Vision for mental health policy

Penelope Campling’s book On the brink with patients’ stories from her life in psychiatry starts at the end of the asylum years, when many of us, as she says, were optimistic about the development of community care. But as I keep saying (see eg. previous post), mental health care, like much of NHS provision, has become too dysfunctional and fragmented. As I’ve also said before (see eg. another previous post), in many ways we are now repeating the worst days of the asylum in the community. 

Rights and recovery-orientated services need to be at the centre not the margins of mental health services (see eg. previous post). There were many strengths in the last Labour government’s mental health strategy (see my Mental Health Policy website, developed at the time, although several links are now defunct). Certainly it seemed to give far better direction than has been the case since Gordon Brown’s government lost the election. Where I think new Labour did not do so well was in managing concern about public safety in the context of the rundown of the asylum. There has been a reinstutionalisation of mental health services over recent years, perhaps most reflected in the increase in secure beds in both the public and particularly the private sector. This has been associated with an inappropriate over-preoccupation with risk in services. Risk is not always best handled by increasing coercion. Risk management needs to be more sensibly based on assessment, formulation and management of risk rather than the failed reliance on risk prediction (see eg. another previous post). 

The current Community Mental Health Framework for Adults and Older Adults to transform mental health services has been too non-specific in providing direction and there has been insufficient progress in  its implementation (see eg. previous post). Community Mental Health Teams have become too large and need to be devolved so that there is one in every Primary Care Network (PCN). The PCN mental health teams also need to work alongside non-medical mental health hubs, one of which again should be in each PCN. We wait to see how specific the new NHS 10-year Health Plan, due in June 2025, will be as far as mental health policy is concerned. 

Taking the debate about antidepressants forward

Joanna Moncrieff’s book Chemically imbalanced at least seems to have ruffled a few feathers, as it has led to a Lancet editorial. It’s not clear, though, from the editorial how the debate about antidepressants can be taken forward.

Of course many people say they have been helped by antidepressants. But the question is whether the outcome is any better than placebo. Although short-term clinical trials show a significant advantage for antidepressant over placebo, the effect size is small and there is a substantial non-response rate. Over the long-term recurrence is high and many still report residual symptoms. Moreover, it is possible that the significant difference in short-term trials is an artefact because of methodological problems, such as unblinding. Making people dependent on antidepressants is not necessarily in their best interest.

Mainstream psychiatry and medicine in general will never accept that antidepressants are ineffective. Unless people themselves no longer wish to see their mental health difficulties as biologic and are no longer interested in oversimplistic resolution of them by a pill or a bit of psychological therapy, then psychiatry will continue to exploit the placebo effect. The Lancet editorial is right to conclude we remain a long way from providing the level of mental health care that so many people need. It’s been a mistake to look for the solution in psychotropic medication.

Making psychiatry more open-minded

Peter Gøtzsche is not joking when he asks if psychiatrists are more mad than their patients (see his Mad in America blog post). I understand what he means about the wishful thinking of biomedical psychiatrists (see eg. previous post). 

It’s important not to distance ourselves from people with whom we just disagree by labelling them insane (see eg. previous post). Even those who are truly delusional because of the idiosyncratic, solipsistic self-centrality of their belief system (see eg. another previous post), which may well only be temporary, have got to that position because it is the only way they can make sense of the situation in which they find themselves (see eg. yet another previous post). Delusional beliefs make sense at least to the person that holds them.

We shouldn’t be too surprised that psychiatrists tend to adopt the biomedical views they do. For example, the belief that brain pathology is the basis for major mental illness helps to avoid having to deal with complicated metaphysics about the mind–body problem. It also appears to bring psychiatry closer to the rest of medicine by seeing mental illness as having a material basis as do physical ill­nesses in general. Furthermore, it also creates a scientific ambition and associated research programme to uncover the neuroscientific causes of mental illness, which attracts massive amounts of research funding. All these wishes and desires are understandable, but they may be more based on faith than science. Peter is right to object to the pseudoscientific nature of much of modern psychiatry (see eg. previous post).