Whistling in the wind

Edward Shorter, in his response to an article by Thomas Szasz, says there are solid biological findings in psychiatry. Shorter, who I've mentioned in a previous post, is the Hannah Professor of the History of Medicine at the University of Toronto. In 1996 he was cross-appointed to a professorship in psychiatry. As a non-clinician, has this professional association gone to his head?

The examples he gives of "obvious evidence" are the role of panicogens in triggering panic disorder; the response of catatonia to barbiturates and benzodiazepines; and what he calls the reliable accompanying of melancholic depression by hypothalamic-pituitary-adrenal dysregulation, as reflected in high levels of serum cortisol, a positive dexametasone suppression test (DST) and a shortened rapid eye movement sleep latency.

The reference Shorter gives for the importance of panicogens is from the proceedings of the 32nd annual meeting of the American Society of Clinical Investigation held in Atlantic City on 6 May 1940. In this study, patients with anxiety neurosis were found to increase sighing respiration more than controls when exposed to carbon dioxide and rebreathing. The feelings that they had during this rebreathing tended to resemble or be identical to their panic attacks. Shorter suggests that studies such as this were marginalised because of the influence of psychoanalysis. He doesn't make any mention of the controversy in the literature about the mechanism of action of lactate, which has been seen as the common pathway for the mechanism of action of carbon dioxide and several other panicogens.

The reference he gives for the evidence of the organicity of catatonia was a study of 4 cases, which were actually thought to be neuroleptic-induced, which responded to intravenous lorazepam. Shorter also mentions the response of catatonia to barbiturates. William Bleckwenn's use of intravenous amobarbital to produce lucid intervals in catatonic patients quickly led to the development of the so-called "truth serum".  How's this proved the organic basis of catatonia?

The reference Shorter gives for the biological basis of melancholic depression is his own recent book, written with Max Fink, entitled Endocrine Psychiatry. Fink has been an advocate of ECT over the years. I need to read the book. The DST was rejected as a biological marker because it was insufficiently sensitive and specific. I know that Fink thinks it shouldn't have been rejected, but this does seem to be a very idiosyncratic view. I'll come back to this when I've read the book.

Shorter seems to be using his historical expertise to suggest that modern psychiatry has overlooked evidence of its biological basis. As I have repeatedly said, please do not misunderstand me. Of course mental illness has a biological basis, as does our "normal" behaviour. But to be suggesting that biological markers have been established, or even overlooked in history, is whistling in the wind. This is what Shorter accuses Szasz of doing by claiming the opposite. As Szasz makes clear in his article, what he is stating is what he calls an "analytic truth", not dependent on scientific research.

Furthermore, Shorter suggests views such as those of Szsaz (he actually says the makers of the movie One flew over the cuckoo's nest) have led to many people committing suicide because they've avoided treatment. Not surprisingly, he doesn't give any reference for this opinion. As I've commented in a previous post, it's a pity debates such as this get so polarised.

And I'm not saying this because I totally agree with Szasz (eg. see my book review). But on the point on which Shorter has attacked him, he's correct. Shorter may be right that mainstream psychiatry now acknowledges a neurological basis for much psychiatric illness, whereas when Szasz was first writing psychoanalysis was more influential (see my article). But it's just as wrong to take a biomedical view now as it was then.

Where should first meeting of International Critical Mental Health Movement be held?

In a previous post I mentioned the idea of setting up an International Critical Mental Health Movement. Is there any momentum for this? I'm happy to help organise the first conference. Where should it be held?

Why did the balance between the genders for psychiatric detention switch?

Kate Millett, the feminist and survivor of mental health services, at a seminar organised by Anthony Stadlen that I attended last Sunday, said that more women than men are detained in psychiatric hospital. My thought, although I did not have the figures, was that in fact more men, particularly young men, are detained because of their violence.

It seems we were both right in a way. Up to 1994-5, when Kate Millett was surviving mental health services, more women than men were formally admitted under civil procedures using the Mental Health Act in the UK. After that time more men were detained (Audini and Lelliott, 2002). And it is particularly younger men where there is the imbalance (see figure). And once admitted they tend to stay in hospital longer, as the ratio of men to women resident in hospital at any one time is even higher (see table).

There does not seem to have been much comment about this switch. Women's disadvantaged social status is commonly seen as a factor generating mental health problems, but this doesn't explain the rise in men being detained. Maybe the emphasis over recent years on risk management and accountability is responsible. Ideas please and I'd also be interested in any references in the literature as I can't easily find them.

There should be concern if children are being prescribed medication as a quick fix.

As I mentioned in a previous post, reviewers have been critical of Richard Bentall's book Doctoring the mind for taking aim at child psychiatrists. They also suggest that he characterises psychologists as better educated and trained than psychiatrists to "understand people and the human experience and to provide healing therapy".

I'm not sure if this is the case, but I do know that psychiatrists are more likely to take a biomedical rather than biopsychological approach. I'm a member of both the Royal College of Psychiatrists and the British Psychological Society (see my talk Psychiatrists can have understanding too).

And, it's the British Psychological Society that has supported a call for a national review of the use of medication to treat children’s behavioural issues (see Treating children's behaviour). Peter Kinderman, Chair of the Division of Clinical Psychology, seems confident that psychiatry colleagues would be equally concerned if there is evidence of inappropriate use of drugs or medication.

I don't know how much these sort of reviews achieve. A previous technical report for MPs is a bit out of date now. Still Richard Bentall is concerned that there is inappropriate use of medication, whereas it seems Peter Kinderman would only be concerned if there was. Perhaps we do need an authorative view to let us know. And the reviewers criticised Richard for not providing a reference to back up his view, so he would at least then have one.

Facts about NAMI funding

In my previous post, I noted that reviewers of Richard Bentall's book Doctoring the mind, which I recommend on my Critical Psychiatry website book recommendations page, criticised him, amongst other reasons, for indicating that the National Alliance on Mental Illness (NAMI) is funded primarily by Big Pharma. According to an article in the NewYork Times, "drug makers from 2006 to 2008 contributed nearly $23 million to the alliance, about three-quarters of its donations".

NAMI now lists on a quarterly basis in its website registry all major corporate and foundation grants and contributions above $5,000. What NAMI emphasises is that, as a matter of policy, it does not endorse any specific treatment or service.

NAMI-Vermont has recently decided to diverge from national policy and no longer accept direct corporate contributions from pharmaceutical companies (see message to the membership). On their website, NAMI-Vermont Board President Ellen Vaut of South Burlington explains: “Though NAMI-Vermont has only received between three and seven percent of its total revenues from pharmaceutical companies in each of the past six years and none during the past fiscal year, we voted to dispel any concerns or public perception that our programs and/or organizational practices are influenced by pharmaceutical company money.”

I guess that the national organsiation will find it difficult to follow this lead because of the higher proportion of pharmaceutical funding. Still, quite why the reviewers of Richard's book criticise him for stating the truth is not clear. Perhaps the truth is "incendiary and divisive".

More heat in the debate about psychiatry

A review in Psychiatric Services is reluctant to recommend Richard Bentall's book Doctoring the Mind because it is said to be "incendiary and devisive". The reviewers are frightened that the book exaggerates issues for service users.

I'm not sure who's doing the exaggerating. Richard is said to suggest that there is a long-standing battle for supremacy between psychologists, "who are educated and trained to understand people and the human experience and to provide healing therapy", and psychiatrists, who are "indoctrinated with the medical model, have unwittingly carried Nazi-era notions of the genetic origins of psychosis into the present and are intent on pumping people full of as much useless, dangerous medicine as possible while simultaneously avoiding any conversation".

Richard is also criticised for saying that as many as 50% of psychotic patients would be better off without taking drugs, for claiming that the term "schizophrenia spectrum disorder" was introduced to get the results wanted in genetic research and for indicating that the National Alliance on Mental Illness is funded primarily by Big Pharma. Furthermore, he is said to provide no reference for his suggestion that child psychiatrists do not seem to be troubled by the as yet unknown long-term impact of psychotropic drugs on the developing brain and for his impression that medications are often prescribed by child psychiatrists without any serious attempt to understand or remedy the awful social circumstances in which psychologically disturbed children often live.

It's unfortunate that Richard's argument noted by the reviewers that "the case for a genetic cause of mental illness has been overstated by psychiatrists and that symptoms are much more the result of psychosocial stressors" including behaviour by families, gets lost in this polarisation of the debate. As I've indicated in a previous post, there seems to be some difficulty in having a calm discussion of these matters.

There were even some flames about my own Critical Psychiatry book (see another previous post), although I never managed to get a review in a mainstream psychiatric journal. Still there was a reasonably generous BMJ review. So maybe we should be grateful that books such as Richard's are at least being considered, even if dismissed, by mainstream psychiatry..

Is deep brain stimulation promising?

Deep brain stimulation (DBS) involves placing one or two thin wires into specific locations deep within the brain and then connecting the wires to a battery situated just beneath the skin. A recent article in the American Journal of Psychiatry reports on the  follow-up of 20 patients who received DBS for treatment-resistant depression.

Unfortunately two of these 20 patients died from suicide and one died from colonic cancer. As I said in my psychiatric update for Openmind, there is no clinical trial data about the effectiveness of DBS. I'm sure case reports, such as the latest article, will be used to justify continuing experimentation with it, however limited. I just wish that psychiatry could focus its efforts on providing more hope and effective treatment than DBS.