What's psychosocial reductionism?

Allen Frances has clarified his position on psychiatric diagnosis in his Saving Normal series on Psychology Today (see article). Although he's been critical of DSM-5, in response to Lucy Johnstone, he makes clear that, for him, the biological model is essential and that neuroscience has been "enormously successful in helping us understand normal brain functioning and that over time, in very small steps, this will result in better understanding of abnormal brain functioning". However, he doesn't explain what he means by this.

And he doesn't seem to understand the meaning of reductionism. Reducing the psychosocial to physiological processes is what psychiatry does all the time. I'm not sure how the psychosocial can be reduced to the psychosocial. Presumably Frances is suggesting that the psychosocial is a simpler form of something more complex, but is it?

Reinvigorating community mental health care

It's worth looking at the article by Peter Tyrer in The Psychiatrist on community psychiatry in the context of today's report from BBC News and Community Care about what they call the crisis in mental health care. To quote from Peter's article:-

The general mantra of ‘community psychiatry good, hospital psychiatry bad’ has … led to the neglect of the proper function of in-patient care, a combination of asylum and rehabilitation. …[A] fundamental wish to improve patients’ autonomy is being removed by an overbureaucratised system of community care that is obsessed by risk, and in danger of promoting greater institutionalisation by a complex regulatory framework that denies the flexibility that is essential to good community psychiatric practice.  

Where in the UK community psychiatry used to be flexible, adventurous, creative and bold, with the many changes imposed from policy managers in recent years it has become constricted, controlled, limiting and self-serving. Autonomy for practitioners has almost entirely disappeared and been replaced by a rigid system of care that leads to patients encountering a bewildering number of health professionals, who carry out specific regimented tasks but who rarely have the chance to develop meaningful relationships with the people they treat.

His solution is to remind ourselves of the core principles of good care:-

1. if good facilities are available for patients to be treated outside hospital, they should be used as much as possible;
2. if a hospital bed is necessary it should be available when required and should be as close as possible to the patient’s home; hospital should be able to serve as a place of refuge and respite as well as a treatment centre;
3. continuity of care may not always be possible but should be striven for as a matter of principle, and all community teams should stay in touch with their patients no matter where they are placed;
4. individual or team-based treatment both have merits and their choice should be determined in collaboration with the patient and his or her carers, and maintained irrespective of treatment setting.

He goes on:-

This can only be achieved by allowing greater autonomy within teams to maintain priorities, reducing the size of the catchment area for each team so that they do not become overwhelmed and depersonalised in their attitudes.... [M]orale [needs to be raised] of a service that has been relegated to the backwaters of care for too long. 

Increase in patient suicides has followed introduction of CTOs

The headline for this piece is deliberately tongue in cheek. It's not supposed to imply that the introduction of community treatment orders (CTOs) has led to an increase in suicides, although, of course, I am aware that this is how it could be taken. It's just that the latest report from the National Confidential Inquiry (NCI) into Suicides and Homicides by People with Mental Illness has implied that CTOs have reduced homicides. I just thought it important to point out, if that claim is being made, that CTOs have not reduced suicides. In theory, CTOs could have either increased or decreased deaths by suicide and homicide. And NCI expected CTOs to have a greater impact on absolute numbers of suicides than homicides. Or maybe it thinks the increase in suicides would have been a lot worse without CTOs.

To be clear, what the report points out is that homicide by mental health patients has fallen substantially since a peak in 2006. This might not have been obvious from recent headlines in The Sun (see previous post). The report goes on to say that one of the clinical explanations may be the introduction of CTOs in 2008.

The report also notes that the number of patient suicides increased in 2011. Although the figures are provisional because the data is incomplete, a higher number of patient suicides is predicted in 2011 than in recent years. There's no speculation that this is due to CTOs; instead the "rise probably reflects the rise in suicide in the general population, which has been attributed to current economic difficulties".

After all, it was NCI that argued for the introduction of CTOs to reduce homicide and suicide. It even went as far as to predict in Safer services that 30 suicides and 2 homicides would be prevented each year. A later report, Safety first, increased that figure to 32 suicides and 3 homicides. The trouble is that the logic used to produce such estimates did not stand up, as all NCI did was assume that CTOs would prevent deaths and then produce figures based on this premise. The fact is that whatever figure was produced is not evidence of the value of CTOs, as it was only an estimate assuming they were going to be effective. Maybe that's why the latest report latches on to the reduction in homicides. NCI needs some evidence to justify its previous speculation, which it couched in pseudoscientific terms. But, of course, this isn't evidence as such because there are all sorts of reasons why the homicide figure may have gone down, in the same way as there are all sorts of reasons why the suicide figure has gone up.

Irrational homicide risk management

The Sun has been taken to task for producing the front page headline that 1200 people have been killed by mental patients in the last 10 years (see Guardian and New Statesman articles). The Daily Star had a similar report. This article quotes from Marjorie Wallace, whose intentions, I think, are to improve funding for mental health services, but her campaigning on behalf of her mental health charity, SANE, has, in my view, actually undermined services.

She complained to The Sun that a failure of communication between one agency and another has been found in 90% of homicide inquiry cases. But, communication is not perfect in everyday practice. In fact, it is commonplace for staff to have to cover 'gaps', such as not having complete information. Such imperfections are usually managed without adverse consequences.

The question is whether such homicides really reflect failings in Britain's mental health system. There has certainly been overreaction in some homicide inquiries, which do not always apply accountability sensibly. It is a phantasy, which we need to disabuse ourselves of, to believe that mental health services can have absolute control in preventing homicides by their patients (see my unpublished article and associated conference presentation). I'm not saying services don't need to be improved, but attacking them for homicides by psychiatric patients is not always the best way to improve them. Political motivation should have nothing to do with sensible risk management.

Psychiatry shooting itself in the foot

Just to reinforce my previous post, the President of the American Psychiatric Association has said that the mass shooting in the Navy Yard in Washington, D.C., like previous such tragedies, "reflects the failings of the U.S. mental health care system" (see post). The answer to my question about why psychiatry accepts this projection is that he believes this will increase the social and political will to provide quality mental health services.

Even if his motive is to provide every person with a mental illness and/or substance use disorder with "access to affordable, quality mental health treatment", he doesn't provide any evidence that psychiatry can identify and treat perpetrators of mass shootings. To encourage this phantasy is a folie a deux between psychiatry and the public.

The omnipotence of the mental health system

Gallup have found that 48% of Americans say that they blame the mental health system "a great deal" and 32% "a fair amount" (ie. 80% total blame) for mass shootings in the United States (see report). Comparative total figures for blaming guns and blaming drugs are 61% and 66 % respectively. The report on Gallup Politics interprets this to mean that Americans believe "more can be done on the mental health side", but it doesn't say what it thinks can be done.

Actually research has shown that the removal of semi-automatic and pump-action shotguns from civilian possession after the 1996 firearm massacre in Tasmania led to no mass shootings in Australia in the 10.5 years afterwards, whereas in the 18 years before the gun law reforms there were 13 (see article). Does the American public really think services have the ability to detect and treat mentally unstable people capable of such crimes? Do they really mean what they say? If so, they seem to think psychiatry is all-powerful. Perhaps that's where psychiatry is going wrong by accepting this projection.

Is psychiatry our necessary shadow?

Tom Burns, who I have mentioned in a previous post, has written a bland apology for psychiatry, Our necessary shadow: The nature and meaning of psychiatry. As he says, he is "convinced psychiatry is a major force for good or I would not have spent my whole adult life in it". Having also spent most of my adult life as a psychiatrist, I suppose I'm inclined to be an apologist as well, but I would only say that psychiatry can do good not that it does. Burns recognises what he calls psychiatry's "mistakes" but sees these as failings that need to be put in perspective, rather than, as I do, something more fundamental about the nature of psychiatry.

Burns describes a new group of anti-psychiatrists, which he says "are, as it were, evidenced-based anti-psychiatrists" [his italics]. In this group he selects from what he calls an "almost endless" list of books: Richard Bentall's Doctoring the mind (see my previous post) and Madness explained; Jo Moncrieff's The myth of the chemical cure (see my post about Jo's new book); and Peter Breggin's Toxic psychiatry and Brain disabling treatments in psychiatry. (See my book recommendations on my critical psychiatry website.)

Burns suggests these new anti-psychiatrists (see previous post about use of the term 'anti-psychiatrist'), although they may share "a deep suspicion of the fundamental legitimacy of psychiatry and psychiatric diagnoses" are more concerned about "the damage done by psychiatry and psychiatrists" [his italics]. From his point of view, "their arguments are generally that psychiatry is too full of itself, or is corrupted by pharmaceutical companies, or that it makes endless mistakes". One of his reasons for writing his book is to "try and explain why psychiatry survives despite this tsunami of criticism". He goes on:

If psychiatrists are false prophets it is because they fail to deliver what they promise; it is not their mistaken metaphysics. It is their incompetence rather than their omnipotence that is the issue.

If I understand him right, he doesn't want to engage with conceptual issues about the nature of mental illness. This is not dissimilar from the position of Anthony Clare in Psychiatry in dissent (see previous post) and fits with Burns ambition to see his book as this generation's "attempt to explain psychiatry fully to the interested outsider", as Clare's book was for a previous generation. I think Burns is setting the barrier of competence too high for psychiatrists! He clearly does have an ideological position eg. he accepts the rather trite position that schizophrenia has a heritability of 80%. Despite what he thinks, as I keep saying, it is important to move on from the biomedical paradigm (see previous post). Burns atheoretical approach does not salvage psychiatry.

Stop thinking about DSM-6

Collection of psychiatrists' views about DSM-5, including those of Charles Nemeroff (see previous post) and Simon Wessely (see another previous post), have been published by BMC Medicine.

Nemeroff and Daniel Weinberger suggest the motivation for DSM-5 was (1) unrealistic anticipations of being able to include genetic markers for mental disorders following the sequencing of the human genome, and (2) unrealistic enthusiasm that brain imaging studies would produce pathognomonic findings about the neurobiology of mental disorders. Their wishful thinking means that only in retrospect do they find this surprising, blaming the complexity of the brain. Actually, it's not just the complexity of the brain that's the issue, but their naivety that the brain-mind problem could be solved. We need to move on from the biomedical paradigm (see previous post).

Nor, as they imply, did the explicit criteria of DSM-III solve the subjectivity and uncertainty of psychiatric diagnosis, which is actually intrinsic to its nature. There needs to be a change of thinking about psychiatric classification. As I said in my previous post in relation to Simon Wessely, please stop talking about DSM-6, at least until there's a proper conceptual understanding of the nature of mental illness. Nemeroff and Weinberger's unrealistic hopes are an insufficient basis on which to proceed.

The truth about antipsychotics is hard to swallow

This website has been given a 20% discount for the important, soon to be published book The bitterest pills by Jo Moncrieff. Order through Palgave.com and use code WBitterest2013. (Do check, though, that this is the best deal - currently seems to be cheaper on the Amazon site).

Current fashion in antidepressant research

Just to reinforce my previous post, Psychiatric Times has a video article suggesting that the next fashion in antidepressant research will be based on glutamine not serotonin. At least one of the apparent drivers for this research is the realisation that antidepressants don't always work (see previous post). But, let's please not let any of these new agents onto the market if they're no better than the old ones.

Serotonin hypothesis of depression was wrong

Move over serotonin; let's exploit glutamate in the treatment of depression. So suggests the journalist, Samantha Murphy, in a New Scientist article. Her argument is that the rise in treatment resistant depression reflects a realisation that antidepressants don't work. She holds out new hope for repetitive transcranial magnetic stimulation (rTMS) (see previous post), cranial electrical stimulation and ketamine. The speculation is that the release of glutamate by these treatments repairs the shrivelled dendrites of depressed people's neurones. She says at least 5 pharmaceutical companies are working on developing ketamine derivatives.

The academic paper to support this journalistic hype may be that by Duman & Aghajanian (2012) in Science. Look out for the promotion of a synaptogenic hypothesis of depression and treatment response. Scientific progress? Surely not.

Is APA prepared to engage with critical psychiatry?

At least Jeffrey Lieberman is prepared to engage with criticism of psychiatry in his role as President of the American Psychiatric Association (see his recent article in Psychiatric News). This is to be welcomed as mainstream psychiatry has tended to marginalise critique (eg. see previous post). True, Lieberman does tend to dismiss questioning of the integrity of psychiatry as Cartesian anti-psychiatry. He clearly has more work to do in taking this issue forward.

He sees psychiatry as a "scientific discipline and full-fledged medical speciality", but then doesn't explain what he means by this. Nor does he say what is meant by "the progress that has been made to deconstruct the almost unfathomable complexity of the brain into its constituent neurobiological mechanisms that mediate emotion, perception, and cognition". If there has been such progress he ought to be able to tell us what it is. He indicates that the technologies of "psychopharmacology, modern neuroimaging methods, and molecular genetics" are what have begun this process, but, again, does not spell out the references. He confidently states that "recent advances in research have shown us that they [mental disorders] are biological in nature and caused by genetics and environmental factors". However, we're clearly supposed to understand more for this claim than the merely tautologous connection.

I agree psychiatry has nothing to be defensive about this "noble mission", unless it's all a myth. Lieberman has a duty to clarify whether he's being realistic or pursuing a wishfulfilling phantasy.

(With thanks to Phil Hickey for a post on his Behaviorism and Mental Health blog).

Why does the APA need new editions of DSM?

Simon Wessely in his blog post about an IOP conference on DSM-5 assumes there will be a DSM-6. Have we now come to expect continuous revision of psychiatric classification? If so, it's difficult to understand why. There has never really been any expansion of "the scientific basis for psychiatric diagnosis and classification" despite this being the apparent impetus for DSM-5 (see website). Maybe APA's motivation for continuous revision is merely financial gain. DSM-IV made at least $100 million, but, even so, DSM-5 should be free open access to all on the internet.

The reason for the DSM-III revision was very clear (eg. see my article). From mainstream psychiatry's point of view, diagnosis was in crisis because of its unreliability. Operational criteria were therefore developed. Unfortunately these may be no more valid than commonsense definitions. So, we could put up with amendments through DSM-III-R, DSM-IV and DSM-IV-TR, but tinkering further with DSM-5 is a step too far.

As Simon says, "The aspiration that DSM-5 would represent as significant a break with the past as DSM-III had been, effecting a second revolution by moving from symptom based diagnosis to aetiologically based diagnosis using the latest advances from neurosciences and genetics turned out to be just that, an aspiration". That's why the current NIMH director has turned his back on DSM-5 (see previous post), although his predecessor was one of the originators of the DSM-5 process in 1999. However, despite all the DSM revisions, there's no getting away from the poor validity and reliability of psychiatric diagnosis. That's its nature and psychiatry's wishful failed ambition needs to be recognised for what it is.

Ban face down restraint in psychiatric hospitals

To his credit, Norman Lamb (who I have mentioned on my personal blog eg. see previous post), Minister of State at the Department of Health, says he is considering just banning face down restraint in psychiatric hospitals (see BBC news story). This is following a call from Mind demanding national standards on the use of physical restraint, accredited training and an end to face down restraint on the basis of data they have secured from NHS trusts under FOI requests (see news item).

It was a pity that the take up from the Blofeld report on the death of Rocky Bennett some years ago focused on institutional racism rather than also on restraint. As I said in my BMJ eletter, "Death of a patient under restraint should help us to refocus on the need for a therapeutic approach rather than just custodial practice in mental health services." Organisational interventions can dramatically reduce the use of seclusion and restraint, reflected in the wide variation found by Mind in their survey. Hence government intervention in the way considered by Lamb could have significant effects.

As I said in another eletter about this issue, we need to highlight "... the importance of the culture of mental health services in limiting the use of such restrictive procedures". The focus on defensive practice over recent years has not been helpful. Restraint may be better seen as an indication of treatment failure, rather than treatment as such.

The ethical corruption of academic psychiatry

Phil Thomas asks why Charles Nemeroff has been asked to give the inaugural annual lecture of the new Centre for Affective Disorders at the Institute of Psychiatry (IOP) (see blog post). After all, Nemeroff has been one of the most blatant examples of psychiatrists' wrongdoing by under-reporting of pharmaceutical company earnings (see previous post). It's this sort of thing that makes even the most biological of psychiatrists concerned about the moral integrity of modern psychiatry (eg. see post by Michael A Taylor).

Ironically, from his previous published research (eg. Nemeroff et al 2003), Nemeroff may be seen as promoting psychotherapy in his lecture rather than necessarily any psychotropic medication. Nonetheless, of course, he does think monaminergic drugs are therapeutic in depression. His speculation is that the reason some people survive early life stress (ELS) is because of their genes. In a clinical trial, it was found that depressed patients with a history of early childhood trauma did better with psychotherapy alone than antidepressant monotherapy. Don't be misled by this! Maybe paradoxically, Nemeroff thinks psychotherapy is a "biological treatment". He believes it changes gene expression. As I've warned previously (see previous post), don't be taken in by such neuropsychotherapy.

Nemeroff's lecture at IOP may not be that much different from the one he gave at NYU last year (see video). It may not be that exciting or interesting. His NIH grant in 2012 caused controversy because of his past ethical problems (eg. see letter from Senator Grassley). The project information for the study explains that he's wishfully looking for the genetic risk factors for PTSD. Maybe the Centre for Affective Disorders will also undertake similarly misguided research. Let's at least know from IOP where it's getting its funding from, because choosing Nemeroff as its inaugural lecturer for its new centre does not bode well.

Abandoning diagnostic criteria for research in mental health

The blog entry by Thomas Insel, NIMH director, has created much comment (eg. New Scientist article and blog post by Phil Thomas). I've mentioned before how grandiose Insel can become in his claims for mental disorders as biological disorders involving brain circuits (eg. see previous post). His RDoC project will not create a new nosology despite his wishful thinking. As he says, we lack the data to "design a system based on biomarkers or cognitive performance". We need to accept the uncertainty of psychiatric practice and medicine in general, rather than promote 'precision medicine' as the solution to mental disorders as he proposes.

Nonetheless, we should welcome NIMH re-orientating its research away from DSM categories. It may actually be progress if this means funding research on patients without relying on diagnostic criteria.

Invitation to Radical Caucus Events at APA on May 18th

THE RADICAL CAUCUS HAS MANY IMPORTANT ACTIVITIES THIS YEAR, AND OUR COLLEAGUES FROM THE CRITICAL PSYCHIATRY NETWORK WILL BE JOINING US. PLEASE COME TO DISCUSS PLANS FOR COLLABORATIVE GLOBAL ACTIVITIES. (NOTE: IF YOU PLAN TO COME TO DINNER PLEASE LET ME KNOW, ALTHOUGH LAST MINUTE GUESTS ARE STILL WELCOME.) ALSO NOTE NEW LOCATION FOR DINNER.

RADICAL CAUCUS EVENTS AT THE 2013 AMERICAN PSYCHIATRIC ASSOCIATION ANNUAL MEETING IN SAN FRANCISCO

Saturday May 18, 2013: 9AM to 12 Noon: Moscone Center, Street Level, Gateway Ballroom 102

Presidential Symposium: “Envisioning a New Psychiatry: Radical Perspectives”

Chairs: Carl I. Cohen , MD; Kenneth Thompson, MD;

Discussants: Sami Timimi, M.D., Helena Hansen, M.D., Ph.D.

Presentations:

· Jean Furtos, MD: “Globalization and Mental Health: The Weight of the World, the Size of the Sky

· Sandro Galea, M.D.: “Re-Engaging Research Around the Socail and Economic Production of Mental Health:Toward a Comprehensive Model of Mental Illness”

· Pat Bracken, M.D, Ph.D: ” Beyond the Technological Paradigm: A Positive Path for psychiatry”

· Steven Moffic, M.D.: Eco-Psychiatry: Why We Need to Keep the Environment in Mind”

· Keris J. Myrick, MBA, Ph.D(cand): Alternative, Complimentary, or Traditional: A Radical Approach from the C/S/X Perspective”

Saturday May 18, 2013; 3:30PM -5:00PM; Moscone Center

Issue Workshop: “United Kingdom Critical Psychiatry Network: Implications for the APA and Global Psychiatry”

Chairs: Helena Hansen, M.D. , Ph.D.; Bradley Lewis, M.D., Ph.D.

Presenters:

Dr Hugh Middleton, MA. MD. MRCP. FRCPsych.

Professor Sami Timimi, MBChB FRCPsych

Dr Pat Bracken, DPM,MA,MD,PhD,MRCPsych

Saturday, May 18, 2013; 6:30PM -8:30PM Hilton San Francisco; Union Square Rooms 19/20 4th Floor, Tower 3

“Radical Caucus Meeting–Open Discussion and Planning Session”

Light Snacks and Beverages

8:30 PM Radical Caucus Annual Dinner Dinner (note new location) 

Basil Canteen located on Folsom street at 11th1489 Folsum St (at 11^th St); 415-552-3963.

All Welcome!!!!

For more information contact: carl.cohen@downstate.edu.

Also visit our new Web site at http://www.radicalcaucus.com.

Please post comments and suggestions.

Carl I. Cohen , M.D.

SUNY Distinguished Service Professor & Director

Division of Geriatric Psychiatry

SUNY Downstate Medical Center

Box 1203

450 Clarkson Avenue

Brooklyn, N.Y. 11203

email: carl.cohen@downstate.edu

ph: 718-287-4806

fax: 718-287-03377

Phantasy dreams about NEI congress

I've mentioned before the apparent fun people have at NEI congresses (see previous post). The latest video from neipsychopharm gives an idea about what you missed from the recent congress. I suppose we can hope that what happened at the congress may help patient care but it's difficult to see how it would.

Call to embrace social paradigm

Leaders of British academic social psychiatry argue in BJPsych editorial that the rules regulating research and the dominant neurobiological paradigm may have stifled creativity. The new charity MQ: Transforming Mental may need to take this perspective more on board. (Why's it called MQ?)

Clutching at genetic straws for impersonal treatment

Jeremy Laurance in The Independent says that a study led by Hugh Gurling has opened up the prospect of so-called personalised treatment of bipolar disorder with drugs targeting the metabotropic glutamate receptor 3 (mGluR3). This is based on a finding that the Kozak sequence variant of the glutamate receptor 3 (GRM3) gene, which encodes for mGluR3, was overrepresented in a sample of bipolar disorder cases compared with controls. As the paper concludes, confirmation of this finding is needed before accepting this potential marker. It could just be a chance finding based on screening until a significant result is found.

As the paper also points out, "The GRM3 gene has been investigated in bipolar affective disorder as part of several genome-wide association studies (GWASs) but failed to reach genome-wide significance in any of these investigations." Still research goes on with this gene because it is assumed the failure to find genetic association is "probably the result of the presence of low-frequency disease alleles and the high degree of etiologic genetic heterogeneity".  Actually it's more likely that there's no genetic link.

I haven't forgotten Hugh Gurling's false claim in Nature in 1988 that he'd found strong evidence for the involvement of a single gene on chromosome 5 in the causation of schizophrenia. Jeremy Laurance shouldn't be so easily taken in by claims for so-called personalised (actually there's nothing personal about it in the sense of relating to patients) psychiatry.

More compulsory community treatment does not reduce readmission rate

Results of OCTET study comparing use of S17 leave and CTO has been published (see paper). The rate of readmission was not reduced by CTO compared to use of S17 leave. Other studies have also shown no reduction in readmission. As might have been expected, this finding was despite the period of supervised community treatment being on average more than three times longer on CTO than by using S17 leave. 

CTOs were actually introduced because it was believed they would reduce death by suicide and homicide, supported by fantasy estimates of how many lives would be saved (see my unpublished paper). Three people died in the CTO group (two by suicide and one by accidental death) and two people died in the S17 leave group (one by suicide and one by natural causes). As death is a rare event, it's not going to be possible to demonstrate in a randomised controlled trial whether CTO reduces death. However, as the authors of the study say, because of the restrictions on patients' liberty, the costs and benefits of CTOs do need to be assessed.

Antidepressant discontinuation problems can be persistent

Article describes patient online reporting of antidepressant discontinuation problems. Persistent post-withdrawal symptoms after 6 weeks are common and can continue for months or years if drug not restarted. I'm not sure how valid the distinction is between immediate withdrawal symptoms and the post-withdrawal phase, but at least this article emphasises that antidepressant discontinuation can be a persistent problem.

(With thanks to post on Mad in America)

Frank Bruno’s 12 rounds to knockout mental health problems

Frank Bruno has spoken to the minister for care services about his treatment by mental health services last year (see EDP report). He had already spoken to the Sunday Mirror. As he says on his website, he wants to highlight "what is wrong in the treatment of mental health patients". 

We're not all exercise fanatics like Frank, and some of his other points may need refining, but his campaign should be supported. I had a letter published in the Observer when he was also sectioned in 2003.

Is the media distorting findings about antidepressant effectiveness?

Adrian Preda in a rapid response to the debate about whether antidepressants are over-prescribed, which I have mentioned previously (eg. see post), makes reference to his blog entry that blames the media for distorting findings and misleading patients. He makes clear that he is worried that depressed patients may not take antidepressant medication.

I think it is clear that Irving Kirsch is making the case that antidepressants are amplified placebos (see previous post). Preda doesn't really deal with this issue. As I keep saying, there doesn't seem to be any argument that the drug placebo difference in clinical trials is small. The question is whether it can be explained by expectancy effects through unblinding in clinical trials.

The challenge of reducing and stopping antidepressants

In a rapid response to the BMJ debate I mentioned in my previous post, Philip Gaskell has highlighted the problem of discontinuation of antidepressants. His clinical experience is that "the suggestion that they [patients] might move to stopping such tablets is greeted with fear and resistance". 

I have focused on antidepressant discontinuation problems since my original BMJ letter and the development of my antidepressant discontinuation reactions webpage. The issue continues to create debate on this blog and the Royal College of Psychiatrists has already produced the results of its survey to which Gaskell refers (see previous post).

Lies, damned lies and statistics of antidepressant effectiveness

The BMJ has published a head-to-head about whether antidepressants are overprescribed, with Des Spence saying Yes and Ian Reid saying No. Reid quotes the study by Fountoulakis & Möller (2011) that provided a re-analysis and re-interpretation of the Kirsch data, which I have mentioned previously (eg. see post). Reid concludes, "Sadly, demonstrations of methodological flaws and selective reporting suggest that the conclusions [of Kirsch] were 'unjustified.'"

What Reid doesn't quote is the response by Kirsch et al (2012) which shows that the original calculations were in fact correct. The discrepancy comes from using different statistical techniques, the effect of which is that the analysis by Fountoulakis & Möller treats individual studies as though they are equivalently powered. This is contrary to the standard meta-analytic technique of weighting studies with a large sample size more than the ones with a small sample size.

Let's not get too hung up about the statistics! What is significant is that Reid uses a discrepancy like this to try and undermine Kirsch's conclusion. The fact is that the effect size in antidepressant trials is much smaller than is commonly assumed. Not everyone responds to antidepressants even in the clinical trials. It is possible that the small effect size could be explained by expectancy effects introduced through unblinding (eg. see the article by Jo Moncrieff and myself).

Event for psychiatrists

Following the special article in the British Journal of Psychiatry (see previous post),  the Critical Psychiatry Network has organised a day at the University of  Nottingham on 15th April 2013 (see provisional programme).

Don't be taken in by neuropsychoanalysis

Oh dear! - in an eletter in response to the article that I keep mentioning about paradigm shift in psychiatry (eg. see previous post), a past chair of the Faculty of Psychotherapy of the Royal College of Psychiatrists confirms he's been taken in by neuropsychoanalysis (see his editorial to which he refers in the eletter). He doesn't mention the case against neuropsychoanalysis (eg. Blass & Carmeli, 2007). I had my own views confirmed in person recently by attending a seminar by Rachel Blass organised by Anthony Stadlen.

Holmes is worried that psychodynamic psychotherapy has become "something of an endangered species", in a similar way to those proposing remedicalised psychiatry are worried that psychiatrists could become extinct (see previous post). I do understand what he is saying about the brain being dynamic rather than static but to believe that psychoanalysis has gained credibility because physical correlates of its "black-box postulates" can now be envisaged on a fMRI scan is neo-phrenological phantasy. Sorry, psychiatry does have to deal with the complexity and uncertainty of human relationships, however "vague and anodyne" Holmes may find this. I take a more pragmatic than postmodern view of psychiatry (see previous post), but still prefer my neo-Meyerian approach to his environmental neuroscience.

I think it's a shame to see the history of psychoanalysis and psychodynamic psychotherapy being given up to modern neuromania.

Clinical psychologists should take on more responsibility

Peter Kinderman and Sam Thompson, in an eletter in response to the article I mentioned in a previous post, suggest replacing psychiatrists with clinical psychologists. I'm not against this development and have even promoted clinical psychology, being a general member of the Division of Clinical Psychology of the British Psychological Society myself. I often tell the story of when I applied for clinical psychology training years ago that I was advised to go back and complete my medical training, which I had given up midstream, as I would then have more influence as a psychiatrist with my views about mental health services.

I would like clinical psychologists to take more responsibility as clinicians, even becoming responsible clinicians under the Mental Health Act (see previous post). They tend to retreat into becoming cognitive behavioural or some other psychological therapist, which is fine for those that want to do it, but mental health services are about more than psychological therapy (and some clinical psychologists don't even get that right eg. see another previous post). I support clinical psychology creating a career structure that pays them more for taking on more clinical responsibility.

How to mislead people with IAPT

Following up my previous post about IAPT (Improving Access to Psychological Therapies), I  have looked at the evaluation by Glenys Parry et al (2011) of the two demonstration sites for the programme. Although this report was published last year, it seems to have raised little interest. I can't even find it referenced on the IAPT website. Perhaps the IAPT programme doesn't want to take note of its findings.

I have been complaining that proponents of IAPT have been making claims for its effectiveness (including numbers of people moving off benefits) without comparative data. Glenys and colleague's study did have comparator sites for each demonstration site, although one of them obtained IAPT funding during the period of the evaluation. At four month follow up, the IAPT cohort and the comparison cohort had improved on all the patient-reported outcome measures with a similar degree of improvement. At eight months there were no statistically significant differences between the cohorts. 

By contrast, a research study comparing face-to-face (FTF) with over-the-telephone (OTT) delivery of low intensity cognitive behavioural therapy has been received enthusiastically by the IAPT programme. The study found that the two methods of delivery were just as effective and it was cheaper to use the phone. I suppose if IAPT doesn't really have much effect, then doing it over the phone isn't going to make it worse and it's better not to waste too much money on the programme.

I agree with Rosemary Rizq that this is a perversion of care (also see her paper -  IAPT, anxiety  and envy). IAPT is turning away from the realities of managing distressed people. Of course, this isn't new for mental health services, but it's particularly blatant with IAPT.

Turning neuroscientists into psychosocial psychiatrists

Interesting paper on Adolf Meyer, about whom I have published, linking his psychobiological ideas with critical psychiatry (eg. see article and edited book).

Having had an elite training in Zurich, Paris, London, Edinburgh, Berlin, and Vienna, Meyer emigrated from Switzerland to USA in 1892 and his first job was at the Illinois Eastern Hospital for the Insane at Kankakee as a pathologist. Disgusted at being seen as the 'ominous crow' who was summoned when a patient's death seemed imminent, he started visiting the wards with another physician discussing possible causes, diagnoses, and treatments at the bedside in the presence of the patient and staff. He fetched patients from the ward and escorted them to the staff residence where his colleagues were occupied with leisure activities and examined them at length. He said he gained the confidence of the patients, found out points overlooked in the ward and roused the interest of the physicians.

Thereafter he threw himself into the clinical field. When he moved to the Worcester Hospital for the Insane in Massachusetts, he standardized procedures for examination, history taking, and ongoing clinical observation; encouraged discussion and collaboration among the staff regarding cases; and integrated the data collected at the bedside with those observed at autopsy. He emulated Kraepelin, whom he had spent a summer on sabbatical with in 1896, by creating a catalogue of detailed case histories, handwritten on index cards.

As the director of the Pathological Institute established by the New York State Commission in Lunacy, he spent a week at every state asylum in New York, leading case conferences, teaching clinics, and ward rounds and demonstrating satisfactory examination and history taking procedures to the staff. He then became the first psychiatrist-in-chief at Johns Hopkins, gaining a reputation as the "Dean of American Psychiatry" before he retired in 1941.

Maybe modern neuroscientists can learn from Meyer's experience of changing from neuropathologist to focusing on the patient as a person. Trouble is too many are attracted to neuroscience as it avoids the need to be centred on patients.

IAPT propaganda truly impressive

The chief executive of the NHS in a foreword to a report on the 3 year review of Improving Access to Psychological Therapies (IAPT) (see my previous comments about this programme eg. Is mental illness curable by CBT?) thinks that the progress made has been "truly impressive". The Care Services minister emphasises that by the end of March 2012 "more than 1 million people have used the new services, recovery rates are in excess of 45% and 45,000 people have moved off benefits".

What isn't spelt out from the figures in the report is that only 60% of the people using the service complete a course of treatment. The percentage of people completing a course of treatment has decreased as the service has grown.

Rccovery is no longer defined in a report of this sort. Maybe we are just supposed to assume we all know what recovery means. To be considered cases at the start of treatment patients are required to score above 9 on the PHQ-9 and/or above 7 on the GAD-7 at assessment. They are said to have recovered if their score goes below these cut-off levels at the end of treatment. The higher patients’ initial PHQ-9 and GAD-7 scores are, the less likely they are, therefore, to recover. Recovery rates have steadily improved from 17% to over 45% over the first three years of the programme, which the report boldly states shows that services are becoming more effective. However, no data is given about whether there have been changes in baseline scores. Is the apparent increase in effectiveness due to milder cases being taken on?

Nor are the so-called economic gains controlled. How many of the 45,000 said to have moved off benefits would have done so without IAPT? Depression and anxiety get better with time without treatment. How many would have recovered without IAPT? The programme cannot make claims about effectiveness as it is not a controlled clinical trial.

This is political exploitation of psychological quackery. The programme now seems to be making a case for more funding to deal with its growing waiting list. Let's have a proper evaluation first.

Psychiatry in dissent

I have mentioned the book Psychiatry in dissent in a previous entry. Vivek Datta echoes this book in the title of  his eletter posted in response to the article about psychiatry beyond the current paradigm that I mentioned in the previous post. He makes clear that the motivation for a remedicalised psychiatry is the fear that psychiatrists will be made redundant in the current financial pressures on health systems (see another previous post).

He misses the point that medicine in general needs to be more patient-centred. Psychiatry could, and in theory should, lead the way on this. Patients should be suspect of a remedicalised psychiatry that clearly is primarily about the interests of psychiatrists, not patients.

Psychiatry beyond the current paradigm

Special article, with my name (see my book chapter on need for paradigm shift in psychiatry) as one of the 29 authors (first author Pat Bracken - see previous post), has been published in the British Journal of Psychiatry. An accompanying editorial by Arthur Kleinman, who I have mentioned in previous posts (eg. see entry), argues that academic psychiatry has been too biomedical. Perhaps it's easier for Kleinman to say this in a British journal, rather than in the USA where NIMH has dominated research (eg. see previous blog entry).

Congratulations to the BJPsych editor for encouraging this debate. I have said previously that I have been surprised by some of his comments from the editor's desk (eg. see post). He has made his position clearer in his current commentary. He seems worried that psychiatry may be no more than quackery. I'm not saying this to encourage a civil war in psychiatry, but his position could encourage neuromania (eg. see previous post). We need to move on from this.

Defining psychiatry

Recent article in The Lancet makes reference to an article that I commented on in a previous post. It suggests that in some ways psychiatry is a "speciality only beginning to define itself". 

Wonder why it's taken so long to do that! Perhaps the article is trying to dissociate itself from psychiatry's history (see my chapter in Mental health ethics). If it's following the previous article, this means believing that psychiatry needs to "realign itself as a key biomedical specialty at the heart of mental health".  That's always been the hope of psychiatry that it will find the biological basis of mental illness. And, what's that got to do with being a "branch of medicine that seeks to support some of the most marginalised members of society", which is what the article says psychiatry is? 

The latter characterisation of psychiatry may even raise questions. The article favourably references The Lancet's Global Mental Health Series, which I have commented on in a previous post. However, social factors, such as poverty and injustice, are not necessarily at the centre of the understanding of mental health problems in modern psychiatric practice. 

The article also mentions the  Schizophrenia Commission's recent report, but doesn't mention the Inquiry into the schizophrenia label (ISL) (see previous post).  Suman Fernando, one of the ISL co-ordinating group, has commented on the report. Psychiatry should be about treating people with mental health problems as persons, but this isn't always the case. A helpful feature of the Schizophrenia Commission's report is its recognition that too many people with a diagnosis of schizophrenia are in secure psychiatric provision.