Choosing the orthodox path in psychiatry

The latest Mad in America podcast includes an interview with Sir Robin Murray, who I have mentioned in previous posts (eg. Schizophrenia is not a neurodevelopment disease). Like him, I wanted to be a psychiatrist through reading Freud as a teenager. Similarly, we both got caught up in the 'anti-psychiatry' conflict and were interested in R.D. Laing. Murray opted for the orthodox view, whereas I gave up my medical training for 8 years and then returned to complete it to become a critical psychiatrist. I ended up having a different view of schizophrenia from him (eg. see my BMJ letter, although there is an error in the letter referring to Lyn Pilowsky as “he”). And, I have spent my working life as a consultant as a full-time clinician, unlike Murray, who was an academic, only working part-time clinically.

Like Anthony Clare (eg. see previous post), Robin Murray took his position partly as a reaction to their understanding of Laing as blaming families for causing schizophrenia. This is actually a misunderstanding of his view, about which Laing complained repeatedly (eg. see extract from my book chapter).

As I said in a post on my personal blog, it's interesting to see Murray questioning the call he made when he started in psychiatry. But he hasn't completely given up his belief in the brain hypothesis of mental illness. For example, in the interview, he talks about dopamine being involved as the "final common pathway for psychosis".

Like him, I'm not encouraging psychiatrists "slagging each other off", but there is a genuine issue about the conceptual nature of mental illness. It's difficult for people, like Robin Murray, to accept that an organic basis is insufficient for understanding mental activity. He's taken this step of faith and to retract it and realise he's made a mistake would be like giving up a religion (see previous post). I'm not necessarily encouraging him to be a philosopher, but he does need to accept that there is a mind-body problem. Organisms as a whole are constantly maintaining their internal environment and cannot be explained mechanically (see another previous post). The activities of the mind cannot be derived completely from the laws of the physical world.

And, I do not want to be misunderstood. Of course I know that minds are enabled by brains. But this does not mean that minds are reducible to brains. To use a quote from Adolf Meyer that I have used before, "person disorders show through the brain but not necessarily in the brain" [Meyer's emphasis].

Is psychiatric diagnosis dead?

The title of the 2018 medical student essay prize established by the Faculty of General Adult and Community Psychiatry of the Royal College of Psychiatrists is 'Is diagnosis dead? Discuss.' It's good to see a Faculty of the College encouraging this debate.

Of course the hope of finding a neurobiological basis for psychiatric diagnosis should be dead, particularly following the failure of DSM-5 (eg. see previous post), but it isn't because the wish to find a physicalist basis for mental illness will never go away. And, psychiatric assessment has never just been about diagnosis and includes formulation (eg. see another previous post), which may well be more important than a single-word diagnosis (eg. see yet another previous post).

Organism and mechanism

The philosophy of biology can contribute to critical psychiatry. I came across Daniel Nicholson's PhD thesis on 'Organism and Mechanism' online.  He quotes from Francis Crick, who said that "The ultimate aim of the modern movement in biology is to explain all of biology in terms of physics and chemistry” (p.9) As Nicholson points out, it's often assumed, as in Jacques Monod's book Chance and Necessity, that "organisms are machines, albeit ones cobbled together by natural selection" (p.13).

However, organisms have a capacity for self-regulation. To use JS Haldane's definition of Claude Bernard's principle, "all physiological activities have as their ultimate objective the preservation of the organism's internal environment. ... [T]he continuous dynamic coordination and regulation of the internal environment ... is responsible for the distinctiveness and irreducibility of living beings" (p. 56). Organisms, unlike machines, are self-organising and self-reproducing. As Nicholson says, “No  machine  is  made  of  parts  that  are constantly  replaced  by  the  machine  itself,  yet  this  is  precisely  what  occurs  in  an organism” (p. 125). Mechanistic understanding of life should therefore be abandoned.

This fundamental difference between organisms and machines applies across the spectrum of the complexity of life, from human mind to blade of grass, to use the quote from Kant about the absurdity of hoping for a Newton of the genesis of but a blade of grass (p.33). Critical psychiatry’s challenge to the technological or mechanical paradigm (eg. see previous post) is no different from that in biology of opposing mechanicism by organicism.

The gap in causality in neuroscience

In a JAMA Psychiatry viewpoint, Amit Etkin suggests that brain neuroimaging risks creating ‘Just-So Stories', internally consistent explanations that have no basis in fact. Nonetheless, he still seems to believe that direct experimental manipulations can overcome this challenge.

The problem is more fundamental. Generating massive amounts of data from neuroimaging of the brain, which is only looking at part of a person, misses the point that whole persons have intrinsic purpose. People cannot be investigated as machines in the same way that their brains can be when they are considered in isolation. No wonder there’s a gap in neuroscientific explanation.

Is cognitive remediation therapy in schizophrenia merely placebo amplification?

I went to an open-minded talk this lunchtime by Professor Dame Til Wykes about therapy for cognition in schizophrenia. She was prepared to consider the negative evidence for effectiveness of treatment, although she was clear that NICE should include cognitive remediation therapy (CRT) as an evidenced-based treatment in its schizophrenia guideline, which it doesn't do at present, as CRT improves cognition and reduces disability in schizophrenia (eg. Wykes et al, 2011).

Til Wykes was honest about her interest in CIRCuiTS (Computerised Interactive Remediation of Cognition - a Training for Schizophrenia), a web-based computerised CRT, which doesn't seem to be freely available on the internet. What worries me is that the cognition therapy industry may be based on an artefact. Let me explain.

If clinical trials are not double-blind, positive findings may merely be a self-fullfilling placebo amplification. The hypothesis that unblinding in clinical trials for antidepressants produces artifactual placebo amplification is controversial (e.g. see previous post). This should be less controversial for psychological therapies, such as CRT, as trials cannot be conducted double-blind (see eg. another previous post). At the most, an attempt may be made to single-blind the assessors, but disclosures by patients do occur, even if participants are told not to reveal their allocation, thereby breaking the blind. Such bias could explain the small-to-moderate effects found in meta-analyses of cognitive remediation.

Psychotherapy and critical psychiatry need to cooperate

I've posted verbatim a copy of the talk I gave recently to the Council for Psychoanalysis and Jungian Analysis, a college of the UK Council for Psychotherapy (see powerpoint slides). Part of the aim of the talk was to challenge the rhetoric about Improving Access to Psychological Therapies (IAPT), particularly from its two main protagonists, David Clark and Richard Layard (as I have done in previous posts, eg. Wider measures of IAPT outcomes needed). Saying that IAPT is a 'marvellous treatment' has to stop. Unrealistic claims about the effectiveness of psychotherapy are a 'perversion of care', to use Rosemary Rizq’s phrase (see previous post).

Critical psychiatry and psychotherapy need to work together to change the dominant technological paradigm in modern mental health services (see previous post). This technological paradigm includes psychological therapy if it is applied in a mechanistic way. As in the position statement from the Division of Clinical Psychology of the British Psychological Society, we need to give up the disease model of mental disorder (see another previous post).

The foundations of critical psychiatry

I’ve mentioned before that the PhD I’ve just started (see previous post) is on ‘The foundations of critical psychiatry’. Critical psychiatry is not new. There are at least three points in the past when its conceptual position has been promoted. These associations are not always well appreciated.

(1) Ernst Von Feuchtersleben (1847) Principles of medical psychology (original German edition, 1845) (eg. see previous post) could be seen as the first attempt to provide an interpretive rather than biomedical account of mental illness. Feuchtersleben has been seen as a 'forgotten psychiatrist' (see article). Following Kant, he recognised that the mind-brain problem is an "enigma, which can never be solved" (p. 16). Despite the success of his book, he was "swimming against the tide" and his "psychosomatic viewpoint made no impact in the second half of the 19th century" (Lesky, 1976; quotes from pp. 154 & 156).

(2) Adolf Meyer's (1866-1950) Psychobiology (eg. see previous post) has the same conceptual understanding of mental illness as critical psychiatry. The problem is that this is not always apparent because of Meyer's tendency to compromise. As I said in my paper, the principles of critical psychiatry "can only be reestablished by a challenge to biomedicine that accepts, as did Meyer, the inherent uncertainty of medicine and psychiatry".

(3) George Engel's (1977) biopsychosocial model (eg. see previous post) was a critique of biomedical dogmatism in the same way as critical psychiatry and proposed a "new medical model". The trouble is that it has tended to be interpreted in an eclectic way and its impact not fully realised (eg. see my review of Nassir Ghaemi's (2009) book The rise and fall of the biopsychosocial model).

Critical psychiatry needs to make more of these and other links with the past. Its conceptual understanding is integral to the history of psychiatry.

Institutional racism and reform of the Mental Health Act

The current review of the Mental Health Act (see previous post) needs to take account of the recently published book Institutional racism in psychiatry and clinical psychology: Race matters in mental health by Suman Fernando. Part of the concern leading to the review is that "People from black and minority ethnic populations are disproportionately affected [by the Mental Health Act], with black people in particular being almost 4 times more likely than white people to be detained" (see news story). The purpose of the review is to understand the cause of this and other issues (see terms of reference). I think it is also important that the government deals with the issue of racism in society in general and not does not deflect it just onto mental health.

Table 5.1 in Suman's book summarises racial inequalities in the UK as far as mental health services are concerned:-

The marginality and social exclusion experienced by minority ethnic groups are likely to be significant factors in this imbalance. Black compared to white patients are diagnosed more frequently as schizophrenic by both black and white clinicians - although to a lesser extent by the former - even when clear-cut diagnostic criteria are presented (Loring & Powell, 1988). African American men receive higher doses of antipsychotic medication than white and are more likely to be described as hostile and violent (Metzl, 2010). It's difficult to think the stereotype of "Big, black and dangerous" is not a factor in disproportionate detention under the Mental Health Act (see blog by Nuwan Dissanayaka).

Racism within psychiatry needs to be addressed (Sashidharan, 2001). There is of course a history of attempting to deal with these problems, which the current review cannot ignore, particularly the report Inside Outside. People who use mental health services should expect services to be non-discriminatory. What we need is a national approach aimed at reducing and eliminating ethnic inequalities in mental health service user experience and outcome, and this includes treatment under the Mental Health Act.

Flaming brains

I have mentioned Carmine Pariante in a previous post. Yesterday I went to a talk he gave in the Cambridge Department of Psychiatry on 'Depression and inflammation in the 21st century'. He has reflected in a recent article on his 20 years research in this field.

It does seem a bit nonsensical to talk about depression as an inflammatory disorder, like rheumatoid arthritis. For a start, any apparent increases in proinflammatory cytokines are generally not of the same order as in autoimmune or inflammatory diseases. I'm not saying that an array of inflammatory mediators have not been found to be higher in depressed patients, although this association can at least be reduced by eliminating confounders (O'Connor et al, 2009). Increased inflammation is also associated with psychosocial stress suggesting that any association is likely to be nonspecific rather than specific in the causality of depression.

Reflections on critical psychiatry

Google books has made freely available the chapter 'Reflections on critical psychiatry' by Pat Bracken and Phil Thomas in the new book Routledge international handbook of critical mental health, edited by Bruce Cohen. As Richard Hassall says (see tweet), it provides a "useful summary of the critical psychiatry stance".

What I like is the way the chapter describes the five dimensions of the critical psychiatry project: ontological, epistemological, empirical/therapeutic, ethical and political. I also like the way the authors say that critical psychiatry challenges the technological paradigm rather than just the biomedical paradigm, recognising that psychological, not just biological,  understanding can also be mechanistic. As they say, "Reductionism and positivism have dominated mental health research". As they go on to conclude, critical psychiatry is about "deconstructing the authority of [modern] ... psychiatry".

Is it better to manage without antidepressants?

A Guardian article is headlined to ask why we shame people for taking antidepressants. I don't think this is what those who are critical of the evidence for the effectiveness of antidepressants are doing. All that is being asked is why there is such a small difference in clinical trials between active and placebo treatment and whether this could be an artefact (eg. see previous post).

The paper that led to the Guardian article (Hieronymus et al published online 25 July 2017) argues against the theory that antidepressants outperform placebo solely or largely because of their side effects. I'm not sure if this is precisely the reason why the argument is made that antidepressants may be merely amplified placebos (see another previous post). There may be other ways in which patients can become unblinded in clinical trials. True, the evidence I summarised from Irving Kirsch's book in that post focuses on side-effects. And, it is also true that there is an expectation that side-effects may be the most common way of unblinding in clinical trials and therefore that the more side-effects that patients experience on the active drug the more they improve in clinical trials. As far as I know, the paper, Barbui et al, referred to in my previous post was never published and I'm not sure why.

Furthermore before Hieronymus et al (2017), there was a BJPsych paper (Barth et al 2016) that also did not find an association between adverse events and efficacy. These authors concluded, "Our results do not support, but also do not unequivocally disprove, the hypothesis that adverse events lead to an overestimation of the effect of SSRIs over placebo". I would agree with this conclusion. And, Hieronymus et al (2017) also admit that their "study does not allow any firm conclusions".

In fact, for citalopram, they found that the rating on the Hamilton Depression Rating Scale (HDRS) for those that reported adverse events was not statistically significant from placebo. This may be why they focus in the paper on the depression rating within HDRS, which did find a significant difference. For the paroxetine trials, the association with adverse events goes in the other direction, although, for some reason which I don't understand, in the paper the authors suggest this observation for paroxetine (do they mean citalopram?) "could be interpreted as support for side effects exerting some impact on the response to the drug through unblinding".

Anyway, I agree papers of this sort do not seem to completely corroborate the amplified placebo hypothesis. But, as Barth et al (2016) point out, reporting of side-effects in clinical trials is extremely variable. Reporting of side-effects may, therefore, not be the best proxy measure of unblinding. We do need studies that systematically check for unblinding (Even et al 2000). There is also the issue about whether depressed people may do better over the long-term without medication (see previous post). I am afraid this debate is likely to keep running and can't be closed down by the Guardian article.

Pledge support for changes in understanding of psychosis

The International Society for Psychological and Social Approaches to Psychosis (ISPS) has produced a 'Liverpool Declaration' before its upcoming 20th International Congress. As the declaration says, psychosis needs to be understood as largely a response to life experiences. For too long, social and psychological experiences have been "viewed as simply ‘triggering’ underlying disease processes, a perspective no longer supported by research". Social and cultural psychiatry should not merely be a diluted form of biomedical psychiatry (see previous post).

Differences within critical psychiatry

I have uploaded a video of my talk 'Critical psychiatry: Its definition and differences' given at the AAPP conference in San Diego in May this year. Critical psychiatrists don't always agree. I suggested in the talk that there are three main areas of disagreement, although these issues may not be totally distinct:-

1. Whether psychiatry should be seen as a medical discipline. Where there is agreement is that psychiatry is different from medicine. The disagreement arises because of how much is made of that difference. Some want to go as far as saying that psychiatry should be non-medical. Others emphasise that medicine covers both physical and mental aspects. The reality is that many patients do complain of physical symptoms which have psychosocial origins and any view on this issue has to take note of psychosomatic medicine.
2. Whether the Mental Health Act should be abolished. Where there is agreement is that critical psychiatry emphasises the rights of people with mental health problems. This emphasis leads some to argue for abolishing all forced treatment and others to accept that detention can be justified by the loss of mental capacity in mental illness. All would accept that psychiatric abuse is not justified and coercion needs to be minimised.
3. Whether it is suitable to see mental disorder as illness and disease. Where there is agreement is that all identify there is a problem with seeing mental disorder as brain disease. But the questions are: should it be seen as illness; and is psychiatric diagnosis valid? Some conclude that mental disorder is not illness and alternatives are required to psychiatric diagnosis and others accept that psychological dysfunction can be understood as illness and that diagnostic concepts should be understood for what they are. Diagnoses should not be reified, and seen as ‘things’. Instead they are merely idealised, hypothetical constructs and if they have any value should be understood as such.

In summary, the essential critical psychiatry position of challenging the claim that mental disorders have been established to be brain diseases can lead to some differing perspectives within critical psychiatry. As I have said several times, critical psychiatry is a 'broad church', but it does coalesce round the view that the biomedical hypothesis that functional mental illness is due to brain disease is based on faith, desire and wish fulfilment rather than logic (eg. see previous post).


(with thanks to Kermit Cole for making the video)

Why fetishise outcome measurement in IAPT?

Jay Watts has a chapter 'IAPT and the ideal image' in The future of psychological therapy in which she describes the chasm between the image and actuality of Improving Access to Psychological Therapies (IAPT). She concludes that "IAPT operates in a virtuality focussing on performativity and surveillance rather than real encounters between clinician and patient".

In particular, she describes the "pernicious pressure on IAPT workers to gain outcome measures for each session". I've mentioned before talks given by David Clark (eg. see previous post) in which he makes much of the fact that IAPT is collecting this data. As Jay says, "During training, workers are sold into the excitement of producing the largest database on wellbeing in history". It would be nice to know what those promoting IAPT think all this effort has achieved, because I can't see much gain. Data accumulates on a monthly basis without much being done to it (see Reports from IAPT). In fact, this process may well be hindering IAPT from really helping people.

I've mentioned before (see previous post), the perversion of care, as Rosemary Rizq called it, of turning away from the realities of managing distressed people. As Rizq says, society has traditionally allocated to mental health practitioners an "unconscious anxiety-containing function". Mental health practitioners experience enormous emotional difficulties in working with mentally distressed and disordered patients. Focusing on outcomes, as Jay says, "stops pain being listened to and the meaning of symptoms heard".

Wider measures of IAPT outcomes needed

Oliver James has posted references on his website, which he mentioned in his talk given at the Limbus Critical Psychotherapy conference on 'Challenging the Cognitive Behavioural Therapies: The Overselling of CBT's Evidence Base'. The essential point he was making is that CBT outcomes over the long-term may not be as good as they appear in clinical trials over the short-term.

I've mentioned before the overstatement about the effectiveness of the Improving Access to Psychological Therapies (IAPT) programme (eg. How do we know that IAPT outcomes are not just due to expectancy effects? and Need to be realistic about value and effectiveness of psychological therapy). As pointed out by Hepgul et at (2015), even if recovery rates for IAPT are 50%, this means "approximately half of patients are not meeting standard definitions of recovery at the end of their treatments". As they go on to say, "Furthermore, it is likely that a substantial proportion of those who do recover may go on to relapse in due course".

One of James' references is Weston et al (2004). This article does not argue that brief, focal treatment cannot produce apparent powerful results over the short-term but recognises that relapse rates are high. Rates can be as high as 85% over 10-15 years (Mueller et al, 1999). The reality is that many psychiatric disorders are characterised by multiple periods of remission and relapse or symptom exacerbation over many years. Some people do seek further treatment after a course of IAPT or other psychological therapy. Weston et al (2004) found that roughly half of the patients in the active condition of clinical trials of empirical supported therapy for depression, panic and generalised anxiety had sought further treatment by 2 years post-treatment. Of those treated for depression, only third of those who improved remained so after two years. The figure for panic was slightly better at roughly half. Controlled data over the longer term is rare but one such study, the NIMH Treatment of Collaborative Depression Research program (Shea et al, 1992), found that 78-88% of those who entered treatment completely relapsed or sought further treatment by 18 months and that this was a no better an outcome than the controls. Uncontrolled data does suggest that the effects of psychotherapy are longer lasting at 6 months post-randomisation, at least for depression, although effects significantly decrease with longer follow-up periods (Karyotaki et al, 2016).

Clinical improvement is not the same as social recovery and there may be residual symptoms even for those classed as recovered with IAPT. In essence, we don't know how many of the so-called recoveries in the IAPT programme are due to the placebo effect or spontaneous improvement. People tend to get better anyway over the shorter term whether they go for IAPT or not. Saying that IAPT is a 'marvellous treatment', and misleading people about how effective it is, has to stop. This is no different from misleading people about how effective medication is (see previous post). I'm not saying that short-term therapy can't be helpful, but we do need to be honest about the limits of therapy. It may be tempting to overstate the case to obtain political funding for services but it's not scientific.

Critical psychiatry is part of medicine

I mentioned on my personal blog (see post) that I am going back to Cambridge University in the autumn to do a PhD in Psychology on "The foundations of critical psychiatry". I'm glad I did a psychology degree when I was younger, otherwise I wouldn't have been able to do this. I have been accepted by the Psychology department, whereas Psychiatry and Clinical Medicine wouldn't have been interested.

It's a pity that mainstream psychiatry sees critical psychiatry as too threatening. I suppose it's understandable when it's questioning the biomedical faith that mental illness is due to brain disease (see previous post). But psychiatry and medicine should be patient-centred (see another previous post).

These differences shouldn't divorce psychiatry from medicine, although some critical practitioners have suggested that mental health services should be non-medical (eg. see previous post). I don't agree with them, as critical psychiatry is part of medicine (see another previous post). Psychiatry should be broad and open enough to welcome my PhD.

Overemphasis on disease entities in psychosis

I have mentioned in a previous post that Jim van Os wants to abandon the term 'schizophrenia'. In a follow up article, Guloksuz and he essentially argue for a unitary model of psychosis.

However, in a way, this is missing the point. They acknowledge the "lack of diagnostic markers in psychiatry" but seem to express surprise that this "impedes an objective classification". They seem to think it was a good idea that RDoC (eg. see previous post) was set up to create a so-called objective classification, whereas what they need to do is recognise that classification is inevitable subjective, at least to some extent (eg. see my article).

They still think that there is a likelihood of "distinct diseases" in the broad psychosis spectrum disorder. This is where they are wrong and they need to give up the wish to discover such entities (eg. see previous post), whether it's schizophrenia or a more unitary psychosis.

Giving up the disease model of mental disorder

I mentioned in my Lancet Psychiatry letter that doctors, because of their medical training, have difficulty in giving up the disease model of mental disorder. Yet this is what the Division of Clinical Psychology (DCP) would encourage them to do (see position statement). This is not a controversial argument. It fits with the WHO QualityRights initiative (see recent Lancet Psychiatry article). As the article says, "A movement to profoundly transform the way mental health care is delivered and to change attitudes towards people with psychosocial, intellectual, and cognitive disabilities is gaining momentum globally".

DCP does not totally dismiss the value of psychiatric classification if only because "these systems provide seemingly ‘tangible’ entities for use in administrative, benefits, and insurance systems". But it does argue for "an approach that is multi-factorial, contextualises distress and behaviour, and acknowledges the complexity of the interactions involved in all human experience". Read how balanced the perspective is. It is relevant to the teaching of doctors as well as clinical psychologists and others working in the mental health field.

Rights-based reform of the Mental Health Act

At the recent General Election, the Conservative Party said that it would replace the 1983 Mental Health Act in England and Wales with new laws tackling "unnecessary detention" (see BBC News story). Their manifesto said:-

We will ... reform outdated laws to ensure that those with mental illness are treated fairly and employers fulfill their responsibilities effectively.

The current Mental Health Act does not operate as it should: if you are put on a community treatment order it is very difficult to be discharged; sectioning is too often used to detain rather than treat; families’ information about their loved ones is severely curtailed – parents can be the last to learn that their son or daughter has been sectioned. So we will introduce the first new Mental Health Bill for thirty-five years, putting parity of esteem at the heart of treatment.

Part of the motivation for this change was probably coming from the mental health charities, which formed a Mental Health Policy Group to produce A Manifesto for Better Mental Health. One of these charities, Mind, had a 2017 election manifesto, which had 6 points, of which one was:-

Change outdated and discriminatory legislation like the Mental Health Act and the definition of disability to ensure everyone with mental health problems gets support and respect.

Of course the 1983 Mental Health Act was amended in 2007 to introduce community treatment orders, amongst other changes. There was a several year debate/protest before this amendment and I had a Mental Health Policy website at the time (now essentially defunct). It was the reform of the Mental Health Act then that led to the formation of the Critical Psychiatry Network in 1999. I think changing the Mental Health Act again in the way suggested by the Conservative party is less likely to lead to as much controversy as previously.

If the Conservative Party has enough support to manage to get replacing the current Mental Health Act into a Queen's Speech, the Mental Health Bill needs to take account of the Convention on the Rights of Persons with Disabilities (CRPD). This is what the UN Special Rapporteur on the right to health has proposed (see previous post) and the rest of this blog uses quotes or amended quotes from his report.

The disability framework should radically reduce medical coercion. It starts from the principle that a disability shall in no case justify a deprivation of liberty. There is shared agreement about the unacceptably high prevalence of human rights violations within mental health settings and that change is necessary. Persons with psychosocial disabilities are generally falsely viewed as dangerous, despite commonly being victims rather than perpetrators of violence.

Change has taken place over recent years to challenge the disability stereotype, as many can live independently when empowered through appropriate legal protection and support. There are limitations to focusing on individual pathology.

Similarly, failure to secure the right to health and other freedoms is a primary driver of coercion and confinement in mental health. Mental health problems and disability are not exactly the same and this does need to be teased out in any new Mental Health Bill. In fact, it is still not clear how non-consensual treatment in mental health should be taken forward following the Convention on the Rights of Persons with Disabilities. This should be a government priority, even for a minority government. It needs to make use of appropriate indicators and benchmarks to monitor progress in respect of reducing medical coercion. The active involvement of mental health professionals in the shift towards rights-compliant mental health services is a crucial element for its success.

Mental health as a global health priority

I have mentioned previously (see post) the value of implicating mental health as one of the United Nations sustainable development goals. As pointed out by the UN Special Rapporteur (see previous post), The 2030 Agenda for Sustainable Development includes Goal 3, which "seeks to ensure healthy lives and promote well-being at all ages", and target 3.4, which "includes the promotion of mental health and well-being in reducing mortality from non-communicable diseases". As he also points out, this 2030 Agenda and other influences from WHO, the Movement for Global Mental Health and the World Bank mean that "mental health is emerging at the international level as a human development imperative".

I have tweeted relevant quotes or amended quotes for global mental health from the Special Rapporteur's report (see my responses to my tweet with the link to the report). I'll try and condense them in this blog.

The report emphasises the importance of parity with physical health in national policies and budgets or in medical education and practice, but suggests nowhere in the world has this been achieved. It does not want to forget that the political abuse of psychiatry remains an issue of serious concern in some countries (see previous post).

I have also previously mentioned the critique of The Movement for Global Mental Health by critical psychiatry (see post). The Special Rapporteur agrees with this critique. As he points out, it's all very well to note that millions of people round the world are grossly underserved by mental health services, but quoting alarming statistics about the scale and economic burden of "mental disorders" must not root the global mental health crisis within a biomedical model, as this approach is too narrow to be proactive and responsive. The scaling-up of mental health care must not involve the scaling-up of inappropriate care. He prefers to talk about actions to "scale across", by which he means embracing "a broad package of integrated and coordinated services for promotion, prevention, treatment, rehabilitation, care and recovery", including "mental health services integrated into primary and general health care, which support early identification and intervention, with services designed to support a diverse community". Furthermore:-

Evidence-based psychosocial interventions and trained community health workers to deliver them must be enhanced. Services must support the rights of people with intellectual, cognitive and psychosocial disabilities and with autism to live independently and be included in the community, rather than being segregated in inappropriate care facilities.

As he does in the rest of the report, the Special Rapporteur is encouraging all countries, including lower and middle-income countries, to develop rights-based mental health care.

Critical psychiatry position adopted by United Nations

The United Nations Special Rapporteur on the right to health, Dainius Pūras, has produced a report which focuses on the right of everyone to mental health (see press release). It is the result of extensive consultations among a wide range of stakeholders, including representatives of the disability community and users and former users of mental health services.

It essentially argues for a rights-based mental health service, as has been recognised by the World Health Organisation, to promote and protect the mental health of entire populations. The Special Rapporteur believes that the crisis in mental health should not be managed as a crisis of individual conditions but as a crisis of social obstacles which hinders individual rights. He calls for mental health leadership to confront the global burden of obstacles and embed right-based mental health innovation in public policy.

I have been merrily tweeting quotes or mostly amended quotes from the report, as it very much comes from a critical psychiatry perspective. For example:-

Mental health services governed by reductionist biomedical paradigm that has contributed to exclusion, neglect, coercion and abuse of people 10 Jun 2017, 10:59

Preoccupation with biomedical interventions, including psychotropic medications and non-consensual measures, is no longer defensible 10 Jun 2017, 11:06

Reductive biomedical approaches that do not adequately address context and relationships cannot be considered compliant with right to health 11 Jun 2017, 18:10

While biomedical component important, its dominance has become counter-productive, disempowering rights and reinforcing stigma and exclusion 11 Jun 2017, 18:11

Medicine, in particular mental health, is to a large extent a social science and this understanding should be used to guide its practice 11 Jun 2017, 18:03

Mental health policies should address the “power imbalance” rather than “chemical imbalance” 11 Jun 2017, 22:43

The Special Rapporteur proposes, as would critical psychiatry, that there are three major obstacles to a rights-based mental health for all: (1) dominance of the biomedical model (2) power asymmetries and (3) the biased use of evidence.

As far as the dominance of the biomedical model is concerned, he concludes that:-

We have been sold a myth that the best solutions for addressing mental health challenges are medications and other biomedical interventions 10 Jun 2017, 11:40

The balance between the psychosocial model and interventions and the biomedical model and interventions should be more appropriate 12 Jun 2017, 10:54

For the rest of this blog, I'll try and condense what Lucy Johnstone called my twitter-friendly summary of the report.

ClinpsychLucy Thanks to @DBDouble for the Twitter-friendly summary. Special Rapporteur who authored the UN report is also a psychiatrist. 12 Jun 2017, 21:42

Anyone who does want to see the list of tweets, though, see my responses to:-

DBDouble UN Report on right of everyone to enjoyment of highest attainable standard of physical and mental health documents-dds-ny.un.org/doc/UNDOC/GEN/… 10 Jun 2017, 10:44

As far as power asymmetries are concerned, the report goes on to note that biomedical gatekeepers, in particular biological psychiatry backed by the pharmaceutical industry, are the dominant influence. National mental health strategies tend to reflect biomedical agendas and obscure the views and meaningful participation of civil society. Such biomedical bias leads to the mistrust of many users and threatens and undermines the reputation of the psychiatric profession. It dominates services, even when not supported by the evidence. In summary, biomedical power undermines the principles of holistic care, governance for mental health, innovative and independent interdisciplinary research and the formulation of rights-based priorities in mental health policy.

The individual relationship between psychiatric professional and user can also be exploited. Power imbalance reinforces paternalism and even patriarchal approaches. The asymmetry between professionals and users disempowers users and undermines their right to make decisions about their health and creates an environment where human rights violations can and do occur. This misuse of power asymmetries thrives, in part, because legal statutes often compel the profession and obligates the State to take coercive action.

As far as biased use of evidence is concerned, the report notes that the evidence base for the efficacy of certain psychotropic medications is increasingly challenged from both a scientific and experiential perspective. Similarly, research is accumulating in support of psychosocial, recovery-oriented services and non-coercive alternatives. There are increasing concerns about overprescription and overuse of psychotropic medications in cases where they are not needed. Because of the biomedical bias in mental health, there exists a worrying lag between emerging evidence and how it is used to inform practice.

There are various reasons for this research bias, some of which are mentioned in the report. There is a long history of pharmaceutical companies not disclosing negative results of drug trials, which has obscured the evidence base. Scientific research in mental health continues to suffer from lack of diversified funding and remains focused on the neurobiological model. Academic psychiatry has outsize influence, informing policymakers on resource allocation and guiding principles for mental health services. It has mostly confined its research agenda to the biological determinants of mental health. There are also implications for teaching in that the biomedical bias in mental health dominates teaching in medical schools, restricting knowledge transfer to the next generation of professionals.

How can all this be changed? There needs to be a strong ethical focus. Mental health services must respect ethics and rights (including “first, do no harm”), choice, control, autonomy, will, preference and dignity. The overreliance on pharmacology, coercive approaches and in-patient treatment is inconsistent with doing no harm, as well as human rights. Abuse of biomedical interventions compromises the right to quality care in mental health services.

The report does make some specific comments about treatment. Psychosocial interventions and support, not medications, should be the first-line treatment option for the majority of people who experience mental health issues. Sadly, such interventions tend to be viewed as luxuries, rather than essential, and therefore lack sustainable investment. In most cases of mild and moderate depression “watchful waiting”, psychosocial support and psychotherapy should be the frontline treatments. It is not a right to health to prescribe psychotropic medication merely because effective psychosocial and public health interventions are unavailable. There are compelling arguments that forced treatment, including with psychotropic medications, is not effective, despite its widespread use. Peer support, when not compromised, is an integral part of recovery-based services. The right to health requires that mental health care comes closer to primary care and general medicine, integrating mental with physical health.

The report does emphasise that people can and do recover from even the most severe mental health conditions and go on to live full and rich lives. It considers that whether the global community has actually learned from the painful past of rights violations in mental health remains an open question.

I worry that this report will just "collect dust". As the Special Rapporteur himself says there is now unequivocal evidence of failures of a system that relies too heavily on the biomedical model of mental health, and yet this model persists despite the critique. I do think critical psychiatry does need to do more to expose the self-interest of modern psychiatry (see previous post). Still, it's very welcome to have United Nations support in this aim.

"Deconstructing" American psychiatry

My previous post mentioned the recent AAPP conference on critical psychiatry. At this conference, Nev Jones proposed Derridean deconstruction as a starting point for an American critical psychiatry. As I mentioned, the American Psychiatric Association (APA) Annual Meeting was taking place at the same time. I wonder whether the guide to the APA Annual Meeting could be a text to "deconstruct". 

The welcome from the APA president in the guide mentions that the "field of psychiatry is rapidly evolving with new science, new technologies, new systems of care, and new collaborations and partnerships". In a conference of this sort, it is what she wants you to believe. But has there really been such progress? Perhaps it is just said to hide the real lack of progress. 

Apart from the programme of sessions, courses, lectures, case conferences, talks, symposia, workshops and new research poster sessions, exhibitors display information about products and services related to psychiatry. The meeting would apparently not be possible without the sponsorship of exhibitors. Some provide extra sponsorship of the meeting and pay for advertisements. There are also promotional programmes supported by pharmaceutical companies. 

There is no attempt to hide the commercialism of APA. In fact, the financial relationships with any commercial interest of presenters are listed, although there are a significant number who say they have nothing to disclose. The irony is that APA seems to think that by being so open about its commercial interests it has purified the scientific content of its meeting programme. In fact it does the reverse.