Don't be taken in by neuropsychoanalysis

Oh dear! - in an eletter in response to the article that I keep mentioning about paradigm shift in psychiatry (eg. see previous post), a past chair of the Faculty of Psychotherapy of the Royal College of Psychiatrists confirms he's been taken in by neuropsychoanalysis (see his editorial to which he refers in the eletter). He doesn't mention the case against neuropsychoanalysis (eg. Blass & Carmeli, 2007). I had my own views confirmed in person recently by attending a seminar by Rachel Blass organised by Anthony Stadlen.

Holmes is worried that psychodynamic psychotherapy has become "something of an endangered species", in a similar way to those proposing remedicalised psychiatry are worried that psychiatrists could become extinct (see previous post). I do understand what he is saying about the brain being dynamic rather than static but to believe that psychoanalysis has gained credibility because physical correlates of its "black-box postulates" can now be envisaged on a fMRI scan is neo-phrenological phantasy. Sorry, psychiatry does have to deal with the complexity and uncertainty of human relationships, however "vague and anodyne" Holmes may find this. I take a more pragmatic than postmodern view of psychiatry (see previous post), but still prefer my neo-Meyerian approach to his environmental neuroscience.

I think it's a shame to see the history of psychoanalysis and psychodynamic psychotherapy being given up to modern neuromania.

Clinical psychologists should take on more responsibility

Peter Kinderman and Sam Thompson, in an eletter in response to the article I mentioned in a previous post, suggest replacing psychiatrists with clinical psychologists. I'm not against this development and have even promoted clinical psychology, being a general member of the Division of Clinical Psychology of the British Psychological Society myself. I often tell the story of when I applied for clinical psychology training years ago that I was advised to go back and complete my medical training, which I had given up midstream, as I would then have more influence as a psychiatrist with my views about mental health services.

I would like clinical psychologists to take more responsibility as clinicians, even becoming responsible clinicians under the Mental Health Act (see previous post). They tend to retreat into becoming cognitive behavioural or some other psychological therapist, which is fine for those that want to do it, but mental health services are about more than psychological therapy (and some clinical psychologists don't even get that right eg. see another previous post). I support clinical psychology creating a career structure that pays them more for taking on more clinical responsibility.

How to mislead people with IAPT

Following up my previous post about IAPT (Improving Access to Psychological Therapies), I  have looked at the evaluation by Glenys Parry et al (2011) of the two demonstration sites for the programme. Although this report was published last year, it seems to have raised little interest. I can't even find it referenced on the IAPT website. Perhaps the IAPT programme doesn't want to take note of its findings.

I have been complaining that proponents of IAPT have been making claims for its effectiveness (including numbers of people moving off benefits) without comparative data. Glenys and colleague's study did have comparator sites for each demonstration site, although one of them obtained IAPT funding during the period of the evaluation. At four month follow up, the IAPT cohort and the comparison cohort had improved on all the patient-reported outcome measures with a similar degree of improvement. At eight months there were no statistically significant differences between the cohorts. 

By contrast, a research study comparing face-to-face (FTF) with over-the-telephone (OTT) delivery of low intensity cognitive behavioural therapy has been received enthusiastically by the IAPT programme. The study found that the two methods of delivery were just as effective and it was cheaper to use the phone. I suppose if IAPT doesn't really have much effect, then doing it over the phone isn't going to make it worse and it's better not to waste too much money on the programme.

I agree with Rosemary Rizq that this is a perversion of care (also see her paper -  IAPT, anxiety  and envy). IAPT is turning away from the realities of managing distressed people. Of course, this isn't new for mental health services, but it's particularly blatant with IAPT.

Turning neuroscientists into psychosocial psychiatrists

Interesting paper on Adolf Meyer, about whom I have published, linking his psychobiological ideas with critical psychiatry (eg. see article and edited book).

Having had an elite training in Zurich, Paris, London, Edinburgh, Berlin, and Vienna, Meyer emigrated from Switzerland to USA in 1892 and his first job was at the Illinois Eastern Hospital for the Insane at Kankakee as a pathologist. Disgusted at being seen as the 'ominous crow' who was summoned when a patient's death seemed imminent, he started visiting the wards with another physician discussing possible causes, diagnoses, and treatments at the bedside in the presence of the patient and staff. He fetched patients from the ward and escorted them to the staff residence where his colleagues were occupied with leisure activities and examined them at length. He said he gained the confidence of the patients, found out points overlooked in the ward and roused the interest of the physicians.

Thereafter he threw himself into the clinical field. When he moved to the Worcester Hospital for the Insane in Massachusetts, he standardized procedures for examination, history taking, and ongoing clinical observation; encouraged discussion and collaboration among the staff regarding cases; and integrated the data collected at the bedside with those observed at autopsy. He emulated Kraepelin, whom he had spent a summer on sabbatical with in 1896, by creating a catalogue of detailed case histories, handwritten on index cards.

As the director of the Pathological Institute established by the New York State Commission in Lunacy, he spent a week at every state asylum in New York, leading case conferences, teaching clinics, and ward rounds and demonstrating satisfactory examination and history taking procedures to the staff. He then became the first psychiatrist-in-chief at Johns Hopkins, gaining a reputation as the "Dean of American Psychiatry" before he retired in 1941.

Maybe modern neuroscientists can learn from Meyer's experience of changing from neuropathologist to focusing on the patient as a person. Trouble is too many are attracted to neuroscience as it avoids the need to be centred on patients.

IAPT propaganda truly impressive

The chief executive of the NHS in a foreword to a report on the 3 year review of Improving Access to Psychological Therapies (IAPT) (see my previous comments about this programme eg. Is mental illness curable by CBT?) thinks that the progress made has been "truly impressive". The Care Services minister emphasises that by the end of March 2012 "more than 1 million people have used the new services, recovery rates are in excess of 45% and 45,000 people have moved off benefits".

What isn't spelt out from the figures in the report is that only 60% of the people using the service complete a course of treatment. The percentage of people completing a course of treatment has decreased as the service has grown.

Rccovery is no longer defined in a report of this sort. Maybe we are just supposed to assume we all know what recovery means. To be considered cases at the start of treatment patients are required to score above 9 on the PHQ-9 and/or above 7 on the GAD-7 at assessment. They are said to have recovered if their score goes below these cut-off levels at the end of treatment. The higher patients’ initial PHQ-9 and GAD-7 scores are, the less likely they are, therefore, to recover. Recovery rates have steadily improved from 17% to over 45% over the first three years of the programme, which the report boldly states shows that services are becoming more effective. However, no data is given about whether there have been changes in baseline scores. Is the apparent increase in effectiveness due to milder cases being taken on?

Nor are the so-called economic gains controlled. How many of the 45,000 said to have moved off benefits would have done so without IAPT? Depression and anxiety get better with time without treatment. How many would have recovered without IAPT? The programme cannot make claims about effectiveness as it is not a controlled clinical trial.

This is political exploitation of psychological quackery. The programme now seems to be making a case for more funding to deal with its growing waiting list. Let's have a proper evaluation first.

Psychiatry in dissent

I have mentioned the book Psychiatry in dissent in a previous entry. Vivek Datta echoes this book in the title of  his eletter posted in response to the article about psychiatry beyond the current paradigm that I mentioned in the previous post. He makes clear that the motivation for a remedicalised psychiatry is the fear that psychiatrists will be made redundant in the current financial pressures on health systems (see another previous post).

He misses the point that medicine in general needs to be more patient-centred. Psychiatry could, and in theory should, lead the way on this. Patients should be suspect of a remedicalised psychiatry that clearly is primarily about the interests of psychiatrists, not patients.

Psychiatry beyond the current paradigm

Special article, with my name (see my book chapter on need for paradigm shift in psychiatry) as one of the 29 authors (first author Pat Bracken - see previous post), has been published in the British Journal of Psychiatry. An accompanying editorial by Arthur Kleinman, who I have mentioned in previous posts (eg. see entry), argues that academic psychiatry has been too biomedical. Perhaps it's easier for Kleinman to say this in a British journal, rather than in the USA where NIMH has dominated research (eg. see previous blog entry).

Congratulations to the BJPsych editor for encouraging this debate. I have said previously that I have been surprised by some of his comments from the editor's desk (eg. see post). He has made his position clearer in his current commentary. He seems worried that psychiatry may be no more than quackery. I'm not saying this to encourage a civil war in psychiatry, but his position could encourage neuromania (eg. see previous post). We need to move on from this.

Defining psychiatry

Recent article in The Lancet makes reference to an article that I commented on in a previous post. It suggests that in some ways psychiatry is a "speciality only beginning to define itself". 

Wonder why it's taken so long to do that! Perhaps the article is trying to dissociate itself from psychiatry's history (see my chapter in Mental health ethics). If it's following the previous article, this means believing that psychiatry needs to "realign itself as a key biomedical specialty at the heart of mental health".  That's always been the hope of psychiatry that it will find the biological basis of mental illness. And, what's that got to do with being a "branch of medicine that seeks to support some of the most marginalised members of society", which is what the article says psychiatry is? 

The latter characterisation of psychiatry may even raise questions. The article favourably references The Lancet's Global Mental Health Series, which I have commented on in a previous post. However, social factors, such as poverty and injustice, are not necessarily at the centre of the understanding of mental health problems in modern psychiatric practice. 

The article also mentions the  Schizophrenia Commission's recent report, but doesn't mention the Inquiry into the schizophrenia label (ISL) (see previous post).  Suman Fernando, one of the ISL co-ordinating group, has commented on the report. Psychiatry should be about treating people with mental health problems as persons, but this isn't always the case. A helpful feature of the Schizophrenia Commission's report is its recognition that too many people with a diagnosis of schizophrenia are in secure psychiatric provision.