Tuesday, October 18, 2016

Psychiatrists are still needed

Frank Blankenship comments on Mad in America about my previous post on "Psychiatry as a cultural system". He suggests there's a simpler explanation for why psychiatrists are resistant to giving up the biomedical model than because it's like a religion - they'd be out of a job!

I do understand his view. I too was schooled in the biomedical perspective that mental illness is brain disease. It's such an ingrained perception in society that people don't think to challenge it. Medical training reinforces this indoctrination (eg. see previous post and my Lancet Psychiatry letter).

I also agree that psychiatrists are worried that non-medical professionals are taking over their job (eg. see previous post). This fear encourages them to adopt a biomedical model by focusing on "what doctors do best".

However, where I disagree is that it is important to remember that medicine is psychosocial as well as biological, if only to ensure that practice is patient-centred. It's not purely a bodily exercise. Even more so, patients go to doctors with physical symptoms which have a psychological origin. Medicine has to adopt a sociopsychobiological approach to provide an integrated perspective in practice (see previous post).

I've also mentioned before my disagreement with Peter Kinderman, who has argued that mental health care should actually be non-medical, as it is not treating 'illness' as we understand it (see
previous post). From his point of view, doctors should concentrate on the biological aspects of mental health care and this should be seen as a minority activity within the field as most psychiatric presentations are psychosocial, not biomedical, in origin. By contrast, Peter Sedgwick, in the same way as I have been saying, would have regarded Peter's position as ‘psycho-medical dualism’, because psychosocial approaches should not be separated too much from medicine. Sedgwick adopted a unitary concept of illness, beneath which is subsumed both physical and mental aspects (Cresswell & Spandler, 2009).

Conceptual conflict exists about the nature of mental illness and this is as much of an issue for psychiatrists as it is for specialists from other mental health disciplines. Merely putting psychiatrists out of a job won't solve this dilemma. And, medicine needs the specialty of psychiatry.

Sunday, October 16, 2016

Too much neuroscience

NIMH has a new director, Dr Joshua Gordon. An article in The New York Times criticises the previous director, Thomas Insel, for shifting the focus of the NIMH research budget too much away from clinical research to neuroscience. Although the article could have been more sceptical of the possibilities of neuroscientific research, there is an important question about whether biomedical research funding is good value for money. Powerful vested interests don't necessarily produce the most neutral scientific progress.

I would like to see more investment in social psychiatry (see previous post) and critical neuroscience (see another previous post).

(With thanks to Facebook post by Christian Perring)

Friday, October 14, 2016

Is psychiatry currently undergoing a crisis?

Richard Bentall (mentioned in eg. previous post) and Simon Wessely (again, mentioned in eg. previous post) go head-to-head in a conference next year, as to whether psychiatry is currently undergoing a crisis. I suppose I can see both sides. Psychiatry ought to be in crisis but it isn't.

As Richard says, the biomedical model is "on the edge". Its wishful thinking about finding a biological basis for mental illness has failed to come to fruition (eg. see previous post) but that doesn't seem to matter. As Simon says, "psychiatry is in good health". It can plough ahead with its ecelectic view that it is not narrowly biomedical even though it does not really take a psychosocial perspective. I'm not sure how this impasse can be broken.

Nonetheless, I think we do need to move forward. We need to accept that psychiatrists find it difficult to give up the biomedical model (see previous post). But more of them need to abandon the faith that mental illness is due to brain disease.

Tuesday, October 11, 2016

Is critical psychiatry merely anti-psychiatry?

I have been looking at a presentation I gave on whether critical psychiatry is the same as "anti-psychiatry" (see powerpoint slides). I have always tended to emphasis critical psychiatry's links with mainstream psychiatry.

For example, I have mentioned Adolf Meyer several times in previous posts (see example). He was the foremost US psychiatrist in the first half of the twentieth century. His approach, which was called Psychobiology, has the same integrated understanding of mind and brain as critical psychiatry. The problem with Meyer was that he did not follow through on his challenge to biomedicine. He had a tendency to compromise. The full impact of his objection to the biomedical model in psychiatry tended to get lost. In a personal note in his papers a few years before he died, he himself admitted that he should have made clear his "outspoken opposition, instead of a mild semblance of harmony" [his emphasis].

Similarly, George Engel promoted the biopsychosocial model, which forms the basis for patient-centred medicine and psychiatry, as does critical psychiatry. As I pointed out in another talk, Engel was specifically responding to a paper by Arnold Ludwig when he published his 1997 paper in Science arguing for a new medical model. He was explicit that he was challenging biomedical dogmaticism. However, what has happened over recent years is that the biopsychosocial model has been interpreted in an eclectic way evading its full ideological impact. Nassir Ghaemi agrees with me on this point (see my review of his book The rise and fall of the biopsychosocial model). Where we disagree is that I don't think he has fully appreciated the validity of Engel's biopsychosocial model in its original form. I have even suggested using the term "sociopsychobiological" to make clear that I am not using biopsychosocial in an eclectic way (see previous post).

The point I'm making is that critical psychiatry does have roots in mainstream psychiatry. It is not "anti-psychiatry" in that sense.

Sunday, October 02, 2016

Psychiatry as a cultural system

Gary Sidley expresses his frustration in a blog recently reposted on Mad in America that it "seems unrealistic – even naïve – to expect that radical change away from bio-medical approaches to human suffering can be achieved organically". Nonetheless, he remains "optimistic that, in the next decade or so, we will witness a radical change in the way we as a society respond to human suffering" (see recent post on Tales from the Madhouse).

I do understand his frustration and I think we may need to understand better why there is such reluctance for psychiatry to change. To do this, it may be helpful to look at the work of Clifford Geertz, who I have mentioned before (see previous post). Geertz saw religion as a cultural system (see his paper). In the same way, psychiatry can also be understood as a cultural system. 

The biomedical model that mental illness is brain disease is both a model of "reality" and for "reality", to use Geertz's terms. Note the use or the word "reality" in inverted commas. A model does not necessarily describe the real world, which is what critical psychiatry would say about the biomedical model, that it does not. The biomedical model is a model for "reality" because it justifies treatments such as physical interventions, including medication.

The biomedical model gives a sense of direction to psychiatry. It induces certain dispositions in psychiatrists to treat people in a particular way. It provides a worldview, which if psychiatrists did not believe it would make their practice uncertain, too uncertain for most. To quote from Geertz, "Man depends upon symbols and symbol systems with a dependence so great as to be decisive for his creatural viability and, as a result, his sensitivity to even the remotest indication that they may prove unable to cope with one or another aspect of experience raises within him the gravest sort of anxiety". The biomedical assumption is clothed with an aura of factuality by people having faith in it. It is sustained by professional institutions. 

Viewed in this way, it's not surprising that people don't want to give up the biomedical model. To do so is like giving up one's religion.

Thursday, September 01, 2016

Neuroscience can be critical

I've said before that neuroscience needs to be more critical (see previous post). If it wants to include psychology, it is essential that it is seen as more than a physical science. Psychology inevitably includes human aspects which cannot be described in physical causal terms. Human knowledge includes meaningful understanding of action.

For example, Andrew Huxley wrote the website introduction to Cambridge Neuroscience. As he said:-
Perhaps the most difficult, and at the same time the most interesting problem in neuroscience, is the nature of consciousness and its relationship to physical events in the brain.
He suggested that:-
[T]his is the biggest problem facing neuroscience at the present time. Whoever solves it will have earned a place in the history of science comparable to that of Newton and Darwin.

This objective has always been the wishful hope of neuroscience. But maybe it needs to take a more pragmatic approach and realise that the mind-brain problem won't be solved, as it is a philosophical not neuroscientific problem. As far as psychiatry is concerned, this means that trying to understand the reasons for mental health problems and helping people deal with them is what is central for practice. Understanding their problems in terms of brain abnormalities is missing the point.

Saturday, August 13, 2016

Changing mental health services

An article in The New York Times says that alternatives such as the Hearing Voices Network (HVN) and Open Dialogue are starting to take hold in the USA. As the article says, these approaches may be better integrated with mainstream services in the UK. Gail Hornstein, whose books To redeem one person is to redeem the world and Agnes's jacket, are well worth reading, is quoted as saying that it is important "these groups do not become medicalized in any way". I understand what she means but the main problem, as I keep saying throughout this blog, is the biomedical assumption of psychiatry. The article also quotes from Caroline White, who has heard voices since she was in grade school and is involved with HVN:-
I was told by one psychiatrist at age 13 or 14 that if I didn’t take the meds, my brain would become more and more damaged ... Of course I believed it. And I became hopeless, because the drugs just made me feel worse.
Both mainstream and alternative mental health services need to stop making such claims and demeaning people in this way.

Sunday, July 03, 2016

Denial of the functional nature of schizophrenia

An article in The Lancet Psychiatry accuses those who refuse to accept the evidence for schizophrenia being an organic condition as being in denial. It does at least admit that the evidence for organicity in schizophenia may be "questionable". But it then goes on to say, "We can no longer divide [mental] illness into organic and inorganic".

I don't think I've ever heard schizophrenia called 'inorganic' before. Rather, the difference is made between organic and functional psychosis. The idea of psychosis was originally a functional concept following Ernst von Feuchtersleben (eg. see previous post). The anatomoclinical method of understanding illness developed in the 19th century, and despite all the wishful speculation since, it has not established a physical basis for functional mental illness. As I said in my previous post, "more caution needs to be made about drawing any conclusions about biological abnormalities in schizophrenia".

The article is worried about the implications of seeing schizophrenia as functional (or, in its terms, non-organic). But functional illness is as much illness as organic illness. There's no need to deny the reality of functional mental illness by calling it organic.

Inferences about the biology of schizophrenia

A seminar on schizophrenia in The Lancet says the syndrome "seems to originate from disruption of brain development caused by genetic or environmental factors, or both". Note the use of the word 'seems'. The article is not saying that schizophrenia does originate from disruption of brain development. In fact, as the sentence stands, it's not absolutely clear that the article is saying any more than the tautologous statement that mental illness is due to the brain. Of course it is. And so is our "normal" behaviour.

More specifically, the article makes out that "advances in genomics, epidemiology, and neuroscience have led to great progress in understanding the disorder". The problem is that it does not make any firm inferences about the biology of schizophrenia. The studies it discusses are plagued by so many inconsistencies and confounders that more caution needs to be made about drawing any conclusions about biological abnormalities in schizophrenia. The findings may well be artefacts or of dubious value as far as establishing the aetiology of schizophrenia. The article is misinforming people in this respect.

The authors imply there is less controversy about the issue of the biological origins of schizophrenia now because of these studies over recent years. They do need to recognise the critical challenge to their position.

Tuesday, June 21, 2016

Stop psychiatric abuse

Peter Breggin has a blog on Mad in America entitled "Forced 'treatment' is torture". His blog follows that by Peter Gøtzsche entitled "Abolishing forced treatment in psychiatry is an ethical imperative". I agree psychiatric abuse must be prevented.

For both Peters, as it did for Thomas Ssasz, psychiatric abuse includes detention in hospital. They want to abolish all forced intervention in psychiatry. Here I do not agree. Society does expect psychiatry to manage madness on its behalf. However much informal and voluntary interventions, including psychotherapy, may have developed since the origins of psychiatry with the asylums in the 19th century, they have not completely replaced the need for compulsory detention. From a position in private practice, Peter Breggin may well have never detained anyone against their will. As he says, "Someone in an out-of-control manic episode or someone threatening to do harm in a psychotic episode presents difficult problems to civil libertarians and to those of us who wish to help people in distress while protecting others from them." However, he can't use these situations to justify mental health legislation, whereas I think I can.

Where I do agree is about the need to improve safeguards for forced medication. In England, apart from the right of appeal to the Mental Health Tribunal and hospital managers, this is primarily about having access to a Second Opinion Approved Doctor (SOAD) but only after 3 months of receiving medication. Patients on a community treatment order (CTO) with the threat of recall to hospital may take medication and be considered to be consenting to medication and therefore not be referred to a SOAD. The Alaska Supreme Court case ruling, referred to by Peter Gøtzsche, needs to be enforced so that someone should not be given medication against their will without "first proving by clear and convincing evidence that it is in their best interests and there is no less intrusive alternative available". We do need to have much more of an open debate about whether there is any justification for the forcible injection of medication, and, therefore, I welcome the two Peters contribution to this debate. Coercion in psychiatry needs to be reduced.

Wednesday, June 15, 2016

Philosophical perspectives on critical psychiatry

Next May's meeting of the Association for Advancement of Philosophy and Psychiatry in San Diego is on "Philosophical Perspectives on Critical Psychiatry: Challenges and Opportunities" (see call for abstracts). It should be an interesting meeting.

I just wanted to comment on the blurb saying that critical psychiatry  is primarily about taking the "profession to task for being a source of oppression". There is no doubt that psychiatry can be oppressive. There is also no doubt about the role of psychiatry in social coercion, as it is expected to manage mental illness on behalf of society. Critical psychiatry does focus on the rights of psychiatric patients.

However, I have always argued that critical psychiatry is primarily about the conceptual nature of mental illness (see my attempt to summarise critical psychiatry in previous post). Reducing people's problems to something the matter with their brain is unhelpful, even oppressive at times. The reference to the Frankfurt school in the blurb may come from one of my references (eg. see chapter 12 of my Critical psychiatry book). I have also always been sceptical whether critical psychiatry is really based on Foucault's thinking, however much Foucault was concerned that the reason of the Enlightenment was oppressive.

Still, the suggested topics for the conference do merit further examination and I encourage you to contribute by submitting an abstract.

Wednesday, May 11, 2016

Antidepressants can cause psychological dependence

Robert Whitaker (who I have mentioned previously eg. see previous post) has posted on the Mad in America blog about the All party parliamentary group for prescribed drug dependence. He includes a link to his slides for his presentation to the group on "Causation, not just correlation: Increased disability in the age of Prozac". The meeting to which he gave this presentation today is a product of the book Cracked: Why psychiatry is doing more harm than good (see my review), which led to the Council for evidenced-based psychiatry (CEP).

There is no doubt that psychotropic medication can lead to psychological dependence. Since my BMJ letter, I have emphasised psychological aspects of antidepressant discontinuation problems (see eg. my Antidepressant discontinuation problems webpage and my book chapter "Why were doctors so slow to recognise antidepressant discontinuation problems?).

As I have also said previously (eg. see post), Robert Whitaker, in his original books Anatomy of an epidemic and Mad in america, has emphasised the vulnerability created by taking psychotropic medication. He may have implied this is more of a physical problem than I think is the case. In his current presentation he mentions the idea of drug-induced oppositional tolerance which comes from Giovanna Fava, which I am not convinced is valid (see previous post). But the correlations Whitaker points to still stand without postulating a biological explanation for why psychiatric drugs may have harmful long-term effects. I think CEP would do better to emphasise the psychological aspects of prescribed drug dependence.

In fact, the problem is not necessarily specific to medication at all. Medicine has always tended to create dependency. This critique of medicine is not new and was famously expounded by Ivan Illich in Limits to medicine (see Jo Moncrieff's recent blog on this classic book). I wouldn't want to go as far as Illich in suggesting there is no need for professional services and that "do it yourself" care is preferable. But there is an onus on doctors to provide proper expert advice and as a society we may well need less medicine not more (see eg. post on my personal blog). 

Saturday, April 23, 2016

Patient safety measures will be associated with suicide reduction when rates are falling

The latest paper from the National Confidential Inquiry into Suicide and Homicide (NCISH) published in The Lancet Psychiatry starts from the hypothesis that implementation of service changes associated with improvements in patient safety have led to a reduction in the rate of suicide. It manages to show an association of about 20-30% reduction in suicide between 1997-2012 with 16 policies and procedures that relate to ward safety (eg. removing non-collapsible curtain rails), availability of community services (eg. implementing a Crisis Resolution and Home Treatment team within community health services), staff training (eg. training clinical staff in suicide risk management), adoption of specific policies (eg. policy regarding response to inpatients who abscond), and adoption of The National Institute for Health and Care Excellence (NICE) guidelines (eg. NICE depression guidelines). An accompanying comment paper hails this finding as a success for clinical governance.

But what if this 20-30% reduction in suicides in the clinical population happened for other reasons rather than anything to do with these 16 service changes? The fact that the incidence rate ratio was very similar for all 16 policies could be said to support this inference of lack of causal effect. The article notes that the incidence rate ratios were higher for the general population than for the patient population in the study, but the patient population in mental health services has also changed over recent years, with probably more minor cases being referred.

Although the paper does acknowledge that this "study was observational therefore we cannot make causal inferences", I can't find any specific mention of the fact that suicide rates were falling during the period under study. If the same study had been done during a period of rising suicide rates, the service changes would have been associated with an increase rather than decrease in suicide. And by writing that "service delivery variables are associated with suicide rates", the paper, as does the comment paper, leads people to think that a causal connection is being inferred, which is what the original hypotheses was. But the study isn't a hypothesis testing paradigm, as the paper notes, because the use of "randomised controlled designs for this research would be extremely challenging".

NCISH seems to have a habit of using data to justify its own prejudices (see previous post). Whatever happened to the principle of scientific scepticism? And how does a paper like this get through The Lancet Psychiatry peer review process?

The gap between neural circuits and understanding people

A new Personal View in The Lancet Psychiatry goes overboard trying to create a taxonomy of brain circuit dysfunctions in depression and anxiety. It suggests 6 neural circuits have been implicated, viz. default mode, salience, negative affect, positive affect, attention and cognitive control:-
Accepting such circuits have been established, eight biotypes of circuit dysfunction in depression and anxiety are then suggested, viz. rumination, anxious avoidance, negative bias, threat dysregulation, anhedonia, context insensitivity, inattention and cognitive dyscontrol:-
It's even suggested how neural circuits might relate to treatments:-

I think what's being proposed is that the precision psychiatry of the future will identify apparent brain circuitry dysfunction and treat on this basis. I guess it won't need to interview patients. The article is certainly a tour de force of imagination, but does it relate to the real world?

As I keep saying, mental function is not well localised in the brain and I'm not sure we've really identified any more localisation of function through identifying the so-called brain circuits mentioned in the article, even if they are valid. As I said in a previous post, "It's a long step to mapping specific mental illnesses to dysfunction of brain circuits". The article suggests that people like me that believe that mental disorders are not brain disorders, which the article concedes is the typical view, have a "limited understanding of real-time coordination in the brain”. I don't think this is the case and the article at least recognises that a lot of money has been spent through the RDoC project (see previous post), the White House's Brain Initiative and DSM-5 (see eg. previous post) to prove me wrong without success. 

The language about brain circuits cannot be incorporated into clinically meaningful taxonomies because, although mental phenomena have a biological substrate, that substrate cannot tell us the meaning of mental phenomena. The psychiatry of the future will still have to interview patients to get them to tell their story. We can't see that in a brain circuit.

Monday, April 18, 2016

Does cannabis cause psychosis?

An article in Biological Psychiatry reviews evidence about the association between cannabis use and psychotic outcomes. Despite the consistent association, the article highlights how difficult it is to infer a causal link because of confounding and bias in the data.

As I said in my BMJ letter, the use of cannabis can cause emotional problems and people may use it to deal with their emotional problems. Cannabis use is likely to be a proxy measure for poor premorbid adjustment associated with psychosis. As the article says, "few studies have adjusted for measures of early life attachment, abuse, and trauma".

Bias may also be introduced as heavy users of cannabis may be rarely unintoxicated, leading to misdiagnosis of the induced psychotic-like experiences, which are usually transient in less heavy users. There is some evidence of a dose-response relationship between cannabis and psychotic diagnosis.

There is also an association between other drugs and psychosis and mixed data about whether the association with cannabis is more specific. Despite the increase in the use of cannabis since the 1960s there is no clear evidence of a corresponding increase in the incidence of psychosis. Cannabis exposure among adolescents and young people is common and psychosis remains rare.

Despite highlighting the methodological difficulties of making causal inferences from observational studies, the article suddenly jumps to the conclusion that, "There is no doubt that a public health message that cannabis use is harmful is appropriate". This leads to today's Guardian editorial saying that what it calls the "small risk of a dreadful outcome", ie. psychotic breakdowns that "smash up lives and can lead to full-blown schizophrenia", is something "well worth a proper public health campaign".

Of course cannabis can cause harm, as can alcohol. But, as the article points out, it is important to have the facts right for any public health campaign to be effective. The causal link between cannabis and psychosis has not been proven.

Saturday, April 09, 2016

Psychosis can be organic in origin

I have been struggling with a post by Vaughan Bell @vaughanbell on the Mind Hacks blog. He suggests that critical mental health writings implicitly demean people with brain disorders, but I don't think they do.

He gives four quotes to support his argument. However, they don't seem to support it. In fact, the first two aren't about brain disorders. The other two mention organic brain problems but are not demeaning of people with these problems. If you don't believe me, look for more detail about these quotes in the appendix to this post.

Essentially, Vaughan Bell does not want to make too sharp a distinction between mental health problems and brain diseases. He thinks critical mental health supporters do this because having a brain disease is demeaning. This is totally missing the point. This isn't the reason for the argument that functional mental illness is not brain disease. In fact, Bell himself acknowledges that there is "no evidence for consistent causal factors". But he goes on to speculate that these factors will be found in the same way as they have for organic brain disease.

Where Bell might have a point is that supporters of the critical mental health approach do not always explicitly state that psychosis can be organic in origin. He uses the example of the BPS report Understanding psychosis, which he says doesn't discuss organic psychosis, although I have already pointed out that, despite its strengths, there are deficiencies with this report (see previous post). To be clear, people can have psychotic symptoms in a toxic confusional state (delirium) and with dementia, such as Alzheimer's disease.

But not being explicit that psychosis can have an organic cause is not the same as being demeaning about people with brain disease. Functional mental health problems are fundamentally social and psychological. It's as important to combat the stigma of organic brain disease as mental health problems.

Attempts have been made to undermine the critical mental health argument by accusations of attacking a 'straw man' (see Guardian article and my response). It seems opponents of critical mental health are not immune to using this form of argument.

Appendix to above

This post has been made as an appendix to the above post. I'm looking in more detail at the quotes Vaughan Bell used to try and justify his argument that critical mental health demeans people with organic brain disease.

The first quote is from Kinderman et al:-
such approaches, by introducing the language of ‘disorder’, undermine a humane response by implying that these experiences indicate an underlying defect
Here the authors of the quote are arguing that mental health problems should not be seen as disorders or pathologised, as they are better seen as understandable responses to difficult circumstances. I do understand what the authors are saying but I have commented before that such a way of viewing mental health problems may be potentially misleading (eg. see previous post). Generally the implication of identifying a mental health problem is that the person's reaction has been maladaptive. This is why the person has gone for help.

Although there is this debate about whether mental health problems should be seen as illness or disorder within the critical mental health movement, I don't see how this quote supports Bell's argument that people with brain disorders are being demeaned by a critical mental health approach. The quote is not talking about people with brain disorders - in fact, it's saying that mental health problems are not brain disorders.

The second quote that Vaughan Bell gives is from Mary Boyle:-
The idea of schizophrenia as a brain disorder might offer further comfort by distancing ‘normal’ from disturbing people. It may do this by placing disturbing people in a separate category and by suggesting uncommon process to account for their behaviour…
Bell seems to have problems with the idea of "distancing". What Mary means is that reducing mental health problems to brain disease may be a way of protecting others from the pain the person is experiencing. Surely this is correct. Again, this quote isn't about people with brain disease.

The third quote is from Lucy Johnstone:-
The fifth category… consists people suffering from conditions of definitely physical origin… where psychiatric symptoms turn out to be indications of an underlying organic disease… medical science has very little to offer most victims of head injury or dementia, since there is no known cure…
Here, Lucy is talking about people with brain disorders. What she is saying is correct that medicine in the literal sense can't cure organic disease. What she goes on to say, which isn't quoted, is that behavioural and social interventions are what is needed. Again, this is correct and isn't being demeaning of people with organic brain disorders.

The final quote is from Doing psychiatry wrong:-
To be sure, these brain diseases significantly affect mental status, causing depression, psychosis, and dementia, particularly in the latter stages of the illness. But Andreasen asks us to believe that these neurological disorders are “mental illnesses” in the same way that anxiety, depression, bipolar disorder, and schizophrenia­ are mental illnesses. This kind of thinking starts us sliding down a slippery slope, blurring distinctions that must be maintained if we are to learn more about why people are anxious, depressed, have severe mood swings, and lose contact with reality.
This quote is saying there is a difference between organic psychosis and functional mental illness, which is correct (eg. see previous post). Again, this isn't demeaning of people with organic brain disorders.

Friday, April 01, 2016

What does it mean to say that psychotherapy is a biological treatment?

BJPsych editorial this month argues that the target of psychotherapy, like pharmacotherapy, is diseased neural functioning. It does recognise that the method of delivery of these said neurobiological changes is different, with pharmacotherapy seemingly working through chemical changes and psychotherapy through the patient-therapist relationship. It starts from the assumption that the brain disease model of mental illness is valid and therefore tries to justify psychotherapy as a treatment by viewing it as biological like pharmacotherapy.

I've commented before on such neuromania (see previous post). Raymond Tallis uses this term 'neuromania', which he critiques, in his book Aping mankind. People do seem to be taken in by such nonsense which is neo-phrenological phantasy (see another previous post).

The problem is that the disease model of mental illness is not valid. Mental phenomena are meaningful. Of course this doesn't mean that mental phenomena don't have a biological substrate. But neuroscience can't tell us anything about the meaning of that biological substrate. If there has been any advance in neurobiology over recent years, it is in recognising the dynamic nature of the brain. Brain cytoarchitecture is fashioned by the social environment but this should lead to an integrated understanding of mind and brain, not promotion of the brain disease model of mental illness.

To suggest that psychotherapy might correct neural functioning presumes that we know what the abnormality was in the first place. However, we don't know the neurobiological basis of mental illness because the abnormality is functional rather than structural. Mental function is not well localised in the brain. In the nineteenth century phrenology attempted to map mental functions onto the outside of the head. This may seem ridiculous now but neuroimaging provides no better explanations. We knew about the limbic system, prefrontal cortex and reticular activating system, for example, before neuroimaging. To suggest that psychotherapy is a biological treatment is counterintuitively stupid not clever. The mind-body problem can't be solved by calling it a myth.

Tuesday, March 29, 2016

Psychiatry is still biomedical, even if not "narrowly biomedical"

Simon Wessely in a Guardian article says that psychiatry does not recognise the narrow biomedical way in which it is sometimes portrayed. Despite what he says, some psychiatrists are narrowly biomedical (see extract from my book chapter). However, I do agree that most psychiatrists are generally more pragmatic.

It's interesting that Simon is an acolyte of Anthony Clare, whose book Psychiatry in dissent was written to create a consensus after the anti-psychiatry debate of the 1960-70s. Clare wanted to avoid psychiatrists having to adopt a model of mental illness (eg. see previous post). This led to the common claim, which I suspect Simon would support, that psychiatrists adopt a biopsychosocial approach to practice (eg. see another previous post).

The problem is that even though most psychiatrists are not narrowly biomedical, they are still biomedical (see my edited book Critical psychiatry). They generally believe that mental illness, at least major mental illness, such as schizophrenia and bipolar I disorder, is due to brain abnormalities, even though the evidence is against this conjecture. It's about time a president of the Royal College of Psychiatrists addressed this issue rather than avoiding and deflecting it, but I don't think Simon will.

Saturday, March 26, 2016

How do we know that IAPT outcomes are not just expectancy effects?

It's some time since I commented on IAPT - Improving Access to Psychological Therapies, now often called Wellbeing Services (eg. see previous post). I've just looked at a recent lecture from David Clark (see video). He's still making claims about outcomes based on lack of comparative data. How do we know that so-called recoveries in the IAPT programme are not due to the placebo effect or spontaneous improvement?

For example, in the lecture Clark makes much of the changes in Buckinghamshire Healthy Minds following a review of notes of the unrecovered patients to identify themes and recurrent patterns in the data (see powerpoint presentation). National figures are that 46% of people are said to recover and a further 15% improve. These are average figures and there is considerable variability by Clinical Commissioning Groups (CCGs). Buckinghamshire was below 50% and by telling staff to increase recovery rates to 65%, lo and behold they did! Isn't this just a Hawthorne effect?

There's a lot of money invested in IAPT so I'm sure Clark doesn't want to think about whether IAPT therapists are mere placebologists. There will always be a problem with assessing the effectiveness of psychotherapy because of the issue of the adequacy of control groups (eg. see my BMJ letter). Psychotherapy trials cannot be conducted double-blind because subjects always know whether they have received the therapy under investigation or a control intervention.

Saturday, March 05, 2016

My baby, psychosis and me

Much of the focus on the two documentaries in the recent BBC In the Mind series has been on the Stephen Fry programme The not so secret life of the manic depressive: Ten years on (see previous post).  The other documentary My baby, psychosis and me was a realistic portrayal of the treatment of two women with puerperal psychosis in a specialised mother and baby unit. One woman, Hannah, made a suicide attempt and was treated with ECT, although the actual treatment was not shown. The other woman, Jenny, was transferred to an intensive care unit, but the treatment there was again not shown. Even the husband was advised not to visit her there.

I have praised the In the Mind series (see previous post as mentioned) for showing what is happening in mental health services. It is important though that the 'sharp end' of psychiatry is not separated off and made invisible.

Definition of sociopsychobiological model of mental illness

I deliberately used the term "sociopsychobiological" in my previous post. This was to try and reverse the eclectic understanding of the biopsychosocial model of mental illness. I do agree with the biopsychosocial model of George Engel (eg. see previous post). But psychiatrists often claim they are biopsychosocial when in fact they are merely supporting a weaker form of the biomedical model (see extract from my last chapter of Critical Psychiatry (2006)).

Promoting the sociopsychobiological approach to mental health

I have been thinking about the motivation of well over 1000 signatories of an open letter to the Director General of the BBC about its coverage of issues on mental health (see previous post). Essentially the complaint is that there is insufficient focus on a sociopsychobiological rather than a biomedical understanding of mental illness. As the signatories to the letter note, this is not primarily a matter of disciplinary conflict. Psychiatrists, such as myself, promote a sociopsychobiological approach. However, the majority of the signatories to the letter are from clinical psychology. I think their anger must express frustration about the dominance of the biomedical model in modern practice. Psychiatry, rather than clinical psychology, may well be the more powerful discipline in this ideological dispute.

Where does this disciplinary power come from? Part of it may be related to the respective roles of psychiatrists and clinical psychologists under the Mental Health Act. Detention under the Mental Health Act requires two medical recommendations. Although clinical psychologists can be Responsible Clinicians, in practice this is not common (see previous post). As I understand it, the British Psychological Society is not prepared to intervene on the issue of whether clinical psychologists who undertake the role of Responsible Clinicians should be paid more like psychiatrists. Perhaps it should to help even out any power disparity.

Sunday, February 21, 2016

What does it mean to say that Stephen Fry's diagnosis has been changed from cyclothymia to bipolar I?

In the recent documentary, The not so secret life of the manic depressive: 10 years on, (see previous post), Stephen Fry's psychiatrist changes his diagnosis from cyclothymia to bipolar I. The implication seem to be that Fry's problems, which may have previously been put down to his personality, are now seen as being due to a real mental illness, whatever that is. 

Does this make any sense? Psychiatric formulation should be about more than a single word diagnosis (see previous post). This doesn't always happen in practice (see another previous post) and patients often complain that psychiatrists don't listen to their story and are just interested in "the diagnosis" and medication. I have also mentioned before my concern about how the diagnosis of bipolar disorder has expanded over recent years (see eg. another previous post), so that its meaning is less clear. Maybe Stephen Fry should resist the extension of his diagnosis. 

The programme makes a distinction between Stephen Fry's symptoms, which tend to be internal to himself, and the presentation of Alika (see his story), which led to him being detained under the Mental Health Act in a manic state. By the way, Alika recovered from this episode, whereas Fry still talks about the problems he has with his "mood swings". Maybe it's better not to classify Fry's presentation in the same way as Alika's, which is what the change to bipolar I might imply. 

Whether Stephen Fry's diagnosis is better understood as cyclothymia or bipolar I, the psychological formulation of his problems in terms of aetiology is still the same. In a way, the single-word diagnosis is the less important part of a formulation. It's only a word used to try and pigeon-hole his difficulties. It doesn't really help him to make sense of them.

Complaining about the dominance of the biomedical model

There have been complaints about the coverage of mental health problems in the recent BBC series In the mind (see open letter). This is because of the lack of challenge to the idea that mental health problems are necessarily manifestations of biological illness. For example, Richard Bentall has also published his open letter to Stephen Fry, who presented the keynote documentary in the series, The not so secret life of the manic depressive: Ten years on. The other main documentary was My baby, psychosis and me. 

This blog has been written to critique the biomedical way of understanding mental health problems. So, you might think I would want to join the list of complainants about the programmes. However, I do not think the Stephen Fry programme explicitly stated that mental health problems are distinct brain conditions. True, psychiatrists are featured in the programme who almost certainly hold that view and the programme did not question this. But I think the programmes were designed to show what's happening in mental health services and, to my mind, the two documentaries did that. However much I wish it wasn't the case, the biomedical view of mental illness is clearly dominant in current practice. Furthermore, the publication of my edited book Critical psychiatry: The limits of madness was intended to try to move beyond the polarisation in the debate about mental illness. I just think that complaining about the programmes is not the most constructive way forward and, in a way, misses the point. 

After all, the documentaries clearly allowed the patients, including Stephen Fry, to explain their perspectives. In particular, I thought the story of Alika Agidi-Jeffs (see clipwas very positive. I also thought Stephen Fry was very brave to talk about the Ugandan incident and the association of his suicide attempt with the stigma of his homosexuality. The complainants believe that patients are experts in their own condition and should be allowed to express their views, so at this level they should welcome the programmes, even if the patients in the programmes themselves may not totally agree with their views. But we shouldn't be surprised by that if they have been treated in a biomedical way.

At one point in the Stephen Fry film, the voiceover said that with her early diagnosis, Cordelia, one of the patients who featured in the programme, knew why she had mood swings. Actually, there's a sense in which just having a diagnostic label like bipolar didn't really help her to understand the reasons for her problems. As I've pointed out in a previous post, the evidence is that patients are ambivalent about a diagnosis of bipolar disorder. A biomedical diagnosis doesn't give a psychological formulation of people's problems, leaving them feeling they haven't really got an explanation. The voiceover in the programme actually in a way acknowledges this by saying that having the diagnosis hasn't helped Cordelia to live with her mood swings.

At another point, the voiceover also says that there is no guarantee of another patient's, Scott's, condition easing. I just wonder if that might be too pessimistic a prognosis. One of the problems with biomedical diagnosis is that it can encourage the sense that one does not have agency to deal with one's problems. Scott's treatment seems to have been primarily medication. It is possible he might have done better with a more psychological approach. 

I think we should applaud Stephen Fry in trying to improve understanding of mental illness in his role as President of Mind. I would encourage him to do even more in this respect by promoting a psychological perspective. Of course it can be difficult to understand why we have the mental health problems that we do. But that shouldn't stop us trying to make sense of them. There was little attempt to do that in the two documentaries. 

Sunday, February 07, 2016

Abandon the notion of mental illness as a distinct, genetic brain disease

Jim van Os makes a case for abandoning the term "schizophrenia" because of its association with suggestions that it is a distinct, genetic brain disease (see BMJ article). He suggests that no such language is associated with other categories of psychotic illness, but I'm not sure this is right, because bipolar disorder may be seen in this way. Van Os also points out that research publications on psychosis tend to concentrate on schizophrenia, although again, I think he probably underestimates the extent of the literature on bipolar disorder. He suggests removing the term "schizophrenia" from psychiatric classifications and recognising the existence of the broad and heterogeneous psychosis spectrum syndrome.

I've previously pointed out (see post) that psychosis has already tended to replace schizophrenia in everyday clinical practice. However, as I've also said, psychiatrists do tend to believe that psychosis is a brain disease (see previous post). I'm all for abandoning the notion of "schizophrenia" if it leads to mental illness not being seen as a brain disease. I agree that language does matter (see another previous post), but what's more important is to change conceptual understanding.

Saturday, January 09, 2016

Now it's mainstream to be critical of MRI brain studies

Daniel Weinberger (who I have mentioned in a previous post) & Eugenia Radulescu (2015) have produced a note of caution about MRI brain scanning in psychiatry. They suggest they are starting a critical perspective on the interpretation of such results. I suppose what's new is that this critique has come from mainstream researchers, who themselves have made claims about brain abnormalities associated with mental illness from such studies. Still, mainstream support for critical psychiatry is welcome. Some adapted quotes from the article in a tweet.

(With thanks to In the News item on Mad in America)

Wednesday, December 16, 2015

Psychiatric interviewing

I have mentioned Susan Lamb before (see eg. previous post). Her most recent article picks up Adolf Meyer's use of the term 'the new psychiatry' (although I don't think he used this phrase that often). Meyer emphasised the importance of history taking and mental state examination rather than neurobiology. To quote from the Meyer reference that Susan gives in the article, "Today it is far more necessary that a physician should learn to cope with the psychic data than even with the anatomy of the cortex." Meyer didn't always express himself that clearly, but what he meant should be apparent and it's still the same today. Psychiatrists need the skill of psychiatric interviewing even more than neurobiological understanding. This isn't always apparent from the way psychiatrists approach their work.

The best Notes on eliciting and recording clinical information were drawn up in a pamphlet by the Teaching Committee at the Institute of Psychiatry and published in 1973. They were used for ensuring a fairly uniform style and layout for recording clinical data throughout the Maudsley and Bethlem Royal Hospitals. These were disseminated throughout the country and I'm glad I was introduced to them in my first placement in psychiatry in Cambridge. It's difficult these days to obtain a copy of this guidance. The copy I currently have was withdrawn from the library of the Kings College School of Medicine and Dentistry, which includes the Institute, as too out of date to be kept on the shelves. But clinical interviewing hasn't really moved on and this edition is clear and concise.

As the pamphlet says, "A high standard of clinical recording is a hallmark of good medical practice and is nowhere more important than in psychiatry". More attention is paid to psychological and social phenomena than in a general medical examination. The interview itself serves as the psychiatrist's main tool of investigation.

Introduction of the anatomoclinical method in medicine in the nineteenth century led to the association of bedside observations of patients with autopsy findings of pathological lesions in organs and tissues. Pathology emerged as a distinct discipline. Microscopic studies established cellular abnormalities for disease and it was generally assumed there would be a histological basis for psychopathology. It was eventually established that dementia paralytica was a late consequence of syphilis. Senile dementia was also seen as having a physical cause such as Alzheimer's disease. 

However, most psychopathology is functional, in the sense that there are no structural abnormalities in the brain. Taking a pragmatic approach, as Susan says, Meyer still used the anatomoclinical method to study psychopathology "functionally in experiences and social interactions" and "not organically, at the level of tissues or cells". This new vision of the clinical skill of psychiatric interviewing made Meyer the dean of American psychiatry in the first half of the twentieth century. 

We need a new "new psychiatry" to help us move on from modern concepts of mental illness as chemical imbalance or some other abnormality in the brain (see previous post). Psychological formulation is a way forward (see previous post), although psychosocial assessment is more embedded in psychiatry than it may often appear in current practice.

Saturday, November 28, 2015

Is 'psychosis' a substitute for 'schizophrenia'?

Huw Green in his article in Social Theory & Health mentions that Mary Boyle reluctantly adopts the word 'psychosis' as a substitute for 'schizophrenia' in order to discuss the topic of psychiatric diagnosis she has chosen to address. He uses this situation to reinforce his view that talk about psychiatric diagnosis is inevitably a form of communication. I have similarly criticised Mary for attempting to abandon psychiatric diagnosis completely (see my article). Psychiatric diagnosis needs to be recognised for what it is - an attempt to describe psychological states. It is, therefore, related to unobservables and not describable in a natural scientific sense. There will inevitably be limitations in the application of psychiatric diagnosis, whatever way symptoms and signs are grouped and conceptualised. Psychiatric practice needs to acknowledge this state of uncertainty. The concepts of mental illness do not need to be abandoned for this reason alone.

It's not surprising, therefore, that Mary reintroduces a notion of psychosis, however much she may think that the concept of schizophrenia is unscientific. But, neither is psychosis an absolute concept. Even the BPS attempt to explain psychosis and schizophrenia in everyday language still uses the terms (see previous post). The usefulness or validity of terms like 'psychosis' and 'schizophrenia' may depend on the ability to identify certain patterns between different patient presentations (see another previous post).

For example, the experience of hearing voices can be a dissociative symptom. This situation may have been used as a rather superficial argument for the abandonment of the diagnosis of schizophrenia but it does create a category of 'dissociative voice hearing'. As Green says, if the new catgory provides "more clinical information than the DSM, there is a chance that [it] will be adopted and applied instead, or even incorporated into that manual". Dissociation, in fact, does feature as a category already in DSM, including dissociative identity disorder (see changes made in DSM-5). It's a weakness of the BPS report, mentioned above, that it makes no attempt to discuss the difference between psychosis/schizophrenia and dissociation. The point I'm making is that it is a meaningful discussion to have and we do need to have words to communicate about it.

As Green concludes, "no psychiatric language is able to 'do justice' to the particulars of any given case". However, it serves a function in giving rise to a general form of pragmatic knowledge. DSM-5 has failed in its attempt to move from symptom-based diagnoses to aetiologically-based diagnoses using the latest advances from neurosciences and genetics (see previous post). We need to make the most of this failure (which should have been predicted anyway) to have a better diagnostic understanding of terms like psychosis and schizophrenia, if they have any meaning at all (see another previous post).

Simplistic notion of antidepressants correcting chemical imbalance in the brain is publically untenable

Jeffrey Lacasse and Jonathan Leo have published an update (see new article) on their article from 10 years ago on drug company advertisements about antidepressants correcting serotonin levels in the brain. As they say, "Some advertisements were more tentative or clever in their wording than others, but it seemed obvious that the drug companies were at least pushing the boundaries" of the scientific evidence. What they've found from data collected in 2014/5 is that the simplistic narrative of chemical imbalance is no longer widespread. Drugs tend to be advertised as "affecting" neurotransmitters rather than normalising transmitter levels. There are still problematic advertisements but the language has been moderated substantially.

I don't think we should necessarily be taken in by this change. Although simplistic notions of biochemical imbalance may no longer be publically tenable or displayed in advertisements, I'm not sure if practising psychiatrists really care that the theory is wrong. In fact, they probably still think that antidepressants correct a chemical imbalance, even if it hasn't definitely been shown in research (eg. see previous post). They like to think antidepressants work in practice, so there must be some reason why they work. So, even if the academic evidence isn't there for 'chemical imbalance', psychiatrists still function as though it justifies their clinical practice. In fact, they may still indicate this to patients. Few psychiatrists tell patients that even in the clinical trials the difference between placebo and active treatment is small. Any difference was called 'clinically insignificant', at least as regards reducing depressive symptoms, by NICE in a previous version of its depression guideline (see my BMJ eletter). There are also a substantial number of patients that do not improve in the clinical trials. Antidepressants are not always as effective as psychiatrists may make out to patients.

Psychiatrists use the chemical imbalance theory as a means of persuading patients to take their medication (see another eletter). The role of psychiatry is to give hope to depressed people. It is also to be honest with them about the cause of their problems and the appropriate treatment. Patients are able to understand that the 'chemical imbalance theory' has only ever been a theory. What they find more difficult to appreciate is why they are told that this theory has been proven, when this is clearly not the case.

Wednesday, November 25, 2015

Uncertainty about the value of Ritalin for ADHD

A comprehensive systematic review has been published in the Cochrane Library of the benefits and harms of methylphenidate (Ritalin) for children and adolescents with attention deficit hyperactivity disorder (ADHD) (see enhanced article). All 185 trials included were assessed to be at high risk of bias. It was possible for people in the trials to know which treatment the children were taking, the reporting of the results was not complete in many trials and for some outcomes the results varied across trials. The authors concluded that the low quality of the underpinning evidence meant they could not be certain of the magnitude of any effects on teacher-reported ADHD symptoms and general behaviour and parent-reported quality of life of the children. The most common adverse events were sleep problems and decreased appetite. To quote from the conclusion, "At the moment, the quality of the available evidence means that we cannot say for sure whether taking methylphenidate will improve the lives of children and adolescents with ADHD".

Saturday, November 14, 2015

Are early intervention services beneficial?

Ghio et al (2015) have published a survey of attitudes of mental health workers towards early interventions in psychiatry. They admit the results may be biased towards a more favourable opinion because the survey was distributed to participants at conferences in Italy on this topic, and these people might have been motivated by specific interests. Overall, professionals seem to have a positive attitude towards early interventions in psychiatry, with perceived outcomes in areas like reducing the severity of long-term social consequences and the disease itself and avoiding chronicity.

As I said in my review of Jo Moncrieff's book The bitterest pills, Jo has provided one of the best summary critiques of early intervention in psychosis (chapter 10 of the book). Duration of untreated psychosis (DUP) is associated with poorer outcome but this was never a new finding as it has always been recognised than more acute onset of psychosis has a better outcome. Despite the attractiveness of early intervention services (EIS), the danger is that they may actually lead to over-treatment.

Whatever the advantages of intensive treatment for reducing readmission, there is little evidence that the underlying psychotic disease process is fundamentally modified by EIS. Two trials of EIS in Copenhagen and Aarhus County, Denmark and Lambeth, London did not specifically examine whether starting anti-psychotic medication early improves outcomes. Nonetheless, drug companies exploit the situation by encouraging early prescribing.

The early intervention approach becomes even more controversial when attempts may be made to bring people into treatment even before they have become psychotic, with the intended aim of reducing DUP even further. Thankfully, psychosis risk syndrome was specifically excluded from DSM-5 for lack of validity and insufficient evidence that early intervention in the so-called prodrome is effective (see previous post).

When I first trained, more people were probably admitted to hospital than now with a first episode of psychosis. However, there was no necessary rush to start anti-psychotic medication. Instead patients may have been assessed drug free for a week, to ensure that the primary diagnosis was psychosis. Overmedicating people with anti-psychotics may create unnecessary dependency and is not good practice.

Thursday, November 12, 2015

Asking the wrong questions about psychiatry

Stephan et al (2015) in two papers in The Lancet Psychiatry entitled 'Charting the landscape of priority problems in psychiatry' (Part I: Classification and diagnosis and Part II: Pathogenesis and aetiology) begin from the fact that "few, if any, breakthroughs in basic scientific research have led to substantive improvements in psychiatric clinical practice". They are right to conclude from this situation that there is a need for refocusing of research agendas in psychiatry.

However, they then start from the wrong premise. They still want to "endow psychiatry with a mechanistic, neuroscientifically informed basis”.  They, therefore, produce a list of 17 problems for psychiatry, created by asking an international group of scientists and clinicians to state what they perceive as “the single most important problem or hypothesis" that needs to be addressed to meet this objective.

How long will it take for psychiatry to realise that its very nature is that it has "major conceptual and practical challenges"? It's no good expecting research to bypass this situation.

Psychiatric diagnoses are simply categories justified by clinical utility. Their value-laden nature are not a sign of scientific deficiency but of their meaningful nature. Mental disorders are not natural kinds and there are inevitably fuzzy boundaries between different syndromes. Psychiatry needs to avoid the reification of diagnostic concepts.

As far as aetiology is concerned, genes set the boundaries of the possible but environments define the actual nature of mental disorder. The human brain is socially constructed in the literal sense that brain cytoarchitecture itself is fashioned by input from the social environment. Minds are enabled but not reducible to brains.

As I keep saying, please do not misunderstand me. Of course mental states map onto the brain. But the localisation of function to structure in the brain is not a new problem. Psychiatry can still be practiced even though there is a mind-brain problem. There's no need to create 17 pseudo-problems to solve by research before progress can be made.

Friday, October 09, 2015

Fixing the brain is not the new world for psychiatry

Joe Herbert starts well in his article on Aeon Why we can't treat mental illness by fixing the brain?. He explains that although we have some understanding of how a brain neurone is activated and how this activation is passed on to another neurone, we do not know the answer to the wider question of "how a collection of neurons makes a thought, a memory, a decision, an emotion". As he says, "The problem of relating events at the level of neurons with the known functions of the brain is a critical one." There is a "mysterious and seemingly unfathomable gap" between psychology and neuroscience, which "bedevils not only psychiatry, but all attempts to understand the meaning of humanity".

Herbert recognises within psychiatry that there is "no evidence at all that the levels of serotonin or noradrenaline in the brains of depressed people are any different from normal". As he says, "a pathologist looking at the brain of a depressed person could not distinguish it from the brain of someone who was mentally well".

This is all well and good. But then he goes on to spoil the article by speculating that "one day, someone, somewhere will make the critical step, or steps, and we will enter a new world of psychiatry". The advance would be one "that can relate what psychiatrists see in their patients to what can be seen in the brain".

I suppose such wishful thinking can be used to justify the research of his Cambridge Centre for Brain Repair. However, there's no need to wait, and I think we'll be waiting forever, for some new breakthrough at a cellular, chemical or 'systems' level. The problem is conceptual and philosophical, not scientific in that sense. Mental health problems can be treated psychosocially now. It's misleading to suggest that the way forward is by moving psychiatry to neurology (see eg. previous post).