Working towards abolishing community treatment orders (CTOs)

As Alex Ruck Keene said in his blog post, last week’s King’s Speech announced the introduction of a Mental Health bill to modernise the Mental Health Act (MHA) 1983. There is a sense in which it could be said to be misleading to imply that the 1983 Act has merely become out of date, which is how the government tends to present the case for reform (see previous post). Both the 1959 and 1983 Acts were progressive Acts in the sense of improving the rights of people with mental health problems. There were some progressive elements to the amendments introduced in 2007 by the previous Labour government, such as the introduction of independent advocacy, although this was never properly funded (see eg. previous post).  Essentially, however, the amended Act was a regressive step, particularly through introducing community treatment orders (CTOs). Hopefully the new Bill will actually further improve the rights of people with mental health problems (see eg. couple of tweets from Mind - first and second) and take into account WHO/OHCHR recent guidance on Mental health, human rights and legislation (see eg. previous post).

The Parliamentary Committee that scrutinised the draft Mental Health bill produced by the last government recommended that CTOs should be abolished for civil patients (see previous post). The Mental Health Alliance was formed in the context of the last Labour government’s attempt at MHA reform which led to the compromise of the 2007 amendments. There were major demonstrations against the Labour government’s proposals at the time (see eg. Early Day Motion). The Critical Psychiatry Network, of which I am a founding member, was one of the original members of the Mental Health Alliance, although it resigned from the Alliance when it became clear that the Alliance was prepared to compromise on CTOs. Evidence since then has only essentially reinforced the view that CTOs do not work (see eg. previous post).

The Alliance still exists and is a broader grouping than originally of mental health organisations. It does need to take on board, as does the government, the full implications of the United Nations Convention on the Rights of People with Disabilities (CRPD) (see eg. previous post). Both the World Health Organisation and the World Psychiatric Association urge countries to take action to promote non-coercive practices in mental health. This should include the UK government following the recommendation from the Parliamentary Scrutiny Committee to abolish CTOs for civil patients.

The government plans to introduce MHA reforms in phases as resources allow, and says it will not commence new powers unless there are sufficient staff in place to ensure it is safe to do so (see background briefing). Personally I’m not really convinced increasing the number of Tribunals and providing more access to SOADs and Tribunals, as proposed by the draft Bill, is really needed. It is also where more funding will be required, which could prevent implementation of any new Act. 

Reform of the Mental Health Tribunal to make it more human rights based could start now (see previous post), I think without any necessary legislative changes. Changes could also be made to improve independent advocacy by encouraging more integration between Independent Mental Health Advocates (IMHAs), mental health lawyers and independent experts (see another previous post), I think, again, without any necessary legislative changes. I suspect also that the CQC could ensure that the proposed S56 to introduce a clinical checklist to be followed by Responsible Clinicians and Second Opinion Approved Doctors (SOADs) could be implemented before such a change is reinforced and make legal in a reformed Act (see previous post). More could also be done to prevent the commissioning of secure placements by commissioners restricting, if not completely preventing, such funding for civil detentions. Work could also be undertaken on creating a new Mental Health Act Commissioner for England, as recommended by the Scrutiny Committee, probably incorporating and building on the current CQC MHA reviewer function (see another previous post). 

As part of taking forward its mental health strategy, the government needs to be clear that MHA reform starts now by improving patients’ rights. This programme of work can be taken forward alongside the development of a new Bill to be presented to parliament. 

The aspirations of psychiatry

King's College London press release announces that the "Wellcome Trust have awarded the funds [£5million] for a new 5-year ground-breaking research project ‘ASPIRE’, aiming to conclusively test if anti-inflammatories can be the right treatment for the right people with depression". Not sure how conclusive the results will be considering the description of the project on the Global Alliance of Mental Illness Advocacy Networks-Europe (GAMIAN-Europe) website. 

Also not quite sure what the Wellcome Trust meant a few years ago when it acknowledged that a radical new approach is needed for mental health research (see previous post), as it now seems to be allocating funding again on the same basis by wasting it on 'pie in the sky’ fantasies about what's possible with mental health treatments. I'm not wanting to polarise debate unnecessarily in psychiatry, and advocate, like Nik Rose (see previous post), for critical friendship between social sciences and neuroscience. However, I think this does need an acknowledgement from neuroscience that too much neuroscience funding is being wasted on the unattainable.

I've been ruthless in my criticism of the conceptual foundations of the psychiatry of Carmine Pariante, the primary investigator of ASPIRE (see eg. previous post). I also did a cutting, satirical review of the book by Ed Bullmore (see previous post), that made the case, like ASPIRE, for anti-inflammatory medications being used as treatment for depression by targeting the right people on the basis of levels of inflammation. To me, it's nonsensical to talk about depression as an inflammatory disorder, like rheumatoid arthritis (see eg. another previous post). More fundamentally, looking for abnormalities of inflammation in the brains of depressed people is a conceptual category error (see eg. last post). 

Summarising the argument of relational psychiatry

Depression of course is mediated via the brain but looking for abnormalities in the brain to explain why people are depressed is a category error. It is a fallacy to identify the brain with the person, in depressed people as much as in people who are not depressed.

I make this statement as a summary of the position of relational psychiatry (see eg. previous post), applying it to all functional mental illness, including schizophrenia and manic-depressive illness, not just depression. As I mentioned in a previous post, Bennett & Hacker call the category mistake of identifying the part with the whole the ‘mereological fallacy’. As I keep saying, psychiatry must stop identifying the brain with the person (see eg. another previous post). 

It is particularly people who have mental health problems who are reduced to their brains, and this is discrimination. However, such thinking permeates modern culture, reducing all people to their brains (see eg. previous post). Children are even being misled about the nature of mental illness (see eg. another previous post). What we need is a change from psychiatry being based on the notion that primary mental illness will be found to have a physical cause, to it moving on to a more relational practice (see eg. my article). 

GP monitoring of those on antidepressants

Tony Kendrick, who I have mentioned before (see eg. previous post) is the first author of a paper about antidepressant withdrawal in general practice. It found that more than 40% of patients could discontinue their antidepressant treatment in a clinical trial, comparing whether adding internet and telephone support to family practitioner review was more effective than practitioner review alone. The numbers that managed to withdraw under the two conditions was not significantly different, although those that had added support had small improvements in depression, antidepressant withdrawal symptoms and mental well-being.

However, only 4.9% of patients who were mailed invitations were eligible and consented to the trial. They had to be well enough to consider discontinuation, wish to do so and be at low risk of relapse. As I said in a previous post, people are generally very reluctant to take part in antidepressant discontinuation trials. There is at least a question about how much the results of the trial are generalisable to all those on antidepressants. Antidepressant discontinuation problems should not be minimised (see eg. last post). 

Nonetheless, if the paper leads to more review by general practitioners of those taking maintenance antidepressants this should be welcomed. Doctors are making far too many patients dependent on antidepressants and need to do more to prevent this happening (see eg. another previous post).

Mainstream psychiatry continues to minimise significance of antidepressant withdrawal

Mainstream psychiatry has minimised the significance of antidepressant withdrawal, as I first pointed out in a BMJ letter in 1997. My complaint then was that the Defeat Depression Campaign, launched in January 1992 by the Royal College of Psychiatrists in association with the Royal College of General Practitioners, advocated educating patients and doctors that discontinuing antidepressant treatment is not a problem. 

As I explained in my book chapter, what caused so much consternation to the Defeat Depression Campaign was that 78% of people in a door-to-door survey of public opinion thought that antidepressants are addictive. I suggested in the BMJ letter that the general public actually understood this issue better than the Royal Colleges of Psychiatrists and General Practitioners. It's common sense to believe that discontinuing taking medication that is thought to improve mood may be difficult. 

The British National Formulary (BNF), which doctors use for reference about medication, has given a warning since 1990 that symptoms may occur if an antidepressant is stopped suddenly after regular administration for 8 weeks or more. In fact, case reports of discontinuation reactions have appeared since antidepressants were first introduced. The Drugs and Therapeutic Bulletin (DTB), which publishes independent, practical, patient-orientated, evidence-based content on medicines for healthcare professionals, recommended in 1999 that if maintenance antidepressant treatment is discontinued that both the doctor and patient need to be alert to the risk of discontinuation effects and the re-emergence of depressive symptoms, which can occur on cessation of any antidepressant. It made clear that antidepressants should not be stopped abruptly, nor treatment courses interrupted, unless there is a good clinical reason, for example a serious adverse effect or patient request.

A new class of antidepressants called serotonin specific reuptake inhibitors (SSRIs) was introduced onto the UK market in 1987. Withdrawal symptoms were only acknowledged by the drug companies after SSRIs had been in widespread clinical use for several years. A consensus meeting of experts, sponsored by Eli Lilly, the manufacturers of fluoxetine, or Prozac™, as it is known by its trade name, was held in Phoenix, Arizona, at the end of 1996. This led to an editorial in the British Medical Journal in 1998 acknowledging that antidepressant  discontinuation problems existed (Haddad et al, 1998). It suggested, though, that they were both preventable and simple to treat. The same authors only two years later acknowledged that discontinuation symptoms are common (Young & Haddad, 2000). 

The National Institute for Health and Clinical Excellence, which evaluates treatments for NHS use, therefore, stated in its 2004 depression guideline the opposite of what was recommended by the Defeat Depression campaign: ie. that all patients prescribed antidepressants should be informed that discontinuation/withdrawal symptoms may occur on stopping, missing doses or, occasionally, on reducing the dose of the drug. It qualified this, though, by saying that symptoms are usually mild and self-limiting but can occasionally be severe, particularly if the drug is stopped abruptly. 

More recently in its 2022 guidance on ‘Medicines associated with dependence or withdrawal symptoms: Safe prescribing and withdrawal management for adults’, NICE clearly states that antidepressants cause withdrawal symptoms even though they have not historically been classified as dependence-forming medicines. In its updated 2022 depression guideline, it now says that withdrawal symptoms can be mild and usually go away within 1 to 2 weeks; can sometimes be more difficult, with symptoms lasting longer (in some cases several weeks, and occasionally several months); and can sometimes be severe, particularly if the antidepressant medication is stopped suddenly. At least the guideline now acknowledges that withdrawal symptoms are not as usually mild and self-limiting as the previous version of the guideline stated. 

This amendment was made after a complaint was made to the Royal College of Psychiatrists, which I signed (see eg. previous post). Although the complaint was initially wrongly dismissed, the College did eventually accept there should be greater recognition of the potential in some people for severe and long-lasting withdrawal symptoms on and after stopping antidepressants and called for NICE to update its guideline on antidepressant withdrawal (see eg. another previous post). 

I still worry, though, that the full importance of antidepressant withdrawal has, after all these years, not been understood by mainstream psychiatry (see previous post). There is in fact limited scientific evidence on this topic and recommendations are too driven by personal opinions or experiences rather than evidence as such (see another previous post). There are also methodological problems with antidepressant discontinuation studies, not least that blinding strategies are often insufficient to properly address placebo and nocebo aspects. What is commonly overlooked is that antidepressant withdrawal symptoms even occur in blinded antidepressant arms when antidepressants are continued. 

This finding has been confirmed in a new systematic review based on short-term industry studies (see Psychology Today article). One in three people were found to have at least one withdrawal symptom in the antidepressant withdrawal arm, but one in six people were still found to have withdrawal symptoms in the control arm even though antidepressants were continued. 

The problem with the new systematic review is that it minimises the frequency of antidepressant withdrawal, suggesting they occur in only 15% of people. But withdrawal symptoms may occur during and despite slow tapering and may persist for a long time (see eg. previous post). Even with the help of CBT to prevent relapse after withdrawal, only 36% of patients succeeded in discontinuing antidepressants over 16 months in a failed trial that found no difference between CBT and controls. Only 28% did not have a recurrence. 

Patients are actually, generally, very reluctant to take part in antidepressant discontinuation trials (see previous post). Fear of recurrence, relapse, or disturbing current mental equilibrium is common and prior failed attempts to discontinue antidepressants reinforce these expectations. People have also commonly been taken in by the myth of chemical imbalance in the brain as the cause of depression (see eg. another previous post) and are, therefore understandably, fearful and uncertain about stopping antidepressants, as the thought is their chemical imbalance could return. This fear overpowers the concern and uncertainty about continuing antidepressants. It's understandable if people think it’s better to be safe than sorry by continuing antidepressants (see eg. yet another previous post). 

So, even though we may have gone from the situation of antidepressant withdrawal symptoms being denied, as in the Defeat Depression campaign, to one in which they are accepted but the significance minimised (see eg. previous post), there is still insufficient understanding of the nature of antidepressant withdrawal. The situation has not really changed from what I wrote in an Openmind article nearly 25 years ago:-

People may form attachments to their medications more because of what they mean to them than what they do. Psychiatric patients often stay on medications, maybe several at once, even though their actual benefit is questionable. Any change threatens an equilibrium related to a complex set of meanings that their medications have acquired. These issues of dependence should not be minimised, yet commonly treatment is reinforced by emphasising that antidepressants, for example, are not addictive.

Even though psychiatrists may want to justify antidepressant treatment, this does not excuse minimising problems caused by taking it. Doctors are advocates of antidepressant treatment and this has led to them overlooking what should have been obvious about the risk of discontinuation problems. Perhaps we shouldn't be too surprised that doctors have been slow to recognise antidepressant discontinuation reactions and continue to minimise their significance, as they focus on short-term fixes of emotional problems (see eg. previous post), they are not properly psychologically minded and they are too quick to peddle medication and oversimplistic psychological interventions (see eg. another previous post). I’m not saying this to polarise debate about modern psychiatry, but the biomedical model that mental illness is due to brain disease has became too dominant and should not be buttressed by denying or minimising the significance of antidepressant withdrawal and other medication side effects.

To keep you in good humour

History of Psychiatry has an interesting article on ‘Cheerfulness in the history of psychiatry’. As the article says, “the notion of the French gaité tends to couple mood with an innate configuration, both procuring laughter, fun and vivacity". It goes on to mention Louis-Antoine Marquis de Caraccioli who was “ a prolific writer of the eighteenth century, [who] dedicated a book to a psychological theme that medicine has forgotten: ‘gaité’ in French". 

The article goes on:-

At the beginning of the nineteenth century, this work inspired two doctoral theses in medicine, … In their texts, Louis Monferran (1785– ?) and Vincent Rémi Giganon (1794–1857) explored the therapeutic benefits of the medical prescription of cheerfulness. In addition to lifestyle recommendations, they focused on the psychotropic substances available to them: alcohol, coca, hemp and opiates. … Giganon [also] … recommended … inhaled nitrous oxide gas.

Well, at least they included lifestyle recommendations as well as various substances. We have learnt a lot about these substances since Montferran and Giganon and can also learn from these authors’ historical theses for the present. Of course psychedelic substances are making a comeback as prescribed medications (see previous post). But, although fighting sadness with cheerfulness may seem to make sense. we also need to be realistic. 

It may be easy to get caught up in the charms of momentary cheerfulness. To quote Giganon from the article. "Laughter, song, wordplay, and jargon may spell doubts and allay suspicions". Or, to quote Monferran, again from the article, "Momentary cheerfulness delights the soul without perturbing it, evokes laughter without ridicule, and refines pleasures without corrupting them”. By contrast, "lasting or internal cheerfulness is based on an inner contentment, a blameless conscience, and the secret applause that follows a good action; this joy is more perfect than momentary cheerfulness". Modern society has become too focused on quick fixes (see previous post) and oversimplistic psychiatric treatment (see another previous post).

Shifting mental health policy

I've mentioned the Beyond Pills All Party Parliamentary Group (APPG) in a previous post. It has recently launched a report entitled Shifting the Balance Towards Social Interventions: A Call for an Overhaul of the Mental Health System. There is a YouTube video available of the excellent launch event of the report, which included presentations by Dainius Pūras (see eg. previous post) and Michelle Funk (see eg. another previous post). 

Mental health practice does need to be rethought (see previous post). Understanding about mental health problems needs to be improved, including what children are told about mental illness (see eg. previous post). The Mental Health Act also needs to be reformed (see another previous post). Rights and recovery-orientated services need to be at the centre, not the margins of mental health services, as currently.

Mental health services need to be realigned with better strategic direction to make them more functional and integrated. For example, there needs to be a mental health hub and community mental health team (CMHT) in each Primary Care Network (PCN). CMHTs have become too large and need to be devolved more locally, alongside non-medical services in the hubs.

Asperger’s autism

Kevin Rebecchi has provided a first English translation and introduction to Hans Asperger’s 1982 chapter ‘Early childhood autism, Asperger type’ published after his death in 1980 (see History of Psychiatry article). Asperger distinguishes his use of the term ‘autistic’ from that of Eugene Bleuler, who gave the name to the apparent impenetrable wall that separated schizophrenic from other people. Leo Kanner separately described what Asperger thought was a rare form of early infantile autism. Asperger differed by seeing people generally as having the ability to behave in an ‘autistic’ manner.

Asperger children were noticeable at school where they were very difficult to discipline and often failed because of their so-called different psyche, being intelligent, highly reflective and observant, seemingly devoid of feelings and yet able to have subtle emotions. Most importantly, it was the visibly limited and self-centred, very idiosyncratic way of dealing with people that was labelled ‘autistic’.

As Rebecchi points out, Lorna Wing introduced the concept of the autistic triad of difficulties in social interaction, communication and imagination and coined the term Asperger’s Syndrome. The study Wing based the autistic triad on was mainly of intellectually disabled children. She disagreed with Asperger and said these children lacked common sense, were not creative but merely logical, did not have high intelligence (several with IQ < 70) and would only repeat things by rote. Asperger’s autism in fact was not really characterised by the autistic triad at all.

Asperger thought the term ‘psychopathy’ applied to the children he described and they were seen as difficult both at home and school. He thought, nonetheless, they should be respected for who they are, and that it was quite wrong to see difficult people who are out of the ordinary as of inferior social value. As far as Asperger was concerned, some autistic people bring much to the world and are “the salt of the earth”. 

As I have said before (see eg. previous post), there is a need for a rethink about autism. It is now seen as part of the umbrella term ‘neurodiversity’ (see another previous post). Its meaning may well have become too vague and restoring understanding, I think, will benefit by looking again at its historical origins, as does Rebecchi.

The origins of the charity Mind

I’m now into my second year of being a Trustee at Norfolk and Waveney Mind. Not many people know about the roots of Mind in the UK, but they go back to Clifford Beers’ book (1908) A mind that found itself. There’s a very good, inclusive biography of Beers available (Dain, 1980). He died as a patient in a psychiatric hospital in 1943.

William James sent a letter to Beers encouraging him to publish his book manuscript. Beers had described his mistreatment by staff in psychiatric hospitals, not dissimilar to the scandals of recent times (see eg. previous post). He wanted to campaign for psychiatric reform and set up the Connecticut Society for Mental Hygiene. Mental hygiene was a movement to prevent insanity by providing information to the public. The term ‘mental hygiene’ was suggested to Beers by Adolf Meyer, Professor of Psychiatry at Johns Hopkins University and commonly seen as the Dean of American psychiatry in the first half of the twentieth century (see eg. my 2007 article). These days we tend to use the term ‘mental health’ in much the same way as ‘mental hygiene’, meaning the conditions and practices that help to maintain mental health. Meyer also sponsored A mind that found itself with William James. There was tension between Meyer and Beers and establishment psychiatrists were very much part of the mental hygiene movement, although Beers wanted more of an advocacy organisation for the insane, more like the modern survivor/user movement in psychiatry since the 1960/70s.

Beers went on to become the secretary in the USA of the National Committee for Mental Hygiene, a voluntary agency for which he raised millions of dollars. The International Committee for Mental Hygiene was formed in 1919 and its name was changed in 1947 to the World Federation for Mental Health, an organisation that still exists today (see its website).

There had been no British equivalent of the lay critique of psychiatry by Beers. However, the link between mental hygiene and the social psychiatry of the Second World War and postwar reconstruction (see my 2015 talk) was already apparent in a 1935 letter for peace drafted by the Netherlands Medical Association and signed by 339 leading psychiatrists round the world. The psychological ideas related to mental hygiene came together in the formation of the World Federation for Mental Health (WFMH) in 1948 at an International Congress in London, of which J. R. Rees (see Wikipedia page), who had been Consulting Psychiatrist to the British Army and co-founder of the Tavistock Clinic (see Wikipedia page), was President. As the original deputy director and then medical director, Rees built the Tavistock into Britain’s most important centre for the study of holistic medicine (see his obituary). He resigned from the Tavistock in 1947 and thereafter was Director of WFMH from 1948-61.

Toms (2010) describes the formation in 1946 of the National Association for Mental Health (NAMH), which became Mind, in the context of the mental hygiene movement. It was formed from three organisations: the National Council for Mental Hygiene (NCMH), the Central Association for Mental Welfare (CAMW) and the Child Guidance Council (CGC)

NCMH had been formed in 1922 by members of the Medico-Psychological Association (see BMJ article). Mental hygiene had also been promoted by the overlapping membership in the origins of the Tavistock clinic in 1920 as the way to prevent mental health problems. The tension about how much mental hygiene was really about lunacy reform, rather than just the prevention of mental illness, mentioned above in the conflict between Beers and Meyer, is also reflected in a 1924 BMJ letter from Lionel Weatherley. 

CAMW was established in 1913, the same year as the Mental Deficiency Act to ascertain the mentally defective population in England and Wales. The Act also founded a Board of Control to oversee the whole mental health system and the Board assisted in the creation of CAMW. Mental deficiency was associated with social inefficiency and social problems. 

CGC was founded in 1926. Both NCMH and CAMW thought child guidance clinics to be central to providing comprehensive mental hygiene for the community to prevent more serious problems later in life. 

Adoption of the brand name Mind signalled the shift to a campaigning organisation for patient rights in 1972. National Mind has listed its main achievements since its formation (see webpage). Local Minds, which are unique and independent charities, deliver services for people with mental health problems and run charity shops which meet the Mind Quality Mark and are part of the Mind Federation. A priority for National Mind in its current restructure is the policy of Federation First.

Biopsychosocial diversity

How about changing the term ‘neurodiversity’ to ‘biopsychosocial diversity’? As I said in a previous post, neurodiversity is an umbrella term. It actually means different things to different people. Fundamentally, it is about recognising personal differences and the need for society to adapt to those differences.

There are also disadvantages with the term ‘neurodiversity’ (see eg. previous post). It tends to imply that people’s brains are different. Of course people’s brains are not the same. They are different people. But that doesn’t necessarily mean that their differences are just due to their brains. Don’t get me wrong! Of course the brain constructs people. But so do their development and experiences, maybe particularly in the family situation but also outside.

It’s wrong to think that people are their brains (see eg. previous post). All sorts of myths are being promulgated about who we are. People need to  be understood as wholes, as their brains are only part of them. Whelpley et al (2023) note the distinction between the social and medical models of neurodiversity and the need for a more person-centred approach to neurodiversity. Maybe switching the term ‘neurodiversity’ to ‘biopsychosocial diversity’ would help to create this more personal focus.

Rethinking mental health practice

As I said, for example in my 2002 article, there is an overemphasis on psychiatric diagnosis. Nonetheless, the current diagnostic system still needs to be referenced when discussing mental health system reform, if only to avoid confusion. Over the longer term language can change. Certainly it has done so in the past, for example reflected in repeated revision of the DSM manual (see eg. previous post). 

As I have also said, the UK mental health system has become too dysfunctional and fragmented (see eg. previous post and another previous post). The problem is not just insufficient funding. Throwing more money at the problem is not going to solve it and hasn’t worked anyway. For example, waiting lists for assessment for neurodiversity are out of control (see eg. previous post). An excellent report from the N8 Research partnership (2024) on autism in children and young people makes 3 recommendations (see last post). These can be summarised more generally as (1) More integrated working within mental health services and between different services, not just health services. (2) Improve training co-produced with people with lived experience to provide and deliver holistic support which is not overmedicalised and focuses on people’s needs rather than being diagnosis-led. (3) Integrated care including both statutory and non-statutory services at local levels should be overseen by a prioritised governmental approach to addressing the crisis. 

The UK is not in the position to be able to put a large amount of money into health services and public services generally. The next UK government needs to act at pace though. Failure to provide appropriate mental health support results in poor long term outcome and high rates of associated health conditions. A major barrier in our existing systems is the perceived need for a medical diagnosis of mental health problems before people can receive support. Overmedicalisation of mental health problems also means the health system simply cannot meet the demand for all such assessments (see eg. previous post). Giving support on the basis of mental health need is required nonetheless, even if people don’t have a mental health diagnosis. Services need to be developed on the basis of this principle, co-ordinated by NHS England and implemented locally. Such a plan should be prioritised by the next government.

Rethinking neurodiversity

I very much like the definition of neurodiversity used at the spotlight conference in Bradford last year:-

Neurodiversity is the term used to describe the wide variety [of] different ways human beings think, learn, communicate and exist in the world. It is an umbrella term - a word that sums up lots of different things and helps us reframe conditions such as autism, ADHD, dyslexia as differences rather than deficits.

As I mentioned in my last post, a recent report on autism in children and young people, one of the main components of said neurodiversity (see previous post), by the N8 Research Partnership talks about the need for a radical rethink on autism. It was the result of a collaborative programme of work between Child of the North and the Centre for Young Lives. Three helpful evidenced-based recommendations are made:-

(1) Build effective partnerships between education and health professionals for assessing and supporting autistic children. This should include delivering assessments in education settings and making a holistic offer of support in schools and nurseries before and after a formal diagnosis is made. 

(2) Provide and extend access to mandatory Continuing Professional Development (CPD) courses for health, education, and social care professionals that improve understanding and awareness of autism (and related issues). These courses should include information on how to create “neurodiverse friendly” environments, and particularly raise awareness of autism in girls and ethnic minority groups. Additional training should be co-produced by individuals with lived experience, delivered to professionals, and integrated into undergraduate health and education professional training, to improve the identification of autistic girls.  

(3) Create formal partnerships at a local authority level comprising sector leaders (including schools, health, voluntary services, faith, universities, educational psychologists, and businesses) to oversee a prioritised governmental ward-level approach to addressing the autism crisis. The partnership should focus on its most disadvantaged wards and provide leadership in trialling data-driven, community and family co-produced, “whole system” approaches to improve autism support with and through education settings.

As the report says, these recommendations have resource implications but offer the potential for decreasing long-term costs by acting now. They should actually benefit the economy by increasing the employment of autistic people. Throwing money at the problem doesn’t solve it. To quote from the report:-

The time has come for everyone to cross organisational and geographical boundaries and commit to working together in the best interests of autistic CYP [children and young people] and their families.

A major barrier to progress is the overemphasis on psychiatric diagnosis (see eg. my article). This relates to the overmedicalisation of developmental and mental health problems (see eg. previous post). I very much agree with the essence of the report that support should be given on the basis of need regardless of the diagnosis of autism.

The industrialisation of neurodiversity

Nuffield Health has highlighted the need for a radical rethink on neurodiversity services (see eg. Sky news report) by its publication of data on waiting lists for assessment for ADHD and autism (see blog post). Increased public awareness of autism, ADHD and other neurodivergent conditions has led to more people seeking support and, as a Guardian report says, the “NHS faces [an] ‘avalanche’ of demand for autism and ADHD”. What’s required is a needs-based rather than diagnosis-led service, as has been argued for autism in children by a report resulting from a collaborative programme of work between Child of the North and the Centre for Young Lives. 

Neurodiversity has become an industry, often more motivated by profit than patient interest. Biomedical myths that suggest emotional problems are due to brain disorder support this development, although the neurodiversity movement itself promotes neurodiversity as not being a mental health problem. Neurodiversity in this sense means intrinsic diversity of brain function (see previous post). Society does need to adapt to individual differences but to suggest these personal differences are due to brain problems is also a biomedical myth.

The internet does seem to have made it relatively easy to sell all sorts of mental health treatments online, including psychological, medication and other physical treatments (see eg. previous post). People talk about COVID causing an increase in demand for mental health treatments, but maybe that’s just because the pandemic was associated with more widespread use of the internet. In another previous post, I expressed scepticism that COVID really increased depression and anxiety, not to minimise the emotional impact of the pandemic, and of course long COVID. Certainly, as I said in my last post, the marketing of digital apps online is out of control.  And it’s particularly the diagnosis-led basis of such interventions than can lead to their exploitation, even to corrupt business practices (see eg. yet another previous post). 

As I keep saying, the cultural process of seeking to create panaceas for emotional and other mental health problems doesn’t always work and may create more problems than it is worth (see previous post). The limitation of treatment to help people cope with their differences from others does need to be recognised, but such people should be able to obtain support if they ask for it. They don’t necessarily require a label of neurodiversity or any other mental health diagnosis to be able to make the most of that support.

Digital apps in mental health

Charlotte Blease (2023) points out that the digital health economy is out of control. There are tens of thousands of apps for people to download. The motivation for these apps may not necessarily be to improve patient care but to make profit (see eg. previous post). 

What's needed is better evidence that these apps are of any benefit to people. Placebo effects need to be controlled in research studies. As Charlotte says, many studies lack a clear description of the nature of the control. Robust placebo design is required in randomised controlled studies. As with psychotherapy trials there will always be a question in assessing the efficacy of mental health apps about the adequacy of control groups (see my BMJ letter). There is enough questioning even of the effectiveness of psychotropic medication (see eg. another previous post) and psychotherapy (see eg. yet another previous post) to reinforce the need to ensure that these apps are not really exploiting people. 

There is concern, of course, in general about misinformation on the internet (see eg. previous post). But medication and other physical treatments for mental health problems and psychological therapy are being oversold on the internet (see eg. another previous post). How are we supposed to decide which is the best app to use? Does it matter? Are they just panaceas (see yet another previous post)? I'm not saying using a digital app may not help. But we do need to recognise their limitations and potential costs and side effects.

Mental Health Act reform by a failed government

The Government has responded to the Joint Committee on the draft Mental Health Bill (see previous post). Tim Spencer-Lane has summarised in a Linkedin post which recommendations from the Scrutiny Committee were rejected and which were accepted by the government. As I said in a tweet, the response is disappointing but not surprising. As I keep saying, current reforms of the Mental Health Act (MHA) do not go far enough (see previous post). I also think that the opportunity should be taken to reform the Mental Health Tribunal (see another previous post) and formalise the role of a triage AMHP (see yet another previous post).

Failure to follow the recommendation about abolishing community treatment orders (CTOs) for civil patients is the most serious issue. What was fudged by the original review led by Simon Wessely was that mental health legislation is about supporting people with mental health problems (see previous post). Instead the government continues to parrot that review by saying that the MHA "governs the compulsory detention and medical treatment of people with severe mental illness, people with a learning disability and autistic people". It does but it also does, or should do, far more than that. 

Increasing coercion, such as CTOs, is not always the best way to manage risk in mental health services. The over-preoccupation with risk, that led to the introduction of CTOs, has not always produced sensible risk management (see previous post). Even more fundamentally, rights and recovery-orientated services need to be at the centre not the margins of mental health services (see another previous post), whereas the government merely says it will keep a rights-based approach under review (see response to recommendation 2 from the Scrutiny Committee). The government does not seem to be taking seriously that system and service changes are required to reduce coercion in mental health services as recommended by both the World Health Organisation and World Psychiatric Association (see yet another previous post). 

The Scrutiny Committee's recommendation for the creation of a MHA Commissioner, rejected by the government, was also helpful. As I said in a previous post, taking over the function of the Mental Health Act Commission (MHAC) by the Care Quality Commission (CQC) has meant, in my view, that a "specific emphasis on the rights of detained patients has been lost, as CQC has the more general role of regulating health and social care". More independence from CQC and NHS England is required to protect the rights of mentally ill people, as reflected in recent scandals exposed by TV programmes like Panorama (see eg. another previous post). The criteria in mental health legislation that allow coercive treatment are too wide to prevent abuse (see yet another previous post) and this must be remedied.

Not sure if the publication of this government response to the scrutiny committee will be taken forward in this parliament, such as having parliamentary time to discuss it. I think any Labour government will have to ask DHSC to go back to first principles, although there are many proposals, both within current draft legislation and elsewhere, including on this blog, which can be taken forward on this basis (see previous post). 

Habituation to antidepressants

Discussion on the Critical Psychiatry Network email list has firmed up my views about antidepressant withdrawal. As I point out on my Antidepressant Discontinuation Reactions webpage, there is confusion about the technical meanings of terms like drug dependence and drug addiction. Dependence and addiction in common parlance, though, tend to mean difficulty in managing without the drug. This is a psychological problem, and can also have a physical cause.

As I also say in a previous post, The National Institute for Health and Care Excellence (NICE) clearly states that antidepressants cause withdrawal symptoms even though they have not historically been classified as dependence-forming medicines. It sees dependence as characterised by tolerance and withdrawal symptoms. Addiction is said to include the additional characteristics of cravings, lack of control, overuse and continued use despite harm, associated with problematic behaviours.

People can become habituated to antidepressants. As I wrote in my OpenMind article :-

People may form attachments to their medications more because of what they mean to them than what they do. Psychiatric patients often stay on medications, maybe several at once, even though their actual benefit is questionable. Any change threatens an equilibrium related to a complex set of meanings that their medications have acquired.

Taking antidepressants can be an identity-altering experience (see previous post). No wonder people can have difficulties discontinuing them. People can be frightened about stopping antidepressants (see another previous post and yet another previous post).

Probably the first systematic review of antidepressant withdrawal was by Fava et al (2015) (see previous post). Personally, like Fava et al, I’ve always emphasised the vulnerability to relapse created by taking antidepressants (see another previous post). I’ve encouraged a focus on psychological aspects of prescribed drug dependence (see eg. my book chapter). Critical psychiatrists who believe in deprescribing often think the evidence for physical dependence is incontrovertible. But I do not agree.

There is little evidence that antidepressants cause increased tolerance, for example, in the same way as alcohol and opiates. Antidepressants are not primarily reinforcing like psychostimulants (see eg. previous post). I, therefore, think it is a mistake to say that antidepressants cause physical dependence. That’s not to diminish the power of psychological dependence, which they do cause.

Functional somatic symptoms caused by antidepressant withdrawal are of course common in medicine. It’s the nature of such symptoms that people find it difficult to appreciate they may not have a physical cause. Hence people who have experienced antidepressant withdrawal often disagree with me, sometimes vehemently. Nonetheless, the commonsense view is that people can become dependent on antidepressants for psychological reasons. This was a finding from the Defeat Depression campaign when it tried to educate the public that antidepressants are not addictive, when commonsense understanding is that they must be in the common parlance definition of addiction, as above, as the public already knew (see my BMJ letter).

As I note on my Antidepressant Discontinuation Reactions webpage, the strongest evidence in favour of physical dependence is neonatal withdrawal reactions. I note there, though, that data from spontaneous reporting is difficult to interpret. I haven’t updated that webpage for some time, but even so, neonatal reactions could be due to serotonin syndrome rather than withdrawal. It worries me about the dose of antidepressants that is getting through to neonates in utero. As far as I can see, the more recent studies of poor neonatal adaptation after antidepressant exposure in third trimester have not been able to distinguish that the cause is withdrawal rather than serotoninergic toxicity.

I’m old enough to remember the debate about whether withdrawal symptoms in benzodiazepines were merely due to habituation or physical dependence, led by someone like Malcolm Lader, who in the end came down on side of physical dependence, but he would never have denied psychological dependence. It is true that what led to the decline in the benzodiazepine market was the claim that benzodiazepines cause physical dependence, which I agree there is evidence for because of convulsions on withdrawal. Still, even with most physically dependence forming substance there is also psychological dependence and this must not be denied.

The problem with benzodiazepines is why the antidepressant market was so worried about also being labelled as causing physical dependence and went for admitting antidepressant discontinuation problems. Paxil/Seroxat makers, seen as being the worse for causing discontinuation, but I think probably unfairly because the fluoxetine people wanted to turn the focus away from themselves by pointing out the longer half-life, also had to admit that it caused addiction because of the common parlance use of the word (see Guardian article). The old common sense distinction between physical and psychological dependence got fudged by the syndromal approach of Edwards et al, even though there was strength in the syndromal approach with its seven elements (see Edwards & Gross (1976)).

Does anyone these days even know what I’m talking about when I say the syndromal approach to alcoholism and drug dependence? As I keep saying, psychological factors in antidepressant withdrawal cannot be denied. I’m just encouraging a sceptical attitude about physical withdrawal.

The truth about ADHD

The Times has an article about ADHD but does not make clear that that there is no evidence that ADHD is a neurodevelopmental condition affecting the prefrontal cortex of the brain, which is what the article says is the case. Nor does it really make sense to say that ADHD is executive brain dysfunction (see previous post). These types of misunderstanding that ADHD is a brain disorder pervade public consciousness, even though they are wrong. 

The Times article quotes the consultant psychiatrist apparently behind the website Parenting Matters as saying there is no increase in actual instances of ADHD, which is misleading at least, if not wrong. He apparently thinks the real problem is just worry about ADHD. The difficulty with that explanation is that it denies that there is any overdiagnosis of ADHD. If there is no overdiagnosis why do numbers of cases continue to rise? At least the article correctly states that there is no blood test for neurodiversity.

Nor does an ADHD diagnosis necessarily mean treatment with Ritalin is required. Anyway, Ritalin does not always work (see previous post). If it ‘works’ it could just be because of the placebo effect. There is no evidence that amphetamine (Ritalin) particularly affects the brain chemical noradrenaline in those with ADHD to produce a paradoxical calming and focusing effect, rather than hyperactivity. Again, these common misunderstandings are widespread.

Last year a Panorama investigation uncovered rogue psychiatrists misdiagnosing ADHD, shining a light on the very real market for a diagnosis (see previous post). This exploitation of people occurs maybe particularly obviously online (see another previous post). Society does need to adapt to individual differences between people, but that doesn’t necessarily mean that increasing the diagnosis of ADHD and other neurodevelopmental diagnoses is the answer to understanding and managing our differences from each other (see yet another previous post).

My BMJ article described how the identifying of behaviour of children when stressed as ADHD can avoid having to deal with the difficult task of improving family and school life. For example, is ADHD an excuse for misbehaviour in schools? Looked at in this way, it is indeed likely that recourse to drug treatment discourages self responsibility and thereby exacerbates the underlying difficulties that it is supposed to remedy. As far as the diagnosis of ADHD in adults is concerned, many psychiatrists think this is an example of the over-medicalisation of everyday life (see previous post).

There needs to be a much more open debate about the societal diagnosis of ADHD. The cultural process of seeking to create panaceas for emotional and other mental health problems doesn’t always work and may create more problems than it is worth (see previous post).

Placebo effect is responsible for antidepressant improvement in clinical trials

Peter Simons has an excellent blog post on Mad in the UK. He makes the case that the apparent benefit of antidepressants in clinical trials is an artefact and that any apparent improvement in depression is due to the placebo effect, not any active effect of the antidepressant.

The effectiveness of treatment is assessed in randomised controlled trials comparing active drug with placebo (see my OpenMind article). Participants are randomly assigned to two groups in the basic design,  in which they are given either the active drug or given a placebo, which is supposed to be inert and indistinguishable from the active drug. In other words, participants should not know to which group they have been allocated, so that they are blinded to which allocation they have been given. This is important as if they did know whether they had been given active drug or placebo then their expectation of the implication of that allocation could affect outcome. If they think, for example, the drug being tested is likely to be effective, then merely knowing the allocation may produce or exaggerate any difference between the two groups. If there is a significant difference between the groups, the finding may merely be a self-fulfilling prophecy that the active drug is better than placebo.

As Justin Karter said in a recent Mad in America blog post, an individual’s subjective belief about receiving active or placebo treatment in a clinical trial can significantly influence the outcome of treatment. If participants are unblinded, or unmasked - another word for unblinded - as to which treatment they have received, then these expectations could still be affecting outcome. Justin reviews a paper by Fassi et al (2023) that demonstrated in neurostimulation studies (see eg. previous post about neurostimulation) that the belief of receiving the active or the placebo condition during a trial can explain the research outcome better than the actual treatment to which the participants are assigned. In other words, the individual differences in subjective treatment explained the variability in outcomes better than the objective treatment.

I participated in a BMJ rapid response discussion following what I think is the most definitive paper about whether trials should obtain data about participants’ guesses as to which treatment they were given at the beginning of a trial. As explained above, trials are expected to be blinded/masked, so that neither patients or doctors, including raters, do not know whether participants are in the treatment or placebo group. As I also said in my last contribution to that rapid response discussion, there is a general positive gloss put on the problem of unblinding/unmasking in clinical trials. I went on:-

The general thought seems to be that measuring unblinding is difficult, so we may as well give up and carry on with our pretence [that trials are blinded]. This may be to continue "turning a blind eye", as used in the phrase in the title of the original paper.

 I suggested:-

I think it may be possible to measure what the degree of unblinding should be from correct hunches from efficacy based on effect size, and if the actual degree of unblinding with correct guesses is significantly greater than this, it would surely imply that bias had been introduced. … I am reluctant to … be as negative about the implications [of measuring unblinding/unmasking] as some of my fellow rapid responders.

I emphasised that in clinical trials that it is the raters that can detect unblinding, not just participants and that raters guesses matter even more than patient guesses, certainly if those patient guesses are not directly communicated to the rater when the assessment by the rater is undertaken.

I concluded:-

If raters are able to be cued in to whether patients are receiving active or placebo treatment, their wish fulfilling expectancies could be affecting outcome ratings. How do we know that small effect sizes [as in antidepressant trials, for example] in particular are not due to this amplified placebo effect? I think we should stop turning a blind eye to this legitimate question. It does need to be answered to give confidence about the use of many medications that are endorsed in clinical practice.

Thankfully, the article by Jureidini et al (2023) reviewed by Peter Simons in his blog post did produce data on unblinding/unmasking in the treatment for adolescents with depression (TADS) study - see my BMJ letter. As I say in that BMJ letter, “Fluoxetine was not in fact statistically better than placebo in this study and only became so when added to cognitive behaviour therapy in an unblinded arm”. It’s therefore wrong to conclusively conclude, as do many people, that the TADS study demonstrated that antidepressants, or at least fluoxetine, improve depression.

There were four treatment arms in the TADS study, which included fluoxetine (Prozac) only; cognitive-behavioral therapy (CBT) only; fluoxetine and CBT; and placebo. In psychotherapy trials it is not possible to blind participants as to whether they are given psychotherapy, such as CBT, from whether they were in the control treatment (see my BMJ letter). They have to be told which group they are in, unless they are deceived about the nature of the trial, which is generally regarded as unethical to do. So it has to be explained to participants that they will be allocated to the experimental therapy in the active condition, or allocated to a control group, which could merely be being put on a waiting list. Obviously they might be hoping that they would be allocated the psychotherapy treatment, rather than continuing on the waiting list for treatment, and are likely to be disappointed if not given that allocation, which could well affect how they rate their degree of improvement or otherwise during the trial. Anyway, psychotherapy trials cannot be conducted double blind and there is always the methodological issue of the adequacy of control groups in clinical trials of such treatment in terms of being able to interpret the effectiveness of psychotherapy.

All four groups in the TADS study guessed treatment allocation more accurately than the 50% that would be expected by chance. Treatment guess had a substantial and statistically significant effect on outcome. The treatment effect was actually then not significant, even though it wasn’t anyway. Removing guesses from the analysis still did not make the treatment effect really significant (p=0.06, when standardly p<0.05 is the significance level used in clinical trials). As Jureidini et al conclude for the TADS study, “treatment guesses strongly predicted outcomes and may have led to the exaggeration of drug effectiveness in the absence of actual effects”. Unblinding, which amplifies the placebo effect, may well be the reason for the small difference in clinical trials between antidepressants and placebo. 

Participants in TADS improved more if they believed they had received the drug rather than placebo. Those that guessed placebo even though they had received fluoxetine actually improved more than those on the drug who guessed correctly. Although this was reversed for those that received placebo ie. that those who guessed correctly when on placebo did worse than those actually on the drug, these findings merely highlight the importance of belief about treatment rather than necessarily the treatment itself in outcome of treatment for depression. In fact, those who were more confident of their guess reinforced this effect more than those who were less confident. 

Interestingly, Jureidini et al did not find much association with side effects of medication as the reason for unblinding. This has been the typical reasoning of Irving Kirsch, for example, that it is side effects of medication that cue people in to their allocation in a clinical trial (see eg. previous post). There is evidence for this hypothesis in that active placebos, which mimic the side effects of the trial drug, generally reduce the effect size. But it’s not the only reason for unmasking in clinical trials, which can even include fraud by the raters, who actually somehow break the blind before they do their assessment. Holding up to the light sealed envelopes which contain the coded allocation of patients, so that the allocation shows through has been highlighted. Anyway, the guesses of trial participants can easily be communicated to raters in the assessment interview. Participants in antidepressants trials do seem to be significantly unblinded, even if they may not be in lithium trials (see my BJPsych 1996 letter).

TADS should never have been used to recommend fluoxetine for adolescent depression. Analysis of the guesses and subjective beliefs of participants merely reinforces this conclusion and highlights the obvious influence of placebo factors in any response to antidepressants. This placebo effect must not be ignored and the pretence that it has been eliminated in randomised controlled trials must stop. The fear that antidepressants may not be effective and that the modern basis of psychiatric practice in medication may collapse does not justify not taking the issue of bias in clinical trials seriously (see eg. previous post).

Independent review following Edenfield scandal

I mentioned the scandal at the Edenfield Centre in a previous post. The independent review of the parent organisation, Greater Manchester Mental Health (GMMH) NHS Foundation Trust, by Professor Oliver Shanley is excellent, in my view. What was striking was the level of distress the inquiry found amongst patients, families and staff. The report made clear that patient care at GMMH has, at times, been poor, and the work of BBC Panorama has made this very clear.

At the same time, the inquiry found there are a great many members of staff who are passionate, evidently talented and highly committed to their patients. But there were repeated stories of senior managers treating staff poorly and fostering a culture of fear and intimidation in order to maintain performance standards. The Trust's management of significant concerns showed slow pace of change, lack of transparency and/or clarity in reporting, lack of scrutiny of key information and lack of rigour in the monitoring of change.

At Edenfield there were a number of factors that enabled the poor care and abuse to take place. These included: 

• patients, their families and/or carers not being listened to or taken seriously

• a weak and fragmented clinical voice

• unsafe levels of staffing and high use of temporary staff

• a poor physical environment

• poor culture, including a lack of psychological safety and low morale, including unsupportive leadership behaviours, unsound HR practices including perceived unfair recruitment and promotion, and a lack of transparency about formal investigations

• conditions leading staff not to adhere to clinical policies such as record keeping and observations

• some staff described being treated unfairly because of a protected characteristic

All these findings led to these recommendations:-

1: The Trust must ensure that patient, family & carer voices are heard at every level of organisation. The Trust must respond quickly when people experience difficulties with services and make lived experience voices central to the design, delivery and governance of its services. The developed strategy in the area of hearing patient, family and carer voices needs to be implemented and evaluated to understand its impact.

2: A strong clinical voice must be developed and then heard and championed from Board to floor, and in wider system meetings.

3: The Board must develop and lead a culture that places quality of care as its utmost priority, which is underpinned by compassionate leadership from Board to floor. This culture must ensure that no staff experience discrimination.

4: The Trust must work with its current and future workforce levels to recognise, adapt to and manage the safety challenges that a staffing shortfall may pose, including ensuring the stability of nursing staff. The Trust must develop a representative, competent and culturally sensitive workforce which is supported to provide services that meet the needs of its communities.

5: The Trust needs to have a better understanding of the quality of its estate and the impact of this on the delivery of high-quality care, including providing a safe environment. It must ensure that essential maintenance is identified and carried out in a timely manner and that the cleanliness of units is maintained.

6: The Trust must ensure that its governance structure (and the culture that this is applied within) supports timely escalation and that the right information can be used at the right level, by the right staff. There must be much greater focus on the validation and triangulation of information to ensure that quality issues can be resolved quickly and learning can take place.

7: The Trust must ensure that Edenfield provides compassionate, high-quality care and that all staff, permanent or temporary, have the skills, knowledge, and support to achieve this.

8: The Trust should review the improvement plan again following receipt of this report’s findings to develop further clarity about the problems that they are trying to solve and the actions that need to be taken to achieve better outcomes. It needs to be clear on how all actions will be evaluated so that it can be assured about whether changes being made are having the desired impact. The plan should be prioritised to ensure that actions are sequenced, build on each other, and prioritise quality of care people. This includes ensuring a balanced approach between the scale of the improvements required and setting out a realistic timescale for implementing identified actions with the support of their system partners.

9: Some common concerns identified across services visited at the Trust were also prevalent within Edenfield. The Trust and wider system must consider how they understand issues identified in these services (and others) in more detail, including through the actions described below. 

10: Organisations with responsibility for regulation, oversight and support to GMMH must review their current systems of quality assurance. They must also review how they work together collectively to identify concerns in a provider at an early stage to prevent tragedies like those seen at Edenfield from reoccurring. Where learning is identified that applies nationally, this must be cascaded by the relevant organisation.

11: NHSE must review and clarify the role of the Greater Manchester Adult Secure (Northwest) provider collaborative and the governance structures needed to oversee this role. Responsibilities of collaborative need to be discharged by staff with the right experience and expertise. In light of concerns identified in relation to Adult Forensic Services (and wider issues in Specialist Services), the role of GMMH as lead provider needs to be reviewed by NHSE. If this arrangement is to continue, support should be provided to GMMH to stabilise the current situation and to develop it to deliver the role effectively in the future.

In conclusion, the report said the priority must be on people, on quality, and listening to those who use and work in services. GMMH has many positive attributes, not least its many talented staff. It must focus on enabling those staff to thrive. This will require a significant cultural shift if the required changes are to happen successfully.

The truth is that GMMH is not totally unique. I think this report has the potential to turn round the dysfunctional state of modern community mental health services in the same way as the Ely and Whittlingham Hospitals reports mentioned in the previous post above did for asylum care.