Parliamentary scrutiny of draft Mental Health Act Reform Bill

I think the key question for parliamentary scrutiny of the draft Mental Health Act Reform Bill (when it is published - see background notes) will be whether the legal capacity of people with mental health problems will be protected even though they may not have mental capacity (see last post). The Joint Committee on Human Rights is calling for evidence. New legislation needs to be compliant with the UN Convention on the Rights of Persons with Disabilities (CRPD). Even though the UK government is saying that its mental health legislation is compliant, I do not think this is the case (see Disability News Service article).

I think the independent review chaired by Simon Wessely (see previous post), on which the draft legislation will be based though consultation on a White paper (see another previous post), was too influenced by the general comments by the Committee on the Rights of Persons with Disabilities, particularly its 11 April 2014 comment, which has been criticised by Freeman et al (2015) amongst others. From my perspective, CRPD does not completely prevent the detention of people with psychosocial disability as long as it is on the same basis as anybody else. If properly legislated for, it should lead to a dramatic reduction in coercion in mental health services (see eg. previous post). The fundamental problem with mental health legislation is that it is discriminatory and this must change.

Creating CRPD compliant mental health legislation

Coercion needs to be reduced in mental health care (see eg. previous post). Mahomed et al (2022) promote the development of supported decision making regimes to eliminate substituted decision making and coercion in mental health care. As the article notes, "Some in the clinical community remain doubtful about the practicality of ...  [ such] provisions" (see previous post). It is true that there are situations in which implementation of supported decision making is a challenge.  I agree with the argument of the article that these concerns should be seen as "opportunities for dialogue" rather than a reason for dismissing the replacement of substituted by supported decision making. Change is required in mental health law because of the unacceptably high current prevalence of human rights violations within mental health settings (see previous post).

WHO QualityRights Core Training has a helpful training and guidance tool on 'Legal capacity and the Right to Decide'. There are a course guide and course slides. One of the main aims of the module is to understand article 12 of Convention on the Rights of Persons with Disabilities (CRPD) and the right to legal capacity. The right to legal capacity is guaranteed by Article 12 of the CRPD. 

People with disabilities have rights and responsibilities like anyone else. They have the right to receive support to help them make decisions and when they receive that support they must be protected against abuse. There is a distinction between legal and mental capacity and disabled people should not be denied the right to make a decision merely because other people do not agree with it and attribute it to their disability. How well people make decisions varies and disabled people should not be discriminated against. Flawed use of mental capacity tests has led to the denial of the right to legal capacity (see previous post). 

Article 12 of the CRPD makes clear that the right to legal capacity can never be taken away from a person. A psychosocial, intellectual or cognitive disability can never justify denying someone the right to legal capacity. Having the right to legal capacity at all times does not mean that people never need or want support in making their decisions (see eg. previous post). 

People should have access to the support of people they trust. Support also has to be tailored to the individual. For example, someone in the early stages of dementia may require less support than in later years. It is the need for support that may fluctuate not the right to exercise legal capacity. Formal professional support should not replace informal support provided by the person's social network and community. 

Support must be based on the will and preferences of the person. Best interpretation of will and preferences needs to replace best interests determinations in decision making law. Supported decision making is a completely different approach to decision making which puts the person at the centre of the decision. Independent support advocacy should be available (see eg. previous post). Obtaining informed consent to treatment is essential in respecting the right to legal capacity. People should not be discriminated against on the basis of a disability. 

People with disabilities can only be detained on the same basis (or for the same reasons) as anybody else. Detention can be violent and abusive, which can amount to torture and ill-treatment in violation of articles 15 and 16 of CRPD. People with disabilities have a right to respect for their physical and mental integrity on an equal basis with others under article 17 of CRPD. They have a right to live independently and to be included in the community under article 19. Health care professionals are required to provide care on the basis of free and informed consent under article 25.

Progress needs to be made in the reduction of coercion in mental health services. Treatment of people with mental health problems should not be unjust or prejudicial. Discrimination within mental health law must end.

Mental health crisis amongst young people?

Sami Timimi (2022), who I’ve mentioned before (see eg. previous post), provides a very helpful contribution to the Psychological Medicine debate about whether antidepressants and ECT are the answer to depression (see eg. last post). What I want to pick up on is what he says about the effect of  ‘desigmatisation’ campaigns on helping people, particularly young people, identify their mental health problems (see previous post). 

Encouraging young people and their families to talk about their problems has created, as Sami says, “a disastrous tsunami … to sweep them away”. He goes on:-

Young people, their parents, and their teachers [have] developed an awareness that ‘illnesses’ like depression are all around us, and you could be one of those affected. … You start to notice how bad you feel sometimes and wonder why you feel like this. Could it be that you are developing a mental disorder?

Sami references a very good Channel 4 Dispatches programme ‘Young, British and Depressed’, in which he appeared. He quotes figures from a survey undertaken for the programme. 68% of young people thought they have had or are currently experiencing a mental health problem. Of those, 62% thought that ‘de-stigmatisation’ campaigns helped them to identify it. Do the majority of young people really have a mental health problem? Surely it’s not meaningful to frame the emotional problems of young people in this way. As Sami says, “This alienation from, and fear of, … emotional turmoil … is the terrifying result of … [a] moral panic about mental health”. He goes on:-

The scene has been perfectly set up for transforming the challenges, confusions, intensity, and changes that happen as we grow and develop, particularly in our adolescent years, into potential obstacles, dysfunctions, dysregulations, and disorders, that can be neatly packaged and given ‘treatments’ to get rid of them.

The mental health system is clearly not functioning for young people. To quote again from Sami, “The perseverative call for more resources is the standard juvenile political response to the chaos our incoherent logic has caused”. Let’s hope the current national review of mental health strategy (see Call for evidence) does something about this situation. Mental health services need to be transformed and the aim to expand them needs to be rethought. Everyone, and perhaps particularly young people, are suffering because of this cultural process to create panaceas for emotional problems. They don’t always work and may create more problems than they are worth. Mental health is too important to leave to the professionals alone.

Blinding psychiatric critique with science

The article by John Read and Joanna Moncrieff, which I've mentioned before (eg. see previous post) on 'Depression: Why drugs and electricity are not the answer' has provoked even more responses. If the one by Goldberg and Nasrallah (2022) is the best case that biomedical psychiatry can make, then it is clearly in trouble. Within the limited space they had, Moncrieff and Read (2022) make a partial response.

The problem is that Goldberg & Nasrallah are blinding people with science. They've not really engaging with psychiatric critique. Most people do not understand  the scientific jargon they use and quote. For example, Jay Joseph (see his guest post) can undermine what they've said about the genetics of depression in a single tweet. But most people are not on top of the literature as he is. Interpretation, at least, of the evidence that Goldberg & Nasrallah give is wrong but it's not apparent from the complex way in which they present it. 

I'm sure speculative papers like Goldberg & Nasrallah will continue to try and present themselves as facts. But it's not a very firm foundation for psychiatric practice.

Towards a psychiatry fit for purpose

Pat Bracken (2022) responds in a more positive way to the review by Read and Moncrieff (2022) 'Depression: Why drugs and electricity are not the answer' than previously published commentaries (see previous post and another). As he says, "Engaging in a non-defensive manner to the sort of evidence summarised by Read and Moncrieff will be a move in the right direction for the profession". It's good to see Psychological Medicine engaging with this debate.

Blaming chemical imbalance in the brain for depression does not make sense

Ang et al (2022) found that 23 out of 30 papers between 1990 and 2010 reviewing the aetiology of depression explicitly discussed the serotonin hypothesis and that 11 of them unequivocally supported the hypothesis. Another 9 papers, mainly stressed that depression is caused by an interaction of a multiplicity of factors and acknowledged the inconsistencies of the research on serotonin function, but nonetheless suggested that serotonin abnormalities mediate depressive symptom production or effects of antidepressants. Only one paper discounted the hypothesis. Of another 30 papers specifically examining the link between serotonin and depression, 16 gave unequivocal support for serotonin having a direct role in the aetiology of depression and only one discounted or challenged the hypothesis. Six well-known psychiatry and psychopharmacology textbooks published in the same period all acknowledged that the serotonin hypothesis is ultimately a hypothesis and not necessarily proven, but nevertheless devoted considerable space to coverage of the theory, providing some degree of support or endorsement for the hypothesis. 

The article therefore confirms that the serotonin theory has been endorsed by the professional and academic community. Psychiatrists need to take responsibility for promoting the theory (see previous post). Psychiatry has always held out the hope that it will find the answer to mental illness but it needs to accept its limitations (see eg. another previous post). Although it may seem to make sense to us that we should be able to find a biological cause for mental illness, such as chemical imbalance in the brain, that doesn't justify wish-fulfilling unproven phantasies and even their publication in the academic literature (see yet another previous post). In fact, it's people that become depressed, not their brains, whether chemically imbalanced or not (see previous post).

Doctors have made too many people dependent on antidepressants

Publication of the NICE guidance on ‘Medicines associated with dependence or withdrawal symptoms: Safe prescribing and withdrawal management for adults’ has not resolved controversy about antidepressant withdrawal. For example, the All Party Parliamentary Group for Prescribed Drug Dependence accuses NICE of failing to listen to patient evidence (see press release). To be fair, NICE probably couldn’t go further based on current evidence but I agree that it has left ambiguity about this issue.

Although NICE admits that there is considerable debate about the definitions of dependence and addiction, it clearly states that antidepressants cause withdrawal symptoms even though they have not historically been classified as dependence-forming medicines. It sees dependence as characterised by tolerance and withdrawal symptoms. Addiction is said to include the additional characteristics of cravings, lack of control, overuse and continued use despite harm, associated with problematic behaviours.

Dependence and addiction in common parlance tend to mean difficulty in managing without the drug (see my webpage). An effort may be required to do without the drug. It is a psychological state, although it can also be physical. The drug may need to be continued or withdrawal symptoms may occur in its absence.

Regular and frequent use of some substances, such as alcohol and opiates, can cause tolerance, so that people experience withdrawal symptoms in the absence of the drug. This is what is meant by physical dependence. Dependence on antidepressants, and more generally, is not just physical (see previous post). 

People are being indoctrinated into believing they need antidepressants (see eg. previous post). No wonder they may have difficulty in stopping them. Doctors need to take responsibility for making so many patients dependent on antidepressants.

The mereological fallacy in psychiatry

The category mistake of identifying the part with the whole was called the mereological fallacy by Bennett & Hacker (2003). The second edition of their book Philosophical foundations of neuroscience (2021) has created a separate chapter (3) dealing with this conceptual problem. For psychiatry this is about identifying the brain with the person (see eg. last post). Peter Hacker refutes the rationale of the mereological fallacy in neuroscience in a YouTube video. 

Psychiatric critique needs to challenge the common mistake in psychiatry that it is the brain that perceives, thinks, feels and intends to do things. Such reasoning doesn’t make sense. Psychiatry treats people living in relationships, not their brains.

More on taking psychiatric critique seriously

Carmine Pariante, who I've mentioned several times before (eg. see previous post), asks in a Psychological Medicine article "Why is it so difficult to say ... the brain regulates emotions and behaviours, in the same way that the heart pumps blood, the stomach absorbs nutrients and the spleen hosts immune cells?" Of course he's right that the brain mediates relational and intentional processes (see previous post). But people feel and act, not their brains, nor even their minds nor their consciousness (see another previous post). To be alive, a person has to be whole. The brain is only part of the person; an organ, like the heart, stomach and spleen, but not the seat of the person as such.

Psychiatry is the science and practice of biological, psychological and social relationships of people and their disorders. Despite what Pariante says, this is not a dualist position (see eg. previous post). A correctly understood biological psychiatry requires an adequate concept of biology, namely that of life bound to the entire organism and its interaction with the environment (see eg. previous post). Psychiatry's primary object, despite Pariante again, is not the brain but the person living in relationships. This fundamental failure to appreciate this philosophical reality is damaging psychiatry.

Pariante, therefore, does not realise that it is not possible in principle to reduce mental illness to brain disease (see previous post). He believes what he calls "the humongous evidence that there are neurochemical abnormalities in people with depression" must be true. But he neglects to say that such evidence is plagued by so many confounders and inconsistencies that it's not possible to say what the biological causes, as such, of depression are. He doesn't say what they are because he can't.

As I said in my last post, biomedical psychiatry needs to take seriously its critique. Pariante has a long way to go to do that.

Taking psychiatric critique seriously

Aftab et al (2022) critique the philosophical and conceptual basis of an article by Read & Moncrieff (2022) about why drugs and ECT are not the answer for depression. I have sympathy with their argument that binary opposition between understanding depression as medical illness and meaningful response to life events is problematic. However, having detected this flaw, Aftab et al then justify not dealing with, even dismissing, the main focus of the Read & Moncrieff article on the effectiveness and safety of antidepressants and ECT.

Aftab et al clearly find it difficult to give up hypotheses of antidepressants (and presumably ECT) correcting biological dysfunction, speculating that antidepressants may enhance synaptic neuroplasticity. They do not seem to fully appreciate that enactive accounts of psychiatry, such as that by Sanneke de Haan (see previous post), provide a philosophical and conceptual critique of naturalistic-reductive approaches to human understanding by focusing on the person as embodied and alive (see eg. another previous post). Aftab et al’s view is what Manschrek & Kleinman (1977) called semi-critical as it doesn’t follow through sufficiently on its critique of the biomedical model (see eg. my article). As I have been arguing throughout this blog, psychiatry needs to move on from its eclectic biopsychosocial view (eg. see previous post and another and yet another) and return to Engel’s original concept of the biopsychopsychosocial model, which was a critique of reductionism in psychiatry and medicine in general (see eg. another previous post). Critical/relational psychiatry is explicitly anti-reductionist and anti-positivist whereas Aftab et al are not. Their approach to psychiatry is still not sufficiently person-centred. 

Including people with personal difficulties in mental health services

The Royal College of Psychiatrists has cancelled a Personality Disorders course (see statement), following concern on Twitter about a flyer for the event (eg. see tweet). I wasn’t totally happy either about the College’s January 2020 position statement on personality disorder (see previous post). 

There is of course some truth in the statement in the flyer that personality disorder is a “thorn in the flesh of many clinicians”. It may not be seen as a proper mental disorder because it’s not mental illness. Some psychiatrists may prefer dealing with what they see as the substance of real mental illness. It’s also commonly a label for people seen as difficult. The minority that seek treatment, according to the flyer, do so “often in a dysfunctional manner” by causing problems. The course was supposed to equip psychiatrists to deal with these kind of people with which they can’t win either way whether they get involved or not.

I guess we all have personality difficulties, some more than others. Psychopathic disorder meaning a “persistent disorder or disability of mind which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned” was removed from specific mention in the Mental Health Act 1983 as a kind of personality disorder by the 2007 amendments, although the definition of mental disorder became very broad. I have expressed concern that the proposed removal of learning disability from the Mental Health Act will in a way potentially encourage the reintroduction of the notion of psychopathic disorder (see eg. previous post). More generally, psychiatry does need to become more inclusive in its services for people with personal difficulties, whatever pattern of problems may be present because their personality.

Social critique of psychiatry

Joanna Moncrieff, who I’ve mentioned before several times (see eg. previous post), analyses the mental health system from a Marxist perspective in a recent article. Marxist theory has been used in critical mental health writings (see eg. my review of book edited by Bruce Cohen). Psychiatry has been seen as a mechanism of social control of behaviour regarded as threatening the stability of the capitalist system. Framing social problems as individual pathology can divert attention away from the political and socioeconomic origins of mental health problems. Interestingly, Jo takes a kind of 'labelling theory' view of mental illness as  “simply the collection of challenging situations that remain when [for example] those that are amenable to the criminal justice system … are taken out of the picture” (see my review of Thomas Scheff’s classic book).

Jo wants to question the notion that mental illness is located in the individual. However, as I pointed out in a previous post, Aubrey Lewis noted that maladaptive behaviour is only pathological if it is accompanied by a disturbance of psychological functioning. Social criteria play no part in the diagnosis of mental illness as such. In a way, that fits with Jo's perspective as she doesn’t really accept the term ‘mental illness’, although she persists with it as “there are no widely accepted alternative ways to describe the problems in question”. 

The social function of psychiatry cannot really be denied as psychiatry manages madness on behalf of society. As Jo notes, “One of the functions of mental health services is to provide support and care for people when they are unable to look after themselves”. I would say this is a reasonable function of the state to support those with mental incapacity and includes intervening to prevent harm to others as well as the person themselves. Modern psychiatry did not really come into existence in the way we understand it now until the local authority asylums were built. The early alienists identified insane individuals who were deserving of poor relief on the basis of their mental state. As I said in the section on Foucault in a previous post, the birth of the asylum needs to be seen as a later phase of what Foucault called the ‘great confinement’, when the mad were extracted from places of confinement and placed into asylums specifically designed for their treatment. Similarly in modern welfare, the mentally ill receive sickness and disability benefits distinguished from unemployment benefits.

Jo says a Marxist analysis “suggests that the [psychiatric] institutions were closed because of the desire to reduce public spending”. I’m sure there was this element in the intention to replace the asylums by community care, although properly implemented community care may well in fact cost proportionately more. But the prime motivation was what David Clark called the 'dismay and disgust with the asylum system'. Attempts were made to make hospitals more therapeutic by opening the locked doors (see eg. my webpage). Essentially, the asylum became irrelevant to the bulk of mental health problems. I do agree with Jo that it is a national scandal the way mentally ill and learning disabled people who are difficult to manage or place have been shipped out of the NHS, but it isn’t just the privatisation of services that’s the problem but also their level of security and risk aversive nature (see eg. my eletter).

I also agree with Jo about the problems of increasing social inequality and poor social mobility over recent years, even if I don’t frame this within a Marxist critique of neo-liberal capitalism as she does. There have also been problems with a target culture created by the Risk Society, which has contributed to a reinstitutionalisation of mental health services over recent years (see eg. previous post). I'm certainly not against the mental health system becoming more transparent and democratic as Jo wants. It should be about encouraging the independence of people as much as they want and are able to be. 

Psychiatry should not fear the introduction of CRPD compliant services

Peter McGovern argues in a BJPsych article that rights and recovery-orientated services should be at the centre not the margins of psychiatry (see my twitter thread with quotes or amended quotes from the article). As the event details of the upcoming conference mentioned in my last post say, Mental Health Act reform needs to comply with the Convention on the Rights of Persons with Disabilities (CRPD) (see eg. previous post). CRPD recognises and promotes the use of supportive rather than substitute decision-making (see eg. another previous post). 

The introduction of Seni’s law (see previous post) should encourage learning from incidents where services have had to resort to the use of force. Psychiatrists must stop endorsing traumatic clinical practice and coercing people into complying with treatments they may actually not find very helpful (see eg. previous post and yet another).

UK Mental Health Act reform: Can it deliver racial justice and ensure the rights and wellbeing of people with mental health problems?

Register for free online conference on Wednesday 9th March 2022. Full programme available.

What does it mean that mental health has got worse in the pandemic?

I thought I’d join what’s called the nation’s biggest mental health conversation, following Time to Talk Day recently. A survey in the East of England found that more than one in 6 adults who say their mental health has got worse during the pandemic have not spoken to anyone about it (see East Anglian Daily Times article). I suppose we shouldn’t be too surprised that 38% of respondents report a worsening of their mental health during the pandemic. As I said in a previous post, the impact of the pandemic should not be underestimated. The viral illness has led to deaths, together with lockdowns to prevent deaths, which have caused significant grief and disruption.

Lucy Foulkes, in her book Losing our Minds (see my review), notes how the conversation about mental health changed even before the pandemic. For example, Time to Change was a social movement, led by Mind and Rethink between 2007-21 to alter the way people think and act about mental health problems. Similarly, the Heads Together campaign of the Royal Foundation of the Duke and Duchess of Cambridge is typical of these kind of initiatives aimed at reducing stigma and discrimination about mental health problems by encouraging people to talk about them. But as Lucy Foulkes points out, despite these campaigns there is still limited understanding of what mental disorders are, what causes them and how they are treated. 

As the Beatles said in their song ‘Help!’, we may well need someone when we’re not feeling so self-assured. But although the NHS promotes this song in its mental health campaign (see my tweet), I’m not convinced that people should necessarily be looking to the NHS when they feel so insecure. After all, the Beatles did say “Help! Not just anybody. Help!” [my emphasis]! Not that a suitable therapist may not be the right person to go to in such a situation. But someone else outside of services may be as well. We all need others at times. We might have more resources to be able to deal with our problems than we think. In fact it may not make much sense even to see dealing with the stresses and strains of life as a mental health problem. A lot of what mental health professionals actually do is help people understand and deal with their difficulties. People might just need pointing in the right direction if they can't make progress sorting out their problems without coming to services. That doesn’t necessarily require a commitment to undertake a personal therapy or the taking of medication.

Although there may not be a clear dividing line between normality and mental disorder, not all negative emotions and experiences should be labelled as mental disorder. Over recent years there has been a considerable increase in numbers of people seen by mental health services. But this rising demand does not necessarily reflect increasing need. Mental health services should prioritise those with the most need. In fact they seem reluctant to admit this. All I'm trying to do is help develop a better narrative. Although it has become common to blame the pandemic for long waiting lists and difficulty in accessing services, overmedicalising stress and unhappiness does not necessarily help (see previous post). I do worry about the rather oversimplistic message that services seem to be giving to people at times (see previous post). It seems counter-productive. Hopefully the pandemic will actually help us deal with these issues better.

Use of force in mental health services

Seni's law, also known as the Mental Health Units (Use of Force) Act 2018, will come into effect on 31 March 2022 (see Mind press release) . The government published guidance at the end of last year to support its implementation. 

As the guidance says, "For too long the use of force has been accepted as the norm in many mental health services". People’s dignity and their civil and political rights must be respected. Although there may be circumstances in which it may be difficult to avoid the use of force, any compulsory treatment should only be used as a last resort after all other treatment and non-treatment options have been considered and excluded, and only when needed to prevent serious and imminent harm to people (see previous post). The aim should be to eliminate seclusion and segregation (see previous post). Restraint, including chemical restraint, needs to be regulated (see eg. previous post). Progress in removal of compulsion should be compliant with the UN Convention on the Rights of People with Disability (CRPD) (see eg. yet another previous post). 

NHS and independent hospitals must appoint a 'responsible person' to produce a policy to reduce the use of force in mental health units and collect data on any use of force. These figures will be published nationally. Staff must receive appropriate training. Hospitals have been given time to ensure Seni's law is implemented and I look forward to seeing its impact in reducing coercion.

Reaction against the neo-Kraepelinian approach

Jerome Wakefield has an article in World Psychiatry on the 'credo' of nine propositions of the neo-Kraepelinian movement. One of my articles examined the same nine assumptions from the hypothetical critical point of view of Adolf Meyer. 

I agree with Wakefield that Robert Spitzer, Chair of the DSM-III taskforce, should not necessarily be seen as a typical neo-Kraepelinian. Spitzer was very clear that, from his point of view, DSM-III was atheoretical (see eg. previous post). I also agree with Wakefield that Spitzer was concerned to counter anti-psychiatric critiques (see eg. another of my articles), particularly the study by Rosenhan (1973) 'On being sane in insane places' (see previous post). The subsequent DSM-5 has of course failed (see eg. previous post).

Where I think Wakefield may have missed a point is that Klerman anticipated a neo-Meyerian revival. He does mention that Klerman noted there was bound to be "a reaction against what will be perceived as the [neo-Kraepelinian] movement’s excesses”. As I said in my 1990 article, this response has been "slow to be formulated". I’ve always argued that critical/relational psychiatry is a neo-Meyerian position in psychiatry (see eg. my talk). 

In defence of the human being

Thomas Fuchs (who I've mentioned several times previously eg. see post) has an important book from last year: In defence of the human being: Foundational questions of an embodied anthropology. I've mentioned before (see previous post) that his earlier book Ecology of the brain: The phenomenology and biology of the embodied mind was also important. 

I've made a twitter thread of quotes or amended quotes from the new book as I've been reading it. Fuchs counters naturalistic-reductive approaches to human understanding by focusing on the person as embodied and alive. For psychiatry, this naturalistic approach, as Fuchs says, has 

led to a reductionist, 'cerebrocentric' view of mental illness, which does not do justice to the patients' experiences and relationships. ... Such views can be contrasted with an embodied and ecological view of the psyche, which can provide a new foundation for psychiatry as relational medicine [emphasis in original].

Therapeutic stance in person-centred psychiatry

Laura Galbusera et al (2021) discuss the importance not only of the personal but also of the interpersonal dimension for person-centred psychiatry. It builds on her paper (2019, with Miriam Kyselo). which sees openness and authenticity as the characteristic principles underlying the therapeutic stance, integrating professionalism into a relationship with the patient. As Adolf Meyer said a long time ago, psychiatry needs to accept its inherent uncertainty (see egs. my article and previous post). The self is social and relational, not a single, egocentric entity. As I've said before (eg. see my article), human cognition needs to be understood in a dynamic, integrated, enactive way as it is embodied in the brain and the body more generally, and embedded in the environment, which is social and cultural, affording various possibilities of action to the organism. Such a view is consistent with Engel's biopsychosocial model (see eg. previous post)

The stance a professional takes therapeutically is an expression of their personhood. Relational psychiatry is the application of the person-centred method in psychiatry (see egs. previous post and another). As Galbusera et al say:

according to [Helmuth] Plessner’s concept of 'eccentric positionality' – which for him is a defining feature of personhood – we are positioned both within and without our own being and are hence capable at the same time of experiencing the world from a first-person perspective and of taking the point of view of others (ie. the third-person perspective) toward ourselves. Personhood consequently is a category that unifies the dichotomy of individuality and sociality by mediating our individual being with social norms and expectations and vice versa.

Openness and authenticity are necessary not only within the clinical domain but also at a societal level in the treatment of those with serious mental illness as persons (see eg. another previous post).

(with thanks to tweet by James Barnes @psychgeist52) 

Power of the placebo antidepressant pill

Sarah Vine describes her history of being prescribed antidepressants and then having withdrawal problems (see Daily Mail article). She explains that antidepressants, in her view, stop the “metaphorical house falling down while you get the metaphorical builders in”. 

Not sure whether the pandemic has really increased antidepressant prescribing (see Lancet Psychiatry letter). The issue about efficacy of antidepressants has not really progressed since NICE produced its first depression guideline (see eletter: What does it mean to say that antidepressants have helped millions of people round the world?). The Critical Psychiatry Network (of which I’m a founding member) had a debate about this issue in 2003 (see another eletter). There is a genuine issue about bias in clinical trials of antidepressants (see yet another eletter). 

All this was looked at in a BMJ editorial in 2004 (see another eletter). The central issue is whether antidepressant trials hide amplified placebo effects and more recent research has not really taken this issue forward (see previous post). Antidepressants may not work any better than placebo. If this is true (which I think it may well be), it would have extraordinary implications for clinical practice. So-called antidepressant efficacy may merely be due to the placebo effect (see eg. my article).

Engaging people in Mental Health Act reform

Reform of the Mental Health Act in England and Wales can learn from reform in other parts of the world, not least Scotland (see previous post) and Italy (see another previous post). I'm also impressed with what the Victoria state government in Australia is doing (see its Mental Health and Wellbeing Act: update and engagement paper). 

The Royal Commission into Victoria's Mental Health System had a vision of a more holistic mental health system, rather than a system that often focuses on a ‘biomedical model’ of treatment and decision making. Treatment, care and support recommendations were about ensuring compulsory treatment is only used as a last resort; moving away from coercive practices; reducing the use of seclusion and restraint with the aim of elimination over a 10-year period; and regulation of chemical restraint (see final report). 

The Victorian Government is doing what I wished the UK government had done in England and Wales (see previous post) by repealing its current Mental Health Act and enacting a new Mental Health and Wellbeing Act. People living with mental illness or psychological distress will be provided with compulsory treatment only as a last resort after all other treatment and non-treatment options have been considered and excluded, and only when needed to prevent serious and imminent harm to themselves or another person (see eg. previous post for comparison of objectives in England and Wales which are much weaker).

There is already a right to a second psychiatric opinion in Victoria and the changes are designed to stop delays by making access to a second opinion more flexible. Reasons for not accepting the opinion of the second psychiatrist will need to be documented and, if necessary, the patient has a right to seek review from the Chief Psychiatrist or to apply to the Mental Health Tribunal for their order to be revoked. I have been arguing for detained patients in England and Wales to have a right to a second opinion, not only on medical but also nursing and social matters (see previous post). This would mean that Second Opinion Approved Doctors could be abolished, as applications can be made about treatment decisions to the Tribunal if needed, and it’s better that the patient is able to choose who provides the second opinion.

Similarly, I think the changes proposed to advocacy in Victoria have helpful implications for reform in England and Wales (see eg. last post). An opt out non-legal advocacy system will be created (see another previous post). Service providers will be required to notify non-legal advocacy services within 24 hours of the making of an order. No restrictions can be placed on the patient’s right to communicate with an advocate. The rights of the advocate to access records and obtain information will also be improved. These matters also need to be taken forward in introducing opt out advocacy in England and Wales.

Although the Independent review in England and Wales was motivated to improve the dignity and respect of detained patients (see previous post) , the Victorian government seems to be dealing with these issues better. It’s not too late to clarify the principles of Mental Health Act reform in England and Wales (see eg. another previous post) with implications for implementation of a new Bill.

(With thanks to Stephen Hinchley at Voiceability for alerting me to the work in Victoria)

Mental health advocacy is not just about IMHAs

The 2007 amendments to the Mental Health Act (MHA) in England and Wales introduced Independent Mental Health Advocates (IMHAs). As the Code of Practice makes clear, IMHAs may, if appropriate, help detained patients to exercise their rights by assisting patients to access legal advice and supporting patients at Tribunal hearings. I’m not convinced this happens as much as it should, and in practice IMHAs tend to regard legal advice and Tribunals as a separate process. Their role may include helping patients to seek advice from a lawyer, but once this has happened the lawyer is expected to take over responsibilities. IMHAs generally concentrate on helping patients with their care plan and if necessary supporting them in care plan review meetings.

The government plans to improve the quality of IMHA services in its MHA reforms (see eg. previous post). I think one way of improving that quality would be for IMHAs to have more integrated relationships with mental health lawyers and independent experts. A proper advocacy service should be seen as made up of IMHAs, mental health lawyers and independent experts. I think this more complete way of viewing advocacy services is even more important as the government also says it wants to expand Tribunal powers to treatment as well as detention decisions. The Responsible Clinician may be required by the Tribunal to reconsider particular aspects of the care plan and the suggestion is that the IMHA can challenge a specific treatment decision on behalf of a patient that lacks the relevant capacity.

Personally I would prefer if the government created a national mental health advocacy service but I am realistic enough to know that politically this is unlikely to happen. I suspect responsibilities will be left to local authorities to commission mental health advocacy services. What I would like to see is an expectation that commissioners purchase the more complete advocacy service I have been suggesting. Providers will have to build up relationships with mental health lawyers and independent experts, who could continue to be funded through legal aid.

I think implementation work leading to a new MHA Reform Bill should look at the commissioning of more compete advocacy services rather than just IMHAs. As I've said before (eg. see previous post), there seems to me to be considerable work to do before a new Bill is put before parliament. 

Dr Ellie helpfully exposes bias of “standard NHS advice” about antidepressants

Dr Ellie Cannon found it weird that she was criticised for giving what she considers standard NHS advice about antidepressants on the This Morning TV programme (see her Mail on Sunday article). Although I had some concerns about the wording in places, I was one of the signatories to an Open Letter to This Morning about the segment on the programme in which she appeared.

I don’t want to undermine her faith in antidepressants as she takes them herself, but I do think it is important that patients are given correct information to help them make decisions about antidepressants with their doctor. I’m not convinced Dr Ellie understands the criticisms of what she said by labelling them “anti-psychiatry”. Although she may have been trying to dispel myths, she has perpetuated the myth that depression is due to a “chemical imbalance” in the brain (see eg. previous post). She’s not the only doctor that misleads her patients in this way.

Radical reform of Mental Heath Act

Several of the posts on this blog over the last few years have been on reform of the Mental Health Act in England and Wales, following the independent review chaired by Simon Wessely (see previous post) and the consultation by the UK government on a White paper (see another previous post). Scotland is pursuing its own reforms (see previous post). 

Involuntary mental health treatment must be implemented respecting people’s dignity and their civil and political rights. Complete removal of compulsion, if it can be achieved, will have to be progressively realised, and it should be possible to do this so that it is compliant with the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). Risk in mental health services is not necessarily best managed by increasing coercion (see eg. previous post).

A new Bill is likely to be presented to parliament next year. The government has decided there will not be a draft Bill for pre-legislative scrutiny. This may be unfortunate as there is apparently considerable uncertainty about the development of policy proposals (see my summary of White paper and government's response to consultation). I fear the Bill may not even go as far as the White paper if there is not sufficient discussion. For example, it's not clear to me how family interests will be protected if the Nominated Person replacing the Nearest Relative is not a family member. Nor do I think it is necessarily sensible to extend holding powers to Accident and Emergency departments. I have deliberately chosen examples which may have appeared to be simple and uncontroversial to show that as far as I can see multiple issues still need to be resolved. How learning disability and autism may no longer be considered as mental disorders for treatment (see eg. another previous post) would be an example of a more complex unresolved problem.

Particular issues I have been promoting on this blog include:-

1. Expanding Mental Health Tribunal powers to decisions about treatment as well as detention (see eg. previous post)
2. Considering a national advocacy service to include Independent Mental Health Advocates (IMHAs), mental health lawyers and independent experts (see previous post)
3. Repealing Community Treatment Orders (CTOs) (see eg. previous post)
4. Abolishing Second Opinion Approved Doctors (SOADs) (see eg. previous post) and
5. Prohibiting civil detentions (part II cases) to secure facilities (see eg. previous post)

I understand that the government does not want to reopen issues about reform of the Mental Health Act considering the protest caused by what was supposed to have been a root and branch reform of the Act producing a green paper in 1999 that led to the compromise of the 2007 amendments (see eg. letter from my MP at the time). Nonetheless I do think there are fundamental issues about the rights of people with mental health problems that do need proper debate.

Evidence about antidepressant withdrawal

Vinkers et (2021) helpfully discuss the evidence related to antidepressant withdrawal. As they say:

When faced with the possibility of discontinuation, patients, their family members and physicians fear recurrence of the disorder, and might also fear antidepressant discontinuation symptoms [see eg. previous post] .... The importance and prevalence of antidepressant discontinuation contrast largely with the limited scientific evidence and clinical attention for this topic. ... [D]iscussions ... are particularly driven by opinions or personal experiences rather than evidence.

There are methodological problems of antidepressant discontinuation studies, not least that blinding strategies are often insufficient to properly address placebo and nocebo aspects (see eg. previous post). The review notes that antidepressant discontinuation symptoms even occur in blinded antidepressant arms when antidepressants are continued. Evidence is needed about the underlying mechanisms of antidepressant withdrawal (see eg. previous post). 

As the also helpful NICE draft guideline recommendations make clear:

Dependence is characterised by tolerance (the need for increasing doses to maintain the same effect) and withdrawal symptoms if the dose is reduced or the medicine is stopped abruptly. Addiction also features tolerance and withdrawal but has the additional characteristics of cravings, lack of control, overuse and continued use despite harm. There is considerable debate in relation to these definitions, and in practice, the terms are often used interchangeably. 

Antidepressants do not cause tolerance in the same way as alcohol and opioids. Nor should people who uses antidepressants be seen as drug addicts, in the sense of drug abusers, as antidepressants are not stimulants as such and do not create cravings (see previous post). As I've said several times before, psychological dependence on antidepressants should not be minimised (see eg. previous post). The exact role of any physical dependence needs further clarification.

Do psychiatrists really want to reduce Mental Health Act detentions?

The Royal College of Psychiatrists (RCPsych) is concerned that reform of the Mental Health Act (MHA) will require extra psychiatrists. It has told the Government that proposed changes (see my summary) cannot be absorbed within the existing workforce (see RCPsych webpage). It bases this conclusion on an independent report which it commissioned from The Strategy Unit. 

I’m not surprised by RCPsych’s concerns. The White Paper proposed that detailed Care and Treatment Plans (CTPs)  - for children, young people, autistic and learning disabled people these will be called Care, Education and Treatment Plans (CETPs) - will be put on a statutory footing and must be in place by day 7 of detention and signed off by the clinical/medical director by day 14 and become living documents to be amended and reviewed. The pivotal person to do this work would be the Responsible Clinician (RC), who will usually be a consultant psychiatrist. In its response to the White paper consultation, the government said it would seek to ensure that these new statutory Plans take into account existing requirements round care planning, that they encourage joint working and that there is flexibility regarding the contents of the Plans so that they are truly patient led. The Care Programme Approach is being replaced by personalised care and support planning (see eg. previous post) and I'm not sure if it's clear what impact this is having, and statutory plans need to reflect these changes. The government also said it would work with stakeholders to review the proposed timelines and governance structure to ensure that any statutory requirements placed on staff are aimed at facilitating a culture of high quality, co-produced care and treatment planning for all patients detained under the Act. Even taking the apparent mollification of these statutory Plan requirements following the consultation, the likelihood is that psychiatrists' workload will have to increase to meet the demand.

Actually, the analysis by The Strategy Unit estimated that the primary driver for an increase in psychiatrists will be the additional time required to prepare and attend Tribunal hearings. I'm sure the statutory Plans will be helpful for that preparation. What surprised me was that none of the scenarios The Strategy Unit used anticipated a reduction in detentions (and presumably therefore Tribunal hearings), including what the report called DHSC assumed growth. The impact assessment (see previous post) produced with the White paper assumed that investment in the Long Term Plan in crisis teams and community mental health teams would slow historical increases in detentions, independent of MHA changes. It did not present monetised benefits for the proposed changes in the Act, instead using a breakeven analysis to illustrate the amount of benefits per patient required to offset the costs of the policy. For example, a reduction of 2 days in the average length of detention was said to be sufficient. 

The sensitivity analyses by The Strategy Unit and the government are complex and I'm not sure I understand them completely.  I'm not against increasing the number of psychiatrists, particularly for inpatient work. What I would like to know is what the government thinks the impact on detentions will be of a new Bill, but I guess we won't get this information completely until the Bill is produced next year. Is it really assuming that detentions will continue to increase despite the changes in legislation, as The Strategy Unit seems to suggest? 

In fact, I have been arguing in several previous posts (see eg. Doctors have too much power in the current Mental Health Act) that the proposals do not go far enough to reduce compulsion. For example, repealing Community Treatment Orders (CTOs) (see eg. another previous post) would both reduce coercion and probably costs. The government does not want to re-open this issue as it caused so much controversy when CTOs were introduced by the 2007 amendments to the Mental Health Act (see my webpage, now largely defunct). But the evidence is that they have not been effective (see another previous post). 

Fundamentally, the new Act should help reverse the re-institutionalisation of mental health services that has taken place over recent years (see previous post), particularly by reducing the number of secure beds both in the NHS and private sector. There doesn't seem to be much point in reforming the Act if this process does not lead to a reduction in detentions and enforced treatment. I think detentions can be further reduced, maybe even further than the government seems to think they can be, by repealing CTOs, expanding Mental Health Tribunal powers (see eg. previous post) and improving advocacy (see eg. another previous post). I wish RCPsych would engage more with these issues than apparently seeking to block reforms of the Act, which, after all, are designed to reduce unnecessary coercion.

Are mental health services exploiting the pandemic?

The impact of the COVID-19 pandemic worldwide should not be minimised. Official counts of death may substantially underestimate true death rates, but even these figures show COVID-19 has killed more than 4.5 million people (see article). The grief and disruption to communities and livelihoods is significant.

Understandably there is concern about the impact on people's mental health, not least because of lockdowns to prevent deaths (see previous post). The COVID-19 Mental Disorders Collaborators have recently published a systematic review in The Lancet of what they say is data reporting the prevalence of major depressive disorder and anxiety disorders during the pandemic. However, there were very few surveys that met their inclusion criteria from low and middle income countries. And, most of the surveys used symptom scales that only estimate probable cases of depression and anxiety. And as the authors say, they assumed the predictive validity of such scales remained constant between before and during the pandemic. However, as they also admit, this assumption has the potential to bias their estimates. To quote from them, "For example, high scores on anxiety disorder symptom scales might reflect a natural psychological and physiological reaction to a perceived threat (ie. the COVID-19 pandemic) rather than a probable anxiety disorder".

Similarly, Rethink yesterday released information (now corrected although not sure if there has been sufficient adjustment) suggesting "Symptoms of psychosis soared during pandemic", and this news story was taken up by the media (eg. The Guardian). It's not clear to me that these figures may in fact be due to an artefact, because of how first episodes of psychosis have been counted (eg. see twitter conversation).

What I want to comment on is how people seem to want to use the pandemic to obtain more funding for mental health services. I'm not saying mental health services are well funded. But data by NHS digital suggests numbers of adults in contact with mental health services are not yet back to pre-pandemic levels (see my tweet). Nor is it clear how extra funding would be used, as psychotropic medication and psychological therapy are not necessarily indicated to deal with the stresses and strains of the pandemic. Mental health services do need to be realistic about what they can do to help people (see eg. previous post).

Evaluating ECT effectiveness

Tania Gergel writes a very personal account in BJPsych of the benefits she has experienced from having ECT treatment. She discusses her treatment in the context of the academic literature about ECT and acknowledges that not all ECT recipients have had such positive gains.

I just wanted to pick up what Gergel says about her reasons for dismissing arguments challenging the effectiveness of ECT (see previous post). No-one is denying that ECT can have a placebo effect and I’m not wanting to undermine her faith in her treatment. 

Gergel argues that ECT would not have continued for 80 years if it wasn’t effective. But apparently successful interventions have been removed from medical practice when they have later been considered to do more harm than good. Examples in psychiatry would include leucotomy for psychosis and malarial treatment of dementia paralytica. The originators of both treatments were awarded the Nobel prize at the time because their discoveries were mistakenly thought to be advances in knowledge. In fact Cerletti was also nominated for the Nobel prize for ECT treatment of schizophrenia and manic-depression. ECT is no longer generally seen as indicated for schizophrenia.

Medicine has always exploited the placebo effect. Dramatic treatments like ECT may seem to be needed in desperate personal situations. Of course ECT was first introduced without anaesthesia and muscle relaxants, and such unmodified ECT continues to be given in some parts of the world. 

Doctors’ belief in their treatment and patients’ faith in it is a powerful mutually reinforcing combination (see eg. my book chapter). Randomised controlled trials were introduced to try to move on from the bias of such personal claims. The trouble is that there is still bias in clinical trials (see eg. my webpage). Even if there is a statistically significant difference between ECT and sham ECT in controlled trials, this difference could be because trials are unblinded, for example, through side effects of ECT treatment. For example, trial subjects may become aware that they have had real ECT because of the initial ECT side effects, such as headache. In which case if unblinded, expectancy effects could still be a self-fulfilling prophecy leading to an overestimate of treatment effectiveness. 

In general, we should be sceptical about the effectiveness of medical interventions because research methods are malleable enough to lead to exaggerated positive claims for treatment benefit (see eg. previous post). Individual experiences like that of Gergel, however well expressed in the BJPsych article, do not really solve this issue.