Labelling differences between people as neurodevelopmental

I want to take further what I was saying about ADHD in a recent post. Over recent years, ADHD has been classified as a neurodevelopmental disorder with identification of comorbidity between ADHD and autistic spectrum disorder (ASD). Claims that ADHD is a genetic condition (see previous post) are consistent with the hypothesis of a genetic neurodevelopmental continuum of intellectual disability, ASD, ADHD and other childhood conditions including tic disorders. The concept of neurodiversity (see article in The Atlantic), meaning intrinsic diversity of brain function, implies that neurodevelopment disorders are not necessarily pathological but may merely represent brain differences. 

People are different. The clamour to find a psychiatric diagnosis to explain our difficulties, eccentricities and odd behaviour may not necessarily increase our understanding of the reasons for these problems and differences. Admittedly these may be difficult to understand, at least initially, but that doesn't mean that we shouldn't try. These issues are complex and differences between people are not just due to their brains or genes. I agree with advocates of neurodiversity about human rights and the need for society to adapt to individual differences. That doesn’t necessarily mean, however, that increasing the diagnosis of ADHD and other neurodevelopmental diagnoses is the answer to understanding and managing our differences from others.

Barriers to debunking the serotonin theory of depression.

I concluded my article on 'Towards a more relational psychiatry: A critical reflection' with the sentence:-

Rather than psychiatric practice being based on the notion that primary mental illness will be found to have a physical cause, psychiatry needs to move on to a more relational practice.

I just want to elaborate what I mean by this in relation to the umbrella review that confirmed there is no convincing evidence to support the theory that depression is caused by low serotonin (see previous post). Even though antidepressants may be serotonin re-uptake inhibitors, they do not seem to correct an imbalance or deficiency of serotonin in the brain (see another previous post). 

This may well be surprising to patients and the general public who have been led to believe in the serotonin theory of depression. Simplistic notions of the serotonin theory have actually been untenable for some time (see eg. previous post). Psychopharmacologists gave up the theory ages ago but it persists in clinical practice as a way of persuading patients to take their medication. I'm sure the fundamental faith of psychiatry that primary mental illness will be found to be due to brain disease will continue. Doctors find it difficult to accept that depression hasn't something to do with serotonin because antidepressants can be serotonin re-uptake inhibitors. They are convinced antidepressants work, so this must be due to their effect on serotonin. 

Our modern understanding of illness and disease as bodily pathology has been remarkably successful in elucidating biological processes of disease. Doctors should take a person-centred approach to attain an understanding of the patient as well as the disease. For psychiatry in particular, the danger is that medicine may treat patients more as objects than people by reducing their problems to brain disease.

After decades of intense neuroimaging research, there is still no neurobiological account of any functional psychiatric condition (see eg. previous post). Psychiatry must stop identifying the brain with the person. People’s experience and relationships with others are at the core of depression and cannot be identified with neuronal or biochemical processes, such as serotonin imbalance or deficiency. We may find it attractive to try and simplify the relationship between mind and brain, but it may well be an enigma we cannot solve. We have to accept the integration of mind and brain in the person. Of course brain disease can cause mental disorder, but it may well not make sense to see depression as being in the brain. Depression is mediated by the brain but there may be no brain abnormality as such. This is what psychiatry will continue to find difficult to accept.

Creating panaceas for emotional and other mental health problems

I want to look at some of the wider implications of the BBC Panorama programme exposure of private ADHD clinics. I'm not convinced the NHS is necessarily coping any better than private services with the burgeoning demand for psychiatric diagnosis of emotional and other mental health problems, of which ADHD is just one of the diagnoses for which remedies are being sought. A uncritical biomedical approach to ADHD can be an excuse for licensed fraudulence (see previous post). 

Panorama is not the first media programme to highlight the exploitation of ADHD diagnosis (eg. see previous post). Adult ADHD is a relatively new diagnosis, as ADHD was originally a diagnosis made in children with symptoms of hyperactivity, impulsivity and inattention. Such behaviours may be displayed when children feel frustrated, anxious, bored, abandoned, or in some other way stressed. The increasing diagnosis of ADHD in children, over many years now, has been compounded by diagnosis in adults without a previous childhood diagnosis, considered to have been a major unrecognised condition (see eg. my article). Many psychiatrists see this as an example of the overmedicalisation of mental health problems (see another previous post), which at least partly explains why adult ADHD services have generally been hived off into a special service, mostly with massive waiting lists.

Not all negative emotions and experiences should be labelled as mental disorder. A moral panic about mental health may encourage the packaging of our everyday problems as conditions that can be diagnosed and treated. The reality is not always so simple (see eg. previous post). As this is mental health awareness week, it is perhaps worth highlighting how destigmatisation campaigns seem to have encouraged this oversimplification (see another previous post). Services themselves also ironically have encouraged the expansion of demand, apparently with the misguided notion that a perseverative call for more funding will provide the answer. The cultural process of seeking to create panaceas for emotional and other mental health problems doesn’t always work and may create more problems than it is worth. 

Changing how mental disorders are studied and managed

As Caio Maximino (2023) says in History of Psychiatry, the "over-reductionist neo-Kraepelinian approach" has been criticised for decades. Like me, he also argues that these criticisms tend to disregard advances in enactivism and phenomenological psychiatry (see eg. previous post). Biomedical psychiatry essentially ignored George Engel’s call for a more integrative approach by moving on with its ontological position that mental phenomena are brain phenomena, even if this is now understood in an eclectic biopsychosocial way (not originally what Engel meant - see eg. previous post). But what's needed is a new epistemology that recognises "the complexity of the relation of biology with interpersonal, social and cultural factors (see another previous post). I have tried to summarise all this in my paper 'Towards a more relational psychiatry: A critical reflection' (see yet another previous post).

Value for psychiatry of the explanation/understanding distinction

Joseph Gough (see Gough (2021) and Gough (2023)) seems to me to wrongly undermine the value for psychiatry of the explanation/understanding distinction from Dilthey. True, Jaspers notion of un-understandability as a basis for defining organic disorders does not hold up. And the apparent incomprehensibility of psychosis can be understood (see Wendler & Fuchs (2023)). 

But there is a very real sense in which we may not be able to say what causes functional mental health problems in physical terms. Relationship with antecedents is not linear but more circular (see previous post). This does not mean that it's not important to try and understand the reasons for mental health problems, even that they may provide a kind of explanation (see another previous post). Naturalistic explanations are inadequate because of the need to take a holistic personalistic view of mental health problems. Mind and body are integrated in the organism but this does not really dissolve the mind-body problem, merely acknowledge it can’t be solved.

Psychiatrists, antidepressants and suicide

David Healy (who I have mentioned before, see eg. previous post) has published a blog post on his website, which he provocatively entitles a 'Royal College of Psychiatrists' suicide note'. His post was in response to a letter written by the President of the Royal College about newspaper articles citing a study by John Read (2023) that David reviewed for the Ethical Human Psychology and Psychiatry journal, which also published an accompanying paper from David. 

John's study examined a data set summarizing 7,829 media reports of Coroners’ inquests in England and Wales between 2003 and 2020 that mentioned antidepressants (ADs). This information was collected on the AntiDepAware website. Overdose of antidepressants was not always the cause of death. John concludes:-

The data set we have summarized here confirms the findings of drug trials showing that ADs are ineffective for many people. The reports document the deaths of several thousand people who killed themselves despite being on ADs, and more than a thousand who actually used the drugs that were supposed to alleviate their depression to kill themselves.

As John also says, the paper has "few firm conclusions". Not many people will be surprised to learn that antidepressants do not necessarily prevent suicide; nor that some people take overdoses of their prescribed medication. I'm not sure that this information really reinforces questioning about whether antidepressants are effective, although I agree this is a major issue (see eg. previous post).

Not that whether antidepressants cause suicide is not also a major issue (see previous post). It's just that I don't think John's study adds too much to this debate either, despite the hype. Nor do I think David's accompanying paper really takes the issue forward. David describes two clinical scenarios, one of for which he was an expert witness at the inquest. As he says, "Coroners have actively steered" him to blame mental illness rather than medication for the cause of death. He is convinced these two cases were antidepressant-induced deaths. 

How to determine causality in such cases is not easy. What worries me about David's position is that he tends to take a physicalist approach to medication and not necessarily consider how people react to the taking of medication (see previous post). How people react to the act of prescribing in itself when they are feeling desperate does need to be taken into account. Antidepressant prescribing may well be a factor in suicide, but it is not necessarily due to the effect of the medication on the brain.

Cultural-ecosocial approach to psychiatry

Gómez-Carrillo et al (2023) argue for the value of a cultural–ecosocial approach to integrating neuroscience in psychiatric theory and practice. I’ve mentioned before (eg. see previous post) that relational psychiatry brings together a cultural-ecosocial psychiatry with developments from anti-cognitivist phenomenological and enactive accounts of psychopathology. Gómez-Carrillo et al also make this link in their article by explicitly recognising the importance of 4E cognition, which examines how cognition is embodied, embedded, enacted, and extended. As they say, "training in systems thinking and social science needs to be a key feature of psychiatric education”.

Mediated by the brain not necessarily the same as caused by the brain

Further to my last post, it may be worth thinking a bit more about why psychiatry, and neuroscience in general, have taken us down the route of the mereological fallacy. It’s become very common to view ourselves in terms of our brains (see eg. previous post). This, of course, has particular implications for psychiatry.

The reason this happens is because people no longer want to make a distinction between the psychological and the biological. It is said to be a false separation (see eg. another previous post). The fear is that the mind/body split of Cartesianism is being perpetuated by seeing mental disorder as psychological, said to be implying it is not biological (see eg. yet another previous post). Better to do away with any distinction at all, is the thought.

As I've said before (see eg. previous post), René Descartes (1596–1650) was the first to apply a natural-scientific mechanistic approach to life  Animate and inanimate matter were understood by the same mechanistic principles. Animals were, therefore, regarded as machines; and human physiology was also seen as mechanistic. Descartes stopped short, though, of including the human mind in this mechanistic framework. The soul was denied any influence in physiology. Descartes thereby avoided the materialistic implication that man himself is a machine. The split he created between mind and brain is what is referred to as Cartesianism. 

One of the first to challenge this perspective was Georg Ernst Stahl (1660–1734). He claimed that living things possess an immaterial soul, although he did not necessarily mean a transcendent soul, that provided the key element of movement to matter within the living body. His ‘dualistic’ notion was different from that of Descartes, in that he differentiated organic life from the inorganic, not the soul from the body. Unlike Descartes, he proposed that the soul and body are not separate but integrated in the organism. Despite his vitalism, Stahl originated a holistic perspective in the life and human sciences. This perspective formed the basis for his emphasis on psychosomatic medicine, and a focus on clinical medicine rather than the physical sciences. But his vitalism is as much derided, now, as Cartesianism. Although it makes sense to distinguish life from inanimate matter, a more modern way of expressing this is through enactivism, rather than vitalism (see eg. previous post). 

The mereological fallacy helpfully highlights that even though mental disorder is mediated by the brain, this does not imply that it is necessarily represented in the brain. Of course, cerebral disease or abnormality can cause mental disorder. But the vast majority of mental disorder is functional, not structural. It is not represented in the brain as such. It doesn’t make sense to see it as being in the brain. Even delirium and dementia caused by cerebral disease should not be seen as being in the brain as such. It’s people that become delirious or demented, not their brains. But the cause of organic mental disorder, such as delirium and dementia, is abnormality in the brain, whereas for functional disorder, it is not. It is more to do with the whole person, not just the brain, and cannot be understood mechanically. The mental is as much biological as the physical. Because the assumption is that mediation by the brain means that all mental disorders must be in the brain, people fail to recognise that mental disorders are not always in the brain. Being more careful and avoiding language to say that the brain is the person would be a start towards that realisation.

People are not their brains

I have been thinking about the implications of the mereological fallacy (see previous post) for psychiatry. Psychiatry must stop identifying the brain with the person (see eg. another previous post). 

People need to be understood as wholes, as their brains are only part of them. The brain mediates cognition, emotions and behaviour but it is not the brain that perceives, thinks, feels and acts. It is people as a whole that do that (see eg. yet another previous post).

Brain disease or abnormality can cause mental disorder. Such organic mental disorders can be due to a primary brain disorder or secondary to a systemic illness, or result from an exogenous toxic agent, or be due to physical withdrawal of an addictive substance. But not all mental disorder is due to brain disease or abnormality. Mental disorder shows through the brain but not necessarily in it.

Brain disease can be detected when assessing for mental disorder by disturbances of sensorium and cognitive functioning (see eg. previous post). In particular, level of consciousness, orientation, attention and memory are affected. Jaspers in his General Psychopathology referred to the "state of consciousness" as the "momentary whole" of the "psychic state". Brain disease may be detected by its effects on consciousness and that sense of wholeness.

Depression and schizophrenia, as examples of functional mental disorders, need to be understood in meaningful context. But the meaning of dementia, as an example of an organic mental disorder, could be said to be more to do with brain abnormality. It's people that become demented rather than their brains, as such, but the brain abnormality of dementia, whether Alzheimer’s or whatever, affects the wholeness of people's experience of themselves.

Publication bias in antidepressant trials

Erick Turner was a former US Food and Drug Administration (FDA) reviewer. At the FDA he was aware of publication bias due to negative results of trials tending not to be published. As he says in an interview with Ayurdhi Dhar from Mad in America (see edited transcript and podcast), there was a “disconnect between what clinicians were seeing and what the FDA reviewers were seeing, and what was known to the FDA and the pharmaceutical industry”. 

I’ve always argued that the apparent small difference between antidepressant and placebo in clinical trials could be due to placebo amplification because of unblinding (see eg. previous post). Although maybe unlikely, I suppose it’s possible that publication bias could completely explain this artefact. Certainly the pharmaceutical industry has taken advantage of the clinical reluctance to consider this issue, although publication bias also plagues psychotherapy trials. As Erick says, the decision as to whether a clinical trial is “good science shouldn’t depend upon whether the results were statistically significant”.

Reducing overprescribing in the NHS

The Department of Health and Social Care (DHSC) produced a report in September 2021 to reduce overprescribing of medication. According to the Sunday Express (see article), NHS England is due to unveil a scheme in the spring aimed at weaning the health service off a culture of ‘a pill for every ill’. 

As the DHSC report says, what’s needed to reduce overprescribing is already known: shared decision-making with patients; better guidance and support for clinicians; more alternatives to medicines, such as physical and social activities and talking therapies; and more Structured Medication Reviews (SMR) for long-term health conditions. The problem is that “Many patients do not feel that they experience a compassionate, coordinated service that pays enough attention to their individual needs, assets, values, preferences and priorities”. The College of Medicine (see webpage) launched its Beyond Pills Campaign in 2022. A cultural change to reduce the reliance on medication and to support shared decision-making would be very welcome, not least for mental health services.

Does psychotropic medication work?

Horatio Clare and Femi Oyebode have made a valiant effort to provide a balanced perspective in the radio series ‘Is psychiatry working?’. In the fourth episode, they ventured into the controversial area of medication, and I just wanted to make a few comments. I hope the final two episodes may help to explain why psychiatric services have become too dysfunctional and fragmented, although that might be for another series.

Almost as a kind of disclaimer, the programme had to say that there is no doubt that psychotropic medication helps millions of people round the world. But what is meant by such a statement? Individual experience may be that psychotropic medication helps. For others it may not be of benefit. Clinical trials tend to show an advantage for eg. antidepressants, but maybe not as great as is commonly assumed and a good proportion of people do not respond to antidepressants, even in the clinical trials. The efficacy of antidepressants is in fact still an open issue in the scientific literature because of methodological problems with the clinical trials (see eg. previous post).

The dynamic of the doctor-patient relationship is important even when medication is used. It is difficult for people to accept that so-called antidepressant efficacy may merely be due to the placebo effect (see eg. another previous post). Even cognitive neuropsychological theories, as for example described by Catherine Harmer in the programme, tend to assume that medication works through brain effects. Of course a placebo effect in itself can make people think more positively and seem to help their depression.

Although Joanna Moncrieff said that antidepressants make people physiologically dependent, the programme did not really deal with this issue (see eg. previous post). The extent to which taking medication can be an identity-altering experience tends to be underestimated (see eg. another previous post). Of course psychotropic medication can have physiological effects. But the whole edifice of modern psychiatry has been built on psychotropic medication being more than placebo and the fear is that it will come crumbling down if this were not true. Not a very firm basis for practice in my view. Psychiatry, of course, existed before the modern psychopharmacological era and isn’t just about medication.

Truth about psychiatric diagnosis

The study by Rosenhan (1973) published in Science has probably always been difficult to believe. I’ve said before, though, that psychiatry doesn’t need to be so defensive about it (see eg. previous post). DSM-III was motivated to improve the reliability of psychiatric diagnosis by introducing operational criteria, at least partly due to the challenge of the Rosenhan study, because Robert Spitzer thought unreliable diagnoses must be invalid. 

The Rosenhan study was actually more designed to challenge the validity rather than reliability of psychiatric diagnosis. Andrew Scull (who I’ve mentioned before eg. see previous post) has recently published an article in History of Psychiatry summarising the evidence that the study was fraudulent. Six of the seeming nine original participants are said to have never been traced. Data from one of the participants was not included in the Science report and this psychology student at the time of the study, who became an academic psychologist, published his own more positive account of his experience (see article). 

At the very least, Rosenhan (1973) is biased, inaccurate, dishonest and exaggerated its findings. As Andrew says, there is a "possibility that they [ie. the six missing participants] may still surface" but he thinks it is more likely they "never existed at all". 

I know of two reports of modified repeats of the Rosenhan study. Because they are later, both were done in the context of the rundown of the traditional psychiatric hospital. Although all Rosenhan's pseudopatients were said to have been admitted to hospital, both these reports suggest that feigning an auditory hallucination does not now generally lead to admission, maybe because of the pressure on beds. Scribner (2001) used 7 volunteers with long well documented histories of chronic schizophrenia, six of whom were actually denied treatment and turned away. The baseline histories were therefore very different from Rosenhan (1973), whose pseudopatients were said not to have had a history of mental disorder. 

The other report was from the book Opening Skinner's Box (2004) by Lauren Slater. Interestingly, she too has been accused of never conducting her study (see article). As she says in the book in her chapter on Rosenhan:

Psychiatry as a field is, of course, predicated on the belief that its own professionals know how to reliably diagnose aberrant mental conditions and to make judgments based on those diagnoses about a person’s social suitability

Interestingly again, she seems to suggest that Martin Seligman, an eminent psychologist, was one of Rosenhan's pseudopatients, which is not mentioned by Scull (2023). As far as I know, Seligman is still alive, so it may be possible to check this.

Slater herself has a "formidable psychiatric history" and was admitted to a psychiatric hospital aged 14. She does not deny the reality of mental illness. Slater says she used someone else's name, so that she wasn't recognised, and denied any psychiatric involvement in the past. She relates that she presented herself nine times saying she was hearing a voice, and that, although she was treated kindly and was not admitted, she was prescribed a total of 25 antipsychotics and 60 antidepressants. Almost every time she says she was given a diagnosis of psychotic depression.

I suppose Rosenhan could be said to have had more impact on psychiatry as a social scientist than Andrew (except maybe Andrew’s influential dismissal of Foucault in the literature - see eg. previous post)! Not excusing Rosenhan's behaviour, but I think the scientific literature is plagued by such dishonesty as Rosenhan's. There is evidence, though, that at least aspects of his Science paper are correct. Certainly it was possible for a person who is not mentally ill to obtain admission to psychiatric hospital and mislead psychiatrists into diagnosing schizophrenia. Maybe this has always been the main message that people have taken from the study. Rosenhan does seem to have elaborated the details to reinforce his conclusion that psychiatric diagnosis is subjective and does not reflect inherent patient characteristics.

What worries me is that Andrew’s complete dismissal of Rosenhan’s study as fraudulent may reinforce the case that psychiatric diagnosis is objective, which it isn’t in any absolute sense. The limitations of psychiatric diagnosis do need to be acknowledged (see eg. previous post). If psychiatric diagnosis is meaningful, there will be inevitable inconsistencies.

Conversation about critical/relational psychiatry

I've posted a summary (see link) of my views about critical/relational psychiatry, which is to be published in a forthcoming Oxford University Press book adaptation (late 2023) of  'Conversations in Critical Psychiatry' edited by Awais Aftab. The essential message of critical/relational psychiatry is that primary mental illness cannot be reduced to brain disease. Such a view tends to be dismissed or marginalised as it may be difficult to believe and accept. Of course mental illness has something to do with the brain, people say. Is critical/relational psychiatry really suggesting otherwise?

Of course it isn’t! The brain mediates our thoughts, emotions and actions, including mental illness. This statement is of course true. But biomedical psychiatry’s claim is that mental illness will be shown to be due to an abnormality in the brain, even that there is considerable evidence already to come to this conclusion. This hypothesis may seem to stand to reason, but it doesn’t. Let me explain.

Abnormalities of the brain can of cause cause mental symptoms. Such is the case for example with a brain tumour. Definite neurological signs may also be present in cerebral disease. Fortunately such organic conditions tend to cause symptoms affecting cognitive functioning that usually allow them to be distinguished from non-organic mental illnesses, like schizophrenia or depressive illness. Primary mental illness, not caused by brain disease, is functional and not structural. It shows through the brain but not in it.

Acknowledging this situation has advantages for psychiatric practice. It should mean that people are not reduced to their brains. They must not be treated as objects. Clinical work needs to be focussed on understanding patients’ histories and mental states and formulating their problems in those terms. Treatment needs to be about supporting them to deal with their problems.

This basic message needs reinforcing in the current mental health system which has become too dysfunctional and fragmented. Psychiatry needs to move on from an outdated belief in mental illness as brain disease.

The Joint Committee on the draft Mental Health bill has produced an impressive report (see eg. last post and twitter thread of what the Committee sees as the highlights. Also, see the walkthrough of conclusions and recommendations by Alex Ruck Keene.). I particularly welcome the Committee’s not necessarily expected recommendation to abolish Community Treatment Orders (CTOs) for civil patients. Although it is keen for the Mental Health Bill to be passed into legislation as soon as possible, it also promotes the need for ongoing reform. The Committee helpfully recommends the creation of the post of Mental Health Commissioner and the introduction of pilots for patients to be able to appeal to a slimmed down Mental Health Tribunal about treatment plans. It makes helpful recommendations about incorporating reference to the principles of racial equality, choice and autonomy, least restriction, therapeutic benefit and person as an individual on the face of the Act.

Although it expresses concern that the introduction of conditional discharge for restricted patients may be overused, the Committee only recommends close monitoring of implementation with a statutory review after 3 years. My main concern about the report is that it does not seem to have considered the need to improve the right to an independent second opinion from a person of the patient’s choice, rather than just from a Second Opinion Approved Doctor (SOAD) appointed by the Care Quality Commission (CQC). As I said in a previous post, the strengthening of the role of SOAD is welcome, but this should be taken further by making the second opinion process even more independent. I think this is particularly the case in the context of developing the role of the Tribunal to consider treatment decisions and I would argue that eventually SOADs could be abolished.

The Committee emphasises the need for adequate resourcing of the MHA changes and sees it as essential that a detailed plan for resourcing and implementation is produced on introduction of the Bill. I look forward to seeing the government's response.

Legislating for Mental Health Act (MHA) reform

My understanding is that the Joint Committee on the draft Mental Health bill should be producing its report this week (see its tweet). I just want to pick up on aspects of the additional written evidence submitted to the Committee since the original batch (see previous post). 

Supplementary written evidence by the Chair and Vice-Chairs of the Independent Review of the Mental Health Act helpfully highlights the need to improve the quality of advocacy services (see twitter thread; also guidance from NICE on how to commission and deliver effective advocacy services) and to enable the Mental Health Tribunal to challenge treatment decisions (see another twitter thread). NHS England expresses concern about the power of supervised discharge (see twitter thread). A letter from from the Joint Committee on Human Rights recommends improvements in MHA complaint handling (see another twitter thread). 

I look forward to seeing how the Committee deals with these and other issues in its report to take forward the Mental Health Bill.

Reimagining psychiatry

Diana and Nik Rose have a Psychological Medicine article entitled ‘Is ‘another’ psychiatry possible?’. They discuss postpsychiatry (see eg. previous post), Open Dialogue,  the Power, Threat and Meaning Framework (PTMF) (see eg. another previous post) and service user involvement in research in this context. As they say, the leaders of the psychiatric establishment are unlikely to accept “reduction in their claims that they are the exponents of highly effective, neurobiological based, targeted treatment of brain disorders”. 

I’ve always said it’s unrealistic to expect a paradigmatic shift in psychiatric practice because the hope of finding a biological basis for mental illness will never go away completely. But the extent to which it’s understood that this belief is wishful thinking may change. Psychiatry does need to become more open minded, more self-critical and less dogmatic in its beliefs and claims. 

Psychiatric practice is too based on speculation

Although psychiatrists generally admit that brain science has not advanced to the point where discernible biological lesions or genetic abnormalities have been found that are reliable markers of functional mental disorder, they tend to assume in practice that such markers will be found. Their clinical work is backed up by a vast research effort motivated to uncover the biological basis of mental illness. Treatments, such as medication, are presumed to correct abnormalities in the brains of mentally disordered people.

There are of course brain impairments that cause mental symptoms. These can primarily be divided into acute and chronic presentations. Acute conditions present with a toxic confusional state or delirium, for example related to the general effects of disease in the body. Chronic irreversible conditions are dementia, such as Alzheimer's disease. Such organic presentations can be differentiated on clinical examination of the mental state, as they have cognitive symptoms and signs affecting intellectual functioning, such as orientation (time, place, person), concentration, attention, memory and level of consciousness. These cognitive abnormalities tend not to be present with functional disorders.

Mental disorders are of course mediated through the brain, but it is a conceptual mistake to regard non-organic disorders as being in the brain. People become mentally ill, not their brains. Functional mental disorder needs to be understood in the context of life, social, family and personal development and current situation. It may not be possible to 'prove' what causes mental illness, and it may be very difficult to make sense of some presentations, such as psychosis, but nonetheless any treatment needs to focus on providing the support and understanding to help people recover from their difficulties as much as they are able and wish to do so.

Mental health treatment online can exploit people

Article in The Wall Street Journal exposes how advertising and other strategies to promote expansion of treatment by digital mental health companies are motivated more by profit and not really improving patient care. For example, heavy advertising of ADHD self-diagnosis online (see eg. MediaMatters article) has encouraged people to seek prescription for stimulant medication. Exploitation of this situation by Cerebral Inc. has been described in four podcasts: Uncontrolled Substances. It isn’t just medication but also other physical treatments and psychological therapy that are being oversold on the internet (see eg. previous post). 

Medicine has always exploited patients but the move to online treatment because of the pandemic may have made this situation more obvious. In the end, it’s also the doctors and other health professionals that need to take responsibility alongside corrupt business practices (see eg. another previous post). 

Causal concepts of disease

I’ve emphasised before (eg. see previous post) how medicine changed in the nineteenth century. K. Codell Carter in his book The rise of causal concepts of disease (2003) mentions how James L. Bardsley, a prominent British physician, in 1845 thought that diabetes ‘has been traced by some patients to sleeping out the whole of the night in a state of intoxication’. This shows how much our ideas of disease before our modern anatomoclinical understanding were influenced by patients’ opinions themselves.

Codell Carter describes the development of what Robert Koch called the aetiological standpoint which understood disease as having natural, universal and necessary causes. He also suggests in the last chapter of the book that how we characterise disease may change in the future. 

The domination of medical thought by the aetiological standpoint has prevented the proper understanding of functional mental illness. Psychiatry’s credibility is wrongly dependent on a biological aetiology of mental illnes, despite brain abnormality not being a sufficient explanation of functional mental illness. Psychiatry’s still stuck in the nineteenth century in its search for natural, universal and necessary causes of mental illness.

Relational psychiatry not merely an embarrassing hangover from 1970s

I have been re-reading my editorial in BJPsych Bulletin entitled ‘Critical psychiatry: An embarrassing hangover from the 1970s?’. I conclude that “Critical[/relational psychiatry] can be understood as a non-eclectic, biopsychosocial, neo-Meyerian approach to psychiatry based on Kant’s critical philosophy”. 

I just thought it may be worth explaining a bit more what I mean by this. I’m arguing that critical/relational psychiatry is not new. Although it’s often seen as a continuation of the anti-psychiatry of the 1960/70s, associated with R.D. Laing and Thomas Szasz, in fact it has a longer pedigree and was actually present in the origins of modern psychiatry in the Enlightenment. 

As described by Foucault in History of madness (see previous post), critical engagement of reason with itself in the Enlightenment brought psychiatry into existence as a distinct discipline. Early psychiatrists identified mental alienation and delusional thinking. The asylums became a specific form of institutional care, built to accommodate people needing treatment for mental illness, rather than such people being, for example, kept in the workhouse. The mentally ill were seen as deserving of poor relief on the basis of their mental state. The twentieth century saw the development of community care making the asylum increasingly irrelevant. Even in modern welfare, though, the mentally ill receive sickness and disability benefits, rather than unemployment benefit.

Anthropological understanding in the Enlightenment, viewing human beings as psychophysical entities, created the idea of the possibility of a natural scientific approach to psychology. However, Immanual Kant developed an alternative pragmatic approach to anthropology. He was clear that life could not be explained in mechanical terms and that psychology is descriptive and cannot be reduced to biology (see eg. previous post). This perspective was eclipsed by positivism later in the 19th century with the progress in understanding of physical illness in biological terms. The expectation was that mental illness would also be understood as a dysfunctional biological process (see previous post). However, it would have been better if psychiatry had stuck with Ernst von Feuchtersleben’s understanding of psychiatry (see eg. previous post) based on Kant’s critical philosophy. To reduce mental illness to brain disease is not possible in principle (see yet another previous post). 

Since then, there have been attempts to recreate an anti-reductionist perspective in psychiatry. For example, although he was not as explicit as he should have been, Adolf Meyer developed a psychobiological approach to psychiatry as an alternative to positivistic psychiatry (see eg. previous post). He was clear that psychopathology needs to be studied functionally in experiences and social interactions rather than at the level of neurobiology. This is not to deny the importance of organic conditions, such as delirium and dementia. Meyer's system never really took hold as a systematic theory, at least partly because he was prepared to compromise with biomedical perspectives, even if he disagreed with them. His views were also eclipsed by a reassertion of biomedical ideas over recent years in so-called neo-Kraepelinianism, developed as a response to anti-psychiatry (see eg. another previous post). 

Another example would be George Engel’s paper in Science in which he suggested there was a need for a new medical model, which he called the biopsychosocial model (see previous post), to replace the biomedical model. The trouble is that ‘biopsychosocial’ over recent years has become an ill-defined basis for psychiatric practice meaning that biological, psychological and social are all more or less equally relevant in all cases and at all times in psychiatric assessment. This eclecticism has been critiqued by Nassir Ghaemi and does seem to have outlived its usefulness (see eg. previous post). 

So, in summary, critical/relational psychiatry is a truly biopsychosocial model. It is not eclectic. It adopts the psychobiological model of Adolf Meyer but not his tendency to compromise with biomedical perspectives. It seeks a return to the Kantian origins of psychiatry, as, for example, expressed by Ernst von Feuchtersleben, to provide a more integrated critical perspective on modern psychiatry (see previous post). 

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.