Saturday, August 04, 2012

Has the psychopharmacological revolution come to an end?

I don't know what to make of Peter Tyrer, the editor of the British Journal of Psychiatry, saying in his latest 'From the Editor's desk' that "The time has come to call an end to the psychopharmacological revolution of 1952". I pointed out in a previous post that he seemed to be agreeing with me about so-called 'remedicalised psychiatry' (eg. see another previous post). But surely this isn't an indication that critical psychiatry's time has come, is it?!

Actually I don't think the psychopharmacological revolution is over. Biomedical psychiatry continues to reign supreme. For example, the British Journal of Psychiatry still publishes uncritical neuroscience editorials (see previous post).

What has inspired Peter Tyrer is an
editorial suggesting that the risk-benefit ratio of antipsychotics needs to be re-evaluated to facilitate informed choice and decision-making. It even suggests reappraising whether anti-psychotic medication must always be first line of treatment for people with psychosis. 

I'm sure proposals like this will be watered down. For example, I have already commented on a paper (see
previous post) that the editorial references that its authors say found "a smaller antipsychotic drug-placebo difference than we had intuitively expected". Those authors went on to publish a subsequent paper which they interpreted as showing that psychiatric drugs were just as effective as other medical drugs. They even seemed to label as anti-psychiatry attempts to interpret trial data in a critical way.

I welcome any indication that mainstream psychiatry is open to critical approaches, but I think we just need to be aware of the power of the biomedical myth (see previous post). Let's see where Peter Tyrer leads the British Journal of Psychiatry in what I guess must be coming up to his retirement as editor.


Sam Barnett-Cormack said...

My last therapist (darn short courses), when agreeing it was worth seeing a psychiatrist to see if my depression should be rediagnosed as bipolar II (it was, in the end), said I should try to see a therapeutically-oriented psychiatrist, rather than a pharmacologically-oriented one. I didn't end up with choice, but the young psych I saw seemed to be a bit of a balance. I am encouraged by the fact the both sorts apparently exist, though saddened that the therapist felt it was important to draw the distinction. She thought that, if I did have bipolar, it was worth focussing on mindfulness and such, not jumping straight into new drugs. The rediagnosing psychiatrist thought this was sensible as well, which I thought was good. He was a junior of some sort, so I guess training doesn't drum a pharmacological approach into them all.

Altostrata said...

"But this is all we've got" is an argument that seems to outweigh "the adverse effects are greater than the benefits," thereby demonstrating that when all you've got is a hammer, you are determined to pound on something.

(By the way, Sam Barnett-Cormack, bipolar II as a condition may not actually exist; welcome to the hall of mirrors of psychiatric diagnosis.)

Sam Barnett-Cormack said...

This is why I don't think of psychiatric diagnosis the same as I would think of, say, my diagnosis of narcolepsy (obtained through objective test results, with a reasonably well understood aetiology) or of asthma (actually, don't know how they do that, I was about 1 or 2 when it happened).

I see it as a description of past experience combined with a broadly statistical understanding of what that means for the future - what treatment, be it pharmacological or not, will be most likely to be effective; what is likely in terms of future development of my symptoms. The realisation that there's a descriptive term for odd episodes in my history (hypomania), that it fits a recognised pattern, is reassuring. The fact that it helps me and doctors, and mental health professionals, have an idea of how to approach the management of my symptoms, now and in the future, is a positive.

Saying that any given psych diagnosis does or doesn't exist is, to my mind, not productive. They are all synthetic, it's all models, not reality. The question instead is whether the diagnosis, the label, is helpful or not.

Amusingly, a neurologist thinks it might be worth trying valproate, but not to help with psych symptoms - to help manage migraines. As it is, I am on an antidepressant, which (with hindsight) probably did cause some rapid cycling - but it serves at least two purposes in my treatment, anyway, helping with low mood and with cataplexy (as part of narcolepsy). It's amazing how so many medications are effective for multiple things.

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