Tuesday, March 29, 2016

Psychiatry is still biomedical, even if not "narrowly biomedical"

Simon Wessely in a Guardian article says that psychiatry does not recognise the narrow biomedical way in which it is sometimes portrayed. Despite what he says, some psychiatrists are narrowly biomedical (see extract from my book chapter). However, I do agree that most psychiatrists are generally more pragmatic.

It's interesting that Simon is an acolyte of Anthony Clare, whose book Psychiatry in dissent was written to create a consensus after the anti-psychiatry debate of the 1960-70s. Clare wanted to avoid psychiatrists having to adopt a model of mental illness (eg. see previous post). This led to the common claim, which I suspect Simon would support, that psychiatrists adopt a biopsychosocial approach to practice (eg. see another previous post).

The problem is that even though most psychiatrists are not narrowly biomedical, they are still biomedical (see my edited book Critical psychiatry). They generally believe that mental illness, at least major mental illness, such as schizophrenia and bipolar I disorder, is due to brain abnormalities, even though the evidence is against this conjecture. It's about time a president of the Royal College of Psychiatrists addressed this issue rather than avoiding and deflecting it, but I don't think Simon will.

Saturday, March 26, 2016

How do we know that IAPT outcomes are not just expectancy effects?

It's some time since I commented on IAPT - Improving Access to Psychological Therapies, now often called Wellbeing Services (eg. see previous post). I've just looked at a recent lecture from David Clark (see video). He's still making claims about outcomes based on lack of comparative data. How do we know that so-called recoveries in the IAPT programme are not due to the placebo effect or spontaneous improvement?

For example, in the lecture Clark makes much of the changes in Buckinghamshire Healthy Minds following a review of notes of the unrecovered patients to identify themes and recurrent patterns in the data (see powerpoint presentation). National figures are that 46% of people are said to recover and a further 15% improve. These are average figures and there is considerable variability by Clinical Commissioning Groups (CCGs). Buckinghamshire was below 50% and by telling staff to increase recovery rates to 65%, lo and behold they did! Isn't this just a Hawthorne effect?

There's a lot of money invested in IAPT so I'm sure Clark doesn't want to think about whether IAPT therapists are mere placebologists. There will always be a problem with assessing the effectiveness of psychotherapy because of the issue of the adequacy of control groups (eg. see my BMJ letter). Psychotherapy trials cannot be conducted double-blind because subjects always know whether they have received the therapy under investigation or a control intervention.

Saturday, March 05, 2016

My baby, psychosis and me

Much of the focus on the two documentaries in the recent BBC In the Mind series has been on the Stephen Fry programme The not so secret life of the manic depressive: Ten years on (see previous post).  The other documentary My baby, psychosis and me was a realistic portrayal of the treatment of two women with puerperal psychosis in a specialised mother and baby unit. One woman, Hannah, made a suicide attempt and was treated with ECT, although the actual treatment was not shown. The other woman, Jenny, was transferred to an intensive care unit, but the treatment there was again not shown. Even the husband was advised not to visit her there.

I have praised the In the Mind series (see previous post as mentioned) for showing what is happening in mental health services. It is important though that the 'sharp end' of psychiatry is not separated off and made invisible.

Definition of sociopsychobiological model of mental illness

I deliberately used the term "sociopsychobiological" in my previous post. This was to try and reverse the eclectic understanding of the biopsychosocial model of mental illness. I do agree with the biopsychosocial model of George Engel (eg. see previous post). But psychiatrists often claim they are biopsychosocial when in fact they are merely supporting a weaker form of the biomedical model (see extract from my last chapter of Critical Psychiatry (2006)).

Promoting the sociopsychobiological approach to mental health

I have been thinking about the motivation of well over 1000 signatories of an open letter to the Director General of the BBC about its coverage of issues on mental health (see previous post). Essentially the complaint is that there is insufficient focus on a sociopsychobiological rather than a biomedical understanding of mental illness. As the signatories to the letter note, this is not primarily a matter of disciplinary conflict. Psychiatrists, such as myself, promote a sociopsychobiological approach. However, the majority of the signatories to the letter are from clinical psychology. I think their anger must express frustration about the dominance of the biomedical model in modern practice. Psychiatry, rather than clinical psychology, may well be the more powerful discipline in this ideological dispute.

Where does this disciplinary power come from? Part of it may be related to the respective roles of psychiatrists and clinical psychologists under the Mental Health Act. Detention under the Mental Health Act requires two medical recommendations. Although clinical psychologists can be Responsible Clinicians, in practice this is not common (see previous post). As I understand it, the British Psychological Society is not prepared to intervene on the issue of whether clinical psychologists who undertake the role of Responsible Clinicians should be paid more like psychiatrists. Perhaps it should to help even out any power disparity.