The mind is indivisible from the brain

Peter White et al in an article in the BMJ propose that classifications of neurological and psychiatric disorders should be merged together into a single category of disorders of the nervous system. They justify this because of what they call the “revolution in the clinical science of the mind, as the techniques of basic neuroscience are successfully applied in mental health”.

This success is apparently demonstrated in brain scans that they say show structural brain abnormalities in various mental health disorders. However, they then don't say what these abnormalities are; nor do they note the dynamic nature of the appearance of the brain on scans; or discuss whether findings are specific. They also make a lot of the results of functional brain imaging showing brain activation but don’t say how it’s helped our understanding of brain function. For example, we already knew before brain scans that the limbic system is involved in supporting a variety of functions such as emotion. 

Of course the mind is indivisible from the brain, as they say. As such, a statement of this sort is tautologous, but White et al are saying more than this. Essentially, they believe that a sharp distinction between organic and functional disorders is unhelpful (an issue I’ve commented on in a previous post). In fact, they don’t seem to realise that DSM-IV has already tried to get rid of this distinction.

The arguments they use about the advantages of a more medicalised psychiatry do not really stand up. They suggest it helps stigma but as I have pointed out previously (see post), it could in fact increase stigma, as people do not really feel understood. Similarly, they think it might help recruitment to psychiatry but as I’ve again pointed out previously (eg see post), it may put people off.

I’m not against psychiatrists getting training in neurology and vice versa, but I do think it’s important that psychiatrists are well trained and they may well get the wrong idea if White et al’s proposal is taken up. Psychiatry, unlike neurology, is not based on treating a physical lesion.

Conflict in psychiatry

Pleased to see that psychiatric trainees are still interested in controversies in psychiatry. The Frontier psychiatrist blog has a post about Anthony Clare's Psychiatry in dissent. I commented in an eletter on an article about this book before Clare died in 2007.

Perhaps Frontier Psychiatrist is right that we need a "contemporary critique of psychiatry aimed at the layman". For the moment maybe my Critical psychiatry is a start.

Different perspectives in psychiatry

George Dawson in a comment on my previous blog entry mentioned an article by McHugh & Slavney, which has just come out in NEJM (not sure how George seemed to know about it before it was published). I agree with the analysis of this paper. A full psychiatric assessment of a patient in terms of family and personal history is too often regarded as almost 'out of date' and unnecessary in psychiatric training these days.

I don't agree, however, with McHugh and Slavney's proposed solution. They say "No replacement of the criterion-driven diagnoses of the DSM would be acceptable". That's just the point and why the DSM system should be abandoned to help psychiatry to realise that full psychiatric assessment is essential to practice. They are also right in a way that "much turns on causation" but then I think this is where they get it wrong by including schizophrenia and panic disorder as brain diseases with delirium. 

Why would psychiatry be better off without a psychiatric classificatory system such as DSM?

I thought it might be helpful to explain a little more why I think DSM-5 shouldn't go ahead. As I've said previously (eg. see earlier post), I am supporting the campaign to abolish psychiatric diagnostic systems. This campaign 'No more psychiatric labels' gives its rationale on its website.

The World Health Organisation started classifying the causes of death in the International Classification of Diseases (ICD). In the sixth revision it extended its classification to causes of morbidity as well as mortality and a chapter was added for psychiatric disorders (which don't cause death as such). The americans have always run a parallel DSM system. ICD-9 and DSM-II were essentially the same.

Criticism of psychiatric diagnosis led to the DSM-III revision, which attempted to define psychiatric disorders using operational criteria. Although it may have been technically atheoretical in its approach, it encouraged a biological understanding of mental illness as due to brain disorder. The misguided hope has been that reliable diagnoses will equate with standardised biological tests developed by advancing neuroscience (eg. see blog by Allen Frances, who has also been critical of DSM-5 because of its potential expansion of the boundaries of psychiatric diagnoses). DSM-IV abolished the distinction between organic and functional disorders as they are all seen as brain disorders (see previous post).

There were of course diagnostic systems before ICD-6 and DSM-I, but it is the authority attached to diagnostic descriptions since DSM-III that causes problems. However important classification may be for scientific communication, it is also essential to realise that diagnosis is also about the reasons why a person has developed problems. Focusing on a single word entity distracts diagnosis from obtaining this personal understanding.

Idealised diagnostic descriptions are not entities as such. This truth has been lost in the pursuit of DSM-5, which should be abandoned. There are alternative ideas about comprehensive diagnosis which could be developed (eg. see World Psychiatric Association (WPA) conference report). Allen Francis has recently suggested in NYTimes that a new organisation is needed to take over from the American Psychiatric Association, but I'm not quite sure why he doesn't consider WPA.

The co-ordinating group of the Inquiry into the 'Schizophrenia" Label want you to visit their inquiry website. You could if you wish provide evidence, write in with a testimony or register as a supporter.

This inquiry has no financial ties to any organisation and is supported (at present) by over 140 individuals and over 30 national and international organisations. The evidence collected will be examined by an independent panel made up of service users, academicians and a lawyer. A report based on evidence will be forwarded to a range of organisations including NICE, the Royal College of Psychiatrists, other professional and statutory bodies, private and third sector organisations, and the Department of Health. Please email the inquiry if you need any further information.

Occupy APA

I went to a meeting of the radical caucus of the APA last Sunday in Philadelphia, where I was attending a conference (see previous post). I suppose the radical caucus could be seen as the US equivalent of the Critical Psychiatry Network. It was interesting to see that similar issues were raised.

A particular issue currently is the DSM-5 revision. As I have mentioned previously (see post), I have signed up for the campaign to abolish psychiatric diagnostic systems like DSM. I think it would help psychiatry to be without a diagnostic system for a while. It managed without one until 1948. The American psychiatric system has become very dependent on DSM for billing purposes, but I'm sure the insurance companies could develop an alternative system unrelated to DSM. After all, in the UK, clusters have been created for the introduction of payment by results without requiring an ICD diagnosis.

The meeting was split on the issue of the need for mental health legislation. As I've said before (see previous post) I think it's important revolutionaries and reformers work together. In the UK context, there is need for further reform of the Mental Health Act following the 2008 amendment. For example, there are ethical problems about enforcing community treatment in a capable patient. I think there is also a need for further safeguards in the use of ECT in a patient who is not consenting to treatment. But, unlike some, I do see a need for legislation.

For further reflections on the meeting, see Brad Lewis's post on Mad in America blog.

Why do people take psychiatric medication if it does not correct a chemical imbalance?

This post is prompted by a comment on a previous entry. The question was whether psychotropic drugs are unnecessary, as people continue to take them even though they don't work by correcting a chemical imbalance.

Believing the chemical imbalance theory provides a good rationale for taking medication (see eg. previous post and eletter). But I guess we will continue to take medication even without really knowing how it works. It is often started when we are feeling desperate, so we are likely to believe whatever's proposed will help. And of course medication might have non-specific effects.

Remember also that discontinuation problems are very common (eg. see my book chapter about antidepressant discontinuation problems.) So I'm not recommending just stopping it. However, I do think it's important to have a debate about the rationale for taking medication (eg. see previous post).


(With thanks to Atariana who has now prompted me to pick up on her comments on my blog a third time.)

Does transcranial magnetic stimulation work?

The comment I mentioned in the last post also asked how repetitive transcranial magnetic stimulation (rTMS) works and whether it is similar to ECT. The comment was made following my mention of rTMS in a previous blog entry in response to the NIMH medical director's blog. The NIMH website itself has a page on brain stimulation therapies, and both ECT and rTMS are in the list.

I've never seen rTMS (although I have seen ECT). My understanding is that an electromagnet is placed over the skull and the patient usually wears earplugs to diminish the noise from the discharging coil. Rhythmic pulses of electromagnetism are delivered usually in daily sessions lasting about 30 minutes for 2-4 weeks and possibly longer. The patient may experience involuntary spasms of scalp muscles.

NICE says there is uncertainty about the procedure's clinical efficacy for depression (see guidance). Despite this, it is available in Canada, for example, and the costs at a MindCare Centre are CAN$250 per treatment, amounting to CAN$5000 to CAN$7500 for a course of treatment. So it's not cheap and I'm not sure if insurance pay out easily on a case-by-case basis.

Even despite the cost, in many ways development of the procedure has been slow but of course there's no drug company behind it. And I'm not sure about its acceptablity. Maybe it makes psychiatry's quackery too transparent. Psychiatry has always been wishful in its thinking about physical treatments (eg. see previous post about deep brain stimulation).

What is critical psychiatry?

A comment on a previous post asked me what critical psychiatry is. Perhaps I should make an attempt to provide an answer in summary form. The Wikipedia entry is informative for those that are interested. Or, if you really want to read more about the subject, there's always my edited book. (Get it from a library rather than buying it.)

I've always said the essential message is that psychiatry can be practiced without taking the step of faith of believing that mental illness is due to brain pathology, such as a chemical imbalance in the brain. This is commonly what patients are told, but the evidence is against it. Don't misunderstand what I'm saying. Of course mental illness must show through the brain - but not necessarily in the brain. There are implications for both assessment and treatment in practice. Diagnosis is not about finding an entity of some kind, but about providing understanding. We also need to be more sceptical about treatments, such as medication.

Any other attempts to summarise critical psychiatry in a paragraph?

Brainy psychiatry

In his NIMH Director's blog, Thomas Insel, who I have mentioned several times before (eg. see previous post), has picked up on the same Lancet article as I did in a previous blog entry. Although the number of graduating US doctors choosing psychiatry seems to be down a bit over recent years, Insel is impressed that the number with PhDs has doubled in the last decade. I'm not sure whether the number of those with PhDs has also increased in other specialities.

Insel defines psychiatry as clinical neuroscience. A recent NIMH training session for top second year psychiatry residents (many with PhDs) treated them to sessions focusing on "neuromodulation— using cognitive training and repetitive transcranial magnetic stimulation (rTMS) — to alter symptoms of depression and anxiety by modulating specific brain circuits".

I can't see that psychiatry is helped by this narrowing of its focus. So-called clinical neuroscience has become too academically dominant, sustained by biomedical research funding. Actually the brightest young doctors need to engage more with the nature of psychiatry.  I will be writing further about promoting critical psychiatry in the academy, hopefully leading to a conference sometime.

No clues needed to explain Breivik's behaviour

Simon Baron-Cohen in an article in The Times predicts that an underdeveloped empathy circuit (whatever that is!?) would be found in an MRI scan of Anders Breivik's brain. I guess Baron-Cohen's unlikely to be given the opportunity to confirm his theory. He admits that neuroscience is an insufficient explanation of Breivik's cruelty and that his "offensive ideological convictions may [my emphasis] be one extra ingredient in the deadly mix".

However difficult it may be to contemplate the reasons for Breivik's killing spree does not excuse trying to reduce the reasons for his behaviour to a brain abnormality damaging his so-called affective empathy. (Autism is said by Baron-Cohen to be an abnormality of cognitive, rather than affective, empathy.)

This illustrates the problem of a biomedical understanding of mental illness. War (which is regarded as a sane action) is justified on the basis of "goodness not evil" in the same way as Breivik has justified his behaviour. Breivik himself compared his sacrifice of 77 people to the dropping of the atom bomb on Japan, preventing more deaths in a civil war which he believes will arise out of multiculturalism. His reasons couldn't be any clearer - speculating about his brain abnormality is a distraction.

Generic quetiapine available

Nigel Hawkes helpfully summarises the patent position of Seroquel in BMJ news item. It's lost its patent for the XL (prolonged release) version in the UK, which has been marketed as an add-on in depression (see previous post). At least sense has prevailed about the issue of exclusivity of information about side effects, but maybe I'm keen to thwart AstraZeneca, like the FDA apparently.

Bring back the functional-organic dichotomy

I'm prompted to make this post by reading Kennneth Kendler's recent article. Of course I'm not Cartesian, but his fear of dualism leads him to praise DSM-IV's dropping of the functional-organic distinction. Actually there is a difference between biomedical and biopsychological understandings of mental illness, and he shouldn't try and deny it.

He favours what he calls empirically based pluralism as he says Engel's biopsychosocial model provides no focus. This is similar to the spat I had with Nassir Ghaemi about his book (see previous post). I don't think critical psychiatry (or Engel's biopsychosocial model) is anti-empirical. In fact, Engel saw the biopsychosocial model as scientific.

What kind of therapy is psychiatry in need of?

Editorial in The Lancet refers to press release from the American Psychiatric Association (APA) about recruitment to psychiatry, a subject which I have commented on in a previous post. It suggests that psychiatry needs to "realign itself as a key biomedical specialty at the heart of mental health", without explaining what it means by this. 

The APA medical director (who did not excel in his response to a hunger strike by survivors in 2003 - see my article) says that this is an exciting time for psychiatry because there have been "more scientific developments in the field than ever before". Of course there is plenty of scientific work going on in psychiatry but he might ignite more interest by questioning what it is really being achieved. Nor are APA promotional videos such as 'The faces of psychiatry' and 'Real psychiatry: Doctors in action' going to stimulate young doctors when they make such trite statements as mental illness is "a misnomer" as it is really brain disease and that mental illness is "no different from heart disease and  hypertension" without any discussion of the issues.

Everybody has won and all must have prizes

Fiona Godlee, BMJ editor, in her latest Editor's Choice, is pleased to see what she calls evidence that counters claims that antidepressants have little or no effect. She finds this evidence in an editorial that commented on a meta-analytic study, which found no substantial difference in efficacy between the second generation antidepressants.

The work that Godlee thinks "may well have dissuaded patients and some clinicians from considering or continuing antidepressants" is that of  Irving Kirsch, which I have discussed in a previous post. What the authors of the editorial say, which Godlee thinks counters Kirsch's work, is that the meta-analysis found that "[j]ust under two thirds of the patients responded to treatment by 12 weeks and just under half achieved full remission". They don't say compared to what or define response or remission. 

Before it can be concluded that this finding means that antidepressants are effective, it is necessary to ask what the controls were. People improve naturally from depression. There is a large placebo response to antidepressants. 

There is also a question about the definitions of response to treatment and remission in clinical trials. Fifty percent reduction in score severity is most commonly used as the measure of response. Many of these patients who are classified as responders nonetheless remain highly symptomatic. A reasonably low cutoff score on rating scales is usually proposed as the definition of remission. This is not the same as being completely asymptomatic.  So, the results noted by Godlee may not be as good as they seem. (See my previous blog entry, How easy is to treat depression?)

Moreover, most head-to-head comparisons of antidepressants do not include a placebo arm. Antidepressant response rates are higher in comparator trials compared to placebo-controlled trials, because of the greater expectancy effect as patients know they will definitely be given an antidepressant rather than have a chance of getting placebo. If all that is being suggested is that the effect size seems larger for trials comparing one drug with another rather than with placebo, this is not a new finding. 

What people find difficult, including the BMJ editor apparently, is accepting that randomised controlled trials of antidepressants (and probably drugs in the rest of medicine - see previous blog entry) have not eliminated expectancy effects because they are not really double-blind (see a critical exploration of the evidence). The throw-away remark in the BMJ editorial (the article is after all more about the comparative efficacy of second generation antidepressants than about the effectiveness of antidepressants as such) should have been subject to more scrutiny before publication. It then wouldn't have been taken up by the editor to undermine the challenge to the wish-fulfilling nature of antidepressant medication.

Conference programme

Psychosis risk syndrome at risk?

Article in The Sydney Morning Herald says Patrick McGorry has changed his mind about including attenuated psychosis syndrome in DSM-5. This coincides with a commentary in The Lancet also concluding that inclusion of this diagnosis would be premature. Even if it is a valid syndrome, a Cochrane review says there is no conclusive evidence that people in the prodrome of psychosis can be helped.

Peter Breggin falls out with David Healy over ECT

Peter Breggin has been critical of David Healy's views about ECT in a blog on The Huffington Post. I also wasn't that impressed with David in a book review I did some years ago.

Psychiatric drugs just as ineffective as other drugs

A BJPsych article, which claims it is the "first attempt to provide a panoramic overview of major drugs", concludes that psychiatric drugs are not generally less efficacious than other drugs. The paper has been commented on in a BMJ news item. The authors of the article note the questioning in the literature of the efficacy of antidepressants, cholinesterase inhibitors for Alzheimer's disease and lithium prophylaxis in bipolar disorder. They also reference a review of their own, which found "a smaller antipsychotic drug-placebo difference than we had intuitively expected".

They say these reports inspired an article in The New Yorker which summarised them. They then go on to suggest that a vocal antipsychiatry movement has been fuelled by this critique of psychiatric medication. To support their argument, they reference Medication madness by Peter Breggin and The emperor's new drugs by Irving Kirsch. I have mentioned the latter in a previous post. Actually, it's not anti-psychiatry to practice in an evidenced-based way. What people seem to be finding difficult is coping with the reality of the evidence.

The study confirms that the highest effect sizes in psychiatry come from withdrawal studies of maintenance treatment. This is higher than that found for acute treatment. As the effect size is small for acute treatment, it is possible the finding is due to an artefact caused by the fact that randomised controlled trials are not as double-blind as is commonly assumed (see, for example, From placebo to panacea: Putting psychiatric drugs to the test). The bias introduced through unblinding could potentially explain the results. As I have mentioned before (eg. see previous post), the higher effect size in withdrawal studies could be due to the nocebo effect of discontinuing medication compounding unblinding.

The fact that non-psychiatric drugs have similar effect sizes in clinical trials should not be interpreted as meaning that psychiatric drugs are effective, but that medical as well as psychiatric clinical trials are subject to the same biases of unblinding. Secondary prevention of cardiovascular events with aspirin or statins has even lower effects sizes than those for psychiatric treatment. It is possible that so-called "hard" endpoints such as death could be affected by these same biases (see, for example, my eletter).

Could psychiatrists become extinct?

Paul Harrison (who I've mentioned in a previous post), Ed Bullmore (again, who I've mentioned in another previous post) and others have posted an eletter in response to a BJPsych editorial entitled "The future of psychiatry". They argue for what they call a "remedicalised psychiatry". By this they mean that psychiatrists should concentrate on "what doctors do best" and challenge their "involvement in activities or services which are not of this kind". They suggest that without change psychiatrists will be left like "the apothecaries 300 years ago: in decline, mental health care increasingly left to a poorly coordinated coalition of other health professionals".

What these authors are at least partly reacting against are the reforms, such as so-called New Ways of Working, influenced by the previous National Director of Mental Health, Louis Appleby. In a recent interview, Appleby said "I get uneasy if it starts to sound as if doctors have a natural entitlement to a unique place in mental health care".

There were problems with New Ways of Working, such as not paying enough attention to the continuity between the new services created and a lack of proper emphasis on the expertise of mental health staff, not just medical staff. Department of Health policy has now moved on. However, I too, like Appleby, have concerns about Harrison, Bullmore et al's stance.

The danger is that their position could be seen as saying that psychiatrists are not concerned with the personal dimension, which is actually the primary element of mental health practice. It doesn't actually matter that, for example, non-psychiatrists prescribe medication or become approved clinicians under the Mental Health Act, as long as they are properly trained to do so. This is where the debate should focus.

By the way, before completing my university medical degrees, I first practiced medicine as a licentiate in medicine and surgery of the Society of Apothecaries, which could approve medical training in the UK until 2003. I had been sceptical about the value of medical training for mental health practice and gave up my medical training for 8 years before returning to complete it (see eg. a talk I gave some years ago). A patient-centred medical training is indispensible in modern mental health practice. The problem is that medical training is not always as patient-centred as it should be.

Critical rationality in psychiatry still required

Another book by Arthur Kleinman has made the BMJ medical classics list (see previous post about the other book) - this time The illness narratives - see review.

Kleinman edited a book with Theo Manschreck in 1977 called Renewal in psychiatry in which they defined critical rationality as a:-

commitment to rational evaluation and derivation of knowledge. It encompasses the critical scrutiny of prevalent beliefs and practices; and refers to the use of explicit values and rigorous methods, clear concepts and argument, precision in thinking, and supportive evidence to help us harness the creativity of imagination and intuition in the discovery of new knowledge. It promotes exacting standards for the process of inquiry, regardless of its object; and it is self-critical. It therefore qualifies as an indispensable standard governing clinical discourse, teaching and research. 

Good to see that someone who could be said to have been involved in the origination of critical psychiatry is getting such recognition.

Champion of mental health awareness dies

Article in Irish Times announcing John McCarthy's death.  Read his "Comparing a diagnosis of cancer and psychiatric disorder".

Have fun with drugs

Looks beautiful in Colorado Springs where the 2011 NEI Global Psychopharmacology Congress has just been held. Not sure about the congress opener though. I'm still waiting for Stephen Stahl to post about the RSM meeting on pharmaceutical sponsorship of psychiatry research (see previous post).

What if the drugs don't work?

Article in the Independent with this title. It mentions a debate between Ian Anderson (see previous blog entry) and Irving Kirsch (see another previous blog entry) with the motion "Antidepressants are useful in the treatment of depression" coming up at the 4th International Congress on Psychopharmacology of the Turkish Association for Psychopharmacology.

There's also a quote from Daniel Carlat (who blogs at The Carlat Psychiatry blog), who admits that, "When I find myself using phrases like 'chemical imbalance' and 'serotonin deficiency', it is usually because I'm trying to convince a reluctant patient to take a medication. Using these words makes their illness seem more biological, taking some of the stigma away." As I wrote in a BJPsych eletter, patients are able to understand that the chemical imbalance theory is only a theory. What they find more difficult to appreciate is why they are told that the theory has been proven when this is clearly not the case (see another previous blog entry).

Pleased also to see that Irving Kirsch is talking more about the nocebo effect from coming off antidepressants, as I have for some time (eg. summarised in my chapter in recent book Demedicalizing misery) . To quote from the Independent article, "If you expect to feel bad when you come off antidepressants, you will, because 'we tend to notice random small negative changes and interpret them as evidence that we are in fact getting worse', Kirsch says".

Psychiatrists should know what they're doing with medication

An editorial this month in the British Journal of Psychiatry is entitled 'No psychiatry without psychopharmacology'. It suggests there is insufficient prioritisation of psychopharmacology in psychiatric training. It asks for psychopharmacology to be affirmed as an integral and significant component of psychiatry, and a consequent expectation of a commensurately high level of knowledge and practice.

As I mentioned in my previous post, I've just come back from a conference in Newcastle. Paul Harrison, the main author of the editorial, gave a presentation at the meeting with the same title as the editorial. He thought that the low priority apparently given to psychopharmacology may be related to what he called the 'anti-pharmacological lobby'.  I suppose I would be seen as part of this lobby, but, despite what Harrison implies, I agree that psychiatrists should be well trained in psychopharmacology.

What I didn't hear in his talk, but is mentioned twice in the editorial, is unquestioned belief in the efficacy of psychiatric medication. To quote from the editorial, research shows that "contemporary psychotropic medications are effective". Again, it says that "the evidence that psychotropic drugs are beneficial when used in the right way and for the correct indications is unequivocal".

Good psychopharmacological training will highlight the weaknesses and bias of randomised controlled trials (eg. see my Bias in controlled trials webpage). The trouble with much prescribing is that it is beyond the evidence (and not even conforming to guidelines such as those produced by NICE). Psychiatrists are insufficiently critical of the evidence base for medication.

Are antidepressants really placebos?

I've just come back from Newcastle, where the Faculty of General and Community Psychiatry of the Royal College of Psychiatrists has been holding its Annual General Meeting (see programme). One of the talks was by Professor Ian Anderson entitled 'Are antidepressants really placebos?' As he himself said, as might be expected, his answer was no.

I'm not sure if the talk really had much more in it than a letter he had published in the British Journal of Psychiatry several years ago. Anderson makes a lot of the fact that continuation studies show high relapse rates. Following the results of the meta-analysis by Geddes et al (2003), the average rate of relapse on placebo is 41% compared with 18% on active treatment. In other words, continuing treatment with antidepressants reduces the odds of relapse by 70%. Anderson doesn't think this could possibly be a placebo effect.

Doctors have always underestimated the difficulties of discontinuing antidepressants (see my Antidepressant discontinuation reactions website). If patients are significantly unblinded in discontinuation studies, the negative placebo (nocebo) response could explain these results because of how reliant people have become on their medication. Any change threatens an equilibrium related to a complex set of meanings that their medication has acquired.

No more psychiatric labels

I have joined the campaign to abolish psychiatric diagnostic systems like DSM called "No more psychiatric labels". There is an overemphasis on biomedical diagnosis in psychiatry (eg. see my article with this title). Psychiatry does need to recognise diagnosis for what it is (eg. see presentation from a talk of mine).

Even Allen Francis, Chair of the DSM-IV taskforce, is critical of the approval of new fad diagnoses in DSM-5 (eg. It's not too late to save 'normal' and a more recent Psychiatric Times article). I think we'd be better off without any psychiatric diagnostic system at all for a while rather than go along with DSM-5.

Are the chinese really taking over drug companies?

Stephen Stahl, whose Essential psychopharmacology book now has his name in the title, has a post on his NEI (Neuroscience Education Institute) blog about drug company research. He mentions a crisis meeting at the Royal Society of Medicine this month, which he says he will report on when he gets back. I look forward to hearing more.

He regrets that "Nobody likes drug companies these days". I don't think he's helping their press by seeming to support drug company sponsorship of medical education and illegal marketing of their drugs. At least he admits that half of prescribing in psychiatry is "off label".

Nor is his case helped by misrepresentation of those who express concern about these practices as believers in psychiatric illnesses being "pure inventions of Pharma". As I've pointed out in a previous post, there's no need to be defensive if pharmaceutical companies really are pulling out of psychiatric research.


(With thanks to a post on Carlat Psychiatry Blog).

Unthinkable? R.D. Laing in Guardian editorial

Not sure what prompted an editorial in the Guardian about R.D. Laing in its Unthinkable? series. The editorial makes reference to a production of Knots at the King's Head Theatre. It suggests it is time for a reassessment of Laing in "an era of big pharma and proliferating diagnoses". Samantha Bark in her response says she was thrilled to see the editorial and makes reference to her PhD thesis on Laing, which I have added as a link on my articles critical of psychiatry webpage.

Critical psychiatry has never hidden its origins in the work of R.D. Laing (see my book chapter Historical perspectives on anti-psychiatry). There were excesses in 'anti-psychiatry'. Critical psychiatry aims to avoid the marginalisation experienced by R.D. Laing and others like him designated as 'anti-psychiatrists'.

Mental illness not same as focal brain lesions

Thomas Insel in his NIMH Director's Blog asks whether a neurological approach to mental illness is helpful. He admits it is an "NIMH mantra" to describe mental disorders as brain disorders. I have previously mentioned his view that mental illnesses are disorders of brain circuits.

He suggests mental illnesses are analogous to heart arrhythmias which may not have a demonstable lesion in the heart. He holds out the hope that mapping patterns of cortical function will find abnormal brain circuitry. The example he gives is of apparent delayed cortical maturation in ADHD. Well, let's see - is this conclusion based on one study ie. Shaw et al (2007), which hasn't been replicated? He also speculates that neuroimaging could allow early detection of so-called circuit disorders.

Insel goes on to state that neuroimaging is beginning to yield biomarkers, but then doesn't say what the biomarkers are. He suggests that deep brain stimulation is demonstrating how changing the activity of specific circuits leads to a remission of refractory depression, but doesn't say what circuits are being changed.

Finally, he at least concedes that, "In truth, we still do not know how to define a circuit". He also concludes that "One thing we can say ... is that earlier notions of mental disorders as chemical imbalances or as social constructs are beginning to look antiquated." Not sure why he includes 'social constructs' in this broadbrush remark, as he's not considered this possibility. His faith in the value of neuroscience to help people recover from mental disorders has been the wish-fulfilling phantasy of modern psychiatry since the 19th century.

NHS treatment of eating disorders

I have already mentioned Bryan Lask in a previous post about eating disorders. He has responded to a Guardian leader about specialist treatment for anorexic children. He believes that eating disorders are "highly complex genetically determined, brain-based disorders". However, he doesn't explain why he thinks this.

He expresses concern about the reduction in the number of young people admitted to specialist inpatient units and suggests that they are being admitted to paediatric units instead. I'm not sure where he gets his figures from. He argues that the motivation for closure of specialist units is financial.

I presume he means that NHS savings mean that the number of referrals to private units has decreased. He is no longer medical advisor to the Huntercombe group which runs three such units. Maybe he's worried they'll be forced to close. Current reforms of the NHS (see my personal blog) may well eventually open up the market for the management of eating disorders, but it's not necessarily always been the best use of money to ship difficult to manage patients out of the NHS (again, see another personal blog entry).

Think about investing in intercultural mental health

My previous entry implied that the 'Grand challenges in global mental health' initiative is a thinly veiled attempt to obtain funding from the Gates Foundation for mental health research. I'm not sure if this is right, as the Gates Foundation Global Health Strategy has "chosen not to focus on research in mental health, even though it is a serious health problem in developing countries, in part because of the very large contributions already being made by the U.S. National Institutes of Health, the pharmaceutical industry, and other funders".

I guess the initiative must be directed at other funders, or maybe it's hoping the Gates Foundation will change its mind. Anyway, well done to the Gates Foundation for not supporting such a project.

Thought needs to be given to the conceptual foundation of any investment in intercultural mental health. 'Grand challenges in global mental health' tied itself to the academic concept of 'global mental health' linked to a past series of Lancet articles. However, there are problems with the validity of the knowledge base for this approach (see Derek Summerfield's BMJ article). The best book in the field of transcultural psychiatry (I prefer the term intercultural - see David Ingleby's chapter from my Critical psychiatry book) is Suman Fernando's Mental health, race and culture.

How to get money for global mental health research

The Grand challenges in global mental health initiative reckons it has identified priorities for research in mental, neurological and substance-use (MNS) disorders (see Nature article). Similar initiatives in global health in general and in chronic non-communicable diseases have led to the commitment of significant new programmes of funding from the Bill and Melinda Gates Foundation amongst other research funders.

The term 'mental health' is seen as a convenient label for MNS disorders, excluding conditions with a vascular or infectious aetiology because these were covered by previous initiatives. This brain disorder bias seems to reflected in the identified priorities. Such priorities obviously also reflect the biases of the assembled international panel. They don't seem particularly interested in what people with mental health problems themselves in different parts of the world want.

Drug companies losing interest in psychiatry is great news

Letter from Sami Timimi in response to BMJ news article about drug companies pulling out of neuroscience research. I've mentioned in a previous post that I'm not sure if this is really the case. But if it is, as Sami points out, that's a good thing - we shouldn't be defensive about it. Psychiatry research has for too long been dependent on drug company sponsorship. The biomedical myth has been used as the justification for too much psychiatry research in general.

Could antidepressants really be a hoax, a mistake or a concept gone wrong?

The New York Times Sunday review has an article by Peter Kramer 'In defense of antidepressants'. He finds it worrisome that antidepressants may be merely placebos with side effects (see previous blog entry).

He suggests that the way pharmaceutical companies produce data submitted to the FDA to obtain a licence for antidepressants is "sloppy" because subjects who don't really have depression are included. He argues that this recruitment bias of an "odd bunch" of people increases the placebo response rate for so-called mild depression, but he doesn't explain why this complication should necessarily change the finding of a small statistical difference between active and placebo groups.

He thinks studies done in specific disorders, such as depression in neurological conditions, eg. stroke, multiple sclerosis and epilepsy; depression caused by interferon; and anxiety disorders in children, have greater external validity. Furthermore, he suggests that results in chronic and recurrent mild depression, such as dysthmia, are more trustworthy, but doesn't give a reference.

He goes on, "Scattered studies suggest that antidepressants bolster confidence or diminish emotional vulnerability — for people with depression but also for healthy people." It was this aspect that was perhaps most questionable about his book Listening to Prozac. He seems to think the placebo effect is a good thing, without realising that what he is describing is a placebo response.

Nor does his argument on maintenance studies wash. He suggests that withdrawing placebo shouldn't have any effect. Again, this does not seem to demonstrate much understanding of the placebo effect. Withdrawing a substance which is believed to have improved mood inevitably will produce a nocebo effect.

Kramer is also critical of a JAMA study picked up by a USA Today piece 'Study: Antidepressant lift may be all in your head'. He suggests the selectivity of the study made it one that "could not quite meet the scientific standard for a firm conclusion". He thinks the media should not embrace what he calls "debunking studies".

He concludes that "it is dangerous for the press to hammer away at the theme that antidepressants are placebos. They’re not. To give the impression that they are is to cause needless suffering." I guess that it's just too difficult to accept that antidepressants could "really be a hoax, a mistake or a concept gone wrong".

Speak out against psychiatry

I like to think of critical psychiatry as a broad church. For example, the last Critical Psychiatry Network conference I organised in Norwich in 2009 was called 'Promoting the critical mental health movement'. As I wrote in the blurb:-

The critical mental health movement is comprised of various perspectives developing a critique of the current psychiatric system. These range from reform to revolution. Although there may be debate about how much can be achieved within psychiatry, the movement is held together by recognition of the need for fundamental change.

Speak Out Against Psychiatry is organising an event at the Royal College of Psychiatrists in London on 27 July. This is a group of people who have either used, or have been in close contact with people who have used, psychiatric services. A lot of the people they have spoken to have had a very negative experience of psychiatry, and many feel they have not been treated like human beings - that they are labeled as “ill” and given drugs rather than being listened to and offered support. The experiences are particularly painful for people who have been detained under the Mental Health Act. When detained in hospital, people can be forced to take medication, and often feel that anything they say is dismissed as a symptom of their “illness” rather than their genuine fears and frustrations of being imprisoned in what can be a terrifying environment.

Speak Out Against Psychiatry wants to give these people the chance to come together and speak about their experiences, and are going to be doing this outside the Royal College of Psychiatrists on the 27th of July between 4pm and 6pm. They also want to give people the opportunity to discuss alternative, humane ways of helping people in distress.

I have always said that the root problem in modern psychiatry is the belief that mental illness is a brain disorder. My personal view is that psychiatry can be practised without the justification of postulating brain pathology as the basis for mental illness. This position should not be misunderstood as implying that mind and brain are separate. Perhaps a way to express what I am saying is that mental disorders must show through the brain but not always in the brain.

I think it is important that there is a forum for debate both within critical psychiatry and between critical and mainstream psychiatry. I have suggested setting up an International Critical Mental Health Movement (see previous blog entry).

Although the manifesto of Speak Out may be more radical than I would express myself, I do think it is important that psychiatry engages in this debate. In this sense, mental health services would be truly centred on users of services. The views of critical psychiatry are not marginal to the present situation in modern mental health services.

Survey about stopping antidepressants

The Royal College of Psychiatrists is doing a survey to look at people's experience of stopping antidepressants. This is to help produce a 'Stopping antidepressants' leaflet. The problems produced by discontinuing antidepressants are seen as an area of disagreement.

Some time ago I set up my Antidepressant discontination reactions website. This was following a letter (at the bottom of the letters on this link) I had published in the BMJ. Psychiatrists were slow to recognise antidepressant discontinuation problems (see powerpoint from a talk).

Psychiatric classic

Nice to see that the BMJ in its Views & Reviews series regards Arthur Kleinman's Rethinking psychiatry as a medical classic. I include it my critical psychiatry website book recommendations page.

A focus on culture arises out of the combination of anthropology and psychiatry. Indigenous healing systems worldwide use nonspecific symbolic techniques to counteract demoralisation. Kleinman promotes a paradigm shift in medical and psychiatric practice to create a robust relationship between psychiatry and the social sciences.

The review was written by a junior doctor (in anaesthetics) who says he was left "uninspired by the basic sociology taught at university". Rethinking psychiatry invigorated a renewed interest for him. This confirms what I said in a previous post about what might attract young doctors into psychiatry.

Psychiatrists do not believe that psychotropic drugs fix chemical imbalances in the brain

A book review of Anatomy of an epidemic is critical of Robert Whitaker for "settling for a simple but crude interpretation: those drugs messed you up". There may be some validity in pointing to the "totalising argument" and the "expansive sweep" of his interpretation. Actually, as I've noted before, I think the value of Whitaker's books is the way he describes the evidence for the vulnerability created by taking medication.

Perhaps surprisingly, the reviewer deflects Whitaker's argument by suggesting he knows of "no serious psychiatrist who believes that psychotropic drugs 'fix chemical imbalances in the brains' of their patients". That's good, because as a recent article in Philosophy, Psychiatry and Psychology points out, theories, such as the dopamine hypothesis of schizophrenia, have "held the status of a scientific paradigm defended by some with great avidity". The article suggests the psychiatric field "needs to become more self-critical about the validity of its theories". There is a sense in which chemical imbalance theories have persisted despite the contrary evidence. Many patients believe them because they think that's what psychiatrists believe.

Attracting people into psychiatry

Thomas Insel, in his NIMH Director's blog, views clinical neuroscience as the answer to psychiatry's recruitment problem. The dean of the Royal College of Psychiatrists, Rob Howard, has also said that recruitment into psychiatry is at a crisis point (see his May 2009 newsletter). Solutions were discussed at a London division academic day (see Frontier Psychiatrist blog).

The problem with Insel's remedy  is that too many young psychiatrists, if they believe him, will become disillusioned. He makes reference to an NIMH Neuroscience and Psychiatry module Translating neural circuits into novel therapeutics, which suggests that impaired GABA neurotransmission in chandelier neurons in the dorsolateral prefrontal cortex contributes to cognitive impairments in schizophrenia, which may be corrected by an agonist for GABA_A alpha 2 subunit receptors. The module mentions a small RCT using such a drug, MK-0777, which seemed to find evidence of improved performance on memory tasks, but doesn't mention a larger scale study which failed to show any improvement in cognition.

Putting on one side that cognitive impairment in schizophrenia may well be functional, the complexity of speculation is supposed to excite people into understanding the pathological basis of psychiatry so that they can develop so-called rational treatments that then undergo rigorous testing. But are hypothetical, wishfulling phantasies really going to attract a new batch of recruits?

Personally, I suspect we need to remind ourselves of the interest in psychiatry which Aubrey Lewis stimulated at the Maudsley Hospital Medical School after he was appointed Professor of Psychiatry in 1948. For him, postgraduate psychiatry should be for "ardent, critical, lively, disputatious and reflective, eager minds" (Lewis, 1947). He encouraged a sceptical approach to psychiatry. He had little patience for imprecision or poorly thought-out ideas.

As Michael Shepherd pointed out in a BJPsych article, "Throughout his professional life Sir Aubrey was at all times an educator who was much concerned with the problems of recruitment into psychiatry, more especially with quality rather than quantity." Doctors with open minds, who are sceptical of psychiatric quackery, need to be attracted into psychiatry.

Whistling in the wind

Edward Shorter, in his response to an article by Thomas Szasz, says there are solid biological findings in psychiatry. Shorter, who I've mentioned in a previous post, is the Hannah Professor of the History of Medicine at the University of Toronto. In 1996 he was cross-appointed to a professorship in psychiatry. As a non-clinician, has this professional association gone to his head?

The examples he gives of "obvious evidence" are the role of panicogens in triggering panic disorder; the response of catatonia to barbiturates and benzodiazepines; and what he calls the reliable accompanying of melancholic depression by hypothalamic-pituitary-adrenal dysregulation, as reflected in high levels of serum cortisol, a positive dexametasone suppression test (DST) and a shortened rapid eye movement sleep latency.

The reference Shorter gives for the importance of panicogens is from the proceedings of the 32nd annual meeting of the American Society of Clinical Investigation held in Atlantic City on 6 May 1940. In this study, patients with anxiety neurosis were found to increase sighing respiration more than controls when exposed to carbon dioxide and rebreathing. The feelings that they had during this rebreathing tended to resemble or be identical to their panic attacks. Shorter suggests that studies such as this were marginalised because of the influence of psychoanalysis. He doesn't make any mention of the controversy in the literature about the mechanism of action of lactate, which has been seen as the common pathway for the mechanism of action of carbon dioxide and several other panicogens.

The reference he gives for the evidence of the organicity of catatonia was a study of 4 cases, which were actually thought to be neuroleptic-induced, which responded to intravenous lorazepam. Shorter also mentions the response of catatonia to barbiturates. William Bleckwenn's use of intravenous amobarbital to produce lucid intervals in catatonic patients quickly led to the development of the so-called "truth serum".  How's this proved the organic basis of catatonia?

The reference Shorter gives for the biological basis of melancholic depression is his own recent book, written with Max Fink, entitled Endocrine Psychiatry. Fink has been an advocate of ECT over the years. I need to read the book. The DST was rejected as a biological marker because it was insufficiently sensitive and specific. I know that Fink thinks it shouldn't have been rejected, but this does seem to be a very idiosyncratic view. I'll come back to this when I've read the book.

Shorter seems to be using his historical expertise to suggest that modern psychiatry has overlooked evidence of its biological basis. As I have repeatedly said, please do not misunderstand me. Of course mental illness has a biological basis, as does our "normal" behaviour. But to be suggesting that biological markers have been established, or even overlooked in history, is whistling in the wind. This is what Shorter accuses Szasz of doing by claiming the opposite. As Szasz makes clear in his article, what he is stating is what he calls an "analytic truth", not dependent on scientific research.

Furthermore, Shorter suggests views such as those of Szsaz (he actually says the makers of the movie One flew over the cuckoo's nest) have led to many people committing suicide because they've avoided treatment. Not surprisingly, he doesn't give any reference for this opinion. As I've commented in a previous post, it's a pity debates such as this get so polarised.

And I'm not saying this because I totally agree with Szasz (eg. see my book review). But on the point on which Shorter has attacked him, he's correct. Shorter may be right that mainstream psychiatry now acknowledges a neurological basis for much psychiatric illness, whereas when Szasz was first writing psychoanalysis was more influential (see my article). But it's just as wrong to take a biomedical view now as it was then.