Getting the right position on antidepressants

The Royal College of Psychiatrists (RCPsych) has been widely praised (eg. by the Council for Evidence-based Psychiatry (CEP) - see press release) for its call for NICE to update its guideline on antidepressant withdrawal (see RCPsych press release). This new statement follows a complaint made to RCPsych - which was wrongly dismissed without, as far as I know, any apology - about a claim, made by its President and Psychopharmacology Committee Chair, that discontinuation problems on stopping antidepressants resolve within two weeks for the vast majority of patients (see previous post).

Instead RCPsych now accepts that “there should be greater recognition of the potential in some people for severe and long-lasting withdrawal symptoms on and after stopping antidepressants”. This is a welcome development and I don’t want to seem negative about it. But I do have concerns overall about the recently released RCPsych position statement on antidepressants and depression.

For example, as far as discontinuation problems are concerned, the statement says “withdrawal symptoms ... are often mild and self-limiting”. I’m not sure this is right. They can be mild and self-limiting, but I’m not convinced they are often so. Nor do I find anywhere in the statement a proposal for research to establish the reason for these problems. This is particularly pertinent because, as the statement points out, there is a lack of evidence that antidepressants are physically addictive.

More generally, the statement overestimates the value of antidepressant treatment. For example, it makes several statements about how long people need to stay on antidepressants, without any references to support this advice. It also makes too much of what it calls the "partial understanding" of how antidepressants work, even assuming that they do work! Although it may indicate we need to move on from the chemical imbalance theory of depression (eg. see previous post), it still seems enamoured of biological theories of antidepressant action, such as neural plasticity. There's no way the RCPsych could consider that the placebo amplification hypothesis to explain trial data could possibly be valid, even though Cipriani et al (2018) (authors it praises) only say antidepressants "might work" (see previous post).

Rhiannon Lucy Cosslett in a Guardian article asks why it took so long for psychiatrists to listen to patients about antidepressant discontinuation problems. The answer is that they tend to focus on short-term fixes, they tend not to be psychologically-minded and they can be too quick to peddle medication (see my book chapter). RCPsych has got a long way to go to deal with these tendencies within its ranks.

Critical psychiatry is reformist

Bonnie Burstow's chapter entitled 'From 'bed-push' to book activism: Anti/Critical psychiatry activism' in the Routledge handbook of radical politics (2019) helpfully summarises her antipsychiatry position. She makes clear that "The chapter is written from an anarchist perspective". Antipsychiatry is distinguished by the fact that

... all antipsychiatry activists seek the total abolition of institutional psychiatry (and this distinction is crucial) not some just part of it and not the mere 'reform' of the institution. This, in practice, would mean that insofar as anything vaguely resembling psychiatry continued to exist, it would have no state powers, no state funding or promotion and no authoritative 'medical’ status [emphasis in original].

I've complained before about how the americanisation of critical psychiatry seems to be devaluing its meaning. For example, the Mad in America website reduces critical psychiatry to a general term for alternatives to the biomedical model in psychiatry (eg. see my book review). At places in her chapter, Bonnie Burstow seems to use the terms 'critical psychiatry' and 'antipsychiatry' interchangeably (as apparently, for example, in the subtitle of the chapter), but I'm not sure if this is intentional.

Rather than allowing the highjacking of the term 'critical psychiatry' by antipsychiatry, I think I need to make clear that critical psychiatry is a reformist movement. There are differences within the movement (see previous post) and although I'm more at the reformist end, I'm not against seeing critical psychiatry as a broad spectrum, which it is (eg. see previous post). But it's unrealistic to expect that the wish to find a physical basis for mental illness will ever go away completely. There's always been this wish, even before our modern understanding of medical psychology developed at the end of the 18th century. I've even argued that critical psychiatry was present in the origins of modern psychiatry (eg. see previous post). Critical psychiatry is certainly a medical enterprise (again, see eg. previous post).

I'm not against activism such as the 'Fast for Freedom' hunger strike in 2003 by six 'psychiatric survivors' (eg. see previous post). I attended an Occupy American Psychiatric Association meeting in the past (see previous post) and I do think there are particular issues about American psychiatry (see eg. previous post) that may require a more radical response. I also use social media as a form of activism, and some of the motivation for doing this is because of the difficulty in getting my perspective into mainstream psychiatric journals.

However, I'm not convinced that there really is what Bonnie Burstow calls "an unstoppable radical politic". But I do respect her position. and value her attempt to restate an antipsychiatry position. I originally called my Critical Psychiatry website the Anti-psychiatry website (see previous post), although it has became more defunct as it has now essentially been taken over by this blog. But I'm glad I changed the name because I never intended to promote anarchy. I'm sure that's what some people fear about critical psychiatry, but that's a misunderstanding.

I agree with Bonnie Burstow that "the mad and the antipsychiatry movements in themselves present challenges". I'm not against reconsidering my politics. But my ultimate aim is to make psychiatry more pluralistic, not to abolish it.

Schizophrenia is not a chronic brain disorder

I've been asked how the American Psychiatric Association (APA) is allowed to call schizophrenia a "chronic brain disorder" on its information webpage about 'What is schizophrenia?'. The answer is that professional bodies, including the Royal College of Psychiatrists (see eg. previous post), can't be relied on for information about psychiatry. There was a time when American psychiatry would have been more cautious about making such a claim. For example, neurobiology was only represented in a few sections of the 1959 American Handbook of Psychiatry (see my book chapter). Any influence of psychoanalysis and Meyerian psychiatry is now difficult to find in modern American psychiatry (see eg. another book chapter).

I'm reminded of the hunger strike on the 16 August 2003 by six "psychiatric survivors" to challenge the APA for evidence to support common claims that major mental illnesses are "proven biological diseases of the brain" and that emotional distress results from "chemical imbalances" in the brain (see Fast for Freedom information webpage). I wrote an article about this situation. It’s still the case that the APA needs to take a more balanced view of the evidence about the neurobiological basis of mental illness. 

People made dependent on psychotropic medication have not abused or misused the drugs

Twitter conversation this morning (see thread leading to my tweet) has made me realise that it may be misleading to say that people who have experienced antidepressant discontinuation problems have become addicted to antidepressants. I'm certainly not wanting to imply that people made dependent on antidepressants have abused or misused the drugs. There is confusion in the nomenclature (see eg. previous post and my Antidepressant Discontinuation Reactions webpage) and I don't want to add to it.

Integrating critical psychiatry into the mainstream

Although the Critical Psychiatry Network was formed over twenty years ago (see my editorial), critical psychiatry remains marginal to mainstream practice. This may be because of its association with so-called anti-psychiatry (eg. see previous post).

Critical psychiatry’s challenge to the ‘disease model’ of mental illness is legitimate (eg. see previous post and my Lancet Psychiatry letter). As I've pointed out in this blog before (eg. see previous post), its point of view has actually always been present historically and philosophically since the origins of modern psychiatry. It is not just a new fad, and grapples with the same conceptual issues that were present with the origin of modern psychiatry. It's always been a minority perspective.

For example, present day psychiatry tends to see itself as ‘biopsychosocial’ (eg. see previous post). It is not only concerned with biological but also psychological and social aspects of disease. Anthony Clare articulated this perspective as the outcome of the anti-psychiatry debate (eg. see previous post). He encouraged the avoidance of doctrinaire devotion to ideology in psychiatry. This ill-defined basis for practice may create theoretical inconsistency, such as viewing more minor psychological disorder as psychosocial, whereas more severe mental illness is identified as biological in origin. It may also lead to the combination of psychotherapy and biological treatments without any systematic theory to support such a strategy ( see my book chapter).

Nassir Ghaemi is critical of such eclecticism, although he incorrectly blames George Engel and Adolf Meyer for this situation (see my review of Ghaemi's book and responses). Both Engel and Meyer had an integrated mind-brain understanding, as does critical psychiatry. Engel’s biopsychosocial model promoted a holistic psychiatry and, like critical psychiatry, is a challenge to biomedical dogmatism (see eg. previous post). True, Meyer’s embracing of the uncertainty of psychiatric practice led to him being prepared to compromise with opposing opinions. He failed to challenge biomedical excesses, complaining that the research evidence was lacking (see another previous post and my article). But Meyer’s Psychobiology, which dominated American psychiatry in the first half of the twentieth century, is a legitimate theoretical framework for the more recent critical psychiatry movement.

The fundamental issue of the relation of mind and body creates the context for conceptual conflict in psychiatry. The first to apply a mechanistic approach to life was René Descartes (1596-1650) (see previous post). Animate and inanimate matter were understood by the same mechanistic principles. Animals are therefore machines; and human physiology is also mechanistic. Descartes stopped short, though, of including the human mind in this mechanistic framework. The soul was denied any influence in physiology. Descartes, thereby, avoided the materialistic implication that man himself is a machine. The split he created between mind and brain is referred to as Cartesianism. However, living beings, including humans, have a purposiveness that cannot be derived from mere physical-chemical processes. Organic life needs to be distinguished from the inorganic, not the soul from the body. Despite Descartes, the soul and body are not separate but integrated in the organism. Critical psychiatry takes an organismic, rather than mechanistic, perspective in the life and human sciences and is not Cartesian.

In the second half of the eighteenth century, reacting against Cartesianism, anthropology established itself as an independent discipline, concerned with the study of man as a psychophysical individual. In this context, medical psychology had its origin with two major variants of anthropological thinking (Verwey, 1985). A medically-orientated anthropology represented by Ernst Platner, among others, was one version. The other was Immanuel Kant’s pragmatic anthropology. Kant, like critical psychiatry, was clear that it is futile to expect to be able to understand and explain life in terms of merely mechanical principles of nature (Zumbach, 1984).

In the same year, 1845, that saw the publication in German of the book that gave Wilhelm Griesinger his reputation in psychiatry, Ernst von Feuchtersleben produced his psychiatric textbook based on Kantian principles (see previous post). Griesinger was dedicated to the idea of the pathology and therapy of mental diseases as a mechanical natural science, although he remained aware of the gap between this ideal and reality. Nonetheless he set the trend for this positivist biomedical understanding that has dominated psychiatry since the middle of the nineteenth century. Such a positivist reduction of mental illness to brain disease is what causes such concern for critical psychiatry. Feuchtersleben, by contrast, like critical psychiatry, recognised that the mind-brain problem is an enigma that can never be solved. He has been called a ‘forgotten psychiatrist’, but should be remembered as creating a framework for critical psychiatry based on Kant’s philosophy.

Critical psychiatry has foundations that go back to the origin of modern psychiatry. It is integral to its history and it is, therefore, a mistake for psychiatry to marginalise it from the mainstream. Critical psychiatry can be understood as a truly biopsychosocial, neo-Meyerian approach to psychiatry based on Kant’s critical philosophy.

Anti-reductionism and critical psychiatry

Immanual Kant in the section on the ‘Critique of Teleological Judgement’ in his Critique of Judgement (1790) said:-

For it is quite certain that we can never adequately come to know the organized beings [living things] and their internal possibility in accordance with merely mechanical principles of nature, let alone explain them; and indeed this is so certain that we can boldly say that it would be absurd for humans even to make such an attempt or to hope that there may yet arise a Newton who could make comprehensible even the generation of a blade of grass according to natural laws that no intention has ordered; rather, we must absolutely deny this insight to human beings.   

What did Kant mean by this and what is its application to psychiatry? As a critical psychiatrist I think I am applying Kant’s critical philosophy to psychiatry.

What Kant was saying is that a mechanistic psychology is impossible. Not that people cannot be studied in a mechanical way, particularly parts of themselves - and as far as psychology is concerned this is the brain - nor that we cannot produce descriptions of thoughts, emotions and behaviour. But a mechanistic conception of nature fails to provide a complete characterisation of living systems.

Why is this? Living things are different from inanimate objects. They have functional and goal-directed characteristics. They have designed and designer-like aspects. They seem to be intended for a definite purpose and they have the ability to form their parts. Living things are purposiveness systems, or to use Kant’s words, teleological systems. A machine is different. It does not serve its own interests but the interests of its maker or user. Organisms, unlike machines, are self-organising and self-reproducing systems.

We therefore need different modes of explanation for teleological and mechanical points of views. For example, understanding the meaning of human action is a different kind of explanation from mechanical explanation. The mechanistic conception of causality fails to provide a complete understanding of human and living systems in general.

In fact, Kant goes further than this. What he says is that how living wholes cause their parts is unknowable to us. We just have to accept that our knowledge is limited because we conceptualise organic matter in a different way to inorganic matter. Life and human sciences are doomed to a kind of pre-scientific descriptivism rather than becoming a natural science.

We can never have theoretical knowledge that anything in nature is teleological, but such judgment is nonetheless necessary and beneficial for us. Which is why we attempt to understand human and living behaviour in mechanical terms. We may well wish we could explain life in mechanistic scientific terms and so-called science has often embarked on what Kant called a “daring adventure of reason”. Despite Kant recognising the wish to have a physical understanding of life and human behaviour, nonetheless he argued that it is absurd and futile to expect to be able to explain mental processes in physical terms.

I want to try and apply this kind of thinking to psychiatry. Mental illness is commonly perceived to be due to brain pathology. This is standard understanding. People may even be told by doctors that their mental health problems are due to a chemical imbalance in the brain or some other biological disease. You may even have heard or read something like this yourself. But critical psychiatry is saying you are being misled by perspectives like this.

Of course acute brain disorders can present as a toxic confusional state. More chronically they can lead to a dementia. But most mental health problems are functional in the sense that they are not structurally represented in the brain.

I don’t want to be misunderstood. Of course I’m not saying that mental health problems have nothing to do with the brain. The mind is clearly enabled by the brain. But what I’m saying is that mental health problems should not be reduced to the brain. And, like Kant, this is primarily a statement about how one explains mental health problems. I’m not saying that mind and brain are different substances. I’m not anti-materialist in this sense. Nor am I saying that it’s not important to use scientific methods. In fact, a lot of what passes for science, certainly in mental health, is more to do with speculation than the real world. Considering the amount of money that’s been spent on mental health research, one might hope that progress would have been made. But essentially results are so clouded by inconsistencies and confounders that it’s not been possible to say anything definitive about the biological basis of mental illness.

You may be surprised by me taking such a position as this. And, you may well not be alone. I am taking a minority view within psychiatry. In fact, psychiatry is more like a faith that doctors are expected to believe in rather than a science as such. If I don’t follow the faith of believing that mental illness is a brain disease, then I’m seen as unorthodox. I do, however, have a few other psychiatrists who agree with me. Twenty years ago we formed the Critical Psychiatry Network. If you’re interested in finding out more, there’s an editorial in February's British Journal of Psychiatry entitled ‘Twenty years of the Critical Psychiatry Network’.

(Adaptation of talk given to Cambridge University Psychology Society, 21 February 2019)

Who's going to take responsibility for promoting the chemical imbalance theory of mental Illness?

I reviewed Ronald Pies' book Psychiatry on the Edge a few years ago (see review and previous post). A recent Psychiatric Times article picks up his theme of debunking the chemical imbalance myths of depression and schizophrenia. I think I do understand his view that these notions were never really taken seriously by most well-informed psychiatrists (see previous post). He does admit, though, that it's not surprising the theory has "taken hold in the minds of so many in the general public". It worries me, though, that he may be seen to be blaming Laura Delano (whose New Yorker article led to his response) for her view, as a patient, "that [her] depression was caused by a precisely defined chemical imbalance, which her medications were designed to recalibrate". I hope he's not.

I'm not quite sure what's achieved by arguing that "there was never a unified, concerted effort within American psychiatry to promote a 'chemical imbalance theory' of mental illness in general", if that's the impression that's been created in Laura Delano and the public in general. Whose fault was it then? Certainly patients are given this professional opinion by psychiatrists (whether they really believe it or not) (see previous post). As I said in my review, Pies thinks that:-

Doctors know it’s an oversimplification ... but use it so patients don’t feel so blameworthy. He does agree this is “a little lazy” ... on the doctors’ part and doesn’t excuse their behavior, but says they are very pressed for time with so many patients to see.

I also agree with Pies that most psychiatrists are more eclectic than just biological (eg. see previous post). In fact, Pies is quite biological in his approach to psychiatry and admits for example that he's enamoured of the idea that depression is a form of inflammation, even though I think this hypothesis is nonsense (eg. see last post). I think Pies is just trying to say that psychiatrists are not simplistic in their biological (which doesn't omit psychosocial aspects) theories of mental illness. That's as may be and it's good he admits the chemical imbalance theory is bogus. But, if he doesn't attribute the chemical imbalance theory to psychiatrists, who take a much more complex view about the nature of mental illness, then who's been responsible for its promotion? Surely he doesn't think it's the silly patients who’ve believed it.