The true situation about antidepressant discontinuation problems

I’ve mentioned before (see previous post) that I signed a complaint to the Royal College of Psychiatrists about a statement made by Wendy Burns, the President, and David Baldwin, the Chair of the Psychopharmacology Committee, that discontinuation problems on stopping antidepressants resolve within two weeks for the vast majority of patients. I do not think this statement is evidenced-based. The complaint has been dismissed by the College as unfounded (listen to MIA Radio podcast)

Minimising the significance of antidepressant discontinuation problems doesn’t seem to matter to the College. I’m not convinced the College membership fully agrees with this unwillingness to engage with the evidence and I am ashamed as a member of the College about this apparent lack of concern. As I said in my previous post, there is a history of antidepressant discontinuation problems being minimised, even denied, and this situation just seems to be being perpetuated by the College.

On the other hand, I guess we shouldn't be too surprised that the College is unconcerned about the truth of a matter of this sort. It finds it difficult to acknowledge the political and ethical implications of psychiatric practice. However neutral and objective the College may like to think it is, it exists, actually, as an institutional structure to justify psychiatric treatment, such as antidepressant medication. So, it would want to minimise problems caused by medication, wouldn't it? More generally, the validity of what it promotes as science does need to be challenged (eg. see previous post). We should not assume that the College has full and absolute legitimacy in truth over psychiatric matters and this has been demonstrated by the way this complaint has been handled.

Let's hope Wendy Burns and David Baldwin are prepared to discuss these matters further now that the complaints procedure is over.

The origin of critical psychiatry

The origin of the term 'critical psychiatry' was probably in an edited book Critical psychiatry: The politics of mental health by David Ingleby (1980). My own edited book Critical psychiatry: The limits of madness (2006) deliberately echoed David's use of the term, and, of course, the name was adopted by the Critical Psychiatry Network (see previous post). David also contributed a chapter to my book.

In the preface to the second impression of his book (2004), David commented that "the notion of mental illness as a brain disease has become even more widely accepted than ever before" (p. 5). The essential position of critical psychiatry can be said to be the critique of this notion. Mental illness should not be reduced to brain disease (eg. see previous post). Even Thomas Szasz contributed to critical psychiatry in this respect, as he regarded the biological basis of mental illness as a myth (eg. see another previous post).

There are, of course, implications of taking this conceptual position. How critical psychiatry's essential understanding is taken forward does lead to differences within critical psychiatry (see previous post). In his introduction to the book, David suggested that, "One premise shared by all contributors to this book is that mental illness is, in fact, a political issue" [his emphasis] (p. 8). In fact, Franco Basaglia (eg. see previous post), one of the contributors to his book, tended to be less concerned about whether mental illness had an organic aetiology. His primary motivation was to abolish the asylum as, as, far as he was concerned, its main purpose was to segregate the under-privileged (see extract from my book chapter).

David made it clear that "mental illnesses ... do exist" (p. 18). He, thereby, moved critical psychiatry on from Szasz's theme of 'the myth of mental illness', in the sense that Szsasz did not believe that the concept of mental illness is valid (see previous post). David also notes how some critical psychologists and others have questioned whether mental health problems "really have much to do with medicine in the first place" (p.8). However, he also quotes Peter Sedgwick, who argued that "mental illness was, after all, a medical problem" [his emphasis] (p. 9).

David juxtaposed 'positivist psychiatry', defining positivism as "the paradigm of studying human beings as if they were things' (p. 13), with 'interpretative' approaches, by which he meant "[u]nderstanding people's 'symptoms' in terms of their social situation" (p.52). Mental illnesses are "meaningful responses to difficult situations ... [but] in many conditions a 'residue' remains refractory to commonsense understanding" (p.13). Here he turned to psychoanalysis to interpret the 'residue' in terms of unconscious meanings.

David concludes his chapter by saying that “until the political component of our disagreements is brought out into the open, we will never go beyond the phoney synthesis of psychiatric ‘eclecticism’” (p.71). His book was written at the end of the period of conflict know as 'anti-psychiatry'. He does mention (on p.7) Anthony Clare's book Psychiatry in dissent, which, as I have said previously, many have seen as the compromise outcome of the anti-psychiatry debate. Clare reinforced an eclecticism in psychiatry by avoiding any clear conceptual basis for psychiatry (eg. see my Psychiatric Bulletin letter). Manschrek & Kleinman called this kind of position in psychiatry 'semi-critical' (see previous post). In many ways, psychiatry is still in this situation (see eg. previous post). The critique of psychiatry does need to go further. Critical psychiatry, in very much the sense originally used by David Ingleby, does need to be seen as a valid solution to the anti-psychiatry debate.

Mind-body relation

Further to my previous post in which I mentioned Charles Myers, I came across a lecture he gave in 1932 entitled ‘The absurdity of any mind-body relation’. (1) What he meant by this was that life has direction and is more than blind mechanism. And, “[c]onscious mind is essentially a specialization, a distillation of that directive activity” (p.8). So mental activity and living bodily activity are identical and it doesn’t make sense to talk about a mind-body relation.

Physical concepts of mechanism are incomplete for a total description of nature (see previous post). The primary distinction is between life and inanimate matter, not life and consciousness (see previous post). To quote from Myers’ lecture, “In no form of life is directive activity wholly absent.” (p.21) As Kant said in the Critique of Judgement,

there will never be a Newton of the blade of grass, because human science will never be able to explain how a living being can originate from inanimate matter

Directive activity is still inherent in plants, even though, as Meyers said, “locomotion and plasticity are minimal” (p.25). This doesn’t mean that there can be no causal explanations for an account of the physical nature of organic matter. But, mechanistic explanations are insufficient for an account of the totality of human and living nature. As Myers concludes, “There is no separable mental or vital force: and the mental must be regarded as identical with the vital.” (p.26) Psychiatry needs to recognise its mistake in reducing mental illness to inanimate brain disease.

(1) Hobhouse memorial lectures 1930-1940 OUP: London

The roots of medical psychology

I’ve mentioned before (eg. see previous post) that I am doing a PhD in psychology at Cambridge University. It’s probably just as well that I’m in the psychology department rather than psychiatry, considering how critical I’ve been of some of the emphasis within the psychiatry department (eg. see previous post).

What may be of interest is that it was actually the psychology department that first started psychiatric training at Cambridge University with the setting up of a Diploma in Psychological Medicine (DPM) course in 1912. It only lasted until 1927 (although no students had enrolled on the course for two years before it was abolished). But the intention had been to make Cambridge the “national centre for the education of psychiatrists” (Forrester & Cameron, 2017: 248).

One of the main driving forces was Charles Myers, who set up the Psychological Laboratory at Cambridge. After the war, he wanted to develop the medical, educational and industrial aspects of psychology. He left Cambridge in 1922, at least partly because of opposition from an emphasis on experimental psychology.

Cambridge psychology needs to be reminded of this root in medical psychology. The British Psychological Society closed the British Journal of Medical Psychology in 2001 and continued it as Psychology and Psychotherapy: Theory, Research and Practice the following year. The first editorial of the newly titled journal said that “the term ‘medical psychology’ is itself becoming anachronistic”. I’m not convinced psychology should be quite so dismissive of this aspect of its history.

Psychiatry should be more scientific

An advertisement article in the Guardian paid for by the Royal College of Psychiatrists uses Mary-Ellen Lynall (who I've mentioned in a previous post) to promote young doctors coming into psychiatry. I'm not sure if it really improves recruitment by speculating that "brain inflammation may be a cause of depression and in five or 10 years we could have a blood test to detect whether that inflammation is present", because this is merely misguided wishful thinking (eg. see previous post).

What worries me is that the apparent motivation for this campaign is that newly qualified doctors don't think psychiatry is very scientific. That's not surprising considering what's promoted as apparent advances in psychiatry, including seeing brain inflammation as the cause of mental illness (eg. see another previous post). Junior doctors are right to laugh at psychiatry if that's all that's on offer.

Psychiatry isn't just about physical disease, as the advertorial indicates. It's a human science, and not just focused on the brain. Nor is the rest of medicine just focused on the body and psychiatry needs to promote itself as a truly patient-centred scientific medical discipline (eg. see another previous post).

Defending Engel's biopsychosocial model

Linda Gask has an essay in The Lancet Psychiatry entitled 'In defence of the biopsychosocial model'. Progress does need to be made on clarifying George Engel's biopsychosocial model (see previous post).

Engel’s model promotes a holistic psychiatry in the same way as critical psychiatry and is a challenge to biomedical dogmatism. His original Science paper was written in response to a paper published in JAMA by Arnold Ludwig (1975) called ‘The psychiatrist as physician’.

Ludwig was concerned about the state of psychiatry, which he saw as under attack from what we now identify as 'anti-psychiatry'. His response was to accept that modern-day psychiatry is vulnerable to such charges. His solution was to retreat to the medical model. As far as Ludwig was concerned, psychiatry should deal with medical illness, including neuropsychiatric and medicopsychiatric disorders, rather than nonpsychiatric problems, which are more appropriately handled by nonmedical professionals. This position is what has more recently been called a 'remedicalised psychiatry' (see previous post). Ludwig was clear that psychiatry's viability was dependent on an understanding of mental illness as due to known, suggestive or presumed brain dysfunction. Interestingly, he predicted, “I am not optimistic that there will be any sudden and dramatic resolution of these issues” (p. 604). Subsequent history could be said to have proved him wrong in the sense that psychiatry has become more biomedical since the publication of DSM-III in 1980 and the development of brain imaging. Modern psychiatry has become more biomedical than even Ludwig anticipated.

Engel, by contrast, was not happy with Ludwig's proposal for change. As far as he was concerned, all medicine, not just psychiatry, was in crisis. He believed doctors had become insensitive to the personal problems of patients and preoccupied with procedures. In short, medicine is too disease-oriented rather than patient-orientated. For Engel, the biopsychosocial model has real advantages, by taking account of cultural, social and psychological considerations as well as biological. Furthermore, it avoids the polarisation between biomedical reductionists, amongst which Engel would have included Ludwig, and exclusionists, like Thomas Szasz, who deny mental illness. Szasz, in fact, had the same biomedical understanding as reductionists of the nature of illness as physical lesion, but did not believe in mental illness because a biological basis has not been established. I have always tried to be clear that there are aspects of Szasz's views which do not coincide with my views about critical psychiatry (eg. see previous post). My views are more identified with Engel's.

What is of interest is that both Ludwig and Engel were trying to salvage psychiatry in the context of ‘anti-psychiatry’. This is why this situation is relevant to critical psychiatry, which has its origins in anti-psychiatry (see my book chapter). I am suggesting that Engel’s biopsychosocial model is a viable form of critical psychiatry.

Many psychiatrists, like Linda in her essay, would say that their approach to psychiatry is biopsychosocial, taking into account psychosocial factors as well as biological. I agree that most psychiatrists are pragmatic in their approach. However, even though most psychiatrists are not narrowly biomedical, they are still biomedical (see previous post), in the sense that they generally believe that mental illness, or at least major mental illness, such as schizophrenia and bipolar I disorder, is due to brain abnormalities, even though the evidence is against this conjecture. More than the empirical evidence, the philosophical argument about the relationship between mind and body is against such speculation. Psychiatrists now rarely become involved in this conceptual debate because they expect that brain research will find the solution to mental illness.

As pointed out by Linda, the biopsychosocial model has been critiqued as being too eclectic by Nassir Ghaemi, leaving psychiatry with no overall theoretical structure as "all theories are possible and all perspectives are valued" (p.1) (see my book review). I agree that psychiatry can be eclectic with, for example, biological and psychotherapeutic treatments being combined without any systematic theory to support such a therapeutic strategy. There is also commonly a split in the aetiological understanding of mental illness, with major psychotic illness being seen as biological in origin, and more minor, neurotic illness seen as having psychosocial causes.

The real origin of eclecticism in modern psychiatry, though, is not in the biopsychosocial model but in the mainstream response to ‘anti-psychiatry’. Anthony Clare’s Psychiatry in dissent, mentioned by Linda, was a response to anti-psychiatry (see previous post). It eschewed a well-defined theoretical basis for practice. In this way, Clare avoided the worst excesses of reductionism and the objectification of patients that caused particular concern to anti-psychiatry. This approach is what is now often labelled as ‘biopsychosocial’ and I worry that Linda is using the term in this way. Most psychiatry is only semi-critical in this sense (see previous post). The true meaning and implications of Engel’s biopsychosocial model have been diluted.

Valid psychiatric diagnosis is unreliable

It's touching to see Paul Salkovskis & Irene Sutcliffe apparently hankering after DSM-III in their The Mental Elf blog post. For some reason they associate DSM-III with ICD-9, which was actually very similar to DSM-II not III. Surely ICD-9 still had some of the "notoriously unreliable" diagnostic definitions Salkovskis & Sutcliffe seem to so dislike. True, they do recognise that biological research has failed to substantiate reliable diagnostic categories, as in DSM-5 (see previous post).

What I'm objecting to is the way Paul Salvoskis & Irene Sutcliffe seem to follow Robert Spitzer in his view that "assuredly an unreliable system must be invalid" (Spitzer & Fleiss, 1974). As I said in my talk (see powerpoint slides), psychiatry should not be panicked by the unreliability of psychiatric diagnosis. If psychiatric diagnosis is going to be meaningful, there will be inevitable inconsistencies. In fact, paradoxically, increasingly internal consistency may well create an overly narrow measure that does not measure the construct optimally, which is called the attenuation paradox.

I'm not against Salkovskis & Sutcliffe encouraging debate about whether psychiatric diagnosis is finished (see previous post). But they speak against the Division of Clinical Psychology (DCP) position statement encouraging people to give up the disease model of mental disorder, which is actually what I think should happen (see previous post).

Most of The Mental Elf post is about the Power Threat Meaning (PTM) Framework, on which I have also blogged (eg. see previous post). Personally I'm not worried that DCP spent money on the launch of the Framework, as it needs to do something with its money. I agree with Salkovskis & Sutcliffe about the Framework being hard to follow, but I've tended to assume it will get easier once I've got used to it. Maybe though it does need a more user-friendly version.

I actually think the summary by Salkovskis & Sutcliffe of the document is quite good. What worries me though is that they seem to still believe in scientific positivism in mental health. They need to accept more the limitations of psychiatric diagnosis (see previous post), and take the PTM Framework more seriously. Lucy Johnstone, one of the main authors of the Framework, is merely arguing for service users to have more choice as to whether they take on a psychiatric label as part of their understanding of their problems (see my book review). Some service users may well find the PTM Framework helpful.

Maybe Foucault understood critical psychiatry after all

Further to my previous post about postpsychiatry, I have found that I like the view of John Iliopoulous that Foucault was not necessarily for or against the Enlightenment (see his PhD thesis (2013) and subsequent book (2017)). The Enlightenment is not so much about the "principles of humanism, liberalism and positivism" (book p.18) but the point when reason itself started to question "the rational foundations of what is accepted as reason" (book p.7). It was this "critical engagement of reason with itself which brought psychiatry as a discipline into existence, and it is the same conflict, the same battle which fuels current debates in psychiatry" (thesis, p.7).

Foucault draws on Kant's philosophy. "Kant's method of questioning the pretensions of rationality, and reflecting on the limits of who we are through reason, inspired Foucault to analyse the birth of the human sciences, and especially of psychiatry" (thesis, p.21-2). In the late eighteenth century, alienism identified certain individuals who were "agents of an experience whose content eludes understanding" (thesis p.167). The insane were separated from places of confinement and placed within asylums.

Madness thus became separated from where it was within medicine in the sixteenth and seventeenth centuries. At that time, "'[m]aladies of the spirit' existed and theories of humours were used to explain mental disorder" (thesis p. 99). From the middle of the nineteenth century, the idea of madness was then "inserted into positive medical knowledge" (book p.20). But, incorporating positivism led to psychiatry losing "its scientific rigour and its validity" (book p. 22).

Iliopoulous also has an article, from which I have produced a tweetorial, that takes this situation forward to the twentieth century. With the development of community care, psychiatry has become accountable to the public.

What I like about this historical narrative is that it fits with my view that there has always been a critical psychiatry perspective since the origins of modern psychiatry (see previous post). Critical reflection is not confined to a particular historical period. Although it may be unrealistic to expect a paradigm shift in psychiatry (see previous post), "Foucault argues that verification and positivism have excluded, set aside and subordinated other modes of truth production" (book p.123). Such critical perspectives are important.

How does a Cambridge professor of psychiatry get away with this?

As a young doctor, Ed Bullmore did not want senior physicians to start thinking he was bonkers, but now he’s long in the tooth it doesn’t seem to matter. He’s written what his publisher calls a “game-changing book” on depression (see book website).

Bullmore reminds me of Henry Cotton (1876-1933), an eminent and notorious American psychiatrist, who believed that the cause of mental illness was the systemic effects of largely hidden chronic infections (see my book review). This is because Bullmore has the same enthusiasm for so-called scientific medicine and advises depressed patients to ask their doctor to consider whether there may be a low-grade inflammation causing their depression. For example, he suggests trying a new dentist in case periodontitis (gum disease) has been missed. You might think this advice may well get him into trouble with the GMC. But, at least Bullmore doesn’t advise removal of teeth or tonsils or even the colon, like Cotton.

To give Bullmore his due, he does admit that finding periodonitis will not immediately make much difference to the treatment of depression. But, he is seriously asking us to consider his theory, which is actually about inflammation in general not just periodonitis, if only, because he is currently leading an academic-industrial partnership, whilst working part-time for a pharmaceutical company, to develop anti-inflammatory drugs to treat depression (see Neil MacFarlane’s review). Initially Bullmore wants to use these drugs for depressed patients that also have a physical illness and then for those depressed patients with raised inflammatory markers.

Don’t be confused into thinking that Bullmore is quite the critical psychiatrist. True, he doesn’t believe in the serotonin theory of depression. His history of the origin of antidepressants with Nathan Kline is actually quite good, although he doesn’t mention Roland Kuhn (see previous post). But, then he takes the radical step of saying that “rheumatoid arthritis is not primarily a disease of the joints” (Loc 963). This does sound bonkers, and what he means is that it is instead a disorder of the immune system. By analogy, we’re not really supposed to view depression as a psychological disorder, but as an inflammatory disease.

I’ve already said in a previous post that this hypothesis doesn’t make much sense. To me, Bullmore seems to compound this situation by confusing feeling sick with feeling depressed. He mentions several times that he had a root-canal filling at the dentist in 2013, and this made him feel blue. The link between inflammation and sickness cannot be disputed, but that inflammation causes depression is just plain wrong and not worth investigating any further. I just think Bullmore, like others, wants to develop an antibody for depression because anti-TNF antibodies for autoimmune and immune-mediated diseases have made billions of dollars over the years. This is despite the only trial of a TNF inhibitor in depression being negative. Bullmore should be put out of his misery.

Also, don’t think Bullmore is a good philosopher because he makes much of Descartes. Sceptics of his theory like me are dismissed as Cartesian, which I’m not. And he doesn’t spell out that his position is reductionist (eg. see previous post). True, he admits he likes such a point of view because it’s simpler. But I’ve made a point in this blog of emphasising that it’s important to integrate mind and brain (eg. see previous post) and medicine and psychiatry (see eg. another previous post). Bullmore could also learn from the philosophy of biology (see previous post).

Let’s conclude with quotes from Bullmore himself, “[I]mmunology has made no difference whatsoever to any patients with depression, psychosis or Alzheimer’s disease” (Loc 443). Nor should it! As Bullmore also says, “Voltaire and Molière filled theatres with their dark comedies about medical buffoonery” (Loc 1243). Bullmore is laying himself open to similar treatment from a modern satirist.

Taking the Independent MHA Review forward

Akiko Hart has a MIA blog post about the interim report of the Independent Review of the Mental Health Act (see eg. previous post). As she says, it may be difficult to see how changing legislation in itself could necessarily address rising detention rates and racial disparities in detention.

The interim report is disappointing because it does not specifically mention institutional racism (see previous post). Nor is reference made to the rights-based report of the UN Special Rapporteur, which takes into account the Convention on the Rights of People with Disabilities (CRPD) (see previous post). It’s also difficult to know what the interim report means when it says “We are  not  persuaded that CTOs [Community Treatment Orders] should  remain in their current form“, when CTOs probably should never have been introduced in the first place.

What is central is the dignity and respect of detained patients. The Independent Review has heard plenty of evidence of unacceptable, including abusive, treatment. The interim report does not specifically mention the Mental Health Act Commission (MHAC), whose functions have been taken over by the Care Quality Commission (CQC). Its statutory responsibility is to interview detained patients and investigate their unsatisfactorily dealt with complaints, as well as deal with any other complaints in relation to detained patients. I guess it could be said that CQC has not been fulfilling this statutory function and changes need to be made.

Opposing increased coercion in reform of the Mental Health Act

I have been looking at some minutes from when the Critical Psychiatry Network first started meeting in January 1999. A paper was written before the meeting by Phil Thomas and Pat Bracken because of concerns about the potential for coercion increasing in the context of the reform at the time of the 1983 Mental Health Act (MHA) (see my website at the time, now essentially defunct because of dead links, but maybe these need to be resurrected). Initially the group was called the 'Bradford group' after the city in which the first meeting took place. At the 6th meeting of the group in October that year the name 'Critical Psychiatry Network' was adopted to reflect the fact that the group had taken on wider critical psychiatry concerns.

As mentioned in a previous post, my edited book Critical psychiatry: The limits of madness came out of three conferences that I organised for the Critical Psychiatry Network (CPN) in 2001-2003, to which I added four chapters. What I suggested in my first chapter was that "although critical psychiatry has its roots in anti-psychiatry, it does represent an advance over the polarisation in the debate about psychiatry engendered by anti-psychiatry" (p.3) (see my chapter in the book on 'Historical perspectives on anti-psychiatry'). In my last chapter, I summarised where CPN had got to by 2006 (see extract), just before the MHA was amended.

More recently Pat and Phil have reflected on where critical psychiatry is now (see previous post). This is relevant, considering that the MHA is again currently under review (see another previous post). There are concerns that people’s dignity, autonomy and human rights are overlooked (see report from Mental Health Alliance, from which CPN resigned when it looked as though the Alliance was going to compromise on the introduction of CTOs, which essentially proved to be the case). I have had no response to an email to the Chair of the Mental Health Alliance about this situation, nor  does the Alliance, I guess like a lot of organisations, seem to have responded to the formal request for evidence from the Independent Review. Still, I have managed to find responses from Agenda, the Law Society, Faith Action, the Royal College of Psychiatrists and a response coordinated by the Centre for Mental Health, Prison Reform Trust, and Together for Mental Wellbeing. Although the Review's website says that it is still open to submissions of evidence, I have not had a response to my email asking for confirmation that it is not too late to submit evidence. There does seem to be a question about how open this review, chaired by Sir Simon Wessely, has been before a report with recommendations is produced in the autumn.

What’s happened to Harvard psychiatry?

Theo Manschrek and Arthur Kleinman in their introduction to a 1977 book, Renewal in psychiatry, that I have mentioned before (see previous post), decried the “current deficiency of critical rationality in psychiatry” (p.1). They wrote these words soon after they started training in psychiatry, but I think they still apply today.

They also edited their book to honour Leon Eisenberg (who I have mentioned in another previous post). Their contribution was written from “strong backgrounds in clinical medicine” (p.2). They recognised “how ubiquitous within psychiatry the practices of uncritical thinking and inattention to methodological issues are” (p.2). People after my own heart!

They divided the state of psychiatry at the time into what they labelled the semicritical and hubris positions. The first is what I have called the atheoretical, eclectic position, for example adopted by Anthony Clare after the anti-psychiatry debate (see previous post). It’s a consensus position taken by mainstream psychiatrists, such as Simon Wessely (see another previous post). It’s sometimes called the biopsychosocial model by its advocates, but this is not fully understanding what George Engel meant when he said there was a need for a new medical model (see another previous post). Manshreck & Kleinman say that the semi-critical position “fails to see the limitations of the medical model in clinical medicine ... and, thus, does not push its critique far enough” (p.7).

The hubris position is what I tend to call the biomedical model. This is a more dogmatic position, which Engel reacted against to produce his biopsychosocial model (see copy of my talk). More recently it has been called a ‘remedicalised psychiatry’ (see another previous post). Manschrek and Kleinman “see this position as very dangerous” (p.7). It’s interesting their book was published in 1977, the same year as Engel’s paper in Science. There is, therefore, no cross referencing. Both propose a new way forward and this is set in the context of what they see as the more radical critique of authors such as Thomas Szasz.

Quoting Callway (1975), Manschrek & Kleinman say that “psychiatry needs to tidy up the mess left by its snake oil salesmen” (p.8) and conclude that “special psychiatric techniques ... have sold themselves too well” (p.8). To discover the ”roots and consequences of this crisis” (p.9), they do an excellent examination of the clinical, biological and sociocultural traditions within psychiatry at the time.

Interestingly they saw psychiatry then as in the same state as the origins of psychology with William James (see my book review). They found that ”much is amiss in psychiatry” (p.22). From their point of view, psychiatry needed a firmer foundation. They recognised the “barriers to the realisation of this consensus“ (p.22) and their solution was that “psychiatrists employ a critical stance toward knowledge” (p.33). I couldn’t agree more.

Manschrek & Kleinman promoted critical rationality as a “tool that ... can go far to discipline the fields of psychiatry” (p.29). Of course, a truly scientific perspective should start from the null hypothesis, even though most so-called scientific research speculates beyond the evidence (for example, see my comments about cannabis and psychosis (see previous post) and/or tobacco and psychosis (see eg. another previous post). Manschrek & Kleinman encouraged explicit goals for training (eg. see previous post) with an emphasis on method. As they said, “rationality alone is not a sufficient answer” (p. 23). I have also looked at the definition of ’critical’ (eg. see powerpoint slide).

What is of interest is what happened to Manschrek & Kleinman's perspective. As is known, Arthur Kleinman went on to become central to integrating anthropology with medicine and psychiatry (see previous posts linking to two of Kleinman's classic books: Rethinking psychiatry and The illness narratives). But what about Theo Manschrek? He was, after all, the first author of this chapter. I suspect he got taken up with neo-Krapelinianism (see eg. my book chapter). I may be wrong but it would be interesting to find out, because the need for a critical rationality in psychiatry is even more pressing now than it was then (eg. see another previous post).

Further reflection on antidepressant efficacy

Having first reflected (if that’s the right word) in the media, Cipriani et al now reflect on their network meta-analysis (see previous post) in Lancet Psychiatry (see article), which is a more sober affair. Again they admit that differences between antidepressants are small, but qualify this by saying that “exceptions exist”, but then do not spell out what those exceptions are. They come up with a slightly lower figure for placebo response in clinical trials than a BMJ editorial (see previous post), but who’s going to argue about a few percentage points in a matter like this? They don’t really say that the range of antidepressant responses for different drugs in the trials included in the analysis could be due to the trials themselves rather than the drugs.

As I said previously, none of this is new. To me, all the fuss about this study, which has led Cipriani et al to reflect on it, seems to have been created because this is 6 years work which only reaches weak conclusions. Going slightly off message, they go on to argue for open access to data from clinical trials at the anonymised individual patient level. Having always been open in this blog, I couldn’t agree more, although I suspect that all this will do is show up even more biases in the data.

Anyway, Cipriani et al seem to be agreeing the debate about antidepressant efficacy has not been ended by their study. As I have said several times previously, I would also encourage them to research the placebo amplification hypothesis, however difficult this may be.

Carmine Pariante is having a great time

I’ve expressed concern before about the scientific credibility of American academic psychiatry (see previous post). Following the recent article from Carmine Pariante, who I have mentioned before (eg. see my previous post with which Pariante said he agreed - with qualification - in a tweet), about ‘A parallel universe ... ‘, I think we should also be concerned about British academic psychiatry. 

Pariante promotes psychoneuroimmunology, otherwise known as immunopsychiatry. He regards this “new discipline as an example of successful translational neuroscience overcoming the brain-mind-body trichotomy” [his emphasis] (quoted from his article). I agree with Pariante that “psychiatrists, psychologists and social scientists can work together to link the mental and the neural” (quoted from his article with Nik Rose - see my previous post). But I don’t think Pariante has understood Nik’s notion of ‘critical friendship’ between social sciences and neuroscience.

The trouble for Pariante is that there is a difference between psychiatry and medicine. There should actually be agreement that psychiatry is different from medicine. Where there is disagreement is about how much to make of that difference (see another previous post). As I keep saying, I don’t want to be misunderstood. As Pariante himself says in the latest article,  “We have a body (which includes a brain)”. Like him, I’m not wanting to create barricades between biomedical and psychosocial approaches in psychiatry. But he does need to understand that minds are enabled but not reducible to brains (eg. see another previous post). 

I think Pariante needs to come down to earth, otherwise it’s going to get him in trouble with the General Medical Council (GMC), as he acts as a Royal College of Psychiatrists spokesman. There’s already been one complaint to the GMC. Perhaps we need Nik to come back out of retirement to sort this mess out.

Clarifying Szasz's critique of psychiatry

Nassir Ghaemi has published his invited commentary which was rejected for a new book on Thomas Szsaz (see article). It's the advantage of the internet that these pieces can still be published, as I know from my own critical psychiatry blog!

Of course, Szasz was known as an anti-psychiatrist (see previous post). I'm glad he had the academic freedom to promote his views (see another previous post). Szasz started at the Chicago Institute for Psychoanalysis from 1951–56. He was particularly influenced by Franz Alexander (see book).

But I worry that Ghaemi has become too much of an 'anti-psychoanalyst' by believing that psychoanalysis in the 1950s, when Szasz was in Chicago, "stunted any free thought". He argues that "[t]he psychiatry that Szasz railed against in his most famous book was full of myths and was mostly false", because it was primarily psychoanalysis. I agree that the prominence of psychoanalysis did help to make psychiatry more pluralistic then. But I don't think Ghaemi fully understands about the myth of mental illness (see another previous post). And, as I've also said before, "Despite his protests, he [Szasz] will always be associated with the history of anti-psychiatry" (quote from previous post).

I'm certainly not resting my criticisms of psychiatry on the same viewpoints as Szasz. Have a look at my actually quite generous, I think, review of one of his books (see book review).  But, in fact, Szasz was quite scathing (as he could be about lots of things) about the Critical Psychiatry Network (eg. see previous post), of which I am a founding member. I don't even take the same view as him on the insanity defence (see previous post).

I did wonder what was going on when Ghaemi seemed to become more questioning about psychiatric diagnosis (see previous post). But it's clear from the latest article that he hasn't given up his beliefs in biological markers and the genetics of mental disorder. This is why he thinks Szasz was wrong. But he's actually not arguing for the right reasons, which is what he accuses Szasz of doing (see another post). Let me work towards a conclusion with a quote from another previous post:-

The primary problem with modern psychiatry is its reduction of mental illness to bodily dysfunction. Objectification of those identified as mentally ill, by insisting on the somatic nature of their illness, may apparently simplify matters and help protect those trying to provide care from the pain experienced by those needing support. But psychiatric assessment too often fails to appreciate personal and social precursors of mental illness by avoiding or not taking account of such psychosocial considerations. Mainstream psychiatry acts on the somatic hypothesis of mental illness to the detriment of understanding people's problems.

Szasz was correct that he first made this argument in The myth of mental illness. 

From my point of view Szasz undermined this argument by insisting on such matters as abolishing all psychiatric coercion. I've said before (see book review) that it can seem quite muddling arguing with Ghaemi but I've tried here to clarify the positions of Szasz and myself, not make them more confusing.


(with thanks to Neil MacFarlane whose tweet linked me to the Ghaemi article)

The psychiatrist as a cultural interpreter

I responded to a BMJ review of Sami Timimi’s book Pathological child psychiatry and the medicalisation of childhood, when the book first came out in 2002 (see response). This was before the publication of Post-psychiatry (discussed in a previous post). So, if Post-psychiatry is seen as one of the first texts of the Critical Psychiatry Network, Sami’s book has priority. Sami has published several other books since (see list on Wikipedia page). He also wrote a chapter for my Critical psychiatry book.

Sami came to England from Iraq when he was aged 14. This means he is very aware of discrimination, although during his training he found himself “becoming more and more critical of ... Arabic culture” (p. 126). Western powers’ involvement in war and destruction in Iraq led to him having a more balanced perspective (see my 2010 Openmind psychiatric update column). As Sami says, "[r]esistance is in my bones" (p.163).

Sami found his psychiatric training “a very confusing experience” (p.1). He found it difficult to understand why he was being indoctrinated in the way he was. He came to appreciate that “the whole mental-health business is about belief systems rather than hard science” (p. 59). He also came to appreciate that "[c]hallenging the mainstream can be a lonely, isolating experience" (p. 71). As I’ve said before (eg. see previous blog), psychiatry is more like a faith than a science. I have tried to take this understanding forward by using Clifford Geertz’s definition of culture as "a system of inherited conceptions expressed in symbolic forms by means of which men communicate, perpetuate, and develop their knowledge about and attitudes toward life" (see eg. another previous post). Sami likened the kind of experience he went through to that described by Frantz Fanon when "black families in Europe often had to choose between alienation or adopting a European outlook and pretending that the racism around them did not exist" (p. 71). When seen as a non-believer at a pro-Ritalin and pro-ADHD conference, Sami "left the conference feeling he had attended an extremist cult convention" (p.85).

Still, Sami is a child and adolescent psychiatrist and this field used to be a haven for those that wanted to escape the abuses within adult psychiatry. Sami rightly worries that the increasing biologising of childhood has brought child and adolescent psychiatry within these parameters. When he and I trained, we were taught that there were emotional and conduct problems in childhood. Now medical students tend not to be taught this, instead being told to focus on ADHD and autistic spectrum disorders. Childhood depression, then, when we trained, was not recognised in the same way as adult depression, like it is now (see my BMJ letter).

In his first book, Sami said, "In essence what all of us who are working in the field of therapy for social suffering are doing is acting as cultural interpreters" (p. 83). Here he is using the notion of symbolic healing. Psychiatric practice is “using culturally meaningful mediated symbols” (p. 80). Sami recognises the way in which the 'new transcultural psychiatry' criticises orthodox psychiatry for "not giving proper consideration to context" (p. 156). He utilises "post-modern therapies" (p.130), defined widely, to include narrative and solution-focused approaches. His honesty even leads to him at times sharing "information from my own life" (p.135).

As Sami himself says, he has used "quiet persistence" (p.163) to get his message across. He has contributed significantly to modern critical psychiatry.

Controversy about cannabis and psychosis

Because of my scepticism, I was alerted when I saw the BJPsych editorial on cannabis and psychosis, which began, “It is now incontrovertible that heavy use of cannabis increases the risk of psychosis”. As I said in a previous post, some “heavy users of cannabis may be rarely unintoxicated, leading to misdiagnosis of the induced psychotic-like experiences, which are usually transient in less heavy users”.  But I ended that post with the conclusion: “The causal link between cannabis and psychosis has not been proven”. 

The new editorial of course recognises that association does not mean cause. But it suggests that alternative explanations have been disproved. As I keep saying, the use of cannabis can cause emotional problems and people may use it to deal with their emotional problems. These problems may well be worse with skunk compared to hash (see Guardian article). Cannabis use is likely to be a proxy measure for poor premorbid adjustment associated with psychosis. I can't see that this most obvious explanation has been eliminated. 

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 completely 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.  

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 than 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).

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 .

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).

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.

Postpsychiatry

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.

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.