Independent review following Edenfield scandal

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

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

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

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

• a weak and fragmented clinical voice

• unsafe levels of staffing and high use of temporary staff

• a poor physical environment

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

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

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

All these findings led to these recommendations:-

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

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

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

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

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

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

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

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

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

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

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

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

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

Overstatement in the critical narrative of antidepressants

I agree with a lot of what Jon Jureidini says in The Conversation (see article) about why so many Australians in particular, and people globally, are taking antidepressants. However, as I've always said about Jo Moncrieff (eg. see my review of her book The bitterest pills), who is one of the principle proponents of the critique of antidepressants expressed by Jon, I do find niggling overstatement in the narrative.

Certainly too much antidepressant prescribing reflects the overmedicalisation of society (see previous post). I think that antidepressants may just be another example of doctors' shameless exploitation of the placebo effect (see another previous post). I also have concern about the misinformation the public are being given about side effects of antidepressants (see yet another previous post).

For example, Jon says that antidepressants are emotionally numbing agents. I’m not sure what he means by this. Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants are generally not very sedative compared to the older tricyclic antidepressants. I agree that antidepressants may prevent people dealing with their problems properly over the longer term. But Jon seems to mean more than this and I’m not clear what he is saying. Certainly people over the longer term report that taking antidepressants often leaves them with a sense of not being themselves (see previous post). They may well say that they experience a flattening of emotional responses. But I don’t think people generally notice that antidepressants on first starting have the physiological effect of emotional numbing, whatever that is.

Of course I’m not denying antidepressants can have a placebo effect. Taking a pill which people are being told improves mood will commonly counteract the demoralisation people generally feel in depression, particularly in those that believe this could be true. As I said, for example, in my OpenMind article, “Expectation that medication will produce improvement may itself produce apparent benefit”. But, over time, the placebo effect may not last, or may diminish, or may even create other problems, perhaps especially over the very long term. These nocebo, meaning negative placebo, effects also need to be taken into account in assessing the psychological impact of taking medication. Adopting the view that one suffers from a biochemically based emotional illness can be an identity-altering experience (see previous post). 

As Jon says, it’s important to emphasise that maybe as many as half of patients stop antidepressants within weeks. Again as Jon says, and here I think he means those that do continue them beyond several weeks, antidepressants should generally be tapered rather than stopped abruptly. Unlike Jon, though, I would say this is only generally the case. How easy people find discontinuing antidepressants can vary considerably. This is not to deny the importance of withdrawal symptoms with antidepressants (see eg. previous post). 

I also agree with Jon about the importance of social factors in depression, although how depressing people find being poor, for example, does vary considerably. My final quibble is about Jon suggesting overprescribing is symptomatic of the medicalisation of distress. Actually, as I’ve already said, I agree overprescribing is a symptom of the overmedicalisation of distress. But the problem is too much medicine, not medicine itself. Psychiatry needs to be far more psychosocial, rather than biomedical, in its approach to depression and other mental health problems. It needs to stop reducing functional mental illness to brain disease.

Formalising role of triage AMHP in new Mental Health Act

I mentioned the death of Matt Simpson in a recent post. His PhD thesis ‘An Appreciative Inquiry into Approved Mental Health Professional decision making at the point of referral for a Mental Health Act assessment' is well worth reading. Essentially it makes the case for more, indeed the formalising of, early decision making by a triage Approved Mental Health Professional (AMHP) to avoid the need for an assessment process involving doctors. The AMHP has a clear duty under S13(1) of the Mental Health Act (MHA) to consider the patient’s case. The thesis also argues for more availability of a shared pathway to assessment by the AMHP with doctors seeking alternatives to detention, promoting a multi-agency emphasis on less restriction.

The thesis is wide-ranging and provides rich detail. As in the title, it used the method of appreciative inquiry, asking AMHPs to consider their current practice, define the aspects of practice that are most valued, and use that understanding to clarify and validate their practice for the future. 

AMHP assessment with doctors usually leads to detention. Indeed, AMHP services are generally structured on arranging joint assessment with doctors as swiftly as possible. As all AMHPs know, though, finding appropriate doctors is not always easy and can take some time, but joint assessment usually takes place on the same day as referral. High likelihood of detention through assessment with doctors doesn’t necessarily align well with the principle of least restriction and maximising the independence of the person.

The concept of assessment was explicitly extended in the research to include the process of information gathering, multi-agency working, and the inclusion of the referred person and their family before the traditional assessment interview with an AMHP and two doctors. As Matt Simpson said in the thesis:-

This S13(1) MHA 1983 decision-making process is an assessment in itself, with AMHPs only involving doctors in an assessment if this process has exhausted all options and detention has become the only viable outcome in the AMHP’s opinion.

Triage AMHPs could be expected to complete an assessment to conclude that either detention appears to be the only viable outcome or that it can be avoided, potentially reducing the numbers of detentions by formalising the process of this stage. AMHPs in the research also advocated for a more formal inclusive and collaborative pathway to assessment with doctors, that shares complexity and explores alternatives to detention. AMHPs need to use their experience to lower the perception of risk if possible and appropriate. 

Reducing detention was the original political motivation for the current MHA reforms (see eg. previous post). There are concerns that current proposals do not go far enough (see eg. another previous post and recent post on The Critical AHMP blog - see previous post). Certainly formalising the role of a triage AMHP has not really been considered in the reform process, as far as I know, and it should be, considering it could well reduce the numbers of detentions. There is also scope, I think, for formalising a requirement in the new Act for AMHPs to discuss alternatives to detention with doctors and other professionals involved in the care of the patient before actually assessing the patient with two doctors with a view to detention. This process could share the responsibility for any decision not to proceed with detention by the AMHP.

It may even be worth considering going even further in reform to reduce detention by removing the risk criterion altogether from the criteria for detention under the Act, as has been done in Italy (see previous post). There is a sense in which mental health services need to concentrate on their therapeutic role rather than necessarily be seen as ‘social policeman’, not that I’m denying the inevitable social role of psychiatry. What determines whether someone needs to be detained is that there are mental changes in the person that require urgent therapeutic detention in hospital which the person does not accept. Of course, some of these people will be at risk to themselves or others, but explicitly removing that focus on risk may lead to a better assessment of the need for intervention, at least for civil cases. 

The Convention on the Rights of People with Disability (CRPD) makes clear that people with disabilities can only be detained on the same basis (or for the same reasons) as anybody else (see eg. previous post). There are plenty of people without mental disorder who are dangerous, but they are not detained unless arrested for and sentenced after a crime. It does seem non-discriminatory, therefore, to remove the risk criterion in the Mental Health Act. Mental health services do need to move away from their over-preoccupation with risk (see eg. another previous post).

Changes have been made in the criteria for detention in the current proposals, basically about trying to shift the criteria to the serious end of the spectrum of mental disorder, although there is a question about how much difference this will really make in practice, as deciding on seriousness is so subjective. Still, it’s not too late in producing a Bill to consider again completely reviewing the criteria for detention in the context of introducing the formal role of the triage AMHP, who will have to make any application to detain on the basis of these criteria, together with two doctors. It’s not new that detention requires the agreement of all three of AMHP plus two doctors. Strengthening the authority of the AMHP in that process, I think, will be helpful. AMHPs need to learn to see their role more as a safeguard against detention, rather than merely rubber-stamping what two doctors think should happen. 

Unrealistic expectation of risk prediction by mental health services

The tragedy of the Nottingham homicides and other attempted murders by Valdo Calocane has highlighted the role of the police and mental health services in preventing such incidents (see eg. Times article). The police have admitted they could have done more to locate him as he was wanted for arrest after assaulting a police officer, but have argued that even if he had been arrested that it was highly unlikely he would have received a custodial sentence (see another Times article). The police also said that he would probably not have engaged with mental health services if re-referred to them, as he had not done so previously.

Calocane has now been detained in a High Security hospital (see judge’s sentencing remarks). It seems that he has had a chronic psychotic illness which has been difficult to treat. Many people with a psychotic illness are lacking insight into their illness and, as they do not see themselves as ill, do not engage well with treatment. Very few of these seriously mentally ill people are dangerous, though, like Calocane.

Assertive outreach (AO) was introduced as part of the NHS plan from 2000 to manage these difficult to engage patients through providing intensive home treatment by specialist teams. Many NHS Trusts have now closed such services as it has been difficult to show in research studies that such specialist teams reduce bed use or produce better clinical outcomes compared to standard services. Nonetheless, research has found that AO generally improves the engagement of such severely mentally ill patients and their satisfaction with services. The public does expect services to keep in touch with the most severely mentally ill, so I think it has been a mistake to close AO services. Too many people have been discharged from mental health services, when they shouldn’t have been, for not engaging with services. 

More generally, people do need to have a more realistic attitude to what mental health services can do to prevent such serious incidents. It’s commonly thought that all that needs to happen is that mentally ill people need to take their medication and everything will be alright. But even if they take their medication, not everyone gets better.

Homicide inquiries in mental health services have often been destructive (see my unpublished paper based on 2013 conference presentation). They all tend to find the same kind of things, for example: poor risk management, communication problems, inadequate care planning, lack of interagency working. The trouble is that these sort of things are everyday difficulties that staff have to manage. Some evidence of the need to improve in those areas will often be found in all cases, not only the ones that lead to homicide. Communication, care planning and joint working can always be improved. Usually this situation does not lead to adverse outcomes.

Moreover, homicide inquiries have encouraged the myth of accurate risk assessment. Mental health services are expected to have foresight which it is unrealistic to expect them to have. Not uncommonly homicide inquiries, because of hindsight bias, unreasonably recommend improved risk assessment. But, merely knowing about risks, even if these could be calculated, may not actually improve practice at all. Such recommendations also encourage an inappropriate separation of risk assessment from an overall full and complete assessment, which is, therefore, not completed properly because the focus is on mere risk assessment. The reality is that we have very little knowledge about the accurate quantification of risk. Risk assessment is actually the management of uncertainty, not certainty. Mental health services should have and still need to challenge the illusion of certainty.

The media are often quick to blame mental health services for homicides by psychiatric patients (eg. see previous post). I do think it is reasonable that someone like Valdo Calocane was sent to a special hospital rather than prison. Mental dysfunction can diminish responsibility for a crime (see eg. another previous post). What people often do not appreciate is that people detained in a special hospital may spend longer there than if they had gone to prison. Their mental state may not improve sufficiently for them to be released and I suspect this may well happen with Calocane.

Mass shootings, particularly in USA, although people run amok in similar ways in all societies (see previous post), are often blamed on poor mental health services (see previous post). Actually the majority of mass shooters are not psychotic, like Calocane. Generally they are aggrieved individuals who blame others for their suffering, as well as themselves, and commonly mass shooters at least attempt suicide after their killing of others. Too often mental health services inappropriately accept the blame for such outrages, apparently with the misguided hope that doing so will increase the social and political will to improve mental health services (see another previous post). Psychiatry does have a role in preventing homicide and suicide but it does need to be far more realistic with the public about what it can achieve.

The Critical AMHP blog

I have just read the posts on The Critical AMHP (Approved Mental Health Professional) blog. I was alerted to it by a tweet announcing the death of Matt Simpson, a contributor to the blog. As I have done previously with other publications (eg. see previous post), I thought it may be worth stringing together some of the tweets I have made as I was reading the blog:-

The post from Matt Simpson entitled Appreciative Angst

“AMHP Number Two Please….”. A post by John Mitchell with the following quotes or slightly amended quotes:-

AMHP services have had to adapt to an often surreal dysfunctionality in wider mental health services. 

National policy demands fewer detentions under the Mental Health Act, not just in the prime case of racialised people, from whom there may be most to learn, but across the board. 

Faced with risks AMHPs [and S12 doctors] were trained to shudder at more than understand, uncertainties of resource, intention, outcome, other professionals more concerned to protect themselves than to reach the person, it can feel difficult not to detain under Mental Health Act.

 “Call the Doctor…Quick!” Assessing Children under the Mental Health Act. A post by Sarah Raymond with worrying quote:-

The numbers of referrals for Mental Health Act assessments on children steadily but slowly increase year on year

‘Dilemmas, Conundrums, and Quagmires.’ Tracing the Threads of Ethical AMHP Practice. A post by Alan Bristol with the following slightly amended quotes:-

Ethical concerns are not only a pressing issue, but the central issue or foundational concern for wider Approved Mental Health Practitioner (AMHP) practice. 

The statutory mental health system is too coercive and potentially anti-therapeutic in its effects, whilst also continually evidencing structurally racist, patriarchal and heteronormative practices.

Another post by John Michell entitled AMHPersonality: Disordered?, about the disadvantages of using detention in the management of personality disorder, with quote:-

Detaining people with ‘personality disorder’ may be unjust, even when refusal to do so may itself feel like an injustice to the person being assessed.

These quotes are necessarily selective but give a flavour of the perspective of The Critical AMHP blog. It deserves to be more widely known.

Reforming the Mental Health Tribunal

As I said in a previous post, I would like to see the hiatus in Mental Health Act reform, due to the lack of inclusion of a new bill in the current session of parliament, used to consider taking current proposals for reform even further. One of the ways in which I think that should happen is looking again at extending the role and powers of the Mental Health Tribunal.

As I have also said (see eg. previous post), the 1959 and 1983 Mental Health Acts were reforming Acts for the rights of people with mental health problems. There is an opportunity to improve the rights of people with mental health problems even further in a new bill. The Mental Health Review Tribunal was originally a standalone body to hear appeals against detention (see eg. Wikipedia entry). Associated with the amendments to the 1983 Act in 2007, the Tribunal merged with the Health and Social Care Chamber of the newly established First-tier Tribunal in 2008. The Tribunal is now called the Mental Health Tribunal, with the ‘Review’ dropped. 

Personally I would reinsert the ‘R’ in the acronym and call it the Mental Health Rights Tribunal in a new bill, making explicit its human rights basis. My experience is that the Tribunal now has become bureaucratic and less focused on patients’rights and has become too much of a rubber-stamping exercise of what the Responsible Clinican is doing. The 1983 Act also introduced the safeguard of Second Opinion Approved Doctors (SOADs), but again, as I have said before (see eg. previous post), the SOAD process has become too much of a rubber-stamping exercise. Safeguards introduced by the 1959 and 1983 Acts, such as Tribunals and SOADs, have actually been watered down in my view.

Sarah Markham asked in a Lancet Psychiatry article whether first-tier tribunals for mental health in England are fit for purpose. As she says, there is concern that Tribunals are dominated by clinical input and that human rights are given lower priority, especially the rights to liberty and access to justice. Tribunals should not merely legitimise coercion and limit access to justice. There are questions about risk assessment with the perceived risk of patients generally being deemed of greater importance than the evidenced facts. She expresses the same concern as me that "tribunals are in effect acting as rubber stamps for medical decisions rather than as an objective and robust accountability organisation and effective protection for individuals".

As I said in my submission to the Parliamentary Scutiny Committee, I have no objection to Tribunals being reduced to a single judge. This would mean that they are no longer dominated by the medical member, whose view panels as a whole rarely oppose. The expert witness role that the medical member provides, in my opinion, would be better provided by independent experts within an integrated advocacy service of mental health lawyers, Independent Mental Health Adocates (IMHAs) and independent experts, not just on medical but also on nursing and social matters.

The Parliamentary Scrutiny Committee recommended introduction of pilots for patients to be able to appeal to a slimmed down Mental Health Tribunal about treatment plans. I think there is time before a bill comes back to take this forward to proceed with a full reform of the Tribunal, so that patients can appeal to the Tribunal both on detention and treatment decisions.

Adapting to individual differences

Rach Idahu has a blog ‘Adulting with ADHD’. BBC News reports that she told BBC Podcast ‘Access All’ that she lost £200 when she late checked in for a flight, even though she did not realise she was late (see article). The article explains that Rach estimates she has lost £4000 to the ADHD tax, by which she means that because of her ADHD she has trouble paying attention to details and may regularly misplace or lose items causing additional expenditure.

Everyone is different as far as their ability to pay attention to detail and misplace or lose items is concerned. As I said in a previous post, ADHD has been classified as a neurodevelopmental disorder over recent years and the diagnosis of ADHD has burgeoned (see another previous post). Professor Amanda Kirby is quoted in the BBC article as saying that “people with ADHD are prone to impulsive behaviour because the neurotransmitter that controls feelings of wellbeing and reward does not function properly". It is true that dopamine has been implicated in motivational function but it is mere speculation to say that dopamine is not functioning properly in ADHD. 

In fact it’s reducing people to machines to think so. Society does need to adapt to the individual differences of people. But to be blaming our brains is not the best way to look at the issue (see eg. yet another previous post). Although it may suit us to think that ADHD is due to brain pathology, it’s actually a mistake to be looking for brain pathology to explain it (see eg. my BJPsych letter).

(With thanks to Evgeny Legedin for alerting me to the BBC News article)

Enlightened thinking about psychiatry

As I said in my editorial, “medical psychology had its origins in two major variants of anthropological thinking”. One was physiological and the other was Kant’s pragmatic perspective. Kant defined anthropology as the doctrine containing our knowledge of human beings (see eg. Howard Caygill’s A Kant Dictionary). A physiological perspective involves people as objects of and in nature, which was named by Thomas Fuchs as the naturalistic perspective (see eg. previous post). The pragmatic perspective sees people as freely acting beings or citizens of the world, called the personalistic perspective in Fuchs’ terms.  

Caygill’s introduction and first chapter to his Kant’s dictionary is the best summary of Kant’s life and work that I know. As he says:-

Anyone practising literary or social criticism is contributing to the Kantian tradition: anyone reflecting on  the epistemological implications of their work will find themselves doing so within the parameters established by Kant [his emphasis]. 

The Enlightenment was the age of criticism with the freedom to examine and criticise the institutions of Church and State. The fundamental condition of the possibility for the age of criticism was the ‘freedom to make public use of one’s freedom in all matters’ [Kant’s emphasis]. As I mentioned on my personal blog (see post), the internet now means public critique is no longer totally dependent on the existence of a publisher, as it was in Kant’s time. At least blogging is freely available on Blogger, which I have used extensively, including 15 years of this blog (see previous post)!

I have mentioned Kant several times previously in this critical/relational psychiatry blog. In particular, I make use of his view that the link between mental and physical is an enigma that can never be solved (see eg. previous post). Kant has been proved right, in a way, that function is not as well localised in the brain as we might hope and expect (see eg. another previous post). As taken forward by Foucault (see eg. yet another previous post), modern psychiatry had its origins in the epoch of criticism, as even reason had to submit to reason’s ‘test of free and open examination’. Kant’s Critique of Judgement, in particular, inquires into the conditions of the possibility of judgement itself. Teleological explanation of nature is required rather than a mechanical one. Mechanical explanation cannot explain living beings. There are limits and boundaries to the extent of legitimate knowledge, including about mental illness (see eg. previous post). 

Despite criticism of biomedical psychiatry, it retains dominance in the field of mental health. I’ve always said the wish to find a biological basis of mental illness will never completely go away. But, like Kant, criticism needs to continue to be persistent and obstinate in examining the basis of psychiatry’s, and not just biomedical psychiatry’s, knowledge claims and practice. Psychiatry, including its critical version, needs to be self-critical.

Acetylcholine’s back: Move over dopamine

Kaul et al (2024) report the results of a trial of xanomeline–trospium (KarXT) in people with schizophrenia experiencing acute psychosis. Even though we’ve been told that dopamine blockade is the way to treat schizophrenia, KarXT does not block D2 dopamine receptors. Instead xanomeline is a dual M1 and M4-preferring muscarinic receptor agonist. It is combined with trospium chloride, a peripherally restricted muscarinic receptor antagonist, to ameliorate peripheral muscarinic effects.

Side effects of KarXT include constipation, dyspepsia, headache, nausea, vomiting, hypertension, dizziness, gastro-oesophageal reflux and diarrhoea. The gastrointestinal side effects of xanomeline had previously stopped its development as a psychotropic drug. The combination with trospium is designed to reduce frequency and severity of such adverse events. 

Schizophrenic symptoms were significantly reduced by KarXT more than placebo after 5 weeks. The study was said to be masked but no measures of unblinding are included in the research report, so it is difficult to assess its bias. If unblinded, it is likely that the fact that this is a new agent, with the hope, therefore, and maybe expectation, that it will be effective could have influenced results. The trial was funded by Karuna Therapeutics, which has other drugs in its pipeline, and has recently been acquired by Bristol Myers Squibb. Already a global pharmaceutical giant, I’m sure KarXT, if successful, will enhance Bristol Myers Squibb’s finances at least over the next decade.

Acetylcholine is a neurotransmitter. It was the first to be discovered as it is secreted by the vagus nerve. There are two main types of receptors: muscarinic and nicotinic. Muscarinic receptors are the main end-receptor in the postganglionic fibres of the parasympathetic nervous system. They are also present in the brain where all five subtypes are expressed.

The dopamine theory of schizophrenia hasn’t stood up for some time (see eg. previous post). Despite some protests that they do not, psychiatrists generally believe that psychotropic medication corrects chemical imbalances in the brain. They’ll adjust without any qualms to thinking that muscarinic receptor agonists modulate dopaminergic, GABAergic, and glutamatergic signaling in schizophrenia. They’ve been waiting for a antipsychotic drug which doesn’t block dopamine D2 receptors for over 70 years, and Karuna Therapeutics has managed to exploit that situation. 

I guess tolerability may be more of a problem than Kaul et al make out, but we shall see. As Cipriani et al (2024) point out, there is no data on comparative benefits and harms of KarXT against existing antipsychotics. Data from longer term trials is also awaited. There are also questions about the actual benefit to patients. Still, I suspect enough has already been invested for the weight of Bristol Myers Squibb to see KarXT to market.

Function is not well localised in the brain

I tend to regard much of modern biomedical research in psychiatry as neo-phrenological phantasy (see eg. previous post). There is no evidence that functional mental illness is caused by brain abnormalities, despite the vast investment in trying to prove just that (see eg. another previous post). Phrenology failed because Gall’s idea that skull features were indicators of specific faculties of mind could not be confirmed empirically. The lack of empirical confirmation of the modern biomedical hypothesis of mental illness has not yet led to its abandonment in the same way. We don’t seem to be able to see the same quackery in biomedical psychiatry as phrenology. Why is that?

At least part of the reason is that the fundamental issue of biomedical psychiatry is more profound than whether phrenology was true. Phrenology was the first doctrine to suggest that cortical functions could be localised. Even though the specific hypothesis that feeling the shape of the skull could detect the relative size of the underlying organs of mental faculties was shown to be false, people have continued to think that brain functions must be localised in the brain at least to some extent. Hence the vast number of false claims that mental illness is due to abnormalities in particular areas of the brain.

There have always been theories of brain function. However, it was not really until the nineteenth century that science seriously considered that the cerebral cortex might be divided into distinct parts responsible for different functions. The cerebral hemispheres consist of a system of sensory and motor centres. But the subjective aspects of brain functions are more obviously part of psychology than neurology. As far as consciousness in general is concerned, it’s actually a category mistake to think it is in the brain (see eg. previous post). The implication is that functional mental illness cannot be reduced to brain disease in principle (see eg. another previous post). More generally, life cannot be explained in terms of mechanical principles of nature (see eg. yet another previous post).

The first cortical localisation that became widely accepted was linking speech to the frontal cortex. Paul Broca associated damage to the frontal cortex with aphasia in 1861. Nine years later Hitzig and Fritsch discovered the dog's cortical motor area from their observations in dogs after a variety of cortical lesions. Friedrich Goltz (1834-1902) was, however, certain that intellect could not be confined to discrete parts of the cerebrum. He rejected physiological reductionism and believed dementia was a function of the whole cerebrum. Sensory and motor functions are localised to some extent but not all human functions are localised in the brain.

The brain lesion literature continued to support the idea that mental illness could be due to pathological changes in higher structures. This led to Moniz being awarded the 1949 Nobel Prize for Medicine or Physiology for his leucotomy procedures. The modern era of psychopharmacology began believing that chlorpromazine caused an equivalent chemical lobotomy. Psychiatry has still not developed from the era of psychopathological structures (see previous post), despite the disaster, for example, of Walter Freeman’s icepick leucotomy (see eg. my OpenMind article and book review).

It suits psychiatry to forget all this history. It continues to fudge the difference between functional and organic mental illness (see eg. previous post). This is despite it learning at least by the beginning of the twentieth century that human function is not as well localised in the brain as we might hope or expect. Nor should it be conceptually (see eg. another previous post). It’s about time psychiatry moved on from its outdated physical model of mental illness.

What’s gone wrong with how we talk about young people’s mental health?

I’ve mentioned Lucy Foulkes before (see previous post). She has an article on Medium entitled ‘The adolescent mental health mess’. As she says, there is “concern that talking so much about mental health has meant milder problems are now confounded with mental disorders, and young people are diagnosing themselves with problems they don’t really have”. She fears that this has led to a backlash so that “all [her emphasis] young people who say they have mental health problems are now being treated with scepticism”. I agree with her that such polarisation is not helpful. Young people should not be prevented from asking for help with mental health problems if they need it.

But, young people do need to be given proper information about mental health. They need to be told that mental illness is not a brain disease (see eg. previous post). As I said in another previous post, young people need to learn that the brain is the origin of thoughts, emotions and behaviour, and to challenge their negative prejudices and not be frightened of mental illness. The way to do that, though, is not to make the misleading and oversimplistic statement that mental diseases, such as depression, are diseases of the brain.

Young people also need better information about the limits of any treatment, and more emphasis on psychosocial intervention than medication and individual psychotherapy. They also may do better going to a non-medical service, such as third sector charitable services, than the NHS. They may even be able to manage within their own resources of support without going to services.

I do think it would be helpful if NHS England could give a better lead about all this. I agree with Lucy that more research is needed, but there is also a need for action now.

Alternatives to coercion in mental health care

Both the World Health Organisation (WHO) and the World Psychiatric Association (WPA) urge countries to take action to promote non-coercive practices in mental health (see recent article). WHO together with the United Nations Office of the High Commissioner for Human Rights (OHCHR) has issued a guidance and practice document on Mental health, human rights and legislation (see previous post). The WHO QualityRights initiative (see eg. previous post) has developed a range of tools and resources to transform mental health services. A discussion paper from a WPA Taskforce on ‘Implementing alternatives to coercion in mental health care’ led to a WPA Position Statement. 

As I’ve said before, mental health legislation needs to become compliant with the United Nations Convention on the Rights of People with Disabilities (CRPD) (see eg. previous post). There are different interpretations of CRPD about whether deprivation of liberty under mental health legislation can ever be lawful (see article). This divide has been known as the ‘Geneva impasse’, as it is reflected within the United Nations human rights system. Personally, I have always thought that CRPD can allow for involuntary treatment as a last resort, for the shortest possible time, subject to safeguards and monitoring by a competent review system. The trouble is that current legislation, and even the present proposals for change by the UK government, do not go far enough (see previous post).

Despite the considerable resistance to change (eg. eg. see previous post), system and service changes to reduce coercion in mental health services are required. There has actually been a reinstitutionalisation of mental health services over recent years and this needs to be reversed to build on the dehospitalisation that led to the closure of the asylums some years ago now (see eg. another previous post).

The reasonableness of madness

PPP article by Justin Garson, with several commentaries and his response, raises issues about the rationality of madness. Justin tries to reframe a basic problem in the philosophy of psychiatry about the nature of madness.

Judgement should be suspended initially in clinical assessment of the rationality or otherwise of even bizarre-seeming behaviour and experience. Doing so in a thoroughgoing way may make the most mad-seeming actions and experience intelligible. Such reactions may even come to be seen as a reasonable response to an unreasonable situation.

As Aaron Esterson said (see previous post), some people who are labelled mad are mad by any criterion. Yet, some are misdiagnosed, and may be confused into believing they are mad or mentally ill, even thinking they have a brain problem, when they have not. Psychiatric diagnosis is not an exact science. And, other people can be so emotionally distraught they seem mad. Even mad people are not necessarily mad in the way they are often said to be by mainstream psychiatry (see eg. my presentation). 

Mad people sacrifice shared understanding with others for the internal logic of their own psychotic thought and experience (see previous post). Delusions are not necessarily un-understandable, nor always "bad for us", nor even particularly an exceptional way of thinking (see another previous post). We actually believe all sorts of things, partly often because there isn't clear evidence one way or another or it’s not clear what the best view should be for some of the things we believe. Power relations in society can also determine what we believe.

As Foucault said, reason questioned the rational foundations of what is accepted as reason in the Enlightenment and was the foundation for the origins of modern psychiatry (see eg. previous post). We need to remind ourselves that the distinction between reason and unreason is not absolute. Justin Garson argues that defining madness as not merely the absence of reason is a more positive way of viewing madness. He says it helps to sustain Mad Pride, mad resistance and mad activism. Such a position foregrounds user/survivor perspectives and can pose an inherent challenge to the biomedical dominance of psychiatry (see eg. my review of Mohammed Rashed’s book). Certainly reducing functional mental illness to brain disease is not helpful.

Fifteen years of the critical/relational psychiatry blog

The first ever blog was about 30 years ago, probably as a place for Justin Hall, a student, to publish his writings on the internet (see The History of Blogging). Other people quickly followed creating “online diaries” and “personal pages” and the term “weblog” was coined in 1997 by Jorn Barger. It took me a while to realise what blogging was and this blog started 15 years ago today. The purchase of the Blogger platform by Google in 2003 making it freely available made it easy to learn how to blog, and I’ve made 659 posts in those 15 years,

Although I do have a personal blog as well, this critical/relational psychiatry blog has been in the area of the blogademia of psychiatry (see post on my personal blog about blogademia). The dogmatic nature of academic psychiatry, and academia in general, means it can be difficult for critical perspectives to be published in mainstream journals (see eg. previous post). Blogging is freely available and publicly accessible and I have tried to maintain academic standards in the posts I have made over the last 15 years.

Shameless exploitation of antidepressant placebo effect

I wasn’t going to blog about Carmine Pariante’s recent New Humanist article, as it just repeats what he has already published. But he has been promoting it as a balanced view on antidepressants (see eg. his tweet), which it isn’t.

I’ve questioned Carmine’s scientific credibility before (see previous post). I think the Royal College of Psychiatrists may even have appreciated that he overstates his case (see another previous post). For example, he wrongly sees critical/relational psychiatry, which has produced the critique of antidepressants he rebuffs, as dualist (see yet another previous post).

Carmine does need to take the critique of antidepressant efficacy more seriously (see previous post). I told him this several years ago (see another previous post). No one’s disputing what he says that many people report benefit with antidepressants. But the question is whether that means that antidepressants work (see yet another previous post), which he says it does. Actually, people’s experience of antidepressants is more complex than mere benefit (see even another previous post). 

Carmine will not like my sceptical argument about the overstatement of psychiatric medication efficacy because of biased clinical trial methodology (see previous post). He worries people are being shamed for taking antidepressants (see another previous post). But he seems to fail to realise that doctors have always exploited the placebo effect. Why he’s being so overdefensive could be because he fears that antidepressants may be another example. The overmedicalisation of society has created too much antidepressant prescribing (see yet another previous post). If psychiatry carries on in the way Carmine wants it to then I anticipate there are going to be serious problems (see last post).

The myth of massive psychiatric need

I want to start this post with a quote:-

There has been a massive growth in mental health services during the past 20 years as psychiatry has extended its boundaries to include an ever-widening array of human problems.

Don’t assume this is a recent quote, although it could be! It was actually written in 1988 in an article entitled ‘More and more is less and less: The myth of massive psychiatric need’.

The article goes on:-

Psychiatric manpower, facilities, and programmes have been vastly increased. However, as more resources are provided, more are perceived to be needed: more and more is less and less.

The article’s warning that the myth of massive psychiatric need was being used to justify additional resources for existing services, rather than solving current problems, has still not been heeded all these years later (see eg. recent post). That’s not to deny requirement for additional investment, but need for services should be prioritised rather than demand.

As supply of services increases, demand also continues to increase. Resources therefore fail to meet that demand. Merely increasing the numbers of professionals doesn’t solve the problem. If treatment is so effective at reducing need, then demand should decrease over time as that need is met, rather than increase. This situation is made even worse by broadening the boundaries of what counts as mental disorder over recent years (see my article referred to in this post).

As the article says, the problem with all this development is that resources are diverted from the most seriously mentally ill. The NHS, including mental health services, has become too fragmented and dysfunctional. We must stop  seeing mental health services as a panacea for society’s difficulties (eg. see previous post). We’re being oversimplistic about what psychiatry can achieve (see eg. another previous post).  Psychiatry, and health services in general, needs to redefine its role.

Preparing for Mental Health Act reforms

Wes Streeting, Shadow Secretary of State for Health and Social Care, has said that one of the first pieces of legislation he would bring forward in government would be on reforming the Mental Health Act (MHA) (see Guardian article). The current government did not include reform of the MHA in the King’s Speech for the current parliamentary session (see eg. Community Care article).

Reforms need to be taken forward in line with the Parliamentary Scrutiny Committee recommendations (see previous post) and recent WHO/OHCHR guidance (see another previous post). The Centre for Mental Health has produced a helpful document on A Mental Health Commissioner for England, a new role proposed by the Scrutiny Committee. I would like to see the opportunity taken, in the time available before legislation comes back again to parliament, to consider further:-

• prohibiting civil detentions to secure facilities
• improving advocacy by creating an integrated service of Independent Mental Health Advocates (IMHAs), mental health lawyers and independent experts 
• extending the role and powers of the Mental Health Tribunal (MHT) to treatment as well as detention decisions, thereby making the role of Second Opinion Approved Doctors (SOADs) redundant

See my submission to the Scrutiny Committee for further details.

Too much antidepressant prescribing reflects the overmedicalisation of society

As the BMJ reports (see article), a group of politicians, experts, and patient representatives has called for the UK government to reverse the rate of antidepressant prescribing. Their BMJ letter comments on both the increasing rates of prescribing (see previous post) and the increasing duration of time on antidepressant treatment (see another previous post). Long-term outcome for depression is not necessarily good (see yet another previous post). There is even evidence that treatment can create a vulnerability to relapse, meaning that people may do better over the long-term by working through their problems without medication (see previous post). The net ingredient cost of antidepressant drugs is not insignificant, and, in the 2022/3 financial year in England, it was over £235 million (see NHS Business Service Authority data).

This call to reduce antidepressant prescribing needs to be understood in the context of the overmedicalisation of society in general. Such overmedicalisation needs to be reversed in the interests of the country’s health as a whole, as the NHS has become unsustainable (see eg. previous post). The cultural process of creating panaceas for emotional and other mental health problems doesn’t always work and may create more problems than it is worth (see eg. another previous post). This may be particularly obvious with the ever increasing demand for mental healthcare for children and young people over recent years (see eg. yet another previous post).

The letter marks the launch of the Beyond Pills All Party Parliamentary Group (APPG) (see Guardian article), which joins the forces of the former APPG for Prescribed Drug Dependence (see eg. previous post) and the College of Medicine Beyond Pills Campaign (see previous post). A cultural change to reduce the reliance on medication and to support shared decision-making is needed, not least for mental health services. The BMJ itself has recently called for a reset in its campaign against too much medicine (see eg. post on my personal blog).

Misleading people that mental illness is brain disease

I’ve reposted a previous post from September 2010 about ‘Misleading children about mental illness’. The link to the NIH curriculum supplement on ‘The science of mental illness’, mentioned in that post, is dead. However, the section on the 2007 published “Information about mental illness and the brain’ from the NIH curriculum supplement series is available (see webpage).

That webpage states:-

As scientists continue to investigate the brains of people who have mental illnesses, they are learning that mental illness is associated with changes in the brain's structure, chemistry, and function and that mental illness does indeed have a biological basis.

This is not true. There is no evidence that functional mental illness is brain disease (see eg. previous post). The implication is that psychiatry needs to abandon its biomedical framework (see previous post). Although psychiatry ignores this critique, the complexity of the relation of biology with interpersonal, social and cultural factors does need to be acknowledged (see another previous post). As in the title of a previous post, psychiatry is too based on speculation rather than fact. For my whole career, I argued that psychiatry needed to incorporate a critical/relational perspective (see previous post). It’s about time that psychiatry became more open and therapeutic.

Misleading children about mental illness

(Originally published Sept 2010)

The NIH curriculum supplement for middle school (grades 6-8), The science of mental illness, aims to introduce students to what it calls the key concept that mental illnesses have a biological basis and are therefore not that different from other illnesses or diseases. It is important to get children to understand that the brain is the origin of thoughts, emotions and behaviour, and they do need to learn to challenge their negative prejudices and not be frightened of mental illness, but the way to do it is not to make the misleading and oversimplistic statement that mental diseases, such as depression, are diseases of the brain.

The curriculum is also keen to convey to students how science can help us make informed decisions. What it does in fact is demonstrate how knowledge is shaped and formed by our modern biomedical beliefs. The propagandist nature of the educational material needs to be made transparent.

Is antipsychotic prescribing justified in children and adolescents?

As I mentioned in my book chapter:-

Joseph Biederman, [was] professor of psychiatry at Harvard Medical School and chief of pediatric psychopharmacology at Harvard's Massachusetts General Hospital, …[and] influenced psychiatric practice to the extent that children as young as two years old … [were] diagnosed with bipolar disorder and treated with a cocktails of drugs, many of which are [still] prescribed ‘off licence’. Through Congressional investigations by Senator Charles Grassley, it … [was] disclosed that Biederman received $1.6 million in consulting and speaking fees between 2000 and 2007.

An obituary regarded him as the ‘father of paediatric psychopharmacology’. Johnson & Johnson gave more than $700,000 to a research center headed by Biederman (see NY Times article), which was involved in research on Risperdal, the company's antipsychotic drug, which is prescribed as a so-called mood stabiliser (see eg. previous post). 

Klau et al (2023) recently examined patterns of paediatric antipsychotic prescribing in Australian primary care services in 2011 and 2017. Antipsychotic prescribing increased in children and adolescents between these dates and most such prescribing was off-label, with an increasing proportion of off-label prescribing. Almost 70% of these patients prescribed antipsychotics were also co-prescribed other psychotropic medication. The most common diagnosis of children and adolescents prescribed antipsychotics was depression/anxiety, although international studies have found ADHD to be one of the most common diagnoses, and the proportion of ADHD diagnoses in this Australian sample doubled from 2011 to 2017. Antipsychotic prescribing for autism increased in those without the additional feature of behavioural problems, which is required for on-label use. Antipsychotic prescribing has also increased for those with eating disorder, even though off label, maybe because the weight gain is seen as potentially beneficial, particularly by olanzapine.

When I first trained in psychiatry, children and adolescents were seen as having emotional and behavioural problems but diagnosis of mental illness, as such, was uncommon. Medication had a very limited role in the context of family and behavioural therapies. As I wrote in my 2003 article:-

Historically, child and family studies … tended to take a more holistic approach to personal and social problems. The speciality of child psychiatry … served as a haven and opportunity for those who wanted to escape the reductionism of their colleagues in adult psychiatry. It … [is] a pity that the discipline has now been so invaded by the biomedical model.

Despite the efforts over the years of psychiatrists, such as Sami Timimi (see eg. previous post), this biomedicalisation has continued. As far as antipsychotics are concerned, there are potential harms such as weight gain. More fundamentally antipsychotics are at least overprescribed in children and adolescents outside licensed indications. Their use at least needs to be reduced and more critical debate is required about any benefit/harm ratio. Overmedicalisation of children’s mental health problems is not helpful (see eg. previous post). Young people need to be given correct information about mental illness (see eg. another previous post). The cultural process of seeking to create panaceas for emotional and other mental health problems of children and adolescents doesn’t always work and may be creating more problems than it is worth. 

The nature of psychiatry

I’ve mentioned Ivana Marková before (see previous post). She has an interesting article in History of Psychiatry in which she draws from Heidegger to explore the question of what psychiatry is. Psychiatry is a form of interpersonal interaction in which there is a specific reaching out of one Being to another. Through recognition of the other’s mental condition there is a corresponding sense that something should be done about it. She uses the word ‘distress’ for the condition being recognised, which is perhaps not ideal, and she may need to supplement her analysis with one about the nature of mental illness (see eg. previous post). 

As she says, meaning is created through interaction of clinician and person. The construction of distinctions and categories in diagnosis cannot be reified, or even necessarily reduced to brain abnormalities, and should not be viewed as always depicting absolute reality. We should not be surprised if we “struggle to fit clinical presentations into the conventional descriptions”. As she says, 

In the face of a psychiatry that is driven ever more by a neurobiological reductionism in research and by a mechanistic and algorithmic approach to the assessment and management of patients, it is increasingly important to rethink a formulation of psychiatry from within [her emphasis].

As she concludes, authentic engagement is required in the practice of psychiatry (see eg. previous post). Trouble is that modern psychiatry too often avoids it, even labelling it as anti-psychiatry (see another previous post).

Foundations of the Critical Psychiatry Network

I’ve mentioned before (eg. see previous post) my article on ‘Twenty years of the Critical Psychiatry Network’ (CPN). Key CPN members have written a chapter in a forthcoming book on ‘The emergence of the UK Critical Psychiatry Network’.

As the chapter says, the issues that brought CPN together still remain. To quote from it, “Psychiatry does not always make decisions in the best interests of patients, yet it presents itself as though it does, therefore avoiding necessary political and democratic scrutiny”.

Blood test for bipolar disorder will never be available

It worries me that organisations acting on behalf of service users and their representatives can be so taken in by biomedical psychiatry. For example, I have recently received an email from Bipolar UK about a JAMA Psychiatry brief report that there could be a simple blood test to diagnose bipolar disorder (see MailOnline report). Simon Kitchen, their CEO, is quoted as saying, such a blood test "would be immeasurably beneficial" for the bipolar community. He does qualify this by saying, “we would like to understand more about likely timescales and implementation. When will this blood test be available?" What concerns me, though, is that there is no questioning about whether this is even a realistic possibility.

I’ve always said the wish to find a physical basis for mental illness will never go away completely (see eg. previous post). The diagnosis of bipolar disorder, like any other psychiatric diagnosis, is not an exact science. There are even issues about whether bipolar disorder, certainly in the wider diagnostic sense it has come to be used over recent years, amounting, essentially, to seeing bipolar disorder as mood instability (see eg. another previous post), can be separated from major depressive disorder (see eg. yet another previous post). As I wrote in my book review:-

There was a time when psychiatry would not have made so much of the difference of whether depressed people also had manic episodes or not. With the development of mood stabilizing medication, this has come to matter more and the concept of bipolar disorder has even been broadened to make more people eligible for these new medications.

As I said in the title of a previous post, psychiatric practice is too based on speculation. It would be helpful if Bipolar UK did not encourage this. However trite it may be to say, people with a diagnosis of bipolar disorder need to be understood as people like everyone else, responding in an intelligible, maybe even reasonable way, to an unreasonable social situation. It may seem attractive to think there will be a blood test to detect the disorder but that’s pie in the sky, not science.