All mental disorders involve cerebral processes

The ICD-10 Classification of Mental and Behavioural Disorders made clear that:

Use of the term "organic" does not imply that conditions elsewhere in this classification are "nonorganic" in the sense of having no cerebral substrate. In the present context, the term "organic" means simply that the syndrome so classified can be attributed to an independently diagnosable cerebral or systemic disease or disorder.

Nonetheless, DSM-IV wrongly abolished the distinction between functional and organic mental disorder (see eg. previous post) because it suggested the term 'organic' perpetuated a false dichotomy and implied that the remaining categories included in the diagnostic manual represented nonorganic conditions. Organic disorders are in fact distinguished on the basis of their aetiology as psychopathological manifestations of cerebral disease or disorder. Functional disorders lack such an aetiological basis.

Zbigniew Lipowski was the member of the DSM-III task force responsible for the revision of the organic category (Lipowski, 1990a). He recognised that affective, personality or delusional symptoms could be due to somatic disease or a toxic factor. The organic category was not abolished in DSM-III.

Lipowski (1990b) expressed concern about the "far reaching changes" proposed to organic mental disorders in DSM-IV. As he said, abolition of the organic category was a radical step which should not have been undertaken lightly. There were no new findings to support such a change, instead "idiosyncratic views".

There was further correspondence between Spitzer et al and Lipowski (1991). As Lipowski pointed out, DSM-IV was at variance with ICD-10. But Spitzer et al's (1992) proposal to retire the term "organic mental disorders" held sway. Lipowski suffered for several years from frontotemporal dementia and amyotrophic lateral sclerosis before he died in 1997 (see Wikipedia entry) and I wonder whether his dementia explains why there doesn't seem to have been a response from him.

Spitzer et al (1992) wrongly relate the distinction between organic and functional to Cartesianism. As Lipowski (1990a) pointed out, Georg Stahl was the first to distinguish mental conditions that are psychological from those that are organic (see previous post). In a way, Spitzer et al (1992) were more interested in avoiding the vitalism of Stahl, rather than adopting a more integrative position in psychiatry (see another previous post). Spitzer el al (1992) did acknowledge the importance of attention to underlying physical disorder or toxic factors. But they did not realise that functional/structural and psychological/biological distinctions are not the same as mind/body dualism.

Instead Spitzer et al (1992) proposed seeing functional disorders as primary mental disorders and organic disorders as secondary mental disorders. I'm not sure how much this distinction has really been taken up. To be clear, I'm not against the more widespread use of the term 'primary mental disorder'. As Spitzer et al (1992) pointed out, Lipowski's definition of organic is in agreement with their definition of secondary. However, there may well be potential misunderstandings with the term 'secondary mental disorder', because, for example, a functional depression may be said to be secondary to a physical illness, in the sense that it follows becoming physically ill because of the nature of being ill. What worries me is that a mistaken fear of dualism seems to have driven the abolition of the term 'organic' (see eg. previous post). At least Spitzer et al (1992) realised that their proposal was not solving the mind-body problem.

The trouble is that the fudging of the distinction between organic/functional has suited biomedical psychiatry which claims that neuroscience is moving us towards having a biological and genetic understanding of primary mental disorders, when, in fact, there are no such clear established biological causes (see eg. previous post). This is why I have argued that critical psychiatry's essential message is that functional mental illness should not be reduced to brain disease (see previous post). In the interests of clarity, I am happy to say that the essential message of critical psychiatry is that primary mental illness should not be reduced to brain disease. I don't want to get caught up in semantic arguments to divert attention from the fact that psychiatry can be practised without the justification of postulating brain pathology as the basis for primary/functional mental illness.

Critical thinking in psychiatry

I've been struggling trying to understand why Awais Aftab hasn't interviewed many critical psychiatrists in his 'Conversations in Critical Psychiatry' series for Psychiatric Times (see post on his blog). I think the title of the series should really be 'Critical Conversations in Psychiatry'.

The last chapter of my edited Critical Psychiatry book (see previous post) had a section on the relationship between critical psychiatry and critical thinking (see extract). Critical psychiatry, of course, wants to promote critical reflection on practice and research in psychiatry. Psychiatrists need to be conceptually competent (see previous post).

Critical psychiatry is also based on critical theory, which is quite a loose term. When the Critical Psychiatry Network was first formed, probably the best known version of critical psychiatry was postpsychiatry (see previous post). I always had my doubts about basing critical psychiatry on postmodernism, and over recent years, perhaps particularly since reading John Iliopoulos's book (see eg. previous post), I think I have gained a better understanding of Foucault. David Ingelby (see another previous post) probably originated the term 'critical psychiatry' and, in the American context, where Awais is based, Manschrek and Kleinman (1977) decried the deficiency of critical rationality in psychiatry in their edited book Renewal in psychiatry (see yet another previous post).

Furthermore, critical psychiatry is a social and professional activity. The Critical Psychiatry Network provides a forum to develop a critique of the contemporary psychiatric system. It is a challenge to the biomedical dominance of psychiatry. More specifically critical psychiatry's challenge to reductionism and positivism, including mechanistic psychological approaches, creates a framework which focuses on the person and has ethical, therapeutic and political implications for clinical practice (see eg. my editorial).

I'm very happy for psychiatrists to identify themselves as critical thinkers. I don't want to undermine the series Awais is doing for Psychiatric Times. On the other hand, the number of psychiatrists prepared to adopt the theory and role of critical psychiatry may well be a different matter. As far as I can see, critical psychiatry is still marginal to mainstream practice. In fact, psychiatrists saying they are "all critical now" is a way of marginalising critical psychiatry further (see previous post).

Meta-analysis of inflammatory markers in depression shows depression is related to stress

If you've been attracted to this post because of its title, you may well be wondering why I'm stating the obvious (see tweet). Of course depression is related to stress. But a recent meta-analysis of inflammatory markers in depression didn't make this point clear. Instead, it indicated (as I've said in a previous post) that the motivation for studying the role of inflammation in depression is to identify a novel therapeutic target. It concluded that depression is a pro-inflammatory state (without being very precise about what that means).

Actually, the meta-analysis is useful as it provides evidence that the inflammatory marker elevations are not due to an inflamed sub-group as such. Nonetheless, if we ever get as far as anti-inflammatory agents being marketed for depression (see previous post), I suspect this will, at least initially, be focused on those with raised markers or those with physical illness as well as depression (see another previous post).

Despite attempts to eliminate confounders, such as smoking and obesity, there are questions about how effective these strategies are. More importantly, any increases in inflammatory markers in depression are generally not of the same order as in autoimmune or inflammatory diseases (see another previous post). Psychosocial stress itself raises inflammatory markers. So, why don't we just stick with the obvious explanation that the increase in inflammatory markers in depression is due to psychosocial stress?

Clarifying the message of critical psychiatry

Reaction to my BJPsych Bulletin editorial has made me realise I need to be clearer in my essential message about critical psychiaty (see previous post). It needs to be more relevant (see twitter conversation) and inclusive without becoming diluted. To this end, let me try to create a basis to build on in a couple of sentences.

Functional mental illness has a dynamic, systemic and purposive character and we need to move on from expecting to explain it in physico-chemical terms. It makes more sense to see it as a process rather than a static substance in the brain (see eg. previous post).

Has psychiatry really moved on from its radical reductionism?

I am grateful for Mohammed Rashed’s commentary on my BJPsych Bulletin editorial. At least we agree radical reductionism has had its day (or at least should have done). I also agree that the argument of critical psychiatry is partly empirical and partly philosophical, although Mohammed does not seem to appreciate that the philosophical implications, as well as empirical, are that there are no structural abnormalities in the brain in functional mental illness.

But Mohammed seems to have missed the point that critical psychiatry is not an argument just against radical reductionism. I would dispute that White et al (2012) do not take a reductionist position (see previous post). For example, they believe brain scans have shown structural brain abnormalities in various mental disorders. Mohammed does not seem to realise that critical psychiatry is against the eclecticism, which he seems to want to perpetuate, which was proposed by Anthony Clare, in particular, as the response to anti-psychiatry (see eg. previous post).

In my effort to show the continuity of critical psychiatry with mainstream psychiatry, I did not mean to give licence to the argument that “we are all now critical psychiatrists”. Psychiatry still needs to move on from a system based on a ‘disease’ model of mental illness (see eg. my Lancet Psychiatry letter). The editorial focused on conceptual aspects but feeds into all the ongoing critiques that Mohammed lists. I may not have succeeded in getting my message across but I am very clear that my version of critical psychiatry is not merely of historical interest. In fact, Mohammed shouldn’t marginalise its impact or indeed its conceptual argument.

Demonstrating brain abnormalities in major mental illness

Following up my last post about Lindsey Sinclair's BJPsych Bulletin commentary, I want to comment on how she insufficiently considers non-specific other explanations (including medication) for the so-called brain abnormalities which she thinks have been demonstrated in major mental illnesses. As she says, the modern resurgence of biomedical psychiatry goes back to a 1976 paper by Eve Johnstone, Tim Crow et al showing cerebral ventricular enlargement in chronic schizophrenia (see previous post). Brain tissue volumes decrease and CSF volumes increase over time may also be due to medication or non-specific factors (see another previous post). Sinclair admits that it has been difficult to prove definitively whether there are differences in volume even before the at-risk mental state (see another previous post).

I just think this evidence demands more cautious assessment. Why doesn't she mention that brain scanning studies are plagued by inconsistencies and confounders? (see yet another previous post). Certainly Sinclair cannot conclude that the null hypothesis has been rejected and that biological abnormalities have been demonstrated in major mental illnesses. In fact, it's more scientific to say they haven't been demonstrated. Sinclair does accept that "neuroscience is unlikely to hold all of the answers to why people develop mental disorders and when they occur in their lifetime". She needs to consider this issue further.

Familial origins of mental health problems

Lindsey Sinclair in her commentary on David Kingdon's article (mentioned in my last post) says that "[b]iological and genetic abnormalities have been demonstrated in major mental illnesses". Her claims need examining further and at least by being so definitive she can be held to them. For the moment, I just want to comment on how she contrasts what she says was the widely held belief 50 years ago that "parents could be responsible for their offspring developing schizophrenia" with what she perceives as the radical change in our biological and genetic understanding of mental health problems started in the past few decades.

As mentioned in a previous post, eminent psychiatrists, such as Anthony Clare and Robin Murray, have taken their position in psychiatry as a reaction to their understanding of R.D. Laing as blaming families for causing schizophrenia. As I said, for example in my book chapter, this is actually a misunderstanding of Laing's views. He wasn't talking about a direct one-to-one causal relationship but understanding schizophrenia in the familial context.

Frieda Fromm-Reichmann (1948) probably coined the term "schizophrenogenic mother". The book by Gail Hornstein (see previous post) To Redeem One Person Is to Redeem the World gives a positive view of her life and legacy. Biological and genetic accounts do not provide any understanding as such of mental health problems.

Neill (1990) asked the question 'Whatever became of the schizophrenogenic mother?'. As Neill said, probably the most important series of family studies was by Theodore Lidz (see extract from by book chapter). These kinds of studies were undertaken by both David Cooper (who probably coined the term 'anti-psychiatry') and R.D. Laing (see further extracts from another book chapter). The link between these family studies and so called 'anti-psychiatry' cannot be denied.

As Neill says, "By the mid-1970s, the concept of the schiophrenogenic mother seemed to have proven too elusive to be useful". Certainly any over-determined view of the familial origins of schizophrenia (which I don't think can be attributed to Laing) was abandoned. Understanding of the reasons for mental health problems is complex and there can never be a proof as such of their cause. Trouble is that too biological a view such as Sinclair's can also be overdetermined.

Disinvesting in neuroscience in psychiatry

David Kingdon (who I've mentioned in a previous post) asks in a BJPsych Bulletin Against the Stream article 'Why hasn’t neuroscience delivered for psychiatry?' As he says, "it is still not possible to cite a single neuroscience or genetic finding that has been of use to the practicing psychiatrist".

As he explains,

The neuroscience tools we have available and indeed, those that are likely to become available in the foreseeable future, are far too insensitive to achieve an understanding of the complexities of human pathological emotional reactions. Can we really expect neuroscience to illuminate the aetiology, to take a common example, of a severe depressive illness in a recently widowed woman who has hated her husband for the last 20 years of his life? Will not a clinical interview always shed more light and lead to more effective interventions in such a scenario than an assessment based on neuroscience?

He goes on:

Might it not be that the difference with other areas of medicine is that there are demonstrable and incontrovertible biological abnormalities in neurological disorders, dementia and so on? No such clear causative changes exist in severe mental illnesses such as depression, anxiety, bipolar disorder and schizophrenia. 

Like me (see eg. previous post), he thinks we may well be setting up unachievable expectations for new entrants to psychiatry by focusing on neuroscience in recruitment. He concludes that "the time has come to challenge the justification for such relatively high levels of investment of time, expertise and resource in neuroscience for mental disorders". I couldn't agree more.

Labelling of personality disorder

Keir Harding has an excellent The Mental Elf blog post summarising the new position statement on personality disorder by the Royal College of Psychiatrists. He expresses disappointment about the way in which the position statement has approached the issue of the diagnosis of personality disorder.

Considering the way I have been critical of those that want to completely abandon the term 'mental illness' in recent posts (see example), it may seem surprising that I agree with Keir. I think a distinction needs to be made between personality disorder and mental illness. In a way, the diagnosis of 'personality disorder' can be taken to imply that the person does not have a mental illness as such. This is why it can become a diagnosis of exclusion, if services are seen as only dealing with people with mental illness. In my practice, I was often reluctant to use the term personality disorder, instead using a description such as 'personal problems or difficulties'. In fact, if the term 'personality disorder' has any meaning, what it does mean is personal problems or difficulties. This isn't to underestimate the potential severity of such problems which can be very incapacitating (and for which such severe conditions a diagnosis of ‘illness’ may actually make sense).

As The Consensus Statement for People with Complex Mental Health Difficulties who are diagnosed with a Personality Disorder makes clear (albeit with slightly clumsy wording), there is a lack of "consensus on what words we should use to talk about the problems and difficulties people with this diagnostic label experience". The implication that there is something wrong with the person's personality can be very misleading and it may well be better if the term is abandoned or replaced. Personality disorder also shouldn't imply that there is no room for improvement.

It is reasonable to expect that the College would properly deal with this issue in its position statement, although the title of its statement 'Services for people diagnosable with personality disorder' implies that the diagnosis, as such, may not necessarily be needed or used. As Adrian James, newly elected President of the College, acknowledges in the foreword, "there is the potential for a diagnosis [of personality disorder] to cause harm, particularly if this is done in a way that lacks appropriate dialogue". However, he goes on, "on balance, we believe that the diagnosis has brought benefits of better describing the impact of such difficulties on people’s health and social outcomes".

It worries me that the position statement countenances the use of the term personality disorder in adolescents, rather than conduct, or even emotional disorders (although these may predispose to a diagnosis of personality disorder as an adult). I'm not sure if the diagnosis of personality disorder as such always "interferes with the sufferer’s sense of wellbeing and ability to function in full in ordinary social settings". Some people diagnosed as being personality disordered (eg. antisocial personality disorder) may well not have any subjective sense of being unwell. Although the College accepts that the issue is controversial, I don't agree that "a range of evidence exists to support a neurobiological role". It is of concern that the College believes that "changing terminology will simply cause confusion and divert attention (and funding support) from the need to develop accessible, effective and safe services". However, a scientific statement about personality disorder shouldn't be determined by such expectations. I'm not sure if the College is making a pitch for psychiatrists to be the only ones that are sufficiently qualified to make a diagnosis of personality disorder.

Like Keir, I am disappointed by this position statement. To me there seems to be more work that the College needs to do. Maybe the wish to come to some agreement amongst The British and Irish Group for the Study of Personality Disorder executive avoided the hard work needed to deal with these issues, although as Keir points out, "The document doesn't actually describe how it came together". In fact, I don't think it does 'come together'.

Psychosomatic medicine and the biopsychosocial model

Nassir Ghaemi has added to the debate in Psychiatric Times on the biopsychosocial (BPS) model (see his article). From his point of view, "the BPS model for the past half century has served as a postmodernist excuse for eclecticism".

I have been critical of Ghaemi's book The rise and fall of the biopsychosocial model (see previous post and my book review with response and reply). However, I do essentially agree with his statement that the "BPS of the past half century is not the same BPS of George Engel in 1977" (see previous post). I can't really accept Ghaemi's simplistic definition of postmodernism as eclecticism (or nihilism), but I think he is right that modern psychiatry is eclectic and that "[m]ental health clinicians ... claim support [for eclecticism] ... in the BPS approach".

As Ghaemi indicates, Engel's BPS model comes from psychosomatic medicine. Ghaemi seems to define psychosomatic medicine as "the idea that unconscious psychology affect[s] ... the body to cause disease". Certainly this idea is present in the history of psychosomatic medicine from Franz Alexander. However, psychosomatic medicine is a wider concept and it now tends to emphasise excessive attention towards physical symptoms rather than stress as such or even unconscious motivation. Ghaemi is essentially anti-psychoanalysis (see previous post), which is why he calls the BPS model a "disproven psychosomatic medicine" model.

But the point of Engel's BPS model is that it promotes an integrated mind-brain understanding. It provides an explanatory anti-reductionist position for psychiatry (see eg. previous post).

Conceptual competence in psychiatry

Awais Aftab and Scott Waterman have an interesting article on conceptual competence in psychiatry. As they say:-

The considerable challenges facing our discipline [psychiatry] will not be met without rethinking our approach to educating and training the next generation of psychiatrists, specifically attending to the implicit—and thus rarely confronted, examined, and questioned—conceptual foundations of the field.

The four elements of conceptual competence are: assumptions and questions; tools;  discourse; and humility. Training can improve conceptual competence.

I asked Awais Aftab in a tweet what the implications for practice are and he gave an interesting and important initial response (see conversation). I don’t think all practitioners need to be philosophers of psychiatry but they do need to understand there is a mind/body problem. I also think it may be worthwhile emphasising how cultural competence overlaps with conceptual competence.

The concept of mental illness

I want to follow up my previous post about the nature of mental illness. The article I've always thought that does the best conceptual analysis of 'mental illness’ is by BA Farrell (see article).

Farrell makes clear that ‘mental illness’ is a statement about psychological functioning. It’s not primarily a statement about statistical abnormality. It standardly implies social maladjustment, but social misfitting is not just due to mental illness. Nor does mental illness necessarily imply bodily dysfunction. As Farrell says, the regulative principles of physical medicine are extended in the concept of mental illness to the psychological reactivity of human organisms. In other words, the psychological functions of the person do not operate within their standard limits when someone is diagnosed as mentally ill. This concept of mental illness fits more clearly with psychotic than neurotic conditions in general, and may well be problematic for personality disorders. What counts as a psychologically morbid process can be open to debate. Applying the concept of mental illness is both descriptive and evaluative in the sense of implying an undesirable and unwelcome state. There are real problems with defining mental illness as behavioural disorder. As Farrell says “all concepts have their difficulties”. We need to work through what we mean by the term ‘mental illness’, rather than merely dismissing it as invalid.

This definition of mental illness is reinforced in an article by Aubrey Lewis. The concept of illness can be ambiguous. It designates a change from a pre-morbid state. As Lewis says, maladaptive behaviour is only pathological if it is accompanied by a disturbance of psychological functioning. Social criteria play no part as such in the diagnosis of illness.  To quote from Lewis: “The concept of disease ... has physiological and psychological components, but no essential social ones”. Doctors may well deal with more than illness. And psychoanalysis generally defines mental illness quite loosely. The recognition of illness may well not be very reliable or valid, and this is even more likely to be the case for mental than physical illness. But Lewis is clear that “it is not possible to set up essentially different criteria for physical health and mental health”.

Psychopathology is, therefore, a morbid process like physical illness. To be diagnosed as mentally ill, a person's psychological processes are dysfunctional. A tweet pulled me up for suggesting that psychosis is maladaptive, as using the word ‘adaptation’, perhaps particularly in the evolutionary sense, may actually explain why people do become psychotic. Psychosis may well increase survival eg. by preventing someone dying by suicide (see my twitter response). I agree that whether mental illness is maladaptive is not the essential relevant criterion to consider. From the individual perspective becoming psychotic may be a necessary reaction. However logical the private sense may seem to the person, it is the loss of common sense viewed by most people that is characteristic of madness. The correctness of our judgments and the soundness of our understanding are subjective but our understanding is also restrained by the understanding of others. As Jaspers said, there may be an 'un-understandability' about psychosis. This applies, however, to others' perspective, as from the individual's point of view a psychotic reaction may make sense (at the time at least).

As both Farrell and Lewis emphasise, our modern idea of illness as physical lesion only really starts from the nineteenth century. The concept of ‘illness’ itself is much more long-standing. Modern critics of the concept of mental illness need to have this longer historical perspective rather than juxtaposing it too much with physical illness and thereby invalidating the concept.

Facing up to the difficulty of treating depression

Following a Guardian article by Ed Bullmore, I tweeted today asking why psychiatry allows and encourages speculation about depression being an inflammatory disorder. As I've said before (eg. see previous post), it’s non-sensical to believe that depression is a form of inflammation. Yet, as in the article by Bullmore, such speculation is promoted as a “new frontier” which could lead to “breakthroughs” in the treatment of depression, with the “potential to transform our thinking about illness more broadly”. Exciting stuff apparently! But why the hype?

Of course part of the reason is to encourage participants to express an interest in the NIMA ATP trial. More fundamentally, the real problem is that depression is not always easy to treat (see previous post). We always need hope that there might be simpler and more effective treatments (see eg. previous post). I don't want to appear pessimistic about the treatment of depression. There can be spontaneous improvement over time. People have considerable personal resources and resilience to be able to overcome and adapt to their difficulties. 

Of course psychiatry is merely responding to our idealistic wish for a simple, quick, cheap, painless and complete cure for depression. It does this for psychological therapy as well as medication (eg. see previous post). But promoting myths that depression is due to inflammation does not justify deflecting from the hard work required to help people recover from their depression. 

Does psychiatry need a diagnostic system?

As I said in a previous post, when commenting on Lucy Johnstone’s article on whether mental illness exists, I was left with the issue about the nature of illness. I’m even more focused on this question, as I am reading Peter Kinderman’s book A manifesto for mental health. Like Lucy, Peter does not want to see emotional problems as illness. He, therefore, doesn’t want to see ‘psychological health issues’, as he calls them, as pathological. He wants to ‘drop the language of disorder’.

I think I do understand what Peter means when he says, “Madness and sanity are not qualitatively different states of mind”. There may not be an absolute distinction (see previous post). I agree with him that psychiatric diagnoses are not ‘things’. We need to focus more on “how and why we feel or act the way we do” rather than naming mental health problems. I even agree that psychiatry could still be practised without a psychiatric classification system (see previous post). Such a situation may well have benefits, as it would encourage psychiatry to focus on formulation, rather than biomedical diagnosis.

But I do worry that the ‘drop the disorder’ mantra is open to misinterpretation. Peter does recognise that, “Giving a name to our distress serves a function”. But he wants to suggest that naming a mental health problem shouldn’t be identifying it as illness. He does nonetheless recognise that people may want the apparent benefits of identifying it as illness.

Talcott Parsons described the two rights afforded to people in the social role of being sick:-

1. The sick person is temporarily exempt from performing ‘normal’ social roles (such as going to work or housekeeping). The more severe the sickness, the greater the exemption. 

2. A genuine illness is seen as beyond the control of the sick person and not curable by simple willpower and motivation. Therefore, the sick person should not be blamed for their illness and they should be taken care of by others until they can resume their normal social role.

These rights are conditional on the patient following two obligations:-

1. The sick person is expected to see being sick as undesirable and so are under the obligation to try and get well as quickly as possible.

2. After a certain period of time, the sick person must seek technically competent help (usually a doctor) and cooperate with the advice of the doctor in order to get better.

Peter thinks simply listing people’s actual experiences and problems is sufficient rather than seeing them as ill. He doesn’t object to people taking time off work “if we’re depressed, or anxious or hearing voices”. And he acknowledges for some that “personal circumstances mean that we can no longer work on a permanent basis”. I agree with Peter that provision of services may only be connected loosely with psychiatric diagnosis. But I worry that by focusing so much on psychological aspects he has ignored the social implications of these experiences and problems. Health care may well be provided for people who are not ill as such, but that doesn’t necessarily invalidate the notion of illness.

People who are disabled also may not necessarily be ill. There is a need for judgement about whether people are ascribed the sick role. If people are in need, the reason for it may be illness. Not all need may be due to pathology, but some of it might be. I just worry that Peter’s insistence on avoiding pathologising is more technical than practical. His laudable aim to encourage understanding of the reasons for mental health problems may undermine the pragmatic sense in which mental illness can be like physical illness. Of course the concepts are not identical. Certainly functional mental illness should not imply physical lesions (see eg. previous post). But there is sufficient overlap for the concept of mental illness still to be useful and valid.

Resistance to critical psychiatry

Giovanni Fava (who I've mentioned previously eg. see post) quotes from Thomas Kuhn’s The Structure of Scientific Revolutions in an article about the importance of pluralism and the challenge to current paradigms in medicine: "Novelty emerges only with difficulty, manifested by resistance, against a background provided by expectation". Critical psychiatry seeks to help psychiatry move on from its current biomedical dominance (see previous post).

Fava describes obstacles to change, including: (1) barriers to publishing, such as the commercial nature of open-access journals, requiring contributors to pay for publishing, as truly innovative research is unlikely to be funded (2) special interest groups, including so-called key opinion leaders, using their power to suppress conflicting information and bias interpretation of the evidence (3) the pseudo-objectivity of evidenced-based medicine failing to recognise its limitations, and (4) the general lack of familiarity of researchers with clinical practice meaning that research lacks clinical relevance.

I've argued that social media can help maintain freedom in an academic system motivated by commercial interests (see post on my personal blog). I have used this blog and tweeting (@DBDouble) to promote critical psychiatry. But we do need academic journals, as Fava says, to "host dissent, debates, and heresy, as long as they are supported by methodological soundness" (see previous post). Academic psychiatry needs to be rebuilt by the recognition of the limits of biologic research (see previous post). Medicine in general needs to be rethought (see another post on personal blog).

Developing global mental health services

I've discussed before (eg. see previous post) how we tend to have an understanding of illness as implying physical abnormality. An article by Suman Fernando highlights how much this perspective is a 'Western' understanding. Even within Western cultures this interpretation of illness is only really since the nineteenth century (eg. see previous post). 

Suman highlights the plurality of mental health systems in place in the global south: "Western systems, traditional indigenous systems, new, innovative systems, and those that attempt to adapt Western systems to make them ‘culturally sensitive’ to local norms". I  don't think we should underestimate the plurality of health care systems in the West with much uptake of 'alternative' and complementary health care besides standard health care.

This blog has been critical of biomedical approaches in psychiatry. I therefore agree with Suman than mental health development should not be colonised by biomedical psychiatry (eg. see previous post). Nor should we medicalise difficult social problems, like poverty and lack of social support, that require political and economic solutions (see previous post). As Suman concludes:- 

the aim of all agencies seeking to develop mental health services must be to enable local people to develop services that are ethical, that is for the benefit of the people concerned as subjects rather than objects of development, and sustainable without dependence on rich countries in the West. 

Integrating critical approaches into the training of psychiatrists

I've mentioned in a previous post that I had an application turned down for last year's International Congress of the Royal College of Psychiatrists (RCPsych) on 'Integrating critical approaches into the training of psychiatrists'. I'm not sure if RCPsych is really interested in an initiative of this sort.

I've said before (see previous post) that there is an orthodoxy in psychiatry. Trainees do need help to manage this indoctrination. Current training could be said to be biased towards neuroscience (see eg. another previous post). It is insufficiently global in its perspective (see previous post) and trainees need help to deal with psychiatry's institutional racism (see another previous post) and institutional corruption in general (see previous post). Trainees need to become more patient-centred (see another previous post) in their practice.

Psychiatry shouldn't see this agenda as a threat. As I've kept emphasising in this blog (eg. see previous post), critical psychiatry is a legitimate part of current psychiatry. It is not anti-psychiatry or a "warped political ideology" (see recent previous post).

Reducing suicide in young people

Jacob Hess comments in an MIA blog post on a NYT Op-Ed essay entitled Why are young Americans killing themselves? In the UK, despite having a low number of deaths overall, rates among the under 25s have generally increased in recent years (Office for National Statistics, 2019). 

Despite some yearly increases (including 2018, the first increase since 2013), suicide rates for all persons have generally decreased since 1981 (see figure). Over this time frame, it is particularly in the over 60s for men and the over 45s for women where this is apparent. Suicide reduction has primarily happened for older people. I'm not saying the recent increase for young people is not of concern but it does need to be set in context. Many factors contribute to trends in suicide rates which can be very difficult to disentangle.

I agree with Jacob Hess that the solution to suicide in young people is not as simple as the Op-Ed piece makes out. It asks, "How is it possible that so many of our young people are … killing themselves when we know perfectly well how to treat this illness?" It then goes on to state that "We know that various psychotherapies and medication are highly effective in treating depression."

Public mental health strategies should not be driven by exaggerated claims for the effectiveness of psychiatric treatment. For antidepressants, for example, there are substantial non-response and recurrence rates (see previous post) and the difference between active and placebo treatment in clinical trials is much smaller than most people realise (see eg. another previous post).

The readiness to use antidepressants in children has increased over recent years (see my BMJ letter) as the concept of childhood depression has been socially constructed (see previous post). Concerns about lack of efficacy and increased suicidality created a hiatus in 2004 in the relentless continuing increase in antidepressant prescribing for children. I suspect that children and young people object more than adults to the medicalising of their mental health problems. We do need to look wider than psychiatric treatment to helping suicidal young people.

Is critical psychiatry a "warped political ideology"?

Paul Morrison @PaulMor64695904 tweets praise for a blog post about antidepressants by George Dawson (who I have mentioned previously eg. see post). He suggests the blog counters the "warped political ideology of anti-psychiatry extremists". I'm not sure what is meant by his claim. I've said before (eg. see previous post) that psychiatrists often label views with which they do not agree as 'anti-psychiatry'.

Dawson regards what he calls the "war on antidepressants" as "really a war on psychiatry".  He doesn't seem to be able to appreciate the institutional corruption of modern psychiatry (see eg. previous post) and even seems to suggest that psychiatrists' conflicts of interest with pharmaceutical companies do not matter (see eg. another previous post). I'm not sure who he's blaming for the widespread belief in the chemical imbalance theory of depression (see previous post). He doesn't seem to be able to accept that the evidence for the effectiveness of antidepressants is still open to question (see previous post); nor that the placebo amplification hypothesis could be valid (see another previous post). In fact he seems to think that the placebo amplification hypothesis is that antidepressants work by side effects, which is a misunderstanding of the theory. He needs to gain more understanding of the position of critical psychiatry (see previous post).

I agree antidepressants are not "tools of the devil" but let's stick to the scientific arguments rather than  stigmatise so-called warped ideology.

Are mental illnesses really medical disorders?

Lucy Johnstone asks the question 'Does mental illness exist' in her IAI (Institute of Art and Ideas) article. Her answer leaves me with the question 'What is medical illness?'.

Lucy doesn't deny the reality of "suicidal despair, hearing hostile voices, crippling anxiety and mood swings". But she does not think these experiences should best be understood as mental illnesses/disorders. In fact she goes further and says that there's never been any evidence to support the idea that these "very real experiences" are best explained as medical disorders.

What she seems to mean by 'medical disorder' is a condition caused by physical pathology. Here, in a way, she follows Thomas Szasz, who thought mental illness is a myth. For Szasz, it was a misnomer to call mental illness an 'illness', because it's not an illness with physical lesions (see eg. previous post).

I agree with Lucy (and Szasz) that functional 'mental illnesses' are not "chemical imbalances, genetic flaws or other bodily malfunctions". Where I have difficulty with her (and Szasz's) view is that I think the best way to understand medicine is that it covers the treatment of both physical and mental illnesses (see eg. another previous post).

In fact, our modern idea of physical pathology only really developed from the mid-nineteenth century with the correlation of pathological, including histological, findings with clinical symptoms (see eg. previous post). The problem for psychiatry was that it did not completely fit with this development of anatomoclinical thinking, which was of such importance for the advancement of modern medicine in general (see eg. another previous post). Modern psychiatry's always hankered after this identification with the rest of medicine. Most psychiatric illness is functional and not organic, in the sense of not having an identifiable physical lesion in the brain (see eg. yet another post). Lucy's correct that much of modern psychiatry assumes that physical pathology will be found to underly what is called 'mental illness'. It's always tended to believe this, but, in my view, thereby avoids philosophical issues about the mind-body problem and the nature of life in general (see eg. previous post).

I also agree with Lucy that psychiatric assessment is about formulation. It's not commonly appreciated that the standardising of procedures for history taking and mental state examination in psychiatry at the beginning of the 20th century was about formulation (see eg. previous post). What should be important in psychiatric assessment is helping people understand their problems. Reducing people's problems to brain disease has the potential to be stigmatising by turning people into objects.

I, therefore, understand Lucy's concern about psychiatric classification. I agree with her critique, if the aim of psychiatric classification is to create a functional diagnostic system based on biological markers. This was the original intention of DSM-5 and it failed (see eg. previous post). But Lucy seems to think that psychiatry needs to have a reliable and valid classificatory system to be a science. Following Peter Breggin, she argues that psychiatry is undermined by not being able to treat mental illness as physical illness.

Here, again, I have difficulty with her view. Any psychiatric classificatory system is merely descriptive, not aetiological, certainly not biologically-based in the sense of brain abnormalities (see eg. previous post). It needs to be understood for what it is, and there may well be nothing to be gained, or even harm caused, by using psychiatric labels. But sometimes it can be helpful to use words to describe mental states. This was in fact how modern psychiatry first started from the end of the eighteenth century by attempting to reason about madness (see eg. previous post). There will be inevitable uncertainty about using these descriptions of the ways in which people react to the situation in which they find themselves (see eg. another previous post). Of course brain abnormalities can cause psychotic symptoms as part of delirium or dementia (see eg. previous post). However, for the vast majority of psychiatric presentations, which are functional, we have to rely on our ability to identify patterns of responses if we are going to create any validity for a psychiatric diagnostic system (see eg. previous post). We are profoundly limited in what we can achieve and too much should not be made of these limitations.

I just worry that Lucy is making too much of this situation. Mental health practice is interdisciplinary but that doesn't mean it's not medical. I just think it's potentially misleading to suggest that what's identified as 'mental illness' may not be a medical problem. Medicine includes both physical and mental aspects.

Reality of mental health problems

I’ve mentioned before several times (eg. see previous post) about the hope that neuroscience will explain mental illness. Psychiatry commonly assumes that there is an underlying hypothetical brain lesion, even if not yet discovered, causing mental health problems. But these are often mere conjectures (eg. see another previous post).

The problem with continually promising ourselves physical lesions is that we can tend to ignore psychosocial facts that are already available. As Adolf Meyer (1906) said, “it has become my conviction that the developments in some mental diseases are rather the results of peculiar mental tangles than the result of any coarsely appreciable and demonstrable brain lesion” (see previous posts about Meyer eg. Pathologist of the mind). This doesn’t mean ignoring organic factors when they exist. But, again following Meyer, “we had better use the facts at hand [psychosocial factors] for what they are worth” rather than “have to invent them [somatic factors] first in order to get anything to work with”.

Pragmatic treatment is about helping the person adapt and adjust. This may well not be easy, but it’s not a reason for avoiding trying to do so or deflecting the problem onto the brain.

The scope of psychotropic medication discontinuation problems

The stakeholder comments submission (see table) from the College of Mental Health Pharmacy about the Scope for the NICE guideline on Safe prescribing and withdrawal management of prescribed drugs associated with dependence and withdrawal is revealing about why antidepressant discontinuation problems are minimised (see eg. previous post). The College questions why antidepressants have been included within the Scope. What it's worried about is that patients might discontinue or not seek antidepressant treatment when they need it, if they know about antidepressant discontinuation problems.

Similarly, prescribers may use the chemical imbalance theory as a way of persuading patients to take antidepressants (see previous post). This is despite the fact that believing the theory may make patients more pessimistic about the prognosis of their depression and lower their perceived ability to regulate their mood (see previous post). More seriously as far as antidepressant discontinuation problems are concerned, believing the chemical imbalance theory may at least contribute to, if not cause, discontinuation problems (see previous post). Eveleigh et al (2019) found evidence from patients that the chemical imbalance theory was a prominent factor in creating fear of discontinuation.

Several stakeholders in the NICE consultation suggested including in the Scope other drugs, such as antipsychotics, which also cause discontinuation problems. NICE refused, saying that such guidance is included within the NICE guideline for psychosis and schizophrenia in adults, although I can't see any mention of discontinuation problems there. NICE only seems to have included antidepressants within the Scope because it was asked to by the Department of Health.

The Royal College of Psychiatrists usefully raises the issue of the psychological component of dependence but I'm not sure that NICE really takes this on board in its response. People who have antidepressant discontinuation problems often experience them very physically. It's good that NICE will presumably expand (although maybe by not very much) on its Depression guideline to produce more detailed advice for safe prescribing, monitoring and safe withdrawal of antidepressants. But people are being made dependent on psychotropic medication in general. The psychological element, at least, of antidepressant discontinuation problems cannot be denied (see previous post). It's understandable NICE may wish to sidestep this complex issue but these wider factors do need to be addressed.

Misdiagnosing dementia

When I first started this blog several years ago now, I indicated I would return to the issue of the National Dementia Strategy (see previous post). Times have moved on and the incentivisation of GPs in the NHS to diagnose dementia, which began in 2011, has been controversial. This is because of the increased number of referrals of people with cognitive complaints not due to dementia (Bell et al, 2015). Mistakes can be made about the diagnosis of dementia and doubts have been expressed about the security of diagnosis for at least some so-called dementia advocates (Howard, 2017) (see previous post).

A systematic review of functional cognitive disorders has just been published in Lancet Psychiatry. Current views of functional neurological disorders tend to emphasise excessive attention towards physical symptoms rather than psychological stress as such in the generation of symptoms. People with functional disorders are more likely to attend alone and be worried about their memory, providing a detailed account of personal history and memory failures more than patients with neurodegenerative disease. Those with functional cognitive disorder phenotypes are at risk of iatrogenic harm because of misdiagnosis or inaccurate prediction of future decline.

Are there no problems with psychiatry?

George Dawson (who I have mentioned previously - see post) has responded in a blog post to a NEJM article by Caleb Gardner and Arthur Kleinman entitled 'Medicine and the Mind — The Consequences of Psychiatry’s Identity Crisis'. As far as Dawson is concerned there is no identity crisis in psychiatry. The only problem he recognises is that:-

most psychiatrists are working in toxic practice environments that were designed by business administrators and politicians. As a result, psychiatrists are expected to see large numbers of patients for limited periods of time and spend additional hours performing tasks that are basically designed by business administrators and politicians and have no clinical value.

Dawson is a believer in psychopharmacology, ECT and transcranial magnetic stimulation and thinks the benefits of psychosocial treatments are significantly limited. He also believes neuroscience research is translating into benefits for clinical practice, but these seem to be more about possibilities for the future rather than now.

Gardner and Kleinman (2019) recommend reducing the amount of spending on biologic research in psychiatry to support only the highest quality such research. They suggest that academic psychiatry needs to be rebuilt by more recognition of the limits of biologic research. Dawson wonders why NEJM has accepted this article, and I agree it is surprising considering how biomedical the perspective of the journal has been about psychiatry. I wonder, though, whether, like Wellcome apparently (see previous post), NEJM has become more sceptical about whether psychiatry is really being advanced by neuroscience.

I'm not saying managed care doesn't create problems for psychiatry, but there are wider conceptual issues that do need to be addressed. I agree with Dawson this issue shouldn't just be decided by rhetoric.

How medical psychology became psychotherapy

A post on the British Psychological Society (BPS) History of Psychology Centre blog marks 100 years since the first BPS Member Networks were formed. The Medical Section was one of the first of the three sections formed in 1919 (the others being Educational and Industrial) and I've posted previously on 'The roots of medical psychology’. The Medical Section is now the Psychotherapy Section - name changed in 1988, having previously changed to Section of Medical Psychology and Psychotherapy in 1976 (see BPS history timeline). I'm not sure if the Psychotherapy Section is aware of this history.

Incorporation of the Society in October 1941 reflected the safeguarding of the professional interests of trained psychologists and instituted different classes of membership (Edgell, 1947). Membership had been opened in 1919 to anyone ‘interested in psychology’, not just recognised scholars or teachers. This deprofesionalisation led to an increase in membership from 98 at the end of 1918 to 427 at the close of 1919. A large proportion of these new members were in the Medical Section. Charles Myers used his First World War medical contacts (some treating shell shock; Myers probably being the first to recognise the essentially psychological nature of shell shock) to persuade them to join the Society (Jackson, 2019).

I'm sure there is a need to protect professional psychological expertise, but there are also advantages in extending general interest in psychology. Professional separation of medicine and psychology is not always helpful.

Creating a ketamine epidemic?

Ketamine has been claimed to be the first truly new pharmacological approach for treating depression in the past 50 years and promoted as the first of a new generation of rapid acting antidepressants (eg. see BMJ news report). US clinics increasingly offer IV infusions of ketamine off label. In March, esketamine, a nasal ketamine-based drug, was approved by the US Food and Drug Administration (FDA) for treatment-resistant depression. This is despite it performing better than placebo only in one out of three studies (see my tweet).

Concern about potential approval of esketamine by the Medicines and Healthcare products Regulatory Agency (MHRA) in the UK has led to discussion through responses to a BMJ article. The latest response by Mark Horowitz and Joanna Moncrieff expresses concern that "history is repeating: a known drug of abuse, associated with significant harm, with scant evidence of efficacy, is being submitted for licensing, without adequate long-term safety studies".

It's important not to forget the epidemic of amphetamine use that peaked round the end of the 1960s (see article). Ketamine has the ability to induce an acutely altered state of consciousness, reminiscent of indigenous medicines such as ayahuasca, peyote, and ibogaine, which have been used for centuries across many cultures (see another article). Amphetamines in general were prescribed readily and with insufficient thought in the past (see yet another article). Amphetamine was said to adjust hormonal balance in the central nervous system by creating or amplifying adrenergic stimulation so as to promote activity and extraversion. It was even said that true addiction to amphetamine probably did not occur.

However, evidence emerged after 1960 that amphetamine is truly addictive, instead of merely habituating. The introduction of monoamine oxidase inhibitor and tricyclic antidepressants from the end of the 1950s did not immediately lead to a significant decline in prescribing of amphetamines, but eventually the claim that the newer drugs were superior to amphetamines held sway. Amphetamines and barbituates had nonetheless seemed better to doctors than the bromides and nerve tonics that had been prescribed up to the 1950s. Psychiatrists used to complain that GPs, when they did use the newer tricyclic antidepressants, did not use them in sufficiently high enough therapeutic doses. This complaint was heard less when the SSRIs were introduced in the 1980s, perhaps partly because fluoxetine, maybe the most successful SSRI, was initially introduced at a single dose.

50 years may seem a long time not to have had any new pharmacological treatment for depression but it's important history isn't repeated. It actually wasn't that long ago that the epidemic of amphetamines was created by doctors. Do they really want to do the same with ketamine?

Neuroscience in psychiatric education

The Royal College of Psychiatrists (RCPsych) has published its first issue of PSynapse, the newsletter for its programme (that I've mentioned previously eg. see post), which has support from Gatsby and Wellcome, to transform UK psychiatric training by integrating modern neuroscience. The newsletter mentions that TrOn (the RCPsych online learning resource to support trainees preparing for its membership examinations) is looking for an additional specific neuroscience trainee editor in addition to its other trainee editors. It also mentions the third RCPsych neuroscience spring conference that marked the launch of the College neuroscience champions scheme, which creates a network of psychiatric trainees across the UK to ensure that neuroscience is properly integrated into their respective deaneries.

I’m not against trainees having a proper understanding of neuroscience. But I don’t think the College programme has incorporated critical neuroscience (see previous post). Wellcome has said it wants a radical new approach to mental health research (see previous post). Yet it’s also supporting the Psychiatry Consortium (mentioned in the PSynapse newsletter) of 6 drug companies, Alzheimer’s Research UK and MQ (mentioned in previous post), to accelerate innovative drug discovery in psychiatric diseases. The newsletter also has a report from the British Neuroscience Association festival of neuroscience in April 2019 which highlights ketamine as a potential antidepressant. The rest of the newsletter reports conversations with two of the leaders in the field of ketamine use for depression in the UK. But there’s no discussion of the potential risks of approving ketamine for antidepressant use (eg. see BMJ response by Mark Horowitz and Joanna Moncrieff).

There is a need for interdisciplinarity in mental health research (see previous post). I hope the College isn’t encouraging a neuro-turn in academic psychiatry (see another previous post). I’d like to see it also incorporating critical psychiatry into psychiatric training (see yet another previous post).


(With thanks to Frederico Magalhaes)