Sensible risk management in mental health

Hawton et al (2022) discuss why reliance on risk prediction of suicide in clinical practice has failed and outline an alternative therapeutic risk assessment, formulation and management model, which uses a person-centred approach. The focus on risk prediction and documenting risk assessment has actually misdirected the effort to prevent suicide.

Time needs to be spent on gaining therapeutic alliances rather than ticking boxes. Risk assessment is not a separate process from a full psychiatric history and mental state examination and formulation. A psychiatric management plan includes planning for safety. 

An ever more rigid and bureaucratic interpretation of risk assessment has been counterproductive, even destructive. Merely knowing about risks, even if these could be calculated precisely, may not improve practice. The fear that things may go wrong in mental health services has distracted from the task of actually making things better for people. Health care is more than a case of following rules and procedures. Conditions to improve patient safety are those that facilitate staff to bridge gaps in care, not the reverse. Risk management is actually the management of uncertainty, not the creating of an illusion of certainty.

Individual response to antidepressants in clinical trials

Stone et al (2022) provide data on response distributions of individual participants in antidepressant trials. It confirms previous data that shows a small 1.75 point random effects difference on the Hamilton Rating scale between drug and placebo (see previous post). The best fitting model of response distributions was three normal distributions, with mean improvements from baseline to end of treatment of 16.0, 8.9, and 1.7 points. These distributions were designated Large, Non-specific, and Minimal responses, respectively. Participants who were treated with a drug were more likely to have a Large response (24.5% v 9.6%) and less likely to have a Minimal response (12.2.% v 21.5%).

It’s important to keep in mind that this is only a best fit model and not necessarily think about it too absolutely. Also, this is not new data proving that antidepressants “work”, even if only for those that have a large or minimal response. As is said in the paper, it is still not possible to exclude the possibility that the effects of antidepressants are accounted for by functional unblinding. The placebo amplification hypothesis could still be a valid explanation of the antidepressant data (see eg. previous post). Raters' expectations and patients' suggestibility could entirely explain the small effect size found.

Stone et al suggest if the placebo amplification hypothesis is true that we "might expect shifts in the means of the response distributions for active drug relative to placebo”, which were not found. However, I'm not sure if this is true as I’m unclear if any lack of shift could instead be a result of the model. To my mind, those in the large or minimal groups could actually be the ones that are more likely to unblinded, whereas the nonspecific group essentially remains blinded. 

Florian Naudet in a useful Twitter thread emphasises that we need to start from the fact that it has been known for a long time that mean antidepressant effects in clinical trials are small. The limitations, at least, of antidepressants do need to be acknowledged. If the further claim that antidepressants are no better than placebo is true (which I think it may well be), it would have extraordinary implications for clinical practice (see eg. previous post). This is why people find it very difficult to consider that antidepressants may be no better than placebo. People do not want to undermine their faith in antidepressants (see another previous post).

Radical reform of psychiatry in Italy and beyond

Excellent podcast interview with John Foot on the politics of Franco Basaglia, based on his book (see eg. previous post). Asylums have closed across the world but as John says there is a need for a new movement.

Improving the draft Mental Health bill

The draft Mental Health Bill for England and Wales currently undergoing parliamentary scrutiny (see eg. previous post), essentially amounts to an amendment of current legislation. I would have preferred (see eg. previous post) if the government had been more ambitious and looked to replace both the current the Mental Health Act (MHA) and the Mental Capacity Act (MCA). 

As I've also mentioned previously (see post), the Victoria state government in Australia is enacting a new Mental Health and Wellbeing bill, now published in its second reading. I find it an impressive document. It has very clear principles, including decision making principles for treatment and intervention, laid out on the face of the Act, which is not really the case for the draft Mental Health bill, although the White paper said it would do this (see another previous post). As I've also said before, the right to a second opinion from any psychiatrist on both detention and treatment is being strengthened in Victoria, whereas the draft bill does not go far enough in this respect (see eg. previous post). 

The Joint Committee on the draft Mental Health bill has called for evidence (see webpage). It wants to hear views on how the draft Bill could be improved, and how issues identified could be resolved. It lists particular areas of interest but answers do not need to be confined to those topics. Response are required by 16 September 2022. 

Understanding causes

Thomas Fuchs (who I’ve mentioned before eg. see previous post) has a recent paper on 'Understanding as explaining: how motives can become causes'. The opposition of ‘understanding' and 'explaining', originally formulated by Wilhelm Dilthey and taken up by Karl Jaspers, distinguished hermeneutic understanding from scientific explanation in terms of causality. There is a sense in which we can’t prove in a natural scientific sense why we do what we do, although that doesn’t mean that we shouldn’t make an attempt to understand the reasons.

But neurobiological causes do not provide sufficient description of psychological experience. Fuchs argues that the concept of cause should not be narrowed down to the natural sciences. Why we do what we do requires personalistic not naturalistic understanding of motivations. The causal role of understandable connections is demonstrated in the concept of circularity from an embodied and enactive point of view (see previous post). Motivational explanation of human behaviour is as justified as looking for physiological explanations. In fact, more than that, neurophysiological explanations are unable to satisfactorily and sufficiently explain human action due to their lack of intentional contextual reference (see previous post).

Exploding myths about depression

Joanna Moncrieff has blogged on the recent paper in Molecular Psychiatry, in which she was the lead author, which has created considerable media publicity (see previous post). She explains what she thinks the implications of the paper are.

I very much welcome this work. However, I do remain perhaps more sceptical than Jo about the evidence. For example, I am not convinced about what she says about the emotional numbing (see eg. previous post) and physical dependency effects of SSRIs (see eg. another previous post).

I also think she is too generous to the idea that even though the serotonin theory of depression is wrong, that there may still be a biological explanation of depression. Don’t get me wrong! Of course depression is due to the brain. That’s mere tautology. But depression is a personal experience. It doesn’t make sense to look for it in the brain (see eg. previous post). 

Scrutinising Mental Health Act reform.

Department of Health and Social Care (DHSC) powerpoint presentation gives an overview of the draft Mental Health bill recently announced (see previous post). Alex Ruck Keene has prepared an unofficial update of the Mental Health Act based on the draft bill. I think it would be helpful if the reformed Act makes clear that if people are admitted to psychiatric hospital then admission should be truly informal whenever possible (see eg. previous post). 

The Joint Committee on the Draft Mental Health Act Reform Bill has been established by the House of Lords and the House of Commons (see UK Parliament webpage). My understanding is that the Committee will be putting out a call for evidence. Their report is required by 16 December 2022.

Debunking the serotonin theory of depression

Moncrieff et (2022) undertook a systematic umbrella review of the evidence for the serotonin theory of depression (see eg. previous post). Their conclusion that the main areas of serotonin research provide no consistent evidence of an association between serotonin and depression, and no support for the hypothesis that depression is caused by lowered serotonin activity or concentrations, has been taken up by the media (see eg. discussion between Joanna Moncrieff, the main author of the review, and Dr Ellie - see previous post - on This Morning TV programme).

Psychiatrists have been using the chemical imbalance theory as a means of persuading patients to take their medication. True, the role of psychiatry is to give hope to depressed people. But it is also to be honest with them about the cause of their problems and the appropriate treatment. It is understandable that patients who receive antidepressant treatment are readily persuaded that they are having appropriate therapy. The trouble is that doctors, too, may be deluded into believing that their prescribing is having specific antidepressant effects. 

Patients are able to understand that the 'chemical imbalance theory' has only ever been a theory. What they find more difficult to appreciate is why they have been told that this theory has been proven, when this is clearly not the case. The doctor–patient relationship needs to become more open, so that doctors are not deceiving their patients about antidepressants. This has to start with doctors becoming more aware of their own bias.

Reduce or eliminate coercion in mental health services?

As I mentioned in a previous post, the Office of the High Commissioner for Human Rights (OHCHR) has called for inputs to the draft Guidance on Mental Health, Human Rights and Legislation published by World Health Organisation (WHO) and OHCHR. The publication aims to be a resource for countries, when considering legislative measures to support the transformation of mental health systems in line with international human rights law. Mental health should be a global health priority and the rights of people with mental health problems need to be protected (see previous post). 

Because it authorises coercion, mental health legislation can condone discrimination and the violation of basic human rights. As I’ve mentioned before (see eg. previous post), the Convention on the Rights of Persons with Disabilities (CRPD), adopted in 2006, calls for a significant paradigm shift within the mental health field. Coercion needs to be reduced in mental health services through making legislation compliant with CRPD (see previous post). There is also limited evidence for the effectiveness of coercion. Non-coercive practices may actually produce better outcomes.

Rates of involuntary hospitalisation and treatment continue to increase around the globe, particularly in high-income countries. This reflects a misguided reinstitutionalisation of services after the earlier rundown of the traditional asylums in the West (see previous post and my eletter). The UK government’s intention to reduce detentions and address racial disparities in its draft Mental Health bill is therefore welcome (see another previous post). However, pre-legislative scrutiny of the draft bill needs to consider whether the proposed changes go far enough (see yet another previous post).

The Committee on the Rights of Persons with Disabilities argues that CRPD precludes all forms of involuntary commitment to mental health facilities, including on the basis of dangerousness or need of care. Certainly mental illness or learning disability in themselves are not a reason for detention. It is the additional risk and need for hospital care that in my view may justify detention (although any separate risk criterion may well be superfluous - see eg. previous post). I do think that extension of the powers of coercion to community treatment orders (CTOs) has been a mistake. My position is that the aim of MHA reform should be to respect and secure the rights of people with mental and intellectual disabilities to progressively reduce compulsion in any necessary hospital treatment, with a view to evaluating whether coercion can be completely eliminated (see previous post).

I do not think the Committee is prepared to compromise on this issue but it does concern me that its intransigence may well be preventing pragmatic progress in reforming the Mental Health Act. Essentially the Committee want to abolish mental health law, whereas I want mental health legislation to become CRPD compliant, despite the resistance to doing so from mainstream psychiatry (see previous post). 

Commissioning advocacy services for a new Mental Health Act

I've mentioned that the UK government has published a draft Mental Health bill (see previous post). Opt out advocacy arrangements are proposed, which is a welcome development (see another previous post). 

The draft bill imposes a duty on social services to ensure that providers of Independent Mental Health Advocates (IMHAs) arrange a visit and determine if inpatients want to use IMHA services. If a patient does want a service, presumably, the expectation is that the IMHA service will provide it. But as I have mentioned before (eg. see previous post), I do not think IMHAs were ever properly funded when they were first introduced by the 2007 Mental Health Act (MHA) amendments. There must be a question mark about whether there are sufficient resources to meet this requirement, although the impact assessment has calculated some figures. Still, it does require a commitment from government to provide additional resources which I think is still awaited.

I think the bill also should change the wording to “needs” IMHA services rather than “wants to use” them, so that people without capacity are accommodated. In general I find it a problem of the draft bill that there is apparently better protection for those with capacity rather than those lacking capacity, when it’s the latter group that’s more likely to need advocacy services and protection in general. 

Anyway, pre-legislative scrutiny of the draft bill is likely to encourage a focus on commissioning of advocacy services. As I’ve said before (eg. see previous post), I’m keen on an integrated service of IMHAs, lawyers and experts being commissioned (with the latter two groups continuing to be paid via legal aid, although the amounts paid, I think, need to be increased as seems to be happening with the rest of legal aid eg. for criminal cases).

Addressing racial disparities in application of the Mental Health Act

Black people are four times more likely to be detained in psychiatric hospital under the Mental Health Act (MHA) and ten times more likely to be subject to a Community Treatment Order (CTO) than white people. The Secretary of State for Health and Social Care claimed that the draft mental health bill recently announced (see last post) will tackle these disparities. This was said to be because of greater scrutiny of decision-making, including a greater use of second opinions on important decisions and expanded access to tribunals. I have been concerned that the reforms may not go far enough to change the current discriminatory nature of the Act (see eg. previous post). 

I wanted to look further at the situation of access to second opinions, which the Secretary of State said would be improved by the draft bill. Certain treatments require the involvement of Second Opinion Approved Doctors (SOADs) appointed by the Care Quality Commission (CQC). If a patient is not consenting to treatment, SOADs currently merely have to certify that it is appropriate that the recommended treatment is given. Their role has been criticised as merely a rubber-stamping exercise. 

The other way patients can obtain a second opinion is if this is requested from an independent expert by the patient's solicitor as part of the process of appeal against detention to the Mental Health Tribunal (MHT). I don't think there's anything in the draft bill that will necessarily increase the availability of these independent opinions, which are probably not as common as they should be. 

The independent expert opinion has the advantage over the SOAD opinion that it is given on behalf of the patient (see previous post), although the focus of the MHT decision for which the opinion has been requested by the patient's solicitor is on detention rather than treatment. The SOAD tends to look at the Responsible Clinician's (RC's) treatment plan to decide if it is appropriate, rather than necessarily considering the patient's point of view, although the CQC says SOADs should decide whether due consideration has been given to the views and rights of the patient when deciding whether the treatment recommended by the RC is clinically defensible (see webpage).

There are welcome changes, which I had not anticipated, in the draft bill that clarify the role of SOADs and I think should make the SOAD certification process less of a 'rubber-stamping' exercise. In particular, SOADs will have a duty under a new section 56(B) to ensure that the RC and other clinicians are complying with another new section 56(A) to follow a 'clinical checklist' when treatment is given under the Act. This checklist includes: that the patient’s wishes and feelings as far as reasonably ascertainable are considered; reasonably practicable steps are taken to assist and to encourage the patient to participate in treatment decisions; people close to the patient are consulted; and any available forms of medical treatment are identified and evaluated. Making these duties of both RCs and SOADs clearer and legal will be helpful, I think.

As far as independent expert opinion on behalf of the patient is concerned, I have been arguing that advocacy services need to be commissioned as an integrated service of Independent Mental Health Advocates (IMHAs), mental health lawyers and independent experts (see eg. previous post). This will strengthen advocacy arrangements in the interests of the patient.  I would argue that an improved integrated advocacy service should actually reduce the number of tribunals, as tribunals should only be needed if there is no agreement between the advocacy service and the Responsible Clinician (RC) about the care plan. In this respect there has been a 'watering down' of the White paper in the draft bill, as the White paper talked about legislating for appeal to the Tribunal on treatment as well as detention decisions. This proposal has been dropped. If it is not going to be reinstated, the bill could still create a right for a patient to have a second opinion of their own choice for medical, nursing and social matters, which would have to be considered by the RC. Even if there is no right to appeal to the MHT if there is any conflict with the RC, the degree of conflict created by legislating for the right to a second opinion nonetheless can be assessed over time, and if needed, consideration given to amending the new Act in due course so that appeals can be made to the Tribunal on treatment matters.

Furthermore, as mentioned above, there is even more disparity for black people for CTOs than there is for detention. Changes are being made to the criteria for CTOs but I'm not convinced these changes will necessarily reduce their use. In fact, the evidence is that CTOs are not effective and I think should be repealed, or at least no new CTOs enacted.  I have had some correspondence with DHSC civil servants about the evidence base and they seem to be saying that the feedback from some patients is that CTOs are helpful, which is true. I have asked, though, whether CTOs are being continued not on the basis of the evidence but because of a minority view of patients who are complying with the CTO anyway. I was told I would get an answer but instead have been offered a meeting instead. Certainly, I would say the lived experience amongst black people does not support the continuation of CTOs or at least any new orders being made. In fact, both Mind and NSUN said in the response to the White paper consultation that CTOs should be repealed. 

More generally, I'm not convinced the draft Bill is as compliant with the UN Convention on the Rights of People with Disability (CRPD) as it should be. The new sections 56(A) and (B), though, may well help in this regard. The World Health Organisation (WHO) in collaboration with the Office of the High Commission on Human Rights (OHCHR) is undertaking an international review of WHO guidance on mental health law in line with CRPD to be held from 1 July to 31 August. The aim is to obtain feedback from national stakeholders on the content of the draft guidance, which will be available online from 1st July. I think this draft guidance will be able to inform debate about the draft bill, perhaps particularly about disparities.

Draft mental health bill announced

The government has announced a draft mental health bill together with better support for people in crisis. I just wanted to pick up on how the draft bill is presented as modernising legislation from almost 40 years ago. Both the 1959 and 1983 Mental Health Acts were progressive Acts, associated with opening of the doors of the traditional asylum and dehospitalisation (see eg. my eletter). What's quietly forgotten is that a root and branch reform of the 1983 Act was initiated from 1999, followed by a several year process of expert review, green and white papers, draft Bill with parliamentary scrutiny and an actual bill. Because of opposition, particularly to the introduction of community treatment orders (CTOs), the 1983 Act was merely amended in 2007, rather than there being, as originally planned, a new Mental Health Act (MHA). CTOs were still introduced in these amendments despite the controversy.

There was some progressive change in the 2007 amendments, such as the introduction of Independent Mental Health Advocates (IMHAs), However, in my view, this development was never properly funded and the draft Bill announced yesterday could have done more to develop advocacy further (see previous post). Although there are amendments being made to CTOs, there was no consultation on this issue in the White paper leading to the draft bill yesterday. In fact several organisations, such as Mind and the National Survivor User Network (NSUN), in their responses to the White paper, suggested CTOs should be repealed and I agree, or at least, no further CTOs should be enacted. There is little evidence of the effectiveness of CTOs.

It could, therefore, be seen as misleading to view the current reforms as merely modernising mental health law from 40 years ago. They need to be understood in the context of the last attempt to reform the 1983 Act, which led to the 2007 amendments. There has been a over-preoccupation with risk in mental health services over recent years, which has been counter-productive (see eg. previous post). True, the current reforms have been more motivated by reducing detention and inequalities in services than managing risk. But they do not go far enough in taking forward the 1959 and 1983 Acts to improve the rights of people with mental health problems (see eg. last post). The draft Mental Health bill also needs to be associated more specifically with the reduction of the use of force in mental health services, as in Seni’s law (see another previous post).

Pre-legislative scrutiny of Mental Health Act reform

I mentioned in my last post that there will be a draft Mental Health Act Reform Bill, probably this summer, which will be subject to pre-legislative scrutiny in the autumn with a Bill potentially next spring. I just wanted to make clear what I thought should be in the draft Bill (see eg. previous post), although it seems most of the proposals in the government response to the White paper will go through into the draft Bill (see my summary). My understanding is that two main proposals will be dropped from the White paper consultation response. Firstly, the proposal for the Tribunal to be able to require the Responsible Clinician to reconsider a specific treatment decision will be dropped, which I think is unfortunate. Secondly, the proposal to give powers to A&E professionals to require individuals in need of urgent mental health care to stay on site pending a clinical assessment will also be dropped, which I think is the right decision. It’s also unclear to me whether there will be proper funding for mental health advocacy, which in my view was never properly funded when introduced by the 2007 amendments to the Act. 

I’m not sure how much scope for amendment there will be in the parliamentary process. As I said in my last post, I'm hoping that pre-legislative scrutiny will allow an examination of whether the draft Bill complies with the UN Convention on the Rights of Persons with Disabilities (CRPD). I don't think the government is right that current legislation, let alone the draft Bill, does. The legal capacity of people with mental health problems needs to be protected even though they may not have mental capacity.

A CRPD compliant law would ensure that people with mental health problems are supported in their decision making. When they receive that support they must be protected against abuse. People should have access to support from people they trust in their social network and community. Formal identification of a nominated person as proposed by the government should be helpful in this respect, although the rights of the family also need to be protected. As I've been arguing, I think mental health advocacy can be improved by a more integrated service of IMHAs, mental health lawyers and independent experts (see eg. previous post). Such a service would be commissioned via integrated care system (ICS) arrangements. Mental health lawyers and independent experts would continue to be paid via legal aid.

A Mental Health Tribunal will only be needed if the new properly funded advocacy service cannot persuade the Responsible Clinician (RC) to go along with its suggestions. It would require reinstatement of the idea, which, as I said, will apparently be dropped in the draft Bill, of extending the role of the Tribunal to treatment as well as detention decisions. This arrangement should cut down dramatically on the number of Tribunals. Current proposals just seem to be accepting of the all too common number of Tribunals which are held. The number of tribunals needs to be reduced. My proposal will also mean that Second Opinion Approved Doctors (SOADs) from the Care Quality Commission (CQC) will not be needed and can be abolished, as the 'second opinion' if needed, will come from the advocacy service rather than needing a so-called approved doctor, who in practice too often merely 'rubber stamps' the RC decisions. It's far better that patients themselves can choose who provides the second opinion (see eg. another previous post).

These Tribunal changes and abolition of SOADs will be cost-saving. If further savings are needed, personally I have no objections to Tribunals being reduced to a single judge for all decisions. As far as treatment decisions are concerned, a single judge makes the decision if a case goes to judicial review. The current problem is that this does not happen very often at all. What I'm suggesting is that such cases should be dealt with under the remit of legal aid. All savings in the arrangements I’m suggesting can be invested in mental health advocacy.

The introduction of a new form of supervised community discharge for criminal cases is controversial and I think probably should be abandoned. The need for it is not clear to me and the history of introducing such enforced community arrangements should encourage caution. It also doesn't seem to fit with the thrust of the reform changes to reduce coercion.

As I have also mentioned before (see eg.  previous post), one of the purposes of the draft bill is to make it easier for people with learning disabilities to be discharged from hospital. Personally, I think the same aim should apply to people with serious mental illness (SMI) as well. Too many people with learning disability and SMI are ending up in inappropriate secure care. I think all civil detentions to secure hospitals should just be prohibited. As far as I am concerned, secure provision should just be reserved for criminal cases to provide its function of alternative to prison. My proposal would encourage a focus on more appropriate open and informal care care for civil cases, which will improve community care.

I look forward to seeing all these issues debated by parliamentarians.

Parliamentary scrutiny of draft Mental Health Act Reform Bill

I think a 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 through 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 readily 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?

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