attempt to classify reaction types, but I have long argued that we need to return to his theoretical principles (eg. see another previous post). Revisions of the DSM have been totally misguided (see yet another post) and the PTM Framework should be seen as a potential way forward.

Friday, March 02, 2018


I have been re-reading the book Postpsychiatry by Pat Bracken (see previous post with link to his profile) and Phil Thomas (see his About Me webpage). They also wrote a chapter for my Critical Psychiatry book and a recent book chapter entitled 'Reflections on critical psychiatry' (see another previous post). Other pieces they have written together include a PPP article.

As Phil says in his 'Critical Psychiatry in The UK: A Personal View':-
Postpsychiatry started life as a series of short articles in Open Mind magazine [see reprints] from 1997 – 2001 .... This was followed by an article in the British Medical Journal Education and Debate section (Bracken & Thomas, 2001), and a book of the same name four years later in Oxford University Press’s series on philosophy and psychiatry (Bracken & Thomas, 2005). 
Postpsychiatry sees psychiatry as a creation of the Enlightenment and a modernist enterprise. The book starts with a reference to Foucault's Madness and Civilisation. Foucault viewed the Enlightenment as oppressive and saw the 'great confinement' in the 17th and 18th centuries as, in Pat and Phil's words, "a massive European move towards the social exclusion of 'unreason'" (p. 91). Pat and Phil note that Foucault moved away from an understanding of power as something negative. As they also say, "in the 20th century, psychiatry became something bigger than simply the governing power of the asylum" (p. 93).

They, therefore, view postmodernism as "an addition to, rather than a rejection of, previous critical positions" and insist that it is "not a flight to mindless relativism" (p. 95).  Just to be clear, they say that "Foucault did not get everything right" (p.189). They, therefore, want to also follow Heidegger and Wittgenstein with a hermeneutical perspective. In the book, they look at what they call the narrative turn in medicine and psychiatry. Overall, they are not proposing "some sort of postmodern canon" (p.189).

Postpsychiatry is, therefore, not arguing for a strong form of social constructivism. My main problem with postpsychiatry is its historical narrative, maybe because it starts from Foucault. I have always tended to emphasise that there has always been a critical perspective within psychiatry (eg. see previous post), since the origins of modern psychiatry, which I would tend to date from state intervention in the asylum, rather than the 'great confinement'. The development of pathology in medicine from the beginning of the nineteenth century and the application of the anatomoclinical method led to psychiatry not completely fitting with an organic understanding of illness and, for example, produced the idea of functional psychosis (see another of my book chapters).

Although Pat and Phil mention the Enlightenment, they don't talk about Romanticism, which, in a way, was a reaction against the norms of the Enlightenment. I have highlighted the work of Ernst von Feuchtersleben in this respect (see eg. another previous post) and he used the critical philosophy of Immanuel Kant to argue against a materialistic understanding of mental illness. Similarly, modernism wasn't the only perspective at the turn of the twentieth century and, as I have said, Pat and Phil themselves mention hermeneutics. Personally, I have emphasised the pragmatic perspective of Adolf Meyer (eg. see another previous post), which, at least in theory, focused on the limitations of psychiatric practice (see eg. my article).

Postpsychiatry may be the best known form of critical psychiatry and is central to critical psychiatry's understanding of its own nature.

Saturday, February 24, 2018

Data on antidepressant winners and losers

Hans Eysenck (1978) called meta-analysis an exercise in mega-silliness. To quote: “A mass of reports - good, bad, and indifferent - are fed into the computer in the hope that people will cease caring about the quality of the material on which their conclusions are based.” Cipriani et al (2018) in their recent network meta-analysis of 21 antidepressant drugs rated the risk of bias of the trials they put into their analysis. Only 18% were seen as low risk. Yet they hoped the results would compare and rank antidepressants for acute treatment in adults.

The article does list some winners and losers, although accepting that there were "few differences between antidepressants when all data were considered". Parikh & Kennedy (2018) add vortioxetine to their list of winners, which must please the manufacturers, as it is not yet off patent. Amitripyline actually had the highest efficacy but didn’t reach the ‘winners’ list, I think because of poor acceptability, defined as dropout rates, in the head-to-head trials, and low certainty of evidence (and maybe some bias against a traditional tricyclic). Unlike Parikh & Kennedy, Cipriani et al don't make any recommendations about antidepressant choice, merely hoping that their "results will assist in shared decision making between patients, carers, and their clinicians".

Such a weak conclusion to their main study may help to explain why in their publicity, which made the Sun, Guardian and front page of The Times, Cipriani et al concentrated on the statistically significant results for antidepressant efficacy, which actually aren't news (see my tweet), although may be for reboxetine (see previous post). I suppose it's not seen as being ideological to create publicity to increase the citation index of a paper! Or, to mislead and avoid dealing with the challenge of the placebo amplification hypothesis (eg. see previous post). To engage with this issue would actually be a more scientific way of proceeding, but the study by Cipriani et al doesn't have any bearing on it (even if they would like it to).

Actually the review paper itself (as opposed to the publicity) does recognise that the short-term benefits of antidepressants are "on average, modest" and that the "long-term balance of benefits and harms is often understudied". Several aspects of their findings do reinforce that there are biases in the data eg. smaller and older studies have larger effect sizes against placebo; novel or experimental drugs of comparison are more effective than when that same treatment was older (which they term the 'novelty effect'). I also wasn't sure whether they had got replies to all of their requests to the pharmaceutical companies for their data. Let's have a more measured debate about the evidence for antidepressant efficacy.

Saturday, February 17, 2018

Transparency about the outcomes of Improving Access to Psychological Therapies

Graham Thornicroft's Lancet editorial on Improving Access to Psychological Therapies (IAPT) glosses over the effectiveness of the programme. True, he does say there has been little evidence of greater workplace productivity, which was the argument used to gain funding for the programme. He also acknowledges that although there has been a substantial increase in treatment of common mental disorders, admittedly particularly with antidepressants rather than psychological therapy, but still the prevalence of disorders has not decreased.

But, there is no questioning of the value of mandatory routine data collection, much of which is useless because it's uncontrolled (see previous post). By being so uncritical, Thornicroft could be said to be condoning the rhetoric of unrealistic claims for the effectiveness of the programme (eg. see another previous post). How much are outcomes just expectancy effects (see previous post)? I'm not wanting to undermine the work of IAPT therapists but we do need realistic assessments of the effectiveness of the programme. The title of the paper by Clark et al (2017), on which the editorial is based, is said to be about transparency about outcomes. I wish it was.

Friday, February 16, 2018

The promise of tranquility of mind

My recent post commented on the public understanding of the concept of bipolar disorder, at least as represented by internet bloggers. As I said in a book review, the aim of treatment of bipolar is euthymia, which means stable mood, neither manic nor depressed. In general parlance, euthymia is a relaxed state of tranquility. To quote from my review, "Democritus regarded this state of being as one in which the soul is freed from all desire and unified with all its parts. He believed it should be the final goal of everything we do in life."

No wonder people want mood stabilisers if this is what is being promised! However, mood instability is not well defined (see previous post). As I quoted in another previous post, "the term mood stabilizer sounds comforting and may reflect our fond and perhaps somewhat naive hopes".  Although a marketing ploy, there has never been any evidence that mood stabilisers are better than placebo in bipolar spectrum. It's also wrong and misleading to believe that mood stabilisers correct a brain abnormality.

Monday, February 12, 2018

Give up trying to explain the relationship of mind to brain

I attended a reading group today to discuss two quite technical papers by Georg Northoff. There is a Psychology Today blog, which makes clear that he is trying to bridge the gap between brain and experience. It's all very well to speculate about spatiotemporal psychopathology, but I think Kant was right that the link between mental and physical is an enigma that can never be solved.

Mind is of course enabled by brain, but it can't be reduced to it. Mind and brain need to be understood as a unity (eg. see previous post). Bodily organs are subject to the laws of physical necessity but consciousness is self-organising. An organic basis is, therefore, insufficient for understanding mental activity. Psychiatrists find it difficult to give up the notion that the understanding of mental activity must be derived from the brain. This doesn't make sense because such reductionism leads to the loss of meaning of human action (eg. see another previous post).

Being bipolar on the internet

Mandla et al (2017) have analysed internet blogs by self-identified bipolar sufferers. They found that most bloggers regard bipolar as consisting of extreme and fluctuating emotions. It encompasses a wide variety of problems and has fluid boundaries with normality. It often fulfils a moral function, in that it is conceived as an autonomous entity, which acts as a repository for disliked or disapproved aspects of the self and provides an explanation for bad behaviour or failure. It's become increasingly popular as a self-diagnosis (Chan & Sireling, 2010).

Bipolar has become so broad and inclusive that it has little in common with the original, narrower concept that was aligned with the diagnosis of "manic-depression" (eg. see previous post). There needs to be wider discussion about these issues.

Sunday, February 11, 2018

The bio-bio-bio model of mental illness

A few years ago, Steven Sharfstein, when he was President of the American Psychiatric Association, said that psychiatry has "allowed the biopsychosocial model to become the bio-bio-bio model' (see Psychiatric News article). This was picked up by John Read in his The Psychologist article.

As I said in my last post, the problem is the eclectic, atheoretical way in which the term 'biopsychosocial model' is often used in modern psychiatry. Where this comes from is the psychiatric consensus, represented by Anthony Clare (see previous post), following the anti-psychiatry debate of the 1960/70s. To avoid the worst excesses of biomedical reductionism, Clare took an atheoretical approach to understanding mental health problems. The trouble with attempting to abstain from theory is that it results merely in the generation of an implicit theory. Despite his well-meaning humanism, Clare's position is still determined by biologism (see extract from my Critical Psychiatry book). As I said in another previous post, although modern psychiatry may not be 'narrowly biomedical', it is still biomedical.

Friday, February 09, 2018

Three cheers for the biopsychosocial model

There is a YouTube video of David Pilgrim's talk at the DCP conference last year. He only gives 'two cheers' for George Engel's biopsychosocial model, whereas I have regarded the model as a basis for critical psychiatry (eg. see previous post). I do this with the reservation that I am not supporting the eclectic, atheoretical way in which the term 'biopsychosocial model' is often used in modern psychiatry.

Where we agree is that the strength of Engel's model is its critique of biomedical reductionism. David accuses the model of being naive about medical knowledge. He argues that the model needs to be more of a theory about health and illness.

I do not think that David’s view sufficiently acknowledges the extent to which the model was not only a challenge to psychiatry, but also to medicine in general, creating the basis for patient-centred medicine (see previous post). As I said in my article:-
In his original paper, Engel talked about neutralizing ‘the dogmatism of biomedicine’ (1977, 135). He commented on the enormous investment in diagnostic and therapeutic technology that emphasizes ‘the impersonal and the mechanical’ (Engel 1977, 135). He quoted from Holman (1976), who argued that:
[T]he Medical establishment is not primarily engaged in the disinterested pursuit of knowledge and the translation of that knowledge into medical practice; rather in significant part it is engaged in special interest advocacy, pursuing and preserving social power. (Engel 1977, 135)
Engel acknowledged the interest in the biopsychosocial model amongst a minority of medical teachers, but also emphasized the difficulties in overcoming the power of the prevailing biomedical structure. 

None of my comments should detract from David’s contribution to recognising the importance of critical realism as a metatheory for psychiatry and clinical psychology (see his chapter in Routlege International Handbook of Critical Mental Health, a book which I have mentioned in a previous post).

Tuesday, January 23, 2018

The limitations of psychiatric diagnosis

The Power Threat Meaning (PTM) Framework provides a way of helping people create a hopeful narrative about their lives and personal difficulties (see BPS News item with links to full framework and a shorter overview). It is a very impressive, well-referenced document. It attempts to provide an over-arching structure, as an alternative to functional psychiatric diagnosis, for identifying patterns of meaning-based threat responses to the negative operation of power causing emotional distress, unusual experiences and troubled or troubling behaviour.

I have always tended to emphasis the limitations of psychiatric diagnosis rather than suggesting a need for an alternative (eg. see previous post). Psychiatric diagnosis needs to be recognised for what it is. It is more important to ask how people are responding and to what, rather than look for a name for their problems. The primary focus should be on understanding the conditions of their mental responses rather than be concerned about symptoms and disease. The person should, therefore, be the essential element in assessment and there will be inevitable uncertainty in practice. Here I totally agree with the PTM Framework.

I just think that this focus on formulation does not necessarily lead to the abandonment of psychiatric diagnosis. Diagnosis can be justified as an attempt to manage clinical complexity and the PTM framework itself does recognise patterns of responses. There will inevitably be fuzzy boundaries between different groupings with no absolute distinctions. Certainly I’m not suggesting there are natural kinds of mental disorders. Diagnostic categories can only be justified by their clinical utility and should be no more than working concepts for clinicians. They are merely unobservable hypothetical constructs, more of a prototype or ideal type. The problem is that psychiatry too easily reifies diagnostic concepts by assuming that they are entities justifying psychiatric treatment. Here I think the PTM framework provides a valuable counter to this tendency.

Friday, December 29, 2017

Choosing the orthodox path in psychiatry

The latest Mad in America podcast includes an interview with Sir Robin Murray, who I have mentioned in previous posts (eg. Schizophrenia is not a neurodevelopment disease). Like him, I wanted to be a psychiatrist through reading Freud as a teenager. Similarly, we both got caught up in the 'anti-psychiatry' conflict and were interested in R.D. Laing. Murray opted for the orthodox view, whereas I gave up my medical training for 8 years and then returned to complete it to become a critical psychiatrist. I ended up having a different view of schizophrenia from him (eg. see my BMJ letter). And, I have spent my working life as a consultant as a full-time clinician, unlike Murray, who was an academic, only working part-time clinically.

Like Anthony Clare (eg. see previous post), Robin Murray took his position partly as a reaction to their understanding of Laing as blaming families for causing schizophrenia. This is actually a misunderstanding of his view, about which Laing complained repeatedly (eg. see extract from my book chapter).

As I said in a post on my personal blog, it's interesting to see Murray questioning the call he made when he started in psychiatry. But he hasn't completely given up his belief in the brain hypothesis of mental illness. For example, in the interview, he talks about dopamine being involved as the "final common pathway for psychosis".

Like him, I'm not encouraging psychiatrists "slagging each other off", but there is a genuine issue about the conceptual nature of mental illness. It's difficult for people, like Robin Murray, to accept that an organic basis is insufficient for understanding mental activity. He's taken this step of faith and to retract it and realise he's made a mistake would be like giving up a religion (see previous post). I'm not necessarily encouraging him to be a philosopher, but he does need to accept that there is a mind-body problem. Organisms as a whole are constantly maintaining their internal environment and cannot be explained mechanically (see another previous post). The activities of the mind cannot be derived completely from the laws of the physical world.

And, I do not want to be misunderstood. Of course I know that minds are enabled by brains. But this does not mean that minds are reducible to brains. To use a quote from Adolf Meyer that I have used before, "mental disorders show through the brain but not necessarily in the brain" [Meyer's emphasis].

Sunday, December 17, 2017

Is psychiatric diagnosis dead?

The title of the 2018 medical student essay prize established by the Faculty of General Adult and Community Psychiatry of the Royal College of Psychiatrists is 'Is diagnosis dead? Discuss.' It's good to see a Faculty of the College encouraging this debate.

Of course the hope of finding a neurobiological basis for psychiatric diagnosis should be dead, particularly following the failure of DSM-5 (eg. see previous post), but it isn't because the wish to find a physicalist basis for mental illness will never go away. And, psychiatric assessment has never just been about diagnosis and includes formulation (eg. see another previous post), which may well be more important than a single-word diagnosis (eg. see yet another previous post).

Sunday, November 26, 2017

Organism and mechanism

The philosophy of biology can contribute to critical psychiatry. I came across Daniel Nicholson's PhD thesis on 'Organism and Mechanism' online.  He quotes from Francis Crick, who said that "The ultimate aim of the modern movement in biology is to explain all of biology in terms of physics and chemistry” (p.9) As Nicholson points out, it's often assumed, as in Jacques Monod's book Chance and Necessity, that "organisms are machines, albeit ones cobbled together by natural selection" (p.13).

However, organisms have a capacity for self-regulation. To use JS Haldane's definition of Claude Bernard's principle, "all physiological activities have as their ultimate objective the preservation of the organism's internal environment. ... [T]he continuous dynamic coordination and regulation of the internal environment ... is responsible for the distinctiveness and irreducibility of living beings" (p. 56). Organisms, unlike machines, are self-organising and self-reproducing. As Nicholson says, “No  machine  is  made  of  parts  that  are constantly  replaced  by  the  machine  itself,  yet  this  is  precisely  what  occurs  in  an organism” (p. 125). Mechanistic understanding of life should therefore be abandoned.

This fundamental difference between organisms and machines applies across the spectrum of the complexity of life, from human mind to blade of grass, to use the quote from Kant about the absurdity of hoping for a Newton of the genesis of but a blade of grass (p.33). Critical psychiatry’s challenge to the technological or mechanical paradigm (eg. see previous post) is no different from that in biology of opposing mechanicism by organicism.

The gap in causality in neuroscience

In a JAMA Psychiatry viewpoint, Amit Etkin suggests that brain neuroimaging risks creating ‘Just-So Stories', internally consistent explanations that have no basis in fact. Nonetheless, he still seems to believe that direct experimental manipulations can overcome this challenge.

The problem is more fundamental. Generating massive amounts of data from neuroimaging of the brain, which is only looking at part of a person, misses the point that whole persons have intrinsic purpose. People cannot be investigated as machines in the same way that their brains can be when they are considered in isolation. No wonder there’s a gap in neuroscientific explanation.

Thursday, November 16, 2017

Is cognitive remediation therapy in schizophrenia merely placebo amplification?

I went to an open-minded talk this lunchtime by Professor Dame Til Wykes about therapy for cognition in schizophrenia. She was prepared to consider the negative evidence for effectiveness of treatment, although she was clear that NICE should include cognitive remediation therapy (CRT) as an evidenced-based treatment in its schizophrenia guideline, which it doesn't do at present, as CRT improves cognition and reduces disability in schizophrenia (eg. Wykes et al, 2011).

Til Wykes was honest about her interest in CIRCuiTS (Computerised Interactive Remediation of Cognition - a Training for Schizophrenia), a web-based computerised CRT, which doesn't seem to be freely available on the internet. What worries me is that the cognition therapy industry may be based on an artefact. Let me explain.

If clinical trials are not double-blind, positive findings may merely be a self-fullfilling placebo amplification. The hypothesis that unblinding in clinical trials for antidepressants produces artifactual placebo amplification is controversial (e.g. see previous post). This should be less controversial for psychological therapies, such as CRT, as trials cannot be conducted double-blind (see eg. another previous post). At the most, an attempt may be made to single-blind the assessors, but disclosures by patients do occur, even if participants are told not to reveal their allocation, thereby breaking the blind. Such bias could explain the small-to-moderate effects found in meta-analyses of cognitive remediation.

Wednesday, October 25, 2017

Psychotherapy and critical psychiatry need to cooperate

I've posted verbatim a copy of the talk I gave recently to the Council for Psychoanalysis and Jungian Analysis, a college of the UK Council for Psychotherapy (see powerpoint slides). Part of the aim of the talk was to challenge the rhetoric about Improving Access to Psychological Therapies (IAPT), particularly from its two main protagonists, David Clark and Richard Layard (as I have done in previous posts, eg. Wider measures of IAPT outcomes needed). Saying that IAPT is a 'marvellous treatment' has to stop. Unrealistic claims about the effectiveness of psychotherapy are a 'perversion of care', to use Rosemary Rizq’s phrase (see previous post).

Critical psychiatry and psychotherapy need to work together to change the dominant technological paradigm in modern mental health services (see previous post). This technological paradigm includes psychological therapy if it is applied in a mechanistic way. As in the position statement from the Division of Clinical Psychology of the British Psychological Society, we need to give up the disease model of mental disorder (see another previous post).

Tuesday, October 24, 2017

The foundations of critical psychiatry

I’ve mentioned before that the PhD I’ve just started (see previous post) is on ‘The foundations of critical psychiatry’. Critical psychiatry is not new. There are at least three points in the past when its conceptual position has been promoted. These associations are not always well appreciated.

(1) Ernst Von Feuchtersleben (1847) Principles of medical psychology (original German edition, 1845) (eg. see previous post) could be seen as the first attempt to provide an interpretive rather than biomedical account of mental illness. Feuchtersleben has been seen as a 'forgotten psychiatrist' (see article). Following Kant, he recognised that the mind-brain problem is an "enigma, which can never be solved" (p. 16). Despite the success of his book, he was "swimming against the tide" and his "psychosomatic viewpoint made no impact in the second half of the 19th century" (Lesky, 1976; quotes from pp. 154 & 156).

(2) Adolf Meyer's (1866-1950) Psychobiology (eg. see previous post) has the same conceptual understanding of mental illness as critical psychiatry. The problem is that this is not always apparent because of Meyer's tendency to compromise. As I said in my paper, the principles of critical psychiatry "can only be reestablished by a challenge to biomedicine that accepts, as did Meyer, the inherent uncertainty of medicine and psychiatry".

(3) George Engel's (1977) biopsychosocial model (eg. see previous post) was a critique of biomedical dogmatism in the same way as critical psychiatry and proposed a "new medical model". The trouble is that it has tended to be interpreted in an eclectic way and its impact not fully realised (eg. see my review of Nassir Ghaemi's (2009) book The rise and fall of the biopsychosocial model).

Critical psychiatry needs to make more of these and other links with the past. Its conceptual understanding is integral to the history of psychiatry.

Monday, October 23, 2017

Institutional racism and reform of the Mental Health Act

The current review of the Mental Health Act (see previous post) needs to take account of the recently published book Institutional racism in psychiatry and clinical psychology: Race matters in mental health by Suman Fernando. Part of the concern leading to the review is that "People from black and minority ethnic populations are disproportionately affected [by the Mental Health Act], with black people in particular being almost 4 times more likely than white people to be detained" (see news story). The purpose of the review is to understand the cause of this and other issues (see terms of reference). I think it is also important that the government deals with the issue of racism in society in general and not does not deflect it just onto mental health.

Table 5.1 in Suman's book summarises racial inequalities in the UK as far as mental health services are concerned:-
The marginality and social exclusion experienced by minority ethnic groups are likely to be significant factors in this imbalance. Black compared to white patients are diagnosed more frequently as schizophrenic by both black and white clinicians - although to a lesser extent by the former - even when clear-cut diagnostic criteria are presented (Loring & Powell, 1988). African American men receive higher doses of antipsychotic medication than white and are more likely to be described as hostile and violent (Metzl, 2010). It's difficult to think the stereotype of "Big, black and dangerous" is not a factor in disproportionate detention under the Mental Health Act (see blog by Nuwan Dissanayaka).

Racism within psychiatry needs to be addressed (Sashidharan, 2001). There is of course a history of attempting to deal with these problems, which the current review cannot ignore, particularly the report Inside Outside. People who use mental health services should expect services to be non-discriminatory. What we need is a national approach aimed at reducing and eliminating ethnic inequalities in mental health service user experience and outcome, and this includes treatment under the Mental Health Act.

Friday, October 20, 2017

Flaming brains

I have mentioned Carmine Pariante in a previous post. Yesterday I went to a talk he gave in the Cambridge Department of Psychiatry on 'Depression and inflammation in the 21st century'. He has reflected in a recent article on his 20 years research in this field.

It does seem a bit nonsensical to talk about depression as an inflammatory disorder, like rheumatoid arthritis. For a start, any apparent increases in proinflammatory cytokines are generally not of the same order as in autoimmune or inflammatory diseases. I'm not saying that an array of inflammatory mediators have not been found to be higher in depressed patients, although this association can at least be reduced by eliminating confounders (O'Connor et al, 2009). Increased inflammation is also associated with psychosocial stress suggesting that any association is likely to be nonspecific rather than specific in the causality of depression.

Monday, October 02, 2017

Reflections on critical psychiatry

Google books has made freely available the chapter 'Reflections on critical psychiatry' by Pat Bracken and Phil Thomas in the new book Routledge international handbook of critical mental healthedited by Bruce Cohen. As Richard Hassall says (see tweet), it provides a "useful summary of the critical psychiatry stance".

What I like is the way the chapter describes the five dimensions of the critical psychiatry project: ontological, epistemological, empirical/therapeutic, ethical and political. I also like the way the authors say that critical psychiatry challenges the technological paradigm rather than just the biomedical paradigm, recognising that psychological, not just biological,  understanding can also be mechanistic. As they say, "Reductionism and positivism have dominated mental health research". As they go on to conclude, critical psychiatry is about "deconstructing the authority of modernist psychiatry".

Monday, September 04, 2017

Is it better to manage without antidepressants?

A Guardian article is headlined to ask why we shame people for taking antidepressants. I don't think this is what those who are critical of the evidence for the effectiveness of antidepressants are doing. All that is being asked is why there is such a small difference in clinical trials between active and placebo treatment and whether this could be an artefact (eg. see previous post).

The paper that led to the Guardian article (Hieronymus et al 2017) argues against the theory that antidepressants outperform placebo solely or largely because of their side effects. I'm not sure if this is precisely the reason why the argument is made that antidepressants may be merely amplified placebos (see another previous post). There may be other ways in which patients can become unblinded in clinical trials. True, the evidence I summarised from Irving Kirsch's book in that post focuses on side-effects. And, it is also true that there is an expectation that side-effects may be the most common way of unblinding in clinical trials and therefore that the more side-effects that patients experience on the active drug the more they improve in clinical trials. As far as I know, the paper, Barbui et al, referred to in my previous post was never published and I'm not sure why.

Furthermore before Hieronymus et al (2017), there was a BJPysch paper (Barth et al 2016) that also did not find an association between adverse events and efficacy. These authors concluded, "Our results do not support, but also do not unequivocally disprove, the hypothesis that adverse events lead to an overestimation of the effect of SSRIs over placebo". I would agree with this conclusion. And, Hieronymus et al (2017) also admit that their "study does not allow any firm conclusions".

In fact, for citalopram, they found that the rating on the Hamilton Depression Rating Scale (HDRS) for those that reported adverse events was not statistically significant from placebo. This may be why they focus in the paper on the depression rating within HDRS, which did find a significant difference. For the paroxetine trials, the association with adverse events goes in the other direction, although, for some reason which I don't understand, in the paper the authors suggest this observation for paroxetine (do they mean citalopram?) "could be interpreted as support for side effects exerting some impact on the response to the drug through unblinding".

Anyway, I agree papers of this sort do not seem to completely corroborate the amplified placebo hypothesis. But, as Barth et al (2016) point out, reporting of side-effects in clinical trials is extremely variable. Reporting of side-effects may, therefore, not be the best proxy measure of unblinding. We do need studies that systematically check for unblinding (Even et al 2000). There is also the issue about whether depressed people may do better over the long-term without medication (see previous post). I am afraid this debate is likely to keep running and can't be closed down by the Guardian article.

Tuesday, August 22, 2017

Pledge support for changes in understanding of psychosis

The International Society for Psychological and Social Approaches to Psychosis (ISPS) has produced a 'Liverpool Declaration' before its upcoming 20th International Congress. As the declaration says, psychosis needs to be understood as largely a response to life experiences. For too long, social and psychological experiences have been "viewed as simply ‘triggering’ underlying disease processes, a perspective no longer supported by research". Social and cultural psychiatry should not merely be a diluted form of biomedical psychiatry (see previous post).

Monday, August 14, 2017

Differences within critical psychiatry

I have uploaded a video of my talk 'Critical psychiatry: Its definition and differences' given at the AAPP conference in San Diego in May this year. Critical psychiatrists don't always agree. I suggested in the talk that there are three main areas of disagreement, although these issues may not be totally distinct:-

  1. Whether psychiatry should be seen as a medical discipline. Where there is agreement is that psychiatry is different from medicine. The disagreement arises because of how much is made of that difference. Some want to go a far as saying that psychiatry should be non-medical. Others emphasise that medicine covers both physical and mental aspects. The reality is that many patients do complain of physical symptoms which have psychosocial origins and any view on this issue has to take note of psychosomatic medicine.
  2. Whether the Mental Health Act should be abolished. Where there is agreement is that critical psychiatry emphasises the rights of people with mental health problems. This emphasis leads some to argue for abolishing all forced treatment and others to accept that detention can be justified by the loss of mental capacity in mental illness. All would accept that psychiatric abuse is not justified and coercion needs to be minimised.
  3. Whether it is suitable to see mental disorder as illness and disease. Where there is agreement is that all identify there is a problem with seeing mental disorder as brain disease. But the questions are: should it be seen as illness; and is psychiatric diagnosis valid? Some conclude that mental disorder is not illness and alternatives are required to psychiatric diagnosis and others accept that psychological dysfunction can be understood as illness and that diagnostic concepts should be understood for what they are. Diagnoses should not be reified, and seen as ‘things’. Instead they are merely idealised, hypothetical constructs and if they have any value should be understood as such.

In summary, the essential critical psychiatry position of challenging the claim that mental disorders have been established to be brain diseases can lead to some differing perspectives within critical psychiatry. As I have said several times, critical psychiatry is a 'broad church', but it does coalesce round the view that the biomedical hypothesis that functional mental illness is due to brain disease is based on faith, desire and wish fulfilment rather than logic (eg. see previous post).

(with thanks to Kermit Cole for making the video)

Wednesday, August 02, 2017

Why fetishise outcome measurement in IAPT?

Jay Watts has a chapter 'IAPT and the ideal image' in The future of psychological therapy in which she describes the chasm between the image and actuality of Improving Access to Psychological Therapies (IAPT). She concludes that "IAPT operates in a virtuality focussing on performativity and surveillance rather than real encounters between clinician and patient".

In particular, she describes the "pernicious pressure on IAPT workers to gain outcome measures for each session". I've mentioned before talks given by David Clark (eg. see previous post) in which he makes much of the fact that IAPT is collecting this data. As Jay says, "During training, workers are sold into the excitement of producing the largest database on wellbeing in history". It would be nice to know what those promoting IAPT think all this effort has achieved, because I can't see much gain. Data accumulates on a monthly basis without much being done to it (see Reports from IAPT). In fact, this process may well be hindering IAPT from really helping people.

I've mentioned before (see previous post), the perversion of care, as Rosemary Rizq called it, of turning away from the realities of managing distressed people. As Rizq says, society has traditionally allocated to mental health practitioners an "unconscious anxiety-containing function". Mental health practitioners experience enormous emotional difficulties in working with mentally distressed and disordered patients. Focusing on outcomes, as Jay says, "stops pain being listened to and the meaning of symptoms heard".

Monday, July 24, 2017

Wider measures of IAPT outcomes needed

Oliver James has posted references on his website, which he mentioned in his talk given at the Limbus Critical Psychotherapy conference on 'Challenging the Cognitive Behavioural Therapies: The Overselling of CBT's Evidence Base'. The essential point he was making is that CBT outcomes over the long-term may not be as good as they appear in clinical trials over the short-term.

I've mentioned before the overstatement about the effectiveness of the Improving Access to Psychological Therapies (IAPT) programme (eg. How do we know that IAPT outcomes are not just due to expectancy effects? and Need to be realistic about value and effectiveness of psychological therapy). As pointed out by Hepgul et at (2015), even if recovery rates for IAPT are 50%, this means "approximately half of patients are not meeting standard definitions of recovery at the end of their treatments". As they go on to say, "Furthermore, it is likely that a substantial proportion of those who do recover may go on to relapse in due course".

One of James' references is Weston et al (2004). This article does not argue that brief, focal treatment cannot produce apparent powerful results over the short-term but recognises that relapse rates are high. Rates can be as high as 85% over 10-15 years (Mueller et al, 1999). The reality is that many psychiatric disorders are characterised by multiple periods of remission and relapse or symptom exacerbation over many years. Some people do seek further treatment after a course of IAPT or other psychological therapy. Weston et al (2004) found that roughly half of the patients in the active condition of clinical trials of empirical supported therapy for depression, panic and generalised anxiety had sought further treatment by 2 years post-treatment. Of those treated for depression, only third of those who improved remained so after two years. The figure for panic was slightly better at roughly half. Controlled data over the longer term is rare but one such study, the NIMH Treatment of Collaborative Depression Research program (Shea et al, 1992), found that 78-88% of those who entered treatment completely relapsed or sought further treatment by 18 months and that this was a no better an outcome than the controls. Uncontrolled data does suggest that the effects of psychotherapy are longer lasting at 6 months post-randomisation, at least for depression, although effects significantly decrease with longer follow-up periods (Karyotaki et al, 2016).

Clinical improvement is not the same as social recovery and there may be residual symptoms even for those classed as recovered with IAPT. In essence, we don't know how many of the so-called recoveries in the IAPT programme are due to the placebo effect or spontaneous improvement. People tend to get better anyway over the shorter term whether they go for IAPT or not. Saying that IAPT is a 'marvellous treatment', and misleading people about how effective it is, has to stop. This is no different from misleading people about how effective medication is (see previous post). I'm not saying that short-term therapy can't be helpful, but we do need to be honest about the limits of therapy. It may be tempting to overstate the case to obtain political funding for services but it's not scientific.

Sunday, July 23, 2017

Critical psychiatry is part of medicine

I mentioned on my personal blog (see post) that I am going back to Cambridge University in the autumn to do a PhD in Psychology on "The foundations of critical psychiatry". I'm glad I did a psychology degree when I was younger, otherwise I wouldn't have been able to do this. I have been accepted by the Psychology department, whereas Psychiatry and Clinical Medicine wouldn't have been interested.

It's a pity that mainstream psychiatry sees critical psychiatry as too threatening. I suppose it's understandable when it's questioning the biomedical faith that mental illness is due to brain disease (see previous post). But psychiatry and medicine should be patient-centred (see another previous post).

These differences shouldn't divorce psychiatry from medicine, although some critical practitioners have suggested that mental health services should be non-medical (eg. see previous post). I don't agree with them, as critical psychiatry is part of medicine (see another previous post). Psychiatry should be broad and open enough to welcome my PhD.

Friday, July 21, 2017

Overemphasis on disease entities in psychosis

I have mentioned in a previous post that Jim van Os wants to abandon the term 'schizophrenia'. In a follow up article, Guloksuz and he essentially argue for a unitary model of psychosis.

However, in a way, this is missing the point. They acknowledge the "lack of diagnostic markers in psychiatry" but seem to express surprise that this "impedes an objective classification". They seem to think it was a good idea that RDoC (eg. see previous post) was set up to create a so-called objective classification, whereas what they need to do is recognise that classification is inevitable subjective, at least to some extent (eg. see my article).

They still think that there is a likelihood of "distinct diseases" in the broad psychosis spectrum disorder. This is where they are wrong and they need to give up the wish to discover such entities (eg. see previous post), whether it's schizophrenia or a more unitary psychosis.

Thursday, July 13, 2017

Giving up the disease model of mental disorder

I mentioned in my Lancet Psychiatry letter that doctors, because of their medical training, have difficulty in giving up the disease model of mental disorder. Yet this is what the Division of Clinical Psychology (DCP) would encourage them to do (see position statement). This is not a controversial argument. It fits with the WHO QualityRights initiative (see recent Lancet Psychiatry article). As the article says, "A movement to profoundly transform the way mental health care is delivered and to change attitudes towards people with psychosocial, intellectual, and cognitive disabilities is gaining momentum globally".

DCP does not totally dismiss the value of psychiatric classification if only because "these systems provide seemingly ‘tangible’ entities for use in administrative, benefits, and insurance systems". But it does argue for "an approach that is multi-factorial, contextualises distress and behaviour, and acknowledges the complexity of the interactions involved in all human experience". Read how balanced the perspective is. It is relevant to the teaching of doctors as well as clinical psychologists and others working in the mental health field.

Tuesday, June 13, 2017

Rights-based reform of the Mental Health Act

At the recent General Election, the Conservative Party said that it would replace the 1983 Mental Health Act in England and Wales with new laws tackling "unnecessary detention" (see BBC News story). Their manifesto said:-
We will ... reform outdated laws to ensure that those with mental illness are treated fairly and employers fulfill their responsibilities effectively.
The current Mental Health Act does not operate as it should: if you are put on a community treatment order it is very difficult to be discharged; sectioning is too often used to detain rather than treat; families’ information about their loved ones is severely curtailed – parents can be the last to learn that their son or daughter has been sectioned. So we will introduce the first new Mental Health Bill for thirty-five years, putting parity of esteem at the heart of treatment.

Part of the motivation for this change was probably coming from the mental health charities, which formed a Mental Health Policy Group to produce A Manifesto for Better Mental Health. One of these charities, Mind, had a 2017 election manifesto, which had 6 points, of which one was:-
Change outdated and discriminatory legislation like the Mental Health Act and the definition of disability to ensure everyone with mental health problems gets support and respect.

Of course the 1983 Mental Health Act was amended in 2007 to introduce community treatment orders, amongst other changes. There was a several year debate/protest before this amendment and I had a Mental Health Policy website at the time (now essentially defunct). It was the reform of the Mental Health Act then that led to the formation of the Critical Psychiatry Network in 1999. I think changing the Mental Health Act again in the way suggested by the Conservative party is less likely to lead to as much controversy as previously.

If the Conservative Party has enough support to manage to get replacing the current Mental Health Act into a Queen's Speech, the Mental Health Bill needs to take account of the Convention on the Rights of Persons with Disabilities (CRPD). This is what the UN Special Rapporteur on the right to health has proposed (see previous post) and the rest of this blog uses quotes or amended quotes from his report.

The disability framework should radically reduce medical coercion. It starts from the principle that a disability shall in no case justify a deprivation of liberty. There is shared agreement about the unacceptably high prevalence of human rights violations within mental health settings and that change is necessary. Persons with psychosocial disabilities are generally falsely viewed as dangerous, despite commonly being victims rather than perpetrators of violence.

Change has taken place over recent years to challenge the disability stereotype, as many can live independently when empowered through appropriate legal protection and support. There are limitations to focusing on individual pathology.

Similarly, failure to secure the right to health and other freedoms is a primary driver of coercion and confinement in mental health. Mental health problems and disability are not exactly the same and this does need to be teased out in any new Mental Health Bill. In fact, it is still not clear how non-consensual treatment in mental health should be taken forward following the Convention on the Rights of Persons with Disabilities. This should be a government priority, even for a minority government. It needs to make use of appropriate indicators and benchmarks to monitor progress in respect of reducing medical coercion. The active involvement of mental health professionals in the shift towards rights-compliant mental health services is a crucial element for its success.