Scottish Mental Health Law Review

The Scottish Mental Health Law Review (SMHLR) final report (see summaries and recommendations; also see previous post about interim report) is intended to shift mental health and capacity law from being too focussed on authorising and regulating actions which may limit a person’s autonomy, to one where a person’s rights are respected, protected, enabled and fulfilled. It recognises that the United Nations Convention on the Rights of People with Disabilities (UNCRPD) (see eg. previous post) has provided an impetus for a shift in how states respond to disability rights. UNCRPD was signed by the UK in 2007, came into force in 2008 and was formally ratified by the UK in 2009. The Scottish Review did not take an absolutist approach to UNCRPD, by which it meant "tearing down the whole house - pulling all our existing systems down and starting from scratch", which it did not see as yet possible or even necessarily desirable. 

UNCRPD and SMHLR both promote a supported decision making (SDM) approach rather than substitute decision making. This is included within what SMHLR calls its Human Rights Enablement (HRE) framework. The framework also includes an Autonomous Decision Making (ADM) test to allow for non–consensual intervention in situations when this is necessary to protect the person’s or others’ rights. 

Any authority for a deprivation of liberty should be granted only to the extent it is needed and only for as long as needed to achieve the protection required. The advantages against harms to human rights need to be assessed. Significant harms to certain human rights would be justifiable only exceptionally, on the basis of very significant advantages in the respect, protection and fulfilment of the person’s human rights overall. A court/tribunal may grant a Standard Order for Deprivation of Liberty in order to preserve the person’s overall human rights or an Urgent Order for Deprivation of Liberty in order to preserve life or health. 

The opinion of the Review was that law reform can help reduce coercion, although it is only part not the whole answer. Reduction of coercion does need to be a priority of services in general. The problem with the reforms in England and Wales is that, although motivated to reduce detention and inequalities, there was no wholesale reform as in Scotland to a Human Rights Enablement framework. It will be interesting to see how mental health law develops in Scotland compared to England and Wales. The Scrutiny Committee is taking its final oral evidence today (see event and previous post).

We have over-medicalised normal life and it's destroying the NHS

Even though she may overstate her case, Katie Musgrave has a helpful article in Pulse about the state of NHS mental health services. I've used the same title as her article for this post, although changing one word: 'medicalisation' to 'over-medicalisation'. As she says, "the system isn't functioning".

I think it's reasonable for a GP, for example, to be discussing a child's "tantrums and mood-swings" with parents. GPs need to deal with mental health as well as physical problems.

But I agree with Musgrave that hoping "an hour on the phone having CBT might solve issues from a difficult childhood, a broken marriage or long-standing financial stresses" oversimplifies people's problems. Addressing "our broken, disconnected communities" is not easy. The NHS has not got "the answer to all of life’s ills". 

I also agree that NHS leaders may not have "the courage to fix this". In fact I think NHS England has encouraged this oversimplification, based on a misguided understanding of the need for early intervention to prevent problems getting worse (see eg. previous post). I'm not wanting to stop people coming forward for help if they need it, but the NHS does need to become more realistic with people about what can be achieved (see eg. another previous post). 

Psychiatric training needs to incorporate a critical perspective

I have been re-reading my first published book chapter in This is madness too (2001). Psychiatry doesn’t seem to have changed much in over 20 years.

It was obvious then that the fantasy hope of a neurobiology that would uncover genetic and neurobiological abnormalities in functional mental illness was nonsense. That hope was said to be inspired by (1) the overwhelming evidence of the efficacy of pharmacologic treatments, (2) a growing appreciation of the heritability of psychiatric disorders, (3) the standard use of objective, criterion-based diagnoses, and (4) the ability to examine the structure and function of the brain directly. I challenged those claims then and my arguments still apply (see eg. last post).

What I then concluded is required is still the same: “The case for an extensive, national programme of training and supervision in order to disseminate a critical perspective on psychiatry is overwhelming.” Psychiatric training has still not incorporated a critical perspective (see previous post). It’s too enamoured of its wish-fulfilling speculations.

Hypothesis of depression as a brain disorder does not just depend on evidence

Bruce Levine (who I've mentioned in a previous post) highlights three reviews in his Counterpunch article that confirm that "there is no scientific evidence for what we have long been told by psychiatry — and the mainstream media — about the neurobiology of depression", ie. that depression is a brain disorder. As one of those reviews by Peter Sterling says, "if neuroscientists are unwilling to acknowledge that their hypothesis of depression as a brain disorder currently lacks evidence, they render it unfalsifiable — and thus 'just like' religion". 

As I've said several times (eg. see previous post), biomedical psychiatry is more like a faith than a science. It doesn't seem to matter that there's no evidence that depression is a brain disorder. There's always enough belief that the answer to mental illness is just round the corner and we merely need to keep looking for it. The brain-defect mythology of depression will therefore persist, as we do not want to admit to the limits of our knowledge about mental illness (see previous post).

But it's not just the lack of evidence for believing that mental illness is brain disease that's the problem. As I've also said before (eg. see another previous post), functional mental illness cannot be reduced to brain disease in principle. The hypothesis is not just an empirical matter. The subject matter of psychiatry is people as a whole, not their brains. Brain abnormality is not a sufficient explanation of depression in the same way as it is for organic mental illnesses, such as dementia. We need to understand the reasons for depression and these meanings are lost by looking for mechanistic explanations in the brain. There are conceptual as well as empirical reasons why depression should not be seen as a brain disorder.

Efficacy of lithium

MailOnline has an article discussing views about lithium for bipolar disorder. Years ago I created a webpage for 'Efficacy of lithium'. Not sure if the debate has progressed much since.

Like a lot of medication, lithium was introduced through a mistaken hypothesis (see webpage). I'm not convinced its efficacy has ever been satisfactorily demonstrated. Rapid withdrawal is associated with higher relapse than gradual withdrawal (see my eletter). Such a finding suggests that nonspecific factors are important in the interpretation of clinical trials (see another eletter). Unblinding can occur in clinical trials of lithium, compromising their results (see my BJPsych letter). Denial of the extent to which lithium may be a placebo effect in clinical practice does not necessarily serve the interests of the many patients who have been made reliant on this medication.

Preventing people becoming reliant on antidepressants

The Economist has an editorial ‘Most people on antidepressants don’t need them: Time to wean them off’. It helpfully focuses on the need for de-prescribing. As I said in a previous post for example, doctors have made too many people dependent on antidepressants. 

It’s not just deprescribing that’s needed. More people need to be managed without antidepressants. There may be a sense in which it’s misleading to say that most people on antidepressants don’t need them. It may be underestimating how much they have become habituated to taking them. People who want to stop antidepressants do need help but it is also important to prevent so many people becoming reliant on them.

Evidence to the Joint Committee on the draft Mental Health bill

My submission to the Joint Committee on the Draft Mental Health Bill has been published, together with four pages of other submissions. As far as I am concerned, the draft Mental Health bill does not go far enough to reverse the re-institutionalisation of services that has taken place over recent years, particularly reflected in the increase in secure psychiatric provision (see eletter). Those secure services (and other inpatient services) are repeating the worst aspects of the asylums even in the NHS (see last post). There needs to be a refocus on developing community care and inpatient services need to become more open and therapeutic.

As I say in my submission, what's needed in legislative changes are: (1) no further community treatment orders (CTOs) (2) prohibiting civil detentions to secure facilities (3) improving advocacy to create an integrated service of Independent Mental Health Advocates (IMHAs), mental health lawyers and independent experts and (4) extending the role and powers of the Mental Health Tribunal (MHT) to treatment as well as detention decisions (thereby making the role of Second Opinion Approved Doctors (SOADs) redundant). A central feature of these changes would be creating a right to a second opinion for detained patients on both treatment and detention, as is being strengthened elsewhere in the world, such as in Victoria, Australia (see previous post). 

Both the National Survivor User Network (NSUN) (see submission) and Mind and ROTA (see submission) agree with me about CTOs. Dr Gareth Owen, in his submission, summarises the lack of evidence for the effectiveness of CTOs. As he says, the amendments proposed in the draft bill are unlikely to reduce CTOs and make their purpose even less clear.

As NSUN say, the revised legislation has not been sufficiently grounded in a rights-based understanding of mental health (see eg. previous post). NSUN and Mind mention the overlap with Seni's law (see previous post), as I did in my submission. Mind make the helpful suggestion of extending the role of the responsible person in each hospital, created by Seni's law, to oversee the promotion of race equity. As I said in my submission, appointment of a responsible person to reduce detention and coercion in each hospital with wider powers than provided by Seni’s law, and not just for racial issues, who could liaise closely with the MHA monitoring division of the Care Quality Commission (CQC), would help to produce a national focus on improving the rights of people with mental health problems delivered through each hospital.

Voiceability (see submission) helpfully endorse the recommendation of the Law Commission that only the Mental Health Act (MHA) should be used to deprive people of their liberty in psychiatric settings. Making this clear in the bill should deal with the fear expressed by several contributors (eg. submission by Lucy Series) that limiting the scope of detention of people with learning disabilities and/or autism under the MHA will not prevent those same people being detained under the Mental Capacity Act. As Voiceability note, however, there are a few examples where the Court of Protection has helped to secure better outcomes for people with a learning disability and autistic people in long-term detention.

Voiceability has also proposed that a national specialist advocacy service for people with a learning disability and autistic people should be commissioned in mental health settings (see paper). Similarly, I am keen to see consideration given to creating a national advocacy service, not only for people with a learning disability and autism, but also for those with mental illness, rather than relying on piecemeal commissioning arrangements. This would be an integrated service of Independent Mental Health Advocates (IMHAs), mental health lawyers and independent experts.

Voiceability also usefully highlight that the primary focus of the Wessely review and White paper was not on Part III patients. I have argued that no further detentions of Part II patients should be made to secure facilities. This will allow secure services to develop their proper function of being an alternative to prison. There may well need to be a national review of forensic/secure services.

The scrutiny committee starts hearing oral evidence this afternoon (see meeting details).

The need for institutional change in mental health services

Another television programme, this time from Channel 4's Dispatches: Hospital undercover are they safe?, underlines how current inpatient psychiatric services are not fit for purpose (see last post). The comment by the retired policewoman who worked as an undercover Health Care Assistant at the acute unit at the Linden Centre in Chelmsford for two months is pertinent:-

I found it tiring, mentally exhausting … and sad. Mentally exhausting because I’ve wanted to do the best I can while I’ve been on there. Sad because I personally think if that was any of my friends or family on one of these wards, I would not want them to be there. And that’s not a reflection on anybody in particular but just the whole set-up.

She’s right to emphasise institutional aspects about “the whole set-up”. The Essex Mental Health Independent inquiry needs to make recommendations for a complete overhaul of inpatient psychiatric services to make them more open and therapeutic. In fact, the whole of mental health services needs better direction.

Psychiatric services have not really progressed since the worst days of the asylums

The scandal at the Edenfield Centre exposed by the BBC Panorama programme is reminiscent of scandals in the asylums from the 1960s. Services haven’t really progressed from the worst aspects of the asylums (see Mail on Sunday article).

The asylum scandals came to light from whistleblowers going to the papers rather than BBC television as in the Edenfield case. Panorama used similar undercover reporting to expose the same sort of abuse of people with learning disability at Winterbourne View and Whorlton Hall (see eg. previous post). The subsequent focus on reviewing the care plans of learning disabled people through independent Care Education and Treatment Reviews (CETRs) has not really reduced segregation, mistreatment and inappropriate provision (see another previous post). 

The phase of public inquiries into the asylums was launched by the Ely Hospital inquiry. In 1967 a nursing assistant at Ely Hospital in Cardiff made a series of allegations about the treatment of patients and the pilfering of property by staff. These allegations were published in the News of the World. The inquiry found examples of callous, ‘old fashioned and unsophisticated’ techniques of nursing control. Although in most instances this practice was not seen as ‘wilful or malicious’, nursing standards were low, supervision weak, reporting of incidents inadequate, and training of nursing assistants virtually non-existent. Staff were found to have pilfered supplies of food. There were determined and vindictive attempts to silence complainants. It also transpired that members of the Nursing Division of the Ministry had visited Ely some years before and had reported ‘scandalous conditions, bad nursing’, and yet nothing had been done about it. In essence the inquiry report confirmed the basis of all the News of the World revelations. 

Another influential inquiry was the Whittingham Hospital inquiry. In 1969 two senior members of the staff at Whittingham Hospital near Preston, Lancashire, made allegations of ill-treatment of patients, fraud and maladministration, including suppression of complaints from student nurses. Two male nurses were convicted of theft. Shortly after the police investigation a male nurse assaulted two male patients, one of whom died. The nurse was convicted of manslaughter and imprisoned. An inquiry was set up after the trial was over. What was significant about the report was that it placed the responsibility on the management for the institutional conditions that led to callous and incompetent nursing and some deliberate cruelty. The inquiry also uncovered suppression and denial of student nurses’ complaints about ill-treatment. 

The political response to this series of inquiries was to set up the Hospital Advisory Service (HAS), which, independent of the normal departmental machinery, provided visiting teams for inspecting hospitals. The Care Quality Commission (CQC) now provides a similar function, although using different methods. Arguably it has more powers than HAS, but it did rate the Edenfield Centre as good. CQC can close private providers but NHS services such as Edenfield can only be put into special administration with its services being taken over by other providers. 

The other main political consequence of the asylum inquiries was the government’s renewal of its promotion of the policy of community care. The view was strengthened that society should not reject its mentally ill and learning disabled people. No longer was it appropriate to consign these people to distant institutions where they lived their lives out of sight and mind of the rest of society, with the potential for them being abused. The white papers Better services for the mentally handicapped (1971) and Better services for the mentally ill (1975) were published. Mental illness hospitals were to be replaced by a local and better range of facilities. On the other hand, the government also wanted to correct the misapprehension that it was actively encouraging a precipitate rundown of psychiatric hospitals.

Louise Hide (2022) provides an overview of the asylum inquiries in her book chapter. This historical perspective is relevant for current problems with services. As I said in my eletter,  open-door policies in traditional psychiatric hospitals led to England reducing its number of inpatients from 1954 before other European countries. The 1959 MHA made informal admission rather than detention the usual method of admission. By 1963, 80% of English psychiatric patients were in open wards. The advantages were striking: tension reduced, violence declined, ‘escapes’ were no longer a problem and staff were able to give their attention more to therapy rather than custody. This therapeutic trend was reinforced by improving patients’ rights in the 1983 MHA. Many old long-stay patients grew old and died in hospital, and the number of new long-stay patients to replace them became much less. With the reduction in hospital bed space, there was a reduction in the average length of stay, although actual numbers of acute admissions increased, including so-called ‘revolving door’ patients. The traditional asylums went into decline and became increasingly irrelevant to the bulk of mental health problems.

There was resistance to the rundown of the psychiatric hospital, not least because it was seen as a challenge to the authority of psychiatrists. Attitudes to community care were polarised and only ended after the traditional hospitals were eventually closed. Fears about public safety due to homicide by psychiatric patients led to the new Labour government’s controversial conclusion that community care had failed. Even if this was true, which I do not think was the case, community care has clearly not developed sufficiently to prevent continuing abuse in hospital. 

The harm caused by inappropriate detention in psychiatric hospital must be acknowledged. Services again need to focus on the development of community care, not that inpatient care may not be needed at times, which, whenever possible, should be truly informal rather than formal under detention. The current draft Mental Health bill being considered by a parliamentary scrutiny committee does not go far enough (see eg. previous post). 

What made progress with the asylum inquiries was the Whittingham hospital inquiry, which saw the problems as institutional rather than only blaming individuals. I think Edenfield needs a similar independent inquiry. It's no good relying on the CQC and NHSE, from which there is a need for independence. Psychiatric services need to become more open and therapeutic. We need government to produce a new mental health strategy (which is currently going through a refresh - see webpage) that makes services more integrated and less dysfunctional.

The implications for psychiatry of patients being human

Thomas Fuchs (who I have mentioned before eg. see previous post) lectures online on 'Personhood and neuroscience'. As he says, "When brain researchers claim that consciousness is undoubtedly located in the brain, they are subject to a category mistake". The point is that it is people who are conscious, not their brains. The brain is only the organ of a living person, not alive as such and can’t be conscious.

Reduction of primary mental illness to brain disease is not possible in principle (see previous post). Neuroimaging studies that literally 'light up the brain' have misled us into accepting the neuro-turn (see another previous post). But the subject matter of psychiatry is the person as a whole, not the brain. The part-function of the brain is not the same as the person (see yet another previous post). More generally, life cannot be understood in mechanical terms, as Kant said some time ago (see previous post). Even though it's absurd to make an attempt to understand primary mental illness in physical terms, nonetheless it seems to make sense to us that we should be able to provide such understanding and explanation (see another previous post). Psychiatry, therefore, always holds out the expectation that it will eventually find the answers to primary mental illness (see yet another previous post). 

As Varela et al (2017) said:

[W]e hold with Merleau-Monty that Western scientific culture requires that we see our bodies both as physical structures and as lived, experiential structures - in short, as both "outer" and inner', biological and phenomenological. ... For Merleau-Monty, as for us, embodiment has this double sense: it encompasses both the body as a lived, experiential structure and the body as the context or milieu of cognitive mechanisms.

The trouble is that subjective experience tends to be seen as a mere epiphenomenon and the focus has become so-called objective scientism.

Psychiatry went through a previous phase of brain mythology in the nineteenth century.  The enthusiastic search for anatomical localisation in psychiatry led to fanciful notions, as, for example, with Theodor Meynert (1833–1892) who throught he had delineated various ‘fibre-systems’ in the brain and deduced functions for these ‘pathways’. Meynert’s research may have appeared so successful because it seemed to give a material explanation of the basis of mental illness in the same way as modern neuroscience. Despite his skills in brain dissection, Meynert's theories were not based on empirical findings. Nor have any definite biomarkers been linked to primary mental illness in modern research studies as they are plagued by inconsistencies and confounders (see eg. previous post).

Anatomoclinical understanding, which relates symptoms and signs to their underlying physical pathology, was a major advance for medicine in the nineteenth century and still underlies our modern understanding of disease. Pathology emerged as a distinct discipline with autopsy findings of lesions in organs and tissues being related to clinical examination at the bedside. Histological studies established cellular abnormalities for disease. Applying this anatomoclinical method to psychiatry was not as successful, however, because it was not always easy to relate mental conditions to underlying brain pathology.

Eventually it was established that dementia paralytica was a late consequence of syphilis. Senile dementia was also seen as having a physical cause such as Alzheimer’s disease. Focal abnormalities in the brain were identified and physical causes of learning disability were recognised. However, most psychopathology is functional, in the sense that there are no structural abnormalities in the brain. A distinction was, therefore, made between functional and organic mental illness (see previous post). This consensual understanding was broken by DSM-IV (see previous post) and DSM-5 failed in its attempt to create a scientific basis for psychiatric diagnosis and classification (see eg. previous post), based on genetic markers and brain imaging (see another previous post).

I'm sure the wish to find a biological basis for primary mental illness will never go away completely. But psychiatry must stop ignoring that patients are people. This is not a unique requirement for psychiatry, as all medicine needs to be more patient-centred (see eg. previous post). But it is particularly acute for psychiatry when primary mental illness cannot be reduced to brain disease.

Rights based legislation in mental health

The World Health Organisation (WHO) QualityRights Toolkit can be used to evaluate adherence by mental health services to the Convention on the Rights of people with Disabilities (CRPD) (see previous post). For example, a report on the quality of institutional care for adults with psychosocial and intellectual disabilities in the WHO European Region found such care far below standard in many European countries. Similarly, none of the CRPD articles was found to be fully adhered to in Czech psychiatric hospitals (see article). 

The toolkit collects data on 25 standards within five interrelated themes:

• The right to an adequate standard of living (Article 28 CRPD); 

• The right to enjoyment of the highest attainable standard of physical and of mental health (Article 25 CRPD); 

• The right to exercise legal capacity and the right to personal liberty and the security of person (Articles 12 and 14 CRPD); 

• Freedom from torture or cruel, inhuman or degrading treatment or punishment and from exploitation, violence and abuse (Articles 15 and 16 CRPD); 

• The right to live independently and be included in the community (Article 19 CRPD).

Assessment of each of the criteria that make up the standards enables assessors to determine whether a particular standard has been met, which in turn, help to determine whether each overarching theme has been met. The government's current reforms of the Mental Health Act need to support the transformation of mental health systems in line with CRPD (see previous post).

The QualityRights initiative is WHO's response to the need for transformation (see another previous post). The quality of mental health services needs to be improved globally and properly supported by human rights based legislation.

Psychiatry must give up mechanistic understandings of mental illness

Nour et al (2022) complain that mechanistic understandings of psychiatric treatments, such as psychotropic medication and psychotherapy, remain elusive. After three decades of intense neuroimaging research, there is still no neurobiological account of any functional psychiatric condition. Nonetheless, Nour et al remain cautiously optimistic that computational psychiatry, with a deeper engagement between psychiatric neuroimaging researchers and artificial intelligence (AI) communities, will still be able to produce clinically relevant mechanistic insights.

Similarly, the Wellcome Trust, a few years ago, recognised that there were underlying problems that needed to be addressed before mental health research could make significant progress (see previous post). What researchers find difficult to accept, though, is that attempts to ‘localise the mind’ through research into brain activities has no future as a research programme. Instead, neurobiology needs to develop its philosophical understanding.

As I mentioned in a previous post, Bennett & Hacker (2021) in the second edition of their Philosophical foundations of neuroscience have separated out a chapter on conceptual problems arising from ascribing to the brain properties that can only sensibly ascribed to the organism as a whole. This is what they call the mereological fallacy. Psychiatry must stop identifying the brain with the person. Instead, 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 (see eg. my article). 

For example, the experience and relationships of people are at the core of depression, and they cannot be identified with neuronal or molecular processes (see eg. previous post). Psychiatrists need to accept that even though physical illness is accompanied by bodily disease, primary mental illness is not accompanied by structural brain disease.

Nor is computational psychiatry the answer. People are not computers. There is a fundamental difference, and not just of degree, between the computing and adaptation capabilities of a computer system and the perceptions, insights, thinking and understanding of a human being (see previous post). A mechanistic conception of nature fails to provide a complete characterisation of living beings (see eg. another previous post).

(With thanks to Mad in America research news item by Peter Simons)

Clinical sense about antidepressants

Cristea & Naudet (2018) conducted a content analysis of citations of Leucht et al (2012) (see previous post), a paper which concluded that psychiatric drugs are no less efficacious than other drugs. They found that identified records were overwhelmingly uncritical of the original paper and suggested it was being used to support the myth that the trivial effects of mental health drugs are to be expected and therefore accepted. 

Such uncritical thinking continues when claims continue to be made that there is no doubt about the effectiveness of antidepressants. For example, Tony Kendrick (@tony_kendrick) tweets that doctors can reassure patients that antidepressants are not simply placebos. But the editorial linked to that tweet is not open-minded enough about the data (see last post). People seem to be on the look out for evidence that counters the claim that antidepressants have little or no effect (see previous post). I’m not saying that antidepressants have been proven to be placebos. But in the same way that doctors have misled patients that the chemical imbalance theory of depression has been proven, I’m afraid we have to live with the uncertainty about whether and how antidepressants “work” (see another previous post).

As I keep saying (eg. see previous post), the reality is that the difference between active and placebo treatment in short-term trials of antidepressants is small. This small difference could be an artefact because of bias in the trial methodology, particularly unblinding. Even in the clinical trials not everyone is helped by antidepressants. They don’t always give the easy and simple answer people may have been misled to expect, particularly over the longer term (see another previous post).

Changing what doctors say about antidepressants

Kendrick & Collinson (2022) discuss the Moncrieff et al (2022) umbrella review about serotonin and depression (mentioned eg. in a previous post). As they say, doctors should not tell people with depression that antidepressants correct an imbalance or deficiency of serotonin, or that they will necessarily need long term treatment. It may well be helpful if the Royal Colleges of General Practitioners and Psychiatrists endorsed this view publicly. Trust between patient and doctor is paramount and doctors have been allowing people to believe that the serotonin theory has been proven, when this is clearly not the case.

Not that I completely agree with what Kendrick and Collinson say about antidepressants. Doctors have obviously used the serotonin imbalance theory as a means of persuading people to take their medication. True, Joanna Moncrieff probably makes too much of SSRIs being emotional suppressants (see previous post) but I do not think she has used the Moncrieff et al (2022) study to justify her scepticism about the efficacy of antidepressants, which is based on independent evidence.

In fact, Kendrick & Collinson do not reference probably the best summary of such effectiveness data (see previous post), which ironically was also published in the BMJ like their editorial. As far as they are concerned antidepressants are effective and typically quote Cipriani et al (2018a) in support, without quoting Cipriani et al (2018b) which provides a more sober interpretation of their findings. Cipriani et al merely conclude that antidepressants may be effective and do not go as far as Kendrick & Collinson in necessarily dismissing more sceptical interpretations of the data (see another previous post). Kendrick & Collinson clearly do not believe the placebo amplification hypothesis as an explanation of the clinical trial data, quoting Hieronymous et al (2018), but do not give a critical enough analysis of that paper (see yet another previous post). They are also too cavalier with the recent Stone et al (2022) study (see previous post), saying that some people experience a substantial response on antidepressants. However, this may be due to those subjects breaking the blind (see note from Irving Kirsch in Radoslaw Stupak's tweet). They also overstate the implications of the ANTLER study, to which Kendrick himself contributed, about maintenance treatment and withdrawal symptoms (see previous post).

Kendrick & Collinson are clearly fearful how patients may react if they interpret the scientific evidence as meaning that antidepressants are not effective. There are risks from stopping antidepressants. Doctors do need to provide as accurate data as possible to help people make up their minds in the inevitable uncertainty about the effectiveness of antidepressants. This includes no longer misleading them about the serotonin theory.

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 (see post on my personal blog). 

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 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).