I've been asked how the American Psychiatric Association (APA) is allowed to call schizophrenia a "chronic brain disorder" on its information webpage about 'What is schizophrenia?'. The answer is that professional bodies, including the Royal College of Psychiatrists (see eg. previous post), can't be relied on for information about psychiatry. There was a time when American psychiatry would have been more cautious about making such a claim. For example, neurobiology was only represented in a few sections of the 1959 American Handbook of Psychiatry (see my book chapter). Any influence of psychoanalysis and Meyerian psychiatry is now difficult to find in modern American psychiatry (see eg. another book chapter).
I'm reminded of the hunger strike on the 16 August 2003 by six "psychiatric survivors" to challenge the APA for evidence to support common claims that major mental illnesses are "proven biological diseases of the brain" and that emotional distress results from "chemical imbalances" in the brain (see Fast for Freedom information webpage). I wrote an article about this situation. It’s still the case that the APA needs to take a more balanced view of the evidence about the neurobiological basis of mental illness.
Twitter conversation this morning (see thread leading to my tweet) has made me realise that it may be misleading to say that people who have experienced antidepressant discontinuation problems have become addicted to antidepressants. I'm certainly not wanting to imply that people made dependent on antidepressants have abused or misused the drugs. There is confusion in the nomenclature (see eg. previous post and my Antidepressant Discontinuation Reactions webpage) and I don't want to add to it.
Although the Critical Psychiatry Network was formed over twenty years ago (see my editorial), critical psychiatry remains marginal to mainstream practice. This may be because of its association with so-called antipsychiatry (eg. see previous post).
Critical psychiatry’s challenge to the ‘disease model’ of mental illness is legitimate (eg. see previous post). As I've pointed out in this blog before (eg. see previous post), its point of view has actually always been present historically and philosophically since the origins of modern psychiatry. It is not just a new fad, and grapples with the same conceptual issues that were present with the origin of modern psychiatry. It's always been a minority perspective.
For example, present day psychiatry tends to see itself as ‘biopsychosocial’ (eg. see previous post). It is not only concerned with biological but also psychological and social aspects of disease. Anthony Clare articulated this perspective as the outcome of the anti-psychiatry debate (eg. see previous post). He encouraged the avoidance of doctrinaire devotion to ideology in psychiatry. This ill-defined basis for practice may create theoretical inconsistency, such as viewing more minor psychological disorder as psychosocial, whereas more severe mental illness is identified as biological in origin. It may also lead to the combination of psychotherapy and biological treatments without any systematic theory to support such a strategy.
Nassir Ghaemi is critical of such eclecticism, although he incorrectly blames George Engel and Adolf Meyer for this situation (see my review of Ghaemi's book and responses). Both Engel and Meyer had an integrated mind-brain understanding, as does critical psychiatry. Engel’s biopsychosocial model promoted a holistic psychiatry and, like critical psychiatry, is a challenge to biomedical dogmatism (see eg. previous post). True, Meyer’s embracing of the uncertainty of psychiatric practice led to him being prepared to compromise with opposing opinions. He failed to challenge biomedical excesses, complaining that the research evidence was lacking (see another previous post and my article). But Meyer’s Psychobiology, which dominated American psychiatry in the first half of the twentieth century, is a legitimate theoretical framework for the more recent critical psychiatry movement.
The fundamental issue of the relation of mind and body creates the context for conceptual conflict in psychiatry. The first to apply a mechanistic approach to life was René Descartes (1596-1650) (see previous post). Animate and inanimate matter were understood by the same mechanistic principles. Animals are therefore machines; and human physiology is also mechanistic. Descartes stopped short, though, of including the human mind in this mechanistic framework. The soul was denied any influence in physiology. Descartes, thereby, avoided the materialistic implication that man himself is a machine. The split he created between mind and brain is referred to as Cartesianism. However, living beings, including humans, have a purposiveness that cannot be derived from mere physical-chemical processes. Organic life needs to be distinguished from the inorganic, not the soul from the body. Despite Descartes, the soul and body are not separate but integrated in the organism. Critical psychiatry takes an organismic, rather than mechanistic, perspective in the life and human sciences and is not Cartesian.
In the second half of the eighteenth century, reacting against Cartesianism, anthropology established itself as an independent discipline, concerned with the study of man as a psychophysical individual. In this context, medical psychology had its origin with two major variants of anthropological thinking (Verwey, 1985). A medically-orientated anthropology represented by Ernst Platner, among others, was one version. The other was Immanuel Kant’s pragmatic anthropology. Kant, like critical psychiatry, was clear that it is futile to expect to be able to understand and explain life in terms of merely mechanical principles of nature (Zumbach, 1984).
In the same year, 1845, that saw the publication in German of the book that gave Wilhelm Griesinger his reputation in psychiatry, Ernst von Feuchtersleben produced his psychiatric textbook based on Kantian principles (see previous post). Griesinger was dedicated to the idea of the pathology therapy of mental diseases as a mechanical natural science, although he remained aware of the gap between this ideal and reality. Nonetheless he set the trend for this positivist biomedical understanding that has dominated psychiatry since the middle of the nineteenth century. Such a positivist reduction of mental illness to brain disease is what causes such concern for critical psychiatry. Feuchtersleben, by contrast, like critical psychiatry, recognised that the mind-brain problem is an enigma that can never be solved. He has been called a ‘forgotten psychiatrist’, but should be remembered as creating a framework for critical psychiatry based on Kant’s philosophy.
Critical psychiatry has foundations that go back to the origin of modern psychiatry. It is integral to its history and it is, therefore, a mistake for psychiatry to marginalise it from the mainstream. Critical psychiatry can be understood as a truly biopsychosocial, neo-Meyerian approach to psychiatry based on Kant’s critical philosophy.
Immanual Kant in the section on the ‘Critique of Teleological Judgement’ in his Critique of Judgement (1790) said:-
For it is quite certain that we can never adequately come to know the organized beings [living things] and their internal possibility in accordance with merely mechanical principles of nature, let alone explain them; and indeed this is so certain that we can boldly say that it would be absurd for humans even to make such an attempt or to hope that there may yet arise a Newton who could make comprehensible even the generation of a blade of grass according to natural laws that no intention has ordered; rather, we must absolutely deny this insight to human beings.
What did Kant mean by this and what is its application to psychiatry? As a critical psychiatrist I think I am applying Kant’s critical philosophy to psychiatry.
What Kant was saying is that a mechanistic psychology is impossible. Not that people cannot be studied in a mechanical way, particularly parts of themselves - and as far as psychology is concerned this is the brain - nor that we cannot produce descriptions of thoughts, emotions and behaviour. But a mechanistic conception of nature fails to provide a complete characterisation of living systems.
Why is this? Living things are different from inanimate objects. They have functional and goal-directed characteristics. They have designed and designer-like aspects. They seem to be intended for a definite purpose and they have the ability to form their parts. Living things are purposiveness systems, or to use Kant’s words, teleological systems. A machine is different. It does not serve its own interests but the interests of its maker or user. Organisms, unlike machines, are self-organising and self-reproducing systems.
We therefore need different modes of explanation for teleological and mechanical points of views. For example, understanding the meaning of human action is a different kind of explanation from mechanical explanation. The mechanistic conception of causality fails to provide a complete understanding of human and living systems in general.
In fact, Kant goes further than this. What he says is that how living wholes cause their parts is unknowable to us. We just have to accept that our knowledge is limited because we conceptualise organic matter in a different way to inorganic matter. Life and human sciences are doomed to a kind of pre-scientific descriptivism rather than becoming a natural science.
We can never have theoretical knowledge that anything in nature is teleological, but such judgment is nonetheless necessary and beneficial for us. Which is why we attempt to understand human and living behaviour in mechanical terms. We may well wish we could explain life in mechanistic scientific terms and so-called science has often embarked on what Kant called a “daring adventure of reason”. Despite Kant recognising the wish to have a physical understanding of life and human behaviour, nonetheless he argued that it is absurd and futile to expect to be able to explain mental processes in physical terms.
I want to try and apply this kind of thinking to psychiatry. Mental illness is commonly perceived to be due to brain pathology. This is standard understanding. People may even be told by doctors that their mental health problems are due to a chemical imbalance in the brain or some other biological disease. You may even have heard or read something like this yourself. But critical psychiatry is saying you are being misled by perspectives like this.
Of course acute brain disorders can present as a toxic confusional state. More chronically they can lead to a dementia. But most mental health problems are functional in the sense that they are not structurally represented in the brain.
I don’t want to be misunderstood. Of course I’m not saying that mental health problems have nothing to do with the brain. The mind is clearly enabled by the brain. But what I’m saying is that mental health problems should not be reduced to the brain. And, like Kant, this is primarily a statement about how one explains mental health problems. I’m not saying that mind and brain are different substances. I’m not anti-materialist in this sense. Nor am I saying that it’s not important to use scientific methods. In fact, a lot of what passes for science, certainly in in mental health, is more to do with speculation than the real world. Considering the amount of money that’s been spent on mental health research, one might hope that progress would have been made. But essentially results are so clouded by inconsistencies and confounders that it’s not been possible to say anything definitive about the biological basis of mental illness.
You may be surprised by me taking such a position as this. And, you may well not be alone. I am taking a minority view within psychiatry. In fact, psychiatry is more like a faith that doctors are expected to believe in rather than a science as such. If I don’t follow the faith of believing that mental illness is a brain disease, then I’m seen as unorthodox. I do, however, have a few other psychiatrists who agree with me. Twenty years ago we formed the Critical Psychiatry Network. If you’re interested in finding out more, there’s an editorial in February's British Journal of Psychiatry entitled ‘Twenty years of the Critical Psychiatry Network’.
I reviewed Ronald Pies' book Psychiatry on the Edge a few yeats ago (see review). A recent Psychiatric Times article picks up his theme of debunking the chemical imbalance myths of depression and schizophrenia. I think I do understand his view that these notions were never really taken seriously by most well-informed psychiatrists (see previous post). He does admit, though, that it's not surprising the theory has "taken hold in the minds of so many in the general public". It worries me that he may be seen to be blaming Laura Delano (whose New Yorkerarticle led to his response) for her view, as a patient, "that [her] depression was caused by a precisely defined chemical imbalance, which her medications were designed to recalibrate". I hope he's not.
I'm not quite sure what's achieved by arguing that "there was never a unified, concerted effort within American psychiatry to promote a 'chemical imbalance theory' of mental illness in general", if that's the impression that's been created in Laura Delano and the public in general. Who's fault was it then? Certainly patients are given this professional opinion by psychiatrists (whether they really believe it or not). As I said in my review, Pies thinks that:-
Doctors know it’s an oversimplification ... but use it so patients don’t feel so blameworthy. He does agree this is “a little lazy” ... on the doctors’ part and doesn’t excuse their behavior, but says they are very pressed for time with so many patients to see.
I also agree with Pies that most psychiatrists are more eclectic than just biological (eg. see previous post). In fact, Pies is quite biological in his approach to psychiatry and admits for example that he's enamoured of the idea that depression is a form of inflammation, even though I think this hypothesis is nonsense (eg. see last post). I think Pies is just trying to say that psychiatrists are not so simplistic in their biological (which doesn't omit psychosocial aspects) theories of mental illness. That's as may be and it's good he admits the chemical imbalance theory is bogus. But, if he doesn't attribute the chemical imbalance theory to psychiatrists, who take a much more complex view about the nature of mental illness, then who's been responsible for its promotion? Surely it's not the silly patients.
An editorial in Acta Psychiatrica Scandinavica asks whether the time has come to treat depression with anti-inflammatory medication. This is based on a meta-analysis which provides evidence that anti-inflammatory treatment can be beneficial. Throughout this blog (eg. see previous post), I have emphasised bias in clinical trials, so I’m not encouraging the use of anti-inflammatory medication to treat depression. Not least the trials in the meta-analysis show a high risk of bias and tend to be done by using the anti-inflammatory drug as an add-on to antidepressant treatment, or in patients who have somatic disease, so an anti-inflammatory effect on somatic disease may be the reason for any improvement in depression scores, rather than a true antidepressant effect.
What I want to note is why anti-inflammatory medication, despite the apparent evidence for its benefit, has not managed to get into guidelines for depression. A planned large scale trial to show that anti-inflammatory medication offers the prospect of better treatment than current treatments would be very expensive. As the editorial says, only drugs with a high likelihood of generating future profit are put through such trials. The editorial goes on:-
In the case of the traditionally used, safe and tolerable anti-inflammatory agents that are already on the market, there is no financial incentive for the pharmaceutical industry to conduct these costly, large-scale RCTs. Rather, they are more likely to fund newly discovered immunotherapies with a poorly characterized safety profile, as such novel immunomodulatory treatments can be patented and monetized.
Nor am I suggesting government funding for such trials. As I indicated in my review of Ed Bullmore’s book (see previous post), it’s non-sensical to think that depression is a form of inflammation. Any apparent increase in inflammatory markers in depression is far less than inflammatory disease in general, and has non-specific causes rather than being a marker for depressive disease as such (see previous post).
The market for depression has been flooded. If people want medication treatment, let’s at least keep it cheap. We should be suspicious of any attempt to make further money out of medication treatment for depression.
I'm presuming critical psychiatry is what the session calls the 'new anti-psychiatry'. I've argued in a previous post that the Power Threat Meaning Framework that Paul Salkovskis is critiquing is not anti-psychiatry. I'm not sure how new the critiques of critical psychiatry really are; nor that they challenge the legitimacy of psychiatry as such. But I guess this is what mainstream psychiatry thinks is the case, which is why they use the term 'anti-psychiatry in the title of the session. As I've said before, it's a pity mainstream psychiatry finds critical psychiatry so threatening (eg. see previous post and extract from chapter 1 of my edited book Critical Psychiatry). There were excesses in anti-psychiatry (see my book chapter) but critical psychiatry shouldn't continue to be tarnished by this rotten reputation.
My own proposal for the International Congress on 'Integrating critical approaches into the training of psychiatrists' was turned down. Jo Moncrieff was going to chair it and the three sessions were on (1) Integrating service user/survivor perspectives (2) Integrating transcultural psychiatry and global psychologies (see new book by Suman Fernando and Roy Moodley) and (3) Integrating critical psychiatry. Maybe the session wasn't accepted because it was seen as too anti-psychiatry. If so, perceptions do need to change about the value of critical psychiatry.
Lisa Cosgove and Jon Jureidini have responded (see article) to a Debate article in the Australian & New Zealand Journal of Psychiatry (ANZJP) criticising the Report, which I have mentioned previously (eg. see previous post), of the United Nations Special Rapporteur on the right to health, Dainius Pūras. This report has also been criticised by the European Psychiatric Association (see previous post). The World Psychiatric Association has also criticised an associated report of Dainius on corruption and the right to health, with a special focus on mental health (see another previous post).
The Debate article is entitled 'Responding to the UN Special Rapporteur’s anti-psychiatry bias'. What it means by 'anti-psychiatry' is challenging the biomedical model and, rather remarkably, it includes the British Psychological Society (BPS) in the global anti-psychiatry movement. The Division of Clinical Psychology within the BPS has produced a valuable position statement on giving up the disease model of mental disorder (see previous post).
The Debate article usefully highlights the right to access to mental health care but seems to limit this right to access to pharmaceuticals. As Lisa and Jon point out, the article mistakenly quotes from Dainius' report saying that it "views inpatient psychiatric care as ‘inconsistent with the principle of doing no harm'" [emphasis in original]. What Dainius actually said was "Overreliance on ... in-patient treatment is inconsistent with the principle of doing no harm, as well as with human rights" [my emphasis]. Furthermore, by quoting Fountoulakis and Möller (2011), the Debate article seems to think that it has undermined the Kirsch meta-analysis of the effectiveness of antidepressants, which is not the case (see previous post). I don't know what evidence the Debate article is referring to that leads to its conclusion "that many psychiatric presentations are effectively and quickly treated with purely biological treatments".
The term 'anti-psychiatry' has general been used by mainstream psychiatry rather than critics themselves. I don't think it's helpful to polarise debate too much but the Debate article should not use the term 'anti-psychiatry' in this sense. Challenging the biomedical model is legitimate within mainstream psychiatry (see previous post). Critical psychiatry is an advance over anti-psychiatry (see previous post) and anti-psychiatry should not be seen as having had no value (see another previous post). It's difficult to get the right balance about how oppositional to be (see previous post). Certainly dogmatic positions such as that taken by the Debate article need to be challenged.
I'm not sure where the apparent quote in the Debate article comes from about the "creeping devaluation of medicine in UK psychiatry ... [being] likened to ‘throwing the baby out with the bathwater’". As far as I know this isn't happening. In fact, although British psychiatry continues to marginalise critical psychiatry, the British Journal of Psychiatry did publish my editorial on 'Twenty years of the Critical Psychiatry Network'. Let's hope there might be more debate about critical psychiatry in Australia and New Zealand, as well as globally in general (eg. see previous post).
(With thanks to Mad in Americapost by Zenobia Morrill)
Antidepressant prescriptions dispensed in England have almost doubled since 2008 (see BBC News article). Helen Stokes-Lampard, Chair of the Royal College of GPs, has responded to this recent release of prescription data by NHS Digital (see press release). She is keen that the rising rate is not necessarily seen as a "bad thing, as research has shown they [antidepressants] can be very effective drugs when used appropriately". I'm not quite sure what she means about antidepressants being effective, as I keep emphasising in this blog that the evidence is still open to interpretation (eg. see previous post).
She suggests improvement in the identification and diagnosis of mental health conditions could help to explain the rise. GPs were traditionally found to fail to diagnose up to half of cases of depression or anxiety on initial presentation (Goldberg & Huxley, 1992). Over the longer term, this figure may not be as high or as clinically important as this initial impression may suggest. Some depressed patients are given a diagnosis at subsequent consultations or recover without a GP’s diagnosis. However, there is still a significant minority of patients (Kessler et al., 2002 found 14% in their study) with a diagnosis of persistent depression that is undetected The failure of detection of depression is commonly presumed to arise because of a lack of psychological mindedness amongst doctors. In general, doctors value objective evidence of disease more than subjective experience. This tendency creates a bias towards the over-diagnosis of physical disease, rather than the detection of mental health problems.
Maybe GPs are now treating and referring more people with anxiety/depression to mental health services, perhaps partly encouraged by the opening up of services by the development of Improving Access to Psychological Therapies (IAPT) over the last 10 years (see graph of increasing numbers of people seen by IAPT) . The number of referrals to general adult mental health services has also increased and figures suggest they have more than doubled since 2003, excluding IAPT referrals (see tweet).
Primary care is an essential element of the provision of mental health services and has always traditionally seen more patients with mental health problems that secondary care. Helen Stokes-Lampard complains that access to alternative treatments to medication, such as CBT and talking therapies, is " patchy across the country". She says this despite the introduction of IAPT which was supposed to bridge this gap.
I want to pick up, though, the way in which Helen Stokes-Lampard seems to dichotomise the treatment of mental health problems between medication and talking therapies. In fact, most people seen by secondary mental health services do not receive psychological therapy as such. Even within IAPT, many people do not even receive short-term therapy but instead guided self-help. Polarising treatment between medication and psychological therapy forgets that much mental health treatment is social intervention - helping people understand and recover from the problems with support and becoming as independent as they are able and capable of being. GPs used to do a lot of this work with patients, perhaps particularly when there was continuity of care in general practice. But maybe primary mental health care has become more difficult with the fragmentation and dysfunctionality within health services in general over recent years.
I'm not defending a rise in antidepressant prescribing as Helen Stokes-Lampard could be said to be doing, but I agree with her that these issues - including the role of primary care in metal health treatment - need to be discussed more widely.
Medium has a new mental health publication - 'Inspire the Mind' - produced by the Stress, Psychiatry and Immunology (SPI) Lab at the Institute of Psychiatry, Psychology and Neuroscience at King’ College London led by Professor Carmine Pariante, who I have mentioned previously (eg. see previous post). It has reprinted 'Facts You Should Know About Psychiatry and Why It Is Helping the Person Next to You' from a HuffPost article, although it's dropped the reference to 29 facts we should know, I think because the booklet from the Royal College of Psychiatrists to which the original article refers no longer exists (if it was ever published). Maybe the College had second thoughts about making such 'scientific' claims (eg. see previous post).
It is important to encourage debate about the potential harm of recreational drugs and whether substitute prescribing of methadone leads to harm reduction, but Pariante seems to think it is clear that cannabis causes schizophrenia, which is not the case (see eg. previous post). Like him, I also agree the development of psychological therapies should be evidenced-based, but he doesn't describe the realities of the Improving access to Psychological Therapies (IAPT) programme (see previous post), nor mention the evidence bias towards specific therapies, such as CBT, or even the problem of the adequacy of controls in evaluating psychological therapy (eg. see previous post). Nor am I sure where his apparently inflated figure of 80% recover for psychological therapy of panic disorder and social anxiety comes from. I doubt research is really needed to show that reducing the maximum pack size of over-the-counter sales of paracetamol, and limiting sale to one pack, reduces paracetamol overdoses (although has such research actually been done?). But Pariante needs to be more careful about making claims for the value of the National Confidential Inquiry into Suicide and Homicide in improving patient safety (eg. see previous post).
I do understand why Pariante wants to answer criticisms of psychiatry. He admits himself that the article is a 'little bit of PR'. But his attempt to create a positive view of psychiatry shouldn't lead to him unscientifically overstating his case.