Further reflection on antidepressant efficacy

Having first reflected (if that’s the right word) in the media, Cipriani et al now reflect on their network meta-analysis (see previous post) in Lancet Psychiatry (see article), which is a more sober affair. Again they admit that differences between antidepressants are small, but qualify this by saying that “exceptions exist”, but then do not spell out what those exceptions are. They come up with a slightly lower figure for placebo response in clinical trials than a BMJ editorial (see previous post), but who’s going to argue about a few percentage points in a matter like this? They don’t really say that the range of antidepressant responses for different drugs in the trials included in the analysis could be due to the trials themselves rather than the drugs.

As I said previously, none of this is new. To me, all the fuss about this study, which has led Cipriani et al to reflect on it, seems to have been created because this is 6 years work which only reaches weak conclusions. Going slightly off message, they go on to argue for open access to data from clinical trials at the anonymised individual patient level. Having always been open in this blog, I couldn’t agree more, although I suspect that all this will do is show up even more biases in the data.

Anyway, Cipriani et al seem to be agreeing the debate about antidepressant efficacy has not been ended by their study. As I have said several times previously, I would also encourage them to research the placebo amplification hypothesis, however difficult this may be.

Carmine Pariante is having a great time

I’ve expressed concern before about the scientific credibility of American academic psychiatry (see previous post). Following the recent article from Carmine Pariante, who I have mentioned before (eg. see my previous post with which Pariante said he agreed - with qualification - in a tweet), about ‘A parallel universe ... ‘, I think we should also be concerned about British academic psychiatry. 

Pariante promotes psychoneuroimmunology, otherwise known as immunopsychiatry. He regards this “new discipline as an example of successful translational neuroscience overcoming the brain-mind-body trichotomy” [his emphasis] (quoted from his article). I agree with Pariante that “psychiatrists, psychologists and social scientists can work together to link the mental and the neural” (quoted from his article with Nik Rose - see my previous post). But I don’t think Pariante has understood Nik’s notion of ‘critical friendship’ between social sciences and neuroscience.

The trouble for Pariante is that there is a difference between psychiatry and medicine. There should actually be agreement that psychiatry is different from medicine. Where there is disagreement is about how much to make of that difference (see another previous post). As I keep saying, I don’t want to be misunderstood. As Pariante himself says in the latest article,  “We have a body (which includes a brain)”. Like him, I’m not wanting to create barricades between biomedical and psychosocial approaches in psychiatry. But he does need to understand that minds are enabled but not reducible to brains (eg. see another previous post). 

I think Pariante needs to come down to earth, otherwise it’s going to get him in trouble with the General Medical Council (GMC), as he acts as a Royal College of Psychiatrists spokesman. There’s already been one complaint to the GMC. Perhaps we need Nik to come back out of retirement to sort this mess out.

Clarifying Szasz's critique of psychiatry

Nassir Ghaemi has published his invited commentary which was rejected for a new book on Thomas Szsaz (see article). It's the advantage of the internet that these pieces can still be published, as I know from my own critical psychiatry blog!

Of course, Szasz was known as an anti-psychiatrist (see previous post). I'm glad he had the academic freedom to promote his views (see another previous post). Szasz started at the Chicago Institute for Psychoanalysis from 1951–56. He was particularly influenced by Franz Alexander (see book).

But I worry that Ghaemi has become too much of an 'anti-psychoanalyst' by believing that psychoanalysis in the 1950s, when Szasz was in Chicago, "stunted any free thought". He argues that "[t]he psychiatry that Szasz railed against in his most famous book was full of myths and was mostly false", because it was primarily psychoanalysis. I agree that the prominence of psychoanalysis did help to make psychiatry more pluralistic then. But I don't think Ghaemi fully understands about the myth of mental illness (see another previous post). And, as I've also said before, "Despite his protests, he [Szasz] will always be associated with the history of anti-psychiatry" (quote from previous post).

I'm certainly not resting my criticisms of psychiatry on the same viewpoints as Szasz. Have a look at my actually quite generous, I think, review of one of his books (see book review).  But, in fact, Szasz was quite scathing (as he could be about lots of things) about the Critical Psychiatry Network (eg. see previous post), of which I am a founding member. I don't even take the same view as him on the insanity defence (see previous post).

I did wonder what was going on when Ghaemi seemed to become more questioning about psychiatric diagnosis (see previous post). But it's clear from the latest article that he hasn't given up his beliefs in biological markers and the genetics of mental disorder. This is why he thinks Szasz was wrong. But he's actually not arguing for the right reasons, which is what he accuses Szasz of doing (see another post). Let me work towards a conclusion with a quote from another previous post:-

The primary problem with modern psychiatry is its reduction of mental illness to bodily dysfunction. Objectification of those identified as mentally ill, by insisting on the somatic nature of their illness, may apparently simplify matters and help protect those trying to provide care from the pain experienced by those needing support. But psychiatric assessment too often fails to appreciate personal and social precursors of mental illness by avoiding or not taking account of such psychosocial considerations. Mainstream psychiatry acts on the somatic hypothesis of mental illness to the detriment of understanding people's problems.

Szasz was correct that he first made this argument in The myth of mental illness. 

From my point of view Szasz undermined this argument by insisting on such matters as abolishing all psychiatric coercion. I've said before (see book review) that it can seem quite muddling arguing with Ghaemi but I've tried here to clarify the positions of Szasz and myself, not make them more confusing.


(with thanks to Neil MacFarlane whose tweet linked me to the Ghaemi article)

The psychiatrist as a cultural interpreter

I responded to a BMJ review of Sami Timimi’s book Pathological child psychiatry and the medicalisation of childhood, when the book first came out in 2002 (see response). This was before the publication of Postpsychiatry (discussed in a previous post). So, if Postpsychiatry is seen as one of the first texts of the Critical Psychiatry Network, Sami’s book has priority. Sami has published several other books since (see list on Wikipedia page). He also wrote a chapter for my Critical psychiatry book.

Sami came to England from Iraq when he was aged 14. This means he is very aware of discrimination, although during his training he found himself “becoming more and more critical of ... Arabic culture” (p. 126). Western powers’ involvement in war and destruction in Iraq led to him having a more balanced perspective (see my 2010 Openmind psychiatric update column). As Sami says, "[r]esistance is in my bones" (p.163).

Sami found his psychiatric training “a very confusing experience” (p.1). He found it difficult to understand why he was being indoctrinated in the way he was. He came to appreciate that “the whole mental-health business is about belief systems rather than hard science” (p. 59). He also came to appreciate that "[c]hallenging the mainstream can be a lonely, isolating experience" (p. 71). As I’ve said before (eg. see previous blog), psychiatry is more like a faith than a science. I have tried to take this understanding forward by using Clifford Geertz’s definition of culture as "a system of inherited conceptions expressed in symbolic forms by means of which men [people] communicate, perpetuate, and develop their knowledge about and attitudes toward life" (see eg. another previous post). Sami likened the kind of experience he went through to that described by Frantz Fanon when "black families in Europe often had to choose between alienation or adopting a European outlook and pretending that the racism around them did not exist" (p. 71). When seen as a non-believer at a pro-Ritalin and pro-ADHD conference, Sami "left the conference feeling he had attended an extremist cult convention" (p.85).

Still, Sami is a child and adolescent psychiatrist and this field used to be a haven for those that wanted to escape the abuses within adult psychiatry. Sami rightly worries that the increasing biologising of childhood has brought child and adolescent psychiatry within these parameters. When he and I trained, we were taught that there were emotional and conduct problems in childhood. Now medical students tend not to be taught this, instead being told to focus on ADHD and autistic spectrum disorders. Childhood depression, then, when we trained, was not recognised in the same way as adult depression, like it is now (see my BMJ letter).

In his first book, Sami said, "In essence what all of us who are working in the field of therapy for social suffering are doing is acting as cultural interpreters" (p. 83). Here he is using the notion of symbolic healing. Psychiatric practice is “using culturally meaningful mediated symbols” (p. 80). Sami recognises the way in which the 'new transcultural psychiatry' criticises orthodox psychiatry for "not giving proper consideration to context" (p. 156). He utilises "post-modern therapies" (p.130), defined widely, to include narrative and solution-focused approaches. His honesty even leads to him at times sharing "information from my own life" (p.135).

As Sami himself says, he has used "quiet persistence" (p.163) to get his message across. He has contributed significantly to modern critical psychiatry.

Controversy about cannabis and psychosis

Because of my scepticism, I was alerted when I saw the BJPsych editorial on cannabis and psychosis, which began, “It is now incontrovertible that heavy use of cannabis increases the risk of psychosis”. As I said in a previous post, some “heavy users of cannabis may be rarely unintoxicated, leading to misdiagnosis of the induced psychotic-like experiences, which are usually transient in less heavy users”.  But I ended that post with the conclusion: “The causal link between cannabis and psychosis has not been proven”. 

The new editorial of course recognises that association does not mean cause. But it suggests that alternative explanations have been disproved. As I keep saying, the use of cannabis can cause emotional problems and people may use it to deal with their emotional problems. These problems may well be worse with skunk compared to hash (see Guardian article). Cannabis use is likely to be a proxy measure for poor premorbid adjustment associated with psychosis. I can't see that this most obvious explanation has been eliminated. 

Tackling institutional racism in mental health services

I’ve posted before on Institutional racism and reform of the Mental Health Act. The Royal College of Psychiatrists has recently produced a position statement on ‘Racism and mental health’. Racial bias, of course, is not new in mental health services. There is also a history of attempting to tackle discrimination, which the College statement essentially ignores. True, it does make reference to the Blofeld report following the death of Rocky Bennett under restraint in my own NHS Trust. I worried at the time that the focus on institutional racism deflected from the other main issue about the dangers of restraint (see my BMJ response). Face down restraint should probably have been completely banned in mental health services (see previous post).

This history is relevant to the current reform of the Mental Health Act, because, in a way, its aim could be said to be to reverse the trend for increased coercion associated with the last reform. As Inside/Outside said, "[I]t is essential to place progressive community based mental health at the centre of service development and delivery". Services are failing to provide an appropriate and professional service to people because of their colour, culture and ethnic origin. This situation needs to be legislated for in any new Mental Health Bill, focusing on reducing coercion.  

Effectiveness of antidepressants

The recent Lancet study, which was reported in the media as ending the debate about the effectiveness of antidepressants, has ironically led to more discussion about their effectiveness (see previous post) and a welcome focus on the nature of discontinuation problems (see another post). It has also led to a definitive summary in a BMJ editorial of the evidence for short-term treatment (less than 8 weeks).

To quote from the editorial:-

Importantly, these findings [the Lancet study] do not support the widespread calls in the popular press for more people to take antidepressants because the meta-analysis and underlying trials do not examine who or how many people should be treated.

And, despite the hope of the Lancet article, the BMJ editorial concludes:-

[T]he way many of the results were reported does not allow clinicians to extract clinically meaningful take home messages to inform conversations with patients.

This is partly because the Lancet study used odds ratios rather than risk ratios. It did not provide evidence about the proportion of people that improved on placebo. The typical placebo response in other literature is 30-40%. Using the average odds ratio from the Lancet study means about 10-12% more people in the treatment group would benefit compared to placebo. So, roughly 8-10 people would need to be treated for one of them to benefit compared to placebo.

Patients need to know that roughly 40% of people in antidepressant trials improve with placebo and 50% in the treatment arm. As the BMJ editorial says:-

Knowing that roughly 80% of patients who get better did not improve because of the antidepressant underlines the importance of starting with low doses, systematically re-evaluating the need for treatment after a response is achieved, and not accepting any enduring adverse effects.

I would also add that it’s important to realise that a good proportion of people are not helped even in the clinical trials.

The BMJ editorial, therefore, usefully highlights the limited clinical scope of the Lancet study. We need at least to also focus on potential harms and long-term treatment. And, we need to ask whether the small statistically significant difference in clinical trials between active and placebo treatment could be an artefact due to placebo amplification (eg. see previous post).

Minimising antidepressant discontinuation problems

Clare Gerada defended the Royal College of Psychiatrists on the Today programme this morning against a complaint (of which I was one of the signatories) that the College is minimising the significance of antidepressant discontinuation problems (see Council for Evidenced-based Psychiatry (CEP) press release). There doesn't seem to be a dispute that antidepressant discontinuation problems occur (eg. see previous post) - Clare Gerada said in about a third of patients - and can be prolonged (see another previous post), but the issue seems to be whether they resolve for the vast majority of patients within two weeks. I don't think the evidence supports that view.

There is a history of doctors thinking they know better about antidepressant discontinuation problems than the public (see my book chapter). The Defeat Depression campaign was a five-year national programme launched in January 1992 by the Royal College of Psychiatrists in association with the Royal College of General Practitioners. A door-to-door survey of public opinion was undertaken to obtain baseline data before the campaign started and most of the people questioned in the sample, that is 78%, thought that antidepressants were addictive. This finding caused some consternation amongst those running the campaign, because, as far as they were concerned, the public was misinformed on this issue. Part of the education programme, therefore, was to teach doctors that patients should be told clearly when antidepressants are first prescribed that discontinuing treatment in due course will not be a problem. Now they seem to be saying that it may be a problem but symptoms generally won't last long.

The first official recognition in the literature that SSRI antidepressants can cause discontinuation problems was in a BMJ editorial in 1998, which suggested they were preventable and simple to treat. The same authors only two years later acknowledged that discontinuation symptoms are common in a letter to the Lancet. I agree there is little evidence of physical addiction, in the sense that the body gets addicted to SSRIs, but commonsense understanding of the word also includes psychological dependence, and despite what the Defeat Depression campaign said, the public knew, even if doctors did not, that taking antidepressants can become a habit.

Doctors did not use their common sense to realise that discontinuing a drug that is thought to improve mood may cause problems - technically called a nocebo, or negative placebo, response. Antidepressants are likely to be habit forming, so however much the medical profession may declare that they are not primarily reinforcing like psychostimulants, the public has always understood that there may be difficulties in discontinuing antidepressants. The general public might reasonably have expected that psychiatrists, who are supposed to be specialists in disorders of the mind, would recognise psychological dependence, base their advice on clinical experience, and use their common sense.

I have always encouraged CEP to focus on psychological aspects of prescribed drug dependence (see eg. previous post). I was even critical of the RCPsych leaflet (see another previous post) that has caused such disquiet, not least because it's been taken down from the College website before it's been properly reviewed, even though I thought it was generally a helpful leaflet.

By the way, from the interview today, Clare Gerada, like her husband (see post), doesn't seem to believe in the placebo amplification hypothesis of apparent antidepressant efficacy, and I'm not sure why .

Commercialisation of precision psychiatry

I sent 7 tweets yesterday in response to a tweet from @PariantSPILab (who I have mentioned previously eg. see post) about a Financial Times article. Apart from several likes and a couple of retweets, I received only one answer from @Truthman30. Am I being marginalised?

The article at least says that "precision psychiatry remains largely in the research phases". But, it quotes Professor Leanne Williams as promoting Spring Health, which says it has a research group that has had several papers published in leading medical journals, starting with one in Lancet Psychiatry in 2016. A Lancet Psychiatry article, published in April 2017, has a lead author who declares that he holds equity in Spring Health. I'm not sure how much Spring Health charges employers for its services provided through health insurance plans.

I've commented before on an article by Leanne Williams (see post), which I think must be the 2016 article referred to by Spring Health. I've no idea what the evidence is referred to in the Financial Times article about venlafaxine only working for certain gene types. I'd never heard of Thalia Eley's attempts to develop "therapy genetics”.

I can understand Leanne Williams wanting more money to fund her research but it does need to be tempered with realism. She says it's "bordering on negligence to not be using a [precision approach to depression care] now". Actually, it's not justifiable clinically to say that everyone needs brains scans and DNA tests for mental health problems, which is how the article headline is framed.

What we need is a truly personalised medicine and psychiatry, not what's called individualised or precision medicine, which is actually commercialising mental health care not making it more personal (see previous post). Psychiatric research has lost its way (see another previous post). We need to accept the uncertainty of psychiatric practice and medicine in general, rather than promote "precision medicine" as the solution to mental disorders (see another post). Actually what we need is proper precision thinking in psychiatry, not the speculation being promoted (see post).

PTM Framework is not anti-psychiatry

I have blogged previously on the Power Threat Meaning (PTM) Framework (see post). Twitter is not always the best place to discuss these kind of issues, as people can act out their nastiness. I don't think people who have called the Framework 'anti-psychiatry' are necessarily "nasty". But it might be worth thinking about what it means to label someone, and even the PTM Framework, as 'anti-psychiatry' (eg. see previous post).

Even respectable psychiatrists recognise some value in what has been called anti-psychiatry (see another post). Critical psychiatry may have its roots in anti-psychiatry, but critical psychiatry also has its roots in mainstream psychiatry and in that sense is not anti-psychiatry (see another previous post). The term 'anti-psychiatry' has always been used as a way of psychiatry marginalising its critics. Anti-psychiatry has been called psychiatry's "nemesis" (eg. see another post), as other branches of medicine don't really have their own internal anti-movement.

I want to encourage people to view the PTM Framework positively. Lucy Johnstone, in a recent MIA podcast, has made clear that any attempt to describe patterns of responses need to be recognised as meaning-based differentiations, not absolute distinctions. I totally agree. I'm not suggesting returning to Meyer's attempt to classify reaction types, but I have long argued that we need to return to his theoretical principles (eg. see another previous post). Revisions of the DSM have been totally misguided (see yet another post) and the PTM Framework should be seen as a potential way forward.

Postpsychiatry

I have been re-reading the book Postpsychiatry by Pat Bracken (see previous post with link to his profile) and Phil Thomas (see his About Me webpage). They also wrote a chapter for my Critical Psychiatry book and a recent book chapter entitled 'Reflections on critical psychiatry' (see another previous post). Other pieces they have written together include a PPP article.

As Phil says in his 'Critical Psychiatry in The UK: A Personal View':-

Postpsychiatry started life as a series of short articles in Open Mind magazine [see reprints] from 1997 – 2001 .... This was followed by an article in the British Medical Journal Education and Debate section (Bracken & Thomas, 2001), and a book of the same name four years later in Oxford University Press’s series on philosophy and psychiatry (Bracken & Thomas, 2005). 

Postpsychiatry sees psychiatry as a creation of the Enlightenment and a modernist enterprise. The book starts with a reference to Foucault's Madness and Civilisation. Foucault viewed the Enlightenment as oppressive and saw the 'great confinement' in the 17th and 18th centuries as, in Pat and Phil's words, "a massive European move towards the social exclusion of 'unreason'" (p. 91). Pat and Phil note that Foucault moved away from an understanding of power as something negative. As they also say, "in the 20th century, psychiatry became something bigger than simply the governing power of the asylum" (p. 93).

They, therefore, view postmodernism as "an addition to, rather than a rejection of, previous critical positions" and insist that it is "not a flight to mindless relativism" (p. 95).  Just to be clear, they say that "Foucault did not get everything right" (p.189). They, therefore, want to also follow Heidegger and Wittgenstein with a hermeneutical perspective. In the book, they look at what they call the narrative turn in medicine and psychiatry. Overall, they are not proposing "some sort of postmodern canon" (p.189).

Postpsychiatry is, therefore, not arguing for a strong form of social constructivism. My main problem with postpsychiatry is its historical narrative, maybe because it starts from Foucault. I have always tended to emphasise that there has always been a critical perspective within psychiatry (eg. see previous post), since the origins of modern psychiatry, which I would tend to date from state intervention in the asylum, rather than the 'great confinement'. The development of pathology in medicine from the beginning of the nineteenth century and the application of the anatomoclinical method led to psychiatry not completely fitting with an organic understanding of illness and, for example, produced the idea of functional psychosis (see another of my book chapters).

Although Pat and Phil mention the Enlightenment, they don't talk about Romanticism, which, in a way, was a reaction against the norms of the Enlightenment. I have highlighted the work of Ernst von Feuchtersleben in this respect (see eg. another previous post) and he used the critical philosophy of Immanuel Kant to argue against a materialistic understanding of mental illness. Similarly, modernism wasn't the only perspective at the turn of the twentieth century and, as I have said, Pat and Phil themselves mention hermeneutics. Personally, I have emphasised the pragmatic perspective of Adolf Meyer (eg. see another previous post), which, at least in theory, focused on the limitations of psychiatric practice (see eg. my article).

Postpsychiatry may be the best known form of critical psychiatry and is central to critical psychiatry's understanding of its own nature.

Data on antidepressant winners and losers

Hans Eysenck (1978) called meta-analysis an exercise in mega-silliness. To quote: “A mass of reports - good, bad, and indifferent - are fed into the computer in the hope that people will cease caring about the quality of the material on which their conclusions are based.” Cipriani et al (2018) in their recent network meta-analysis of 21 antidepressant drugs rated the risk of bias of the trials they put into their analysis. Only 18% were seen as low risk. Yet they hoped the results would compare and rank antidepressants for acute treatment in adults.

The article does list some winners and losers, although accepting that there were "few differences between antidepressants when all data were considered". Parikh & Kennedy (2018) add vortioxetine to their list of winners, which must please the manufacturers, as it is not yet off patent. Amitripyline actually had the highest efficacy but didn’t reach the ‘winners’ list, I think because of poor acceptability, defined as dropout rates, in the head-to-head trials, and low certainty of evidence (and maybe some bias against a traditional tricyclic). Unlike Parikh & Kennedy, Cipriani et al don't make any recommendations about antidepressant choice, merely hoping that their "results will assist in shared decision making between patients, carers, and their clinicians".

Such a weak conclusion to their main study may help to explain why in their publicity, which made the Sun, Guardian and front page of The Times, Cipriani et al concentrated on the statistically significant results for antidepressant efficacy, which actually aren't news (see my tweet), although may be for reboxetine (see previous post). I suppose it's not seen as being ideological to create publicity to increase the citation index of a paper! Or, to mislead and avoid dealing with the challenge of the placebo amplification hypothesis (eg. see previous post). To engage with this issue would actually be a more scientific way of proceeding, but the study by Cipriani et al doesn't have any bearing on it (even if they would like it to).

Actually the review paper itself (as opposed to the publicity) does recognise that the short-term benefits of antidepressants are "on average, modest" and that the "long-term balance of benefits and harms is often understudied". Several aspects of their findings do reinforce that there are biases in the data eg. smaller and older studies have larger effect sizes against placebo; novel or experimental drugs of comparison are more effective than when that same treatment was older (which they term the 'novelty effect'). I also wasn't sure whether they had got replies to all of their requests to the pharmaceutical companies for their data. Let's have a more measured debate about the evidence for antidepressant efficacy.

Transparency about the outcomes of Improving Access to Psychological Therapies

Graham Thornicroft's Lancet editorial on Improving Access to Psychological Therapies (IAPT) glosses over the effectiveness of the programme. True, he does say there has been little evidence of greater workplace productivity, which was the argument used to gain funding for the programme. He also acknowledges that although there has been a substantial increase in treatment of common mental disorders, admittedly particularly with antidepressants rather than psychological therapy, but still the prevalence of disorders has not decreased.

But, there is no questioning of the value of mandatory routine data collection, much of which is useless because it's uncontrolled (see previous post). By being so uncritical, Thornicroft could be said to be condoning the rhetoric of unrealistic claims for the effectiveness of the programme (eg. see another previous post). How much are outcomes just expectancy effects (see previous post)? I'm not wanting to undermine the work of IAPT therapists but we do need realistic assessments of the effectiveness of the programme. The title of the paper by Clark et al (2017), on which the editorial is based, is said to be about transparency about outcomes. I wish it was.

The promise of tranquility of mind

My recent post commented on the public understanding of the concept of bipolar disorder, at least as represented by internet bloggers. As I said in a book review, the aim of treatment of bipolar is euthymia, which means stable mood, neither manic nor depressed. In general parlance, euthymia is a relaxed state of tranquility. To quote from my review, "Democritus regarded this state of being as one in which the soul is freed from all desire and unified with all its parts. He believed it should be the final goal of everything we do in life."

No wonder people want mood stabilisers if this is what is being promised! However, mood instability is not well defined (see previous post). As I quoted in another previous post, "the term mood stabilizer sounds comforting and may reflect our fond and perhaps somewhat naive hopes".  Although a marketing ploy, there has never been any evidence that mood stabilisers are better than placebo in bipolar spectrum. It's also wrong and misleading to believe that mood stabilisers correct a brain abnormality.

Give up trying to explain the relationship of mind to brain

I attended a reading group today to discuss two quite technical papers by Georg Northoff. There is a Psychology Today blog, which makes clear that he is trying to bridge the gap between brain and experience. It's all very well to speculate about spatiotemporal psychopathology, but I think Kant was right that the link between mental and physical is an enigma that can never be solved.

Mind is of course enabled by brain, but it can't be reduced to it. Mind and brain need to be understood as a unity (eg. see previous post). Bodily organs are subject to the laws of physical necessity but consciousness is self-organising. An organic basis is, therefore, insufficient for understanding mental activity. Psychiatrists find it difficult to give up the notion that the understanding of mental activity must be derived from the brain. This doesn't make sense because such reductionism leads to the loss of meaning of human action (eg. see another previous post).

Being bipolar on the internet

Mandla et al (2017) have analysed internet blogs by self-identified bipolar sufferers. They found that most bloggers regard bipolar as consisting of extreme and fluctuating emotions. It encompasses a wide variety of problems and has fluid boundaries with normality. It often fulfils a moral function, in that it is conceived as an autonomous entity, which acts as a repository for disliked or disapproved aspects of the self and provides an explanation for bad behaviour or failure. It's become increasingly popular as a self-diagnosis (Chan & Sireling, 2010).

Bipolar has become so broad and inclusive that it has little in common with the original, narrower concept that was aligned with the diagnosis of "manic-depression" (eg. see previous post). There needs to be wider discussion about these issues.

The bio-bio-bio model of mental illness

A few years ago, Steven Sharfstein, when he was President of the American Psychiatric Association, said that psychiatry has "allowed the biopsychosocial model to become the bio-bio-bio model' (see Psychiatric News article). This was picked up by John Read in his The Psychologist article.

As I said in my last post, the problem is the eclectic, atheoretical way in which the term 'biopsychosocial model' is often used in modern psychiatry. Where this comes from is the psychiatric consensus, represented by Anthony Clare (see previous post), following the anti-psychiatry debate of the 1960/70s. To avoid the worst excesses of biomedical reductionism, Clare took an atheoretical approach to understanding mental health problems. The trouble with attempting to abstain from theory is that it results merely in the generation of an implicit theory. Despite his well-meaning humanism, Clare's position is still determined by biologism (see extract from my Critical Psychiatry book). As I said in another previous post, although modern psychiatry may not be 'narrowly biomedical', it is still biomedical.

Three cheers for the biopsychosocial model

There is a YouTube video of David Pilgrim's talk at the DCP conference last year. He only gives 'two cheers' for George Engel's biopsychosocial model, whereas I have regarded the model as a basis for critical psychiatry (eg. see previous post). I do this with the reservation that I am not supporting the eclectic, atheoretical way in which the term 'biopsychosocial model' is often used in modern psychiatry.

Where we agree is that the strength of Engel's model is its critique of biomedical reductionism. David accuses the model of being naive about medical knowledge. He argues that the model needs to be more of a theory about health and illness.

I do not think that David’s view sufficiently acknowledges the extent to which the model was not only a challenge to psychiatry, but also to medicine in general, creating the basis for patient-centred medicine (see previous post). As I said in my article:-

In his original paper, Engel talked about neutralizing ‘the dogmatism of biomedicine’ (1977, 135). He commented on the enormous investment in diagnostic and therapeutic technology that emphasizes ‘the impersonal and the mechanical’ (Engel 1977, 135). He quoted from Holman (1976), who argued that:

[T]he Medical establishment is not primarily engaged in the disinterested pursuit of knowledge and the translation of that knowledge into medical practice; rather in significant part it is engaged in special interest advocacy, pursuing and preserving social power. (Engel 1977, 135)

Engel acknowledged the interest in the biopsychosocial model amongst a minority of medical teachers, but also emphasized the difficulties in overcoming the power of the prevailing biomedical structure. 

None of my comments should detract from David’s contribution to recognising the importance of critical realism as a metatheory for psychiatry and clinical psychology (see his chapter in Routlege International Handbook of Critical Mental Health, a book which I have mentioned in a previous post).

The limitations of psychiatric diagnosis

The Power Threat Meaning (PTM) Framework provides a way of helping people create a hopeful narrative about their lives and personal difficulties (see BPS News item with links to full framework and a shorter overview). It is a very impressive, well-referenced document. It attempts to provide an over-arching structure, as an alternative to functional psychiatric diagnosis, for identifying patterns of meaning-based threat responses to the negative operation of power causing emotional distress, unusual experiences and troubled or troubling behaviour.

I have always tended to emphasis the limitations of psychiatric diagnosis rather than suggesting a need for an alternative (eg. see previous post). Psychiatric diagnosis needs to be recognised for what it is. It is more important to ask how people are responding and to what, rather than look for a name for their problems. The primary focus should be on understanding the conditions of their mental responses rather than be concerned about symptoms and disease. The person should, therefore, be the essential element in assessment and there will be inevitable uncertainty in practice. Here I totally agree with the PTM Framework.

I just think that this focus on formulation does not necessarily lead to the abandonment of psychiatric diagnosis. Diagnosis can be justified as an attempt to manage clinical complexity and the PTM framework itself does recognise patterns of responses. There will inevitably be fuzzy boundaries between different groupings with no absolute distinctions. Certainly I’m not suggesting there are natural kinds of mental disorders. Diagnostic categories can only be justified by their clinical utility and should be no more than working concepts for clinicians. They are merely unobservable hypothetical constructs, more of a prototype or ideal type. The problem is that psychiatry too easily reifies diagnostic concepts by assuming that they are entities justifying psychiatric treatment. Here I think the PTM framework provides a valuable counter to this tendency.

Choosing the orthodox path in psychiatry

The latest Mad in America podcast includes an interview with Sir Robin Murray, who I have mentioned in previous posts (eg. Schizophrenia is not a neurodevelopment disease). Like him, I wanted to be a psychiatrist through reading Freud as a teenager. Similarly, we both got caught up in the 'anti-psychiatry' conflict and were interested in R.D. Laing. Murray opted for the orthodox view, whereas I gave up my medical training for 8 years and then returned to complete it to become a critical psychiatrist. I ended up having a different view of schizophrenia from him (eg. see my BMJ letter, although there is an error in the letter referring to Lyn Pilowsky as “he”). And, I have spent my working life as a consultant as a full-time clinician, unlike Murray, who was an academic, only working part-time clinically.

Like Anthony Clare (eg. see previous post), Robin Murray took his position partly as a reaction to their understanding of Laing as blaming families for causing schizophrenia. This is actually a misunderstanding of his view, about which Laing complained repeatedly (eg. see extract from my book chapter).

As I said in a post on my personal blog, it's interesting to see Murray questioning the call he made when he started in psychiatry. But he hasn't completely given up his belief in the brain hypothesis of mental illness. For example, in the interview, he talks about dopamine being involved as the "final common pathway for psychosis".

Like him, I'm not encouraging psychiatrists "slagging each other off", but there is a genuine issue about the conceptual nature of mental illness. It's difficult for people, like Robin Murray, to accept that an organic basis is insufficient for understanding mental activity. He's taken this step of faith and to retract it and realise he's made a mistake would be like giving up a religion (see previous post). I'm not necessarily encouraging him to be a philosopher, but he does need to accept that there is a mind-body problem. Organisms as a whole are constantly maintaining their internal environment and cannot be explained mechanically (see another previous post). The activities of the mind cannot be derived completely from the laws of the physical world.

And, I do not want to be misunderstood. Of course I know that minds are enabled by brains. But this does not mean that minds are reducible to brains. To use a quote from Adolf Meyer that I have used before, "person disorders show through the brain but not necessarily in the brain" [Meyer's emphasis].

Is psychiatric diagnosis dead?

The title of the 2018 medical student essay prize established by the Faculty of General Adult and Community Psychiatry of the Royal College of Psychiatrists is 'Is diagnosis dead? Discuss.' It's good to see a Faculty of the College encouraging this debate.

Of course the hope of finding a neurobiological basis for psychiatric diagnosis should be dead, particularly following the failure of DSM-5 (eg. see previous post), but it isn't because the wish to find a physicalist basis for mental illness will never go away. And, psychiatric assessment has never just been about diagnosis and includes formulation (eg. see another previous post), which may well be more important than a single-word diagnosis (eg. see yet another previous post).

Organism and mechanism

The philosophy of biology can contribute to critical psychiatry. I came across Daniel Nicholson's PhD thesis on 'Organism and Mechanism' online.  He quotes from Francis Crick, who said that "The ultimate aim of the modern movement in biology is to explain all of biology in terms of physics and chemistry” (p.9) As Nicholson points out, it's often assumed, as in Jacques Monod's book Chance and Necessity, that "organisms are machines, albeit ones cobbled together by natural selection" (p.13).

However, organisms have a capacity for self-regulation. To use JS Haldane's definition of Claude Bernard's principle, "all physiological activities have as their ultimate objective the preservation of the organism's internal environment. ... [T]he continuous dynamic coordination and regulation of the internal environment ... is responsible for the distinctiveness and irreducibility of living beings" (p. 56). Organisms, unlike machines, are self-organising and self-reproducing. As Nicholson says, “No  machine  is  made  of  parts  that  are constantly  replaced  by  the  machine  itself,  yet  this  is  precisely  what  occurs  in  an organism” (p. 125). Mechanistic understanding of life should therefore be abandoned.

This fundamental difference between organisms and machines applies across the spectrum of the complexity of life, from human mind to blade of grass, to use the quote from Kant about the absurdity of hoping for a Newton of the genesis of but a blade of grass (p.33). Critical psychiatry’s challenge to the technological or mechanical paradigm (eg. see previous post) is no different from that in biology of opposing mechanicism by organicism.

The gap in causality in neuroscience

In a JAMA Psychiatry viewpoint, Amit Etkin suggests that brain neuroimaging risks creating ‘Just-So Stories', internally consistent explanations that have no basis in fact. Nonetheless, he still seems to believe that direct experimental manipulations can overcome this challenge.

The problem is more fundamental. Generating massive amounts of data from neuroimaging of the brain, which is only looking at part of a person, misses the point that whole persons have intrinsic purpose. People cannot be investigated as machines in the same way that their brains can be when they are considered in isolation. No wonder there’s a gap in neuroscientific explanation.

Is cognitive remediation therapy in schizophrenia merely placebo amplification?

I went to an open-minded talk this lunchtime by Professor Dame Til Wykes about therapy for cognition in schizophrenia. She was prepared to consider the negative evidence for effectiveness of treatment, although she was clear that NICE should include cognitive remediation therapy (CRT) as an evidenced-based treatment in its schizophrenia guideline, which it doesn't do at present, as CRT improves cognition and reduces disability in schizophrenia (eg. Wykes et al, 2011).

Til Wykes was honest about her interest in CIRCuiTS (Computerised Interactive Remediation of Cognition - a Training for Schizophrenia), a web-based computerised CRT, which doesn't seem to be freely available on the internet. What worries me is that the cognition therapy industry may be based on an artefact. Let me explain.

If clinical trials are not double-blind, positive findings may merely be a self-fullfilling placebo amplification. The hypothesis that unblinding in clinical trials for antidepressants produces artifactual placebo amplification is controversial (e.g. see previous post). This should be less controversial for psychological therapies, such as CRT, as trials cannot be conducted double-blind (see eg. another previous post). At the most, an attempt may be made to single-blind the assessors, but disclosures by patients do occur, even if participants are told not to reveal their allocation, thereby breaking the blind. Such bias could explain the small-to-moderate effects found in meta-analyses of cognitive remediation.

Psychotherapy and critical psychiatry need to cooperate

I've posted verbatim a copy of the talk I gave recently to the Council for Psychoanalysis and Jungian Analysis, a college of the UK Council for Psychotherapy (see powerpoint slides). Part of the aim of the talk was to challenge the rhetoric about Improving Access to Psychological Therapies (IAPT), particularly from its two main protagonists, David Clark and Richard Layard (as I have done in previous posts, eg. Wider measures of IAPT outcomes needed). Saying that IAPT is a 'marvellous treatment' has to stop. Unrealistic claims about the effectiveness of psychotherapy are a 'perversion of care', to use Rosemary Rizq’s phrase (see previous post).

Critical psychiatry and psychotherapy need to work together to change the dominant technological paradigm in modern mental health services (see previous post). This technological paradigm includes psychological therapy if it is applied in a mechanistic way. As in the position statement from the Division of Clinical Psychology of the British Psychological Society, we need to give up the disease model of mental disorder (see another previous post).

The foundations of critical psychiatry

I’ve mentioned before that the PhD I’ve just started (see previous post) is on ‘The foundations of critical psychiatry’. Critical psychiatry is not new. There are at least three points in the past when its conceptual position has been promoted. These associations are not always well appreciated.

(1) Ernst Von Feuchtersleben (1847) Principles of medical psychology (original German edition, 1845) (eg. see previous post) could be seen as the first attempt to provide an interpretive rather than biomedical account of mental illness. Feuchtersleben has been seen as a 'forgotten psychiatrist' (see article). Following Kant, he recognised that the mind-brain problem is an "enigma, which can never be solved" (p. 16). Despite the success of his book, he was "swimming against the tide" and his "psychosomatic viewpoint made no impact in the second half of the 19th century" (Lesky, 1976; quotes from pp. 154 & 156).

(2) Adolf Meyer's (1866-1950) Psychobiology (eg. see previous post) has the same conceptual understanding of mental illness as critical psychiatry. The problem is that this is not always apparent because of Meyer's tendency to compromise. As I said in my paper, the principles of critical psychiatry "can only be reestablished by a challenge to biomedicine that accepts, as did Meyer, the inherent uncertainty of medicine and psychiatry".

(3) George Engel's (1977) biopsychosocial model (eg. see previous post) was a critique of biomedical dogmatism in the same way as critical psychiatry and proposed a "new medical model". The trouble is that it has tended to be interpreted in an eclectic way and its impact not fully realised (eg. see my review of Nassir Ghaemi's (2009) book The rise and fall of the biopsychosocial model).

Critical psychiatry needs to make more of these and other links with the past. Its conceptual understanding is integral to the history of psychiatry.

Institutional racism and reform of the Mental Health Act

The current review of the Mental Health Act (see previous post) needs to take account of the recently published book Institutional racism in psychiatry and clinical psychology: Race matters in mental health by Suman Fernando. Part of the concern leading to the review is that "People from black and minority ethnic populations are disproportionately affected [by the Mental Health Act], with black people in particular being almost 4 times more likely than white people to be detained" (see news story). The purpose of the review is to understand the cause of this and other issues (see terms of reference). I think it is also important that the government deals with the issue of racism in society in general and not does not deflect it just onto mental health.

Table 5.1 in Suman's book summarises racial inequalities in the UK as far as mental health services are concerned:-

The marginality and social exclusion experienced by minority ethnic groups are likely to be significant factors in this imbalance. Black compared to white patients are diagnosed more frequently as schizophrenic by both black and white clinicians - although to a lesser extent by the former - even when clear-cut diagnostic criteria are presented (Loring & Powell, 1988). African American men receive higher doses of antipsychotic medication than white and are more likely to be described as hostile and violent (Metzl, 2010). It's difficult to think the stereotype of "Big, black and dangerous" is not a factor in disproportionate detention under the Mental Health Act (see blog by Nuwan Dissanayaka).

Racism within psychiatry needs to be addressed (Sashidharan, 2001). There is of course a history of attempting to deal with these problems, which the current review cannot ignore, particularly the report Inside Outside. People who use mental health services should expect services to be non-discriminatory. What we need is a national approach aimed at reducing and eliminating ethnic inequalities in mental health service user experience and outcome, and this includes treatment under the Mental Health Act.

Flaming brains

I have mentioned Carmine Pariante in a previous post. Yesterday I went to a talk he gave in the Cambridge Department of Psychiatry on 'Depression and inflammation in the 21st century'. He has reflected in a recent article on his 20 years research in this field.

It does seem a bit nonsensical to talk about depression as an inflammatory disorder, like rheumatoid arthritis. For a start, any apparent increases in proinflammatory cytokines are generally not of the same order as in autoimmune or inflammatory diseases. I'm not saying that an array of inflammatory mediators have not been found to be higher in depressed patients, although this association can at least be reduced by eliminating confounders (O'Connor et al, 2009). Increased inflammation is also associated with psychosocial stress suggesting that any association is likely to be nonspecific rather than specific in the causality of depression.

Reflections on critical psychiatry

Google books has made freely available the chapter 'Reflections on critical psychiatry' by Pat Bracken and Phil Thomas in the new book Routledge international handbook of critical mental health, edited by Bruce Cohen. As Richard Hassall says (see tweet), it provides a "useful summary of the critical psychiatry stance".

What I like is the way the chapter describes the five dimensions of the critical psychiatry project: ontological, epistemological, empirical/therapeutic, ethical and political. I also like the way the authors say that critical psychiatry challenges the technological paradigm rather than just the biomedical paradigm, recognising that psychological, not just biological,  understanding can also be mechanistic. As they say, "Reductionism and positivism have dominated mental health research". As they go on to conclude, critical psychiatry is about "deconstructing the authority of [modern] ... psychiatry".

Is it better to manage without antidepressants?

A Guardian article is headlined to ask why we shame people for taking antidepressants. I don't think this is what those who are critical of the evidence for the effectiveness of antidepressants are doing. All that is being asked is why there is such a small difference in clinical trials between active and placebo treatment and whether this could be an artefact (eg. see previous post).

The paper that led to the Guardian article (Hieronymus et al published online 25 July 2017) argues against the theory that antidepressants outperform placebo solely or largely because of their side effects. I'm not sure if this is precisely the reason why the argument is made that antidepressants may be merely amplified placebos (see another previous post). There may be other ways in which patients can become unblinded in clinical trials. True, the evidence I summarised from Irving Kirsch's book in that post focuses on side-effects. And, it is also true that there is an expectation that side-effects may be the most common way of unblinding in clinical trials and therefore that the more side-effects that patients experience on the active drug the more they improve in clinical trials. As far as I know, the paper, Barbui et al, referred to in my previous post was never published and I'm not sure why.

Furthermore before Hieronymus et al (2017), there was a BJPsych paper (Barth et al 2016) that also did not find an association between adverse events and efficacy. These authors concluded, "Our results do not support, but also do not unequivocally disprove, the hypothesis that adverse events lead to an overestimation of the effect of SSRIs over placebo". I would agree with this conclusion. And, Hieronymus et al (2017) also admit that their "study does not allow any firm conclusions".

In fact, for citalopram, they found that the rating on the Hamilton Depression Rating Scale (HDRS) for those that reported adverse events was not statistically significant from placebo. This may be why they focus in the paper on the depression rating within HDRS, which did find a significant difference. For the paroxetine trials, the association with adverse events goes in the other direction, although, for some reason which I don't understand, in the paper the authors suggest this observation for paroxetine (do they mean citalopram?) "could be interpreted as support for side effects exerting some impact on the response to the drug through unblinding".

Anyway, I agree papers of this sort do not seem to completely corroborate the amplified placebo hypothesis. But, as Barth et al (2016) point out, reporting of side-effects in clinical trials is extremely variable. Reporting of side-effects may, therefore, not be the best proxy measure of unblinding. We do need studies that systematically check for unblinding (Even et al 2000). There is also the issue about whether depressed people may do better over the long-term without medication (see previous post). I am afraid this debate is likely to keep running and can't be closed down by the Guardian article.