Effectiveness of ECT still uncertain

A BJPsych Advances article by Ian Anderson, who I have mentioned before (eg. see previous post), has critiqued the review by Read et al (2019) of the methodological problems of the available 11 RCTs and 5 meta-analyses comparing ECT with sham ECT.  Anderson agrees that the RCT evidence has limitations, as do the meta-analyses. 

Impeaching clinical studies is easy as there are always methodological difficulties. Essentially, Read et al are saying that the statistical advantage for ECT over sham ECT has not been demonstrated, whereas Anderson thinks it may have been. I do think, though, that Anderson ought to spell out which studies he is relying on for that conclusion. 

As with antidepressant studies, where I think the statistical difference overall in clinical trials between active and placebo treatment cannot be denied, placebo amplification, for example through unblinding, could still explain any statistical difference (eg. see previous post). Read et al argue that none of the ECT studies convincingly demonstrate they are double-blind. 

Enactivism can help clarify Engel’s biopsychosocial model

As I’ve said before (see previous post), I think Engel’s biopsychosocial (BPS) model can be made more explicit by utilising enactivism. My last post argued that Engel’s BPS model needs revitalising. Enactivism may be a way to do so. As Sanneke de Haan says in a recent paper, “Just like the BPS model, an enactive approach argues for a holistic conception of psychiatric disorder”. I also agree with her that “enactivism offers a [more] coherent account of how physiological, psychological, and social processes relate” than does Engel’s model on its own. People have been able to wrongly claim that they are adopting the BPS model, when in fact they have been using it in a eclectic way that does not spell out how the biological and psychosocial connect to each other (eg. see previous post).

I’m not sure if I agree with Sanneke that “Questions about causality are questions about ontology”. As I said in my article, I think anti-reductionism is primarily explanatory rather than ontological. What’s needed is a new epistemology (see previous post). Still, enactivism’s focus on the ‘life-mind-continuity thesis’ is helpful. As I keep emphasising (eg. see previous post), organisms, unlike machines, are self-organising and self-reproducing systems. Sanneke’s enactive psychiatry sees psychiatric disorders as abnormal sense-making (see previous post). Causes are non-linear when complex organisms are understood in a dynamic way (see another previous post). How living wholes cause their parts is actually unknowable to us (see yet another previous post). Cognition is more than mere information processing, as it is embodied in the brain and the body more generally and embedded in the environment, which is social and cultural, affording various possibilities of action to the organism (see my article). For psychiatry to continue to use a biology which sees mental illness as a static entity rather than a dynamic process is outdated. Enactivism may well help psychiatry to move on to a more relational mental health practice.

(With thanks to an MIA blog post by Micah Ingle)

Scientific validity of a pragmatic biopsychosocial model

The Academia platform has reminded me of a paper by Bradley Lewis on ‘The biopsychosocial model and philosophical pragmatism: Is George Engel a pragmatist?’. Like me (eg. see previous post), Brad argues that “Engel’s model is worth revitalising” (p. 299). I’m not as convinced as him that Engel “based the model on Von Bertalanffy’s biological systems theory” (p.300) (eg. see my article). General systems theory was a suitable conceptual basis for discrediting a reductionistic approach to biology for Engel but I don’t think he was necessarily making the biopsychosocial model dependent on it. As Brad points out, Engel saw the biopsychosocial model as more scientifically valid than biological reductionism. I agree with Brad about the similarities between Engel’s model/philosophy and pragmatism. Of course, Adolf Meyer, whom Engel also quotes, was very influenced by American pragmatism (eg. see my book chapter). 

Brad is interested in postpsychiatry (see his guest blog in a previous post). Postpsychiatry is perhaps the best known version of critical psychiatry (see another guest post from Pat Bracken and Phil Thomas). As I’ve been saying (eg. see previous post), a more truly biopsychosocial model, which critiques the biomedical model to produce a more relational practice, is needed not only for psychiatry but also for medicine in general. This was what George Engel meant when he proposed his biopsychosocial model.

Long-term segregation of people with learning disability and autistic people should be prevented

The government has responded to a review of people with a learning disability and autistic people who have been placed in long-term segregation (LTS) under the Mental Health Act (see letter from Helen Whatley, Minister of Care). The independent Oversight Panel was chaired by Baroness Hollins (see her letter to the Secretary of State). As the thematic review says, “some of the issues highlighted … are considered likely to be applicable in many assessment and treatment units (ATUs) and secure hospitals more generally and not just for those people who are subject to LTS”. In general, there was little evidence of any therapeutic benefit from hospital admission, and people’s health, dignity and well-being had been harmed.

As I've said before (eg. see previous post), I'm not convinced proposals to improve the situation through Independent Care (Education) and Treatment Reviews alone is the best way forward. Obviously people who have ended up in long-term secure provision do need to be helped to move on. But there is also a need for prevention of further such cases by prohibiting admissions to secure facilities under civil detention arrangements (see eg. another previous post). Secure hospitals should be reserved for criminal cases. As the review found, many of the patients in long-term segregation had actually acquired a criminal record through being in hospital. Such restrictive treatment needs to be stopped and such challenging people managed in a more open and therapeutic way. Psychiatric treatment is not just about custody.

Rights-based reform of mental health law in Scotland

The Scottish Mental Health Law Review has produced an impressive July 2021 interim report. It follows a ‘human rights model’ of disability. It sees the aim of legislation as being to secure human rights, which should be respected, of all those who may currently fall within the category of ‘mental disorder’. It will consider further, including with people with lived experience, about replacing the term ‘mental disorder’ with ‘mental and intellectual disabilities’. Specific mental health and capacity legislation needs to  be reinforced by legislative, policy and practice reform in a wider human rights agenda. Complete removal of compulsion, if it can be achieved, will have to be progressively realised and mental health law reframed to ensure it gives effect to an individual's rights, will and preferences in a non-discriminatory way. Although not straightforward, it should be possible to do this so that it is compliant with the UN Convention on the Rights of People with Disability (UNCRPD) (see eg. previous post). 

I'm pleased to see that Scottish mental health law reform takes UNCRPD into account, whereas I think the review in England and Wales essentially avoided the issue (see previous post). Service users and carers are front and centre of the Scottish review and three people with lived experience are part of the Executive Team, whose work is being intensified before the review is due to complete its work in September 2022.