Saturday, October 26, 2019

How medical psychology became psychotherapy

A post on the British Psychological Society (BPS) History of Psychology Centre blog marks 100 years since the first BPS Member Networks were formed. The Medical Section was one of the first of the three sections formed in 1919 (the others being Educational and Industrial) and I've posted previously on 'The roots of medical psychology’. The Medical Section is now the Psychotherapy Section - name changed in 1988, having previously changed to Section of Medical Psychology and Psychotherapy in 1976 (see BPS history timeline). I'm not sure if the Psychotherapy Section is aware of this history.

Incorporation of the Society in October 1941 reflected the safeguarding of the professional interests of trained psychologists and instituted different classes of membership (Edgell, 1947). Membership had been opened in 1919 to anyone ‘interested in psychology’, not just recognised scholars or teachers. This deprofesionalisation led to an increase in membership from 98 at the end of 1918 to 427 at the close of 1919. A large proportion of these new members were in the Medical Section. Charles Myers used his First World War medical contacts (some treating shell shock; Myers probably being the first to recognise the essentially psychological nature of shell shock) to persuade them to join the Society (Jackson, 2019).

I'm sure there is a need to protect professional psychological expertise, but there are also advantages in extending general interest in psychology. Professional separation of medicine and psychology is not always helpful.

Friday, October 25, 2019

Creating a ketamine epidemic?

Ketamine has been claimed to be the first truly new pharmacological approach for treating depression in the past 50 years and promoted as the first of a new generation of rapid acting antidepressants (eg. see BMJ news report). US clinics increasingly offer IV infusions of ketamine off label. In March, esketamine, a nasal ketamine-based drug, was approved by the US Food and Drug Administration (FDA) for treatment-resistant depression. This is despite it performing better than placebo only in one out of three studies (see my tweet).

Concern about potential approval of esketamine by the Medicines and Healthcare products Regulatory Agency (MHRA) in the UK has led to discussion through responses to a BMJ article. The latest response by Mark Horowitz and Joanna Moncrieff expresses concern that "history is repeating: a known drug of abuse, associated with significant harm, with scant evidence of efficacy, is being submitted for licensing, without adequate long-term safety studies".

It's important not to forget the epidemic of amphetamine use that peaked round the end of the 1960s (see article). Ketamine has the ability to induce an acutely altered state of consciousness, reminiscent of indigenous medicines such as ayahuasca, peyote, and ibogaine, which have been used for centuries across many cultures (see another article). Amphetamines in general were prescribed readily and with insufficient thought in the past (see yet another article). Amphetamine was said to adjust hormonal balance in the central nervous system by creating or amplifying adrenergic stimulation so as to promote activity and extraversion. It was even said that true addiction to amphetamine probably did not occur.

However, evidence emerged after 1960 that amphetamine is truly addictive, instead of merely habituating. The introduction of monoamine oxidase inhibitor and tricyclic antidepressants from the end of the 1950s did not immediately lead to a significant decline in prescribing of amphetamines, but eventually the claim that the newer drugs were superior to amphetamines held sway. Amphetamines and barbituates had nonetheless seemed better to doctors than the bromides and nerve tonics that had been prescribed up to the 1950s. Psychiatrists used to complain that GPs, when they did use the newer tricyclic antidepressants, did not use them in sufficiently high enough therapeutic doses. This complaint was heard less when the SSRIs were introduced in the 1980s, perhaps partly because fluoxetine, maybe the most successful SSRI, was initially introduced at a single dose.

50 years may seem a long time not to have had any new pharmacological treatment for depression but it's important history isn't repeated. It actually wasn't that long ago that the epidemic of amphetamines was created by doctors. Do they really want to do the same with ketamine?

Friday, October 18, 2019

Neuroscience in psychiatric education

The Royal College of Psychiatrists (RCPsych) has published its first issue of PSynapse, the newsletter for its programme (that I've mentioned previously eg. see post), which has support from Gatsby and Wellcome, to transform UK psychiatric training by integrating modern neuroscience. The newsletter mentions that TrOn (the RCPsych online learning resource to support trainees preparing for its membership examinations) is looking for an additional specific neuroscience trainee editor in addition to its other trainee editors. It also mentions the third RCPsych neuroscience spring conference that marked the launch of the College neuroscience champions scheme, which creates a network of psychiatric trainees across the UK to ensure that neuroscience is properly integrated into their respective deaneries.

I’m not against trainees having a proper understanding of neuroscience. But I don’t think the College programme has incorporated critical neuroscience (see previous post). Wellcome has said it wants a radical new approach to mental health research (see previous post). Yet it’s also supporting the Psychiatry Consortium (mentioned in the PSynapse newsletter) of 6 drug companies, Alzheimer’s Research UK and MQ (mentioned in previous post), to accelerate innovative drug discovery in psychiatric diseases. The newsletter also has a report from the British Neuroscience Association festival of neuroscience in April 2019 which highlights ketamine as a potential antidepressant. The rest of the newsletter reports conversations with two of the leaders in the field of ketamine use for depression in the UK. But there’s no discussion of the potential risks of approving ketamine for antidepressant use (eg. see BMJ response by Mark Horowitz and Joanna Moncrieff).

There is a need for interdisciplinarity in mental health research (see previous post). I hope the College isn’t encouraging a neuro-turn in academic psychiatry (see another previous post). I’d like to see it also incorporating critical psychiatry into psychiatric training (see yet another previous post).

(With thanks to Frederico Magalhaes)

Thursday, October 17, 2019

Psychiatry's reductionist tendencies

Rebecca Roache (who I’ve mentioned previously) has a useful PPP article which discusses the different forms of reductionism in relation to psychiatry. I’ve tried to make my view clear that critical psychiatry’s anti-reductionism is primarily explanatory (see eg. previous post).

Roache says that psychiatrists writing about the biopsychosocial model often contrast it with reductionism. Indeed I did so in my article (as did George Engel originally). I wish, though, that Roache had been clearer that Engel’s biopsychosocial model and Meyer’s Psychobiology are not eclectic (see eg. previous post).

Roache also seems to go along with Nassir Ghaemi that Roy Grinker originated the term 'biopsychosocial'. There is no use of the term in the reference she gives (viz. Grinker 1994), which she says was a 1954 lecture by Grinker. In fact, it's a paper that was first presented in October 1952. I'm grateful to an unpublished review of Ghaemi's The rise and fall of the biopsychosocial model by Neil Vickers that points out that Grinker used the near synonym ‘psycho-somatic-social’, not 'biopsychosocial' in this presentation. He first used the term ‘the biopsychosocial model’ in 1962, some eight years after Nathan Ackerman (1954). It was also used in two papers by F. A. Weiss in 1958. As Neil says, "In short, the case for Grinker’s priority is not credible." John Romano and George Engel had been talking about an integration of biological, psychological and social factors in psychosomatic medicine at least since 1945. True, Engel may well have had Grinker in mind when he linked the biopsychosocial model to systems theory, but I don't think his biopsychosocial model is dependent on systems theory as such.

I agree with Roache's critique of the confusion in the psychiatric academic literature about reductionism. There is widespread hope in psychiatry that neuroscience will explain mental illness. As I keep saying, critical psychiatry's challenge to this 'disease' model of mental illness is legitimate (see eg. previous post). I'd be interested to know if Rebecca Roache agrees with me.