Something Rotten in the
State of British Psychiatry?

Philip Thomas, MD
55
299

Delegates attending the International Congress of the Royal College of Psychiatrists at London’s Barbican Centre in June this year will almost certainly not hear about the results of the seven-year outcome of the Dutch First Episode (FE) study widely discussed on Mad in America in recent months.

At the end of last year, Dr. Joanna Moncrieff, who has done more than anyone in the UK in recent years to draw attention to the problematic nature of the evidence base and theories used to justify drug treatment in psychiatry, wrote a proposal to the Organising Committee (the body within the College responsible for deciding on the scientific content of the Congress) entitled Re-evaluating Antipsychotics – Time to Change Practice? The aim of the short symposium was to discuss recent research findings suggesting that long-term anti-psychotic treatment is associated with poor social outcome and poor physical health.

Dr. Lex Wunderink had agreed to speak about the Dutch FE findings that maintenance treatment was associated with lower rates of social recovery than people who discontinued treatment (Wunderink, 2013). Professor Sir Robin Murray from the Institute of Psychiatry had agreed to talk about the evidence from brain imaging studies that the use of anti-psychotics is associated with brain shrinkage. For her part, Dr. Moncrieff planned to talk about the growth in prescribing and marketing of anti-psychotics. These three speakers are acknowledged authorities in the area and can hardly be seen to represent a controversial choice.

These are important matters of great topical concern to psychiatrists, people using mental health services, carers, mental health professionals and policy makers. In a democracy they are issues that warrant urgent discussion and debate both within and outside professional circles. They are of direct relevance to the way that people under the treatment of psychiatrists in the NHS are advised, because they concern the evidence used to justify that advice by their doctors. The regulatory body for doctors in the UK, the General Medical Council, makes it quite clear that the duties of a doctor include ‘… Keep[ing] your professional knowledge and skills up to date…’ and ‘…Give patients the information they want or need in a way they can understand.’ (GMC, 2013).

It is impossible for patients to make informed decisions about their care if their doctors are not fully aware of the latest evidence concerning the risks and benefits of the treatments they are proposing to use. Dr. Moncrieff’s proposals flagged up matters that are vitally important in respect of this as far as the management of psychosis is concerned.

To her astonishment the Organising Committee rejected the proposed symposium. When she wrote to Dr. Helen Miller, one of the organising committee chairs asking why, she was told there were too many competing proposals. Dr. Moncrieff then asked if any of the symposia selected by the committee covered the same area as her proposal. She received no reply (Moncrieff, 2014).

Many of us, like Dr. Moncrieff, are astounded, and find it disgraceful that the professional body for psychiatry in the UK appears to be so blasé about the important issues that this symposium intended to cover. It suggests that the College does not consider these matters important or relevant. Dr. Moncrieff writes as follows:

“At best psychiatry appears indifferent and complacent. At worst it is subconsciously attempting to hush up inconvenient data, so that, along with its partner, the pharmaceutical industry, it can continue ‘business as usual.’ Either way, it appears that the critics are right: the profession has its head firmly in the sand.”
(Moncrieff, 2013)

Complacency is one thing, but there is evidence that that is only a part of the problem. A spate of recent editorials in the British Journal of Psychiatry has dealt with what is seen by many as a crisis in psychiatry. Two of these, written by prominent academic psychiatrists, convey a sense of perturbation at what is ostensibly described as a ‘threat’ to the medical identity of the profession.

One of the most influential of these figures, Professor Nick Craddock, Director of the National Centre for Mental Health at the Medical Research Centre for Neuropsychiatric Genetics and Genomics in Cardiff, has written two editorials in recent years. In the first paper (Craddock et al, 2008), the authors suggest that psychiatry faces a crisis of authority brought about by a ‘downgrading’ of core elements of medical care in psychiatry, particularly the belief that the profession offers specific treatments based in diagnosis. They identify a number of factors important in understanding how this happened. These include scepticism within the profession towards the value of scientific studies of mental illness, a broadening of the concept of ‘mental illness’ which undermines the priority of serious mental illness for those responsible for commissioning mental health services, and interprofessional rivalries between psychiatrists and other professional groups in mental health. They claim that patients have a right to expect more than what they describe as ‘non-specific psychosocial support’. At some future point they claim that advances in molecular genetics and neuroscience will yield new targeted biological treatments for psychosis.

A different perspective on the crisis came from a group of British psychiatrists associated with the Critical Psychiatry Network (CPN) in the UK (Bracken et al, 2012). We argued that good psychiatric practice primarily involves the non-technical, or non-specific, aspects of care, based in human relationships, meanings and values. The crisis of psychiatry arose partly because the ‘technological paradigm’ (diagnostic systems, causal models of mental distress, evidence based medicine) obscured the value of non-specific elements of care. In addition we argued that the technological paradigm is seriously flawed. Empirical evidence from within evidence-based medicine indicates that the benefits people gain from many psychiatric drugs have less to do with their ‘specific’ properties than they have to do with the placebo effect, a non-specific element of care. This also holds for psychological therapies.  The evidence indicates that it is not the specific elements of CBT (for example) that are responsible for positive outcomes, but the quality of the therapeutic relationship as seen by the client.  The paper concludes by setting out the challenge this poses for the future of psychiatry, and the need for a radical shift in the values base of mental health work. This involves a move to a post-technological psychiatry that, whilst not abandoning science and evidence, foregrounds the ethical and hermeneutic aspects of our work.

Professor Craddock’s most recent paper (Craddock & Mynors-Wallis, 2014) consists of an attempt to rescue the concept of psychiatric diagnosis from the criticism that arose from the development of DSM-5. Although the authors restate many of their earlier points, the tone is different. There is a note of desperation as they exhort the profession to see that that they are no different from other hospital consultants in other medical specialities:

“When a patient consults a psychiatrist they have a right to expect an expert
diagnostic assessment and the psychiatrist has a professional responsibility to provide such an assessment and use it to guide available evidence-based treatments.” (Craddock & Mynors-Wallis, 2014: 94)

Towards the end of the paper they hammer home the point about medical responsibility. Making a diagnosis and using evidence-based treatment is not a matter of ‘personal choice’ for the doctor, but a matter of professional duty or ‘responsibility’ to the patient. They emphasise this through reference to the Royal College of Psychiatrists’ document Good Psychiatric Practice, ‘…in which diagnosis is mentioned on six occasions and which provides absolute clarity about the necessity for a psychiatrist to be able to use diagnosis effectively.’ (Craddock & Mynors-Wallis, 2014: 94 – 95). The implication here is that, in Professor Craddock’s opinion, for psychiatrists not to offer evidence-based treatments based in psychiatric diagnoses is a matter of professional malpractice.

It is clear that one of the targets of Professor Craddock’s ire is the Critical Psychiatry Network. Despite the fact that they refer to Dr. Timimi’s No Psychiatric Labels Campaign in the 2014 article, and despite its hectoring tone, Professor Cradock and his co-author fail to engage with the arguments advanced by the Critical Psychiatry Network. They also provide no response to the growing weight of evidence confirming the limited effectiveness or ineffectiveness of drug treatments in psychiatry, and the irrelevance of medical-type diagnosis to the administration of these treatments.

It is difficult to avoid the conclusion that the psychiatric establishment in the UK is in a sorry state. Rather than face up to genuine concern raised by recent scientific evidence it is failing to engage with this in a mature and transparent matter. This is poor leadership. Some of those at the heart of power in the College feel under threat because they are unable to face up to to this mounting challenge to the legitimacy and effectiveness of the currently favoured biologically oriented approach to helping those with mental health problems.

As a consequence of this challenge to its orthodoxies and ideologies (for that is all they are), the higher echelons of the profession in the UK are responding in one of two ways. As Dr. Moncrieff suggests, the Royal College of Psychiatrists is burying its head in the sand in the hope that these matters will blow over. In contrast, Professor Craddock prefers to come out fighting. His latest blustering editorial with its desperate appeal to the ethics of duty and responsibility, and veiled intimidations of professional censure, smacks of desperation.

As Dr. Timimi has pointed out in the vigorous debate currently taking place within CPN about the College’s failure to accept Dr. Moncrieff’s proposed symposium, they are alarmed about the threat to the current psychiatric orthodoxy. The sense of crisis however, comes not from the failings of some psychiatrists to subscribe to biomedical orthodoxy, but from the lack of evidence to support this position. It is therefore no surprise to see that the arguments they put forward are emotive and ideological, and notable for their lack of any attempt to support their arguments with scientific evidence.

Oh, and I forgot to mention something else that might just be relevant. Professor Craddock is the editorials editor for the British Journal of Psychiatry. Might there just be a conflict of interest (none declared in his recent article) here? It’s very difficult to see him acting in this capacity by offering the authorship of Bracken et al (2012) the right of response through an editorial in the journal, but it would be gratifying to be proved wrong on this.

Oh, and there’s something else I forgot to mention. Along with Dr. Helen Miller, Professor Craddock is one of the Organizing Committee chairs for the 2014 International Congress, all of which makes me wonder if there is indeed something rotten in the state of British psychiatry.

References:

Bracken, P., Thomas, P., Timimi, S., Asen, E. Behr, G. et al (2012) Psychiatry beyond the current paradigm. British Journal of Psychiatry, 201:430-434 DOI:10.1192/bjp.bp.112.109447

Craddock, N., Antebi, D., Attenburrow, M-J., Bailey, A., Carson, A. et al (2008) Wake-up call for British psychiatry. British Journal of Psychiatry 193, 6–9. doi: 10.1192/bjp.bp.108.053561

Craddock, N. & Mynors-Wallis, L. (2014) Psychiatric diagnosis: impersonal, imperfect and important.  British Journal of Psychiatry, 204, 93 – 95.  DOI: 10.1192/bjp.bp.113.133090

GMC – General Medical Council (2013) Duties of a Doctor. Accessed on 8th Feb 2014

Moncrieff, J, (2013) Psychiatry has its head in the sand: Royal College of Psychiatrists rejects discussion of crucial research on antipsychotics. Accessed on 8th Feb 2014

Moncrieff, J. (2013a) The Bitterest Pills: The Troubling Story of Antipsychotic Drugs. Basingstoke, Palgrave Macmillan.

Wunderink, L., Nieboer, R.,  Wiersma, D. Sytema, S., Nienhuis, F. (2013)  Recovery in Remitted First-Episode Psychosis at 7 Years of Follow-up of an Early Dose Reduction/Discontinuation or Maintenance Treatment Strategy: Long-term Follow-up of a 2-Year Randomized Clinical Trial. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2013.19

55 COMMENTS

  1. Yes there’s something rotten in the state of British and Scottish psychiatry which I can testify to. Thanks for your post Phil which confirms my concerns as a mother, carer and survivor, of mental illness and psychiatric treatment.

    I had to take up the survivor terminology in the last few years because saying I was “recovered” didn’t really describe the struggles it took to get out from under psychiatry. It’s a political term, being a survivor, and I speak out about it at any and every opportunity, on national mental health groups, in blogs and Emails.

    Despite recovering the schizoaffective label in my “notes” remains, stuck like glue, although the psychiatrist who wrote it now says it’s “in perpetuity”. What does that mean? Who knows. To me it means he/they got it wrong. It wasn’t lifelong mental illness and I didn’t require to be on the lithium, and so I got off it, myself, by taking charge and defying the psychiatrist, in 2004.

    I’ve never believed a word of it, the mental illness mantras and lifelong prognoses. A load of cow dung.

  2. You don’t even need a official diagnose by a psychiatrist for stigma. Everybody “knows” what depression, mania or psychosis looks like and that it is caused by chemical imbalance in the brain, so people are often diagnosed and stigmatized by others even before their first contact with psychiatry.

    The foundation of psychiatry is discrimination.

      • But, the intent behind eugenics, has always been discrimination. So you are right, Oli. And there is no more scientific validity behind the “mental illnesses” of today, than there was behind the “mental illnesses” of the Nazi doctors.

        But I am a little confused by why my former Jewish psychiatrists Rabin (biblically translated “rabbi”) and Kohn (a Jewish kohen is also a type of Jewish priest), who are incapable of comprehending my concerns of complete hypocrisy. Especially since, according to their medical records, my “mental illness” was belief in the “Holy Spirit” and “God.”

        • And the psychiatric end result was, according to all my family’s medical records, covering up the sodomy of my three year old son, by a Lutheran pastor, and / or his wealthy friends.

          Shame on psychiatry for gaining power within society by promising such unethical cover ups of illegal matters to the religions and governments, via their unscientific defamation and chemical lobotomization of people.

          • Duane,

            My continuing faith was my saving grace, too.

            But it is shameful for Holy Spirit and God denying psychiatric practitioners, to be in the business of force medicating women so they may cover up homosexual child abuse, for the religions. And cover up a “bad fix” on a broken bone. Unfortunately that’s what is quite obvious happened, when looking at the totality of my child’s and my medical records.

            I don’t think society should continue to advocate belief in scientifically unprovable and invalid “disorders.” Because, of course, they will be used for unethical reasons, even by doctors and religions.

            US psychiatry is in the business of covering up child sodomy now. I think people need to know this. And maybe what I ran into is much more common than we know?

            http://www.personalgrowthcourses.net/video/conspiracy_of_silence

          • Someone Else,

            I believe that wickedness will be dealt with by a force much larger than us, in a time and place not of our choosing.

            The best we can do is remember that love is the greatest healer – capable of healing beyond our comprehension.

            Duane

          • Duane,

            I agree, “the wickedness will be dealt with by a force much larger than us, in a time and place not of our choosing.”

            But the story of my dreams is this beautiful love story all sung out in music lyrics, which leads to God calling judgement day. If it came true it would be wonderful for the decent on this planet. I know it’s silly, but I pray for my dreams to come true. Yet for now, I merely wait for Him. Wishful dreaming.

            By the way, thank you for expressing regret at what happened to my family. When dealing with sexual abuse cover ups by pastors, all you get from the religion is denial, denial, denial, and “I don’t want to pay you,” – even though I had initially asked for help, not payment. The egomania and hypocrisy of the religions and medical communities are staggering. It’s as if they’ve all gone off worshiping only money and Satan.

            Information is power, and now everyone has access to tons of information. Thank God, I’m very grateful I was able to research and explain how I was made sick with drugs.

            But it still baffles my mind that seemingly an entire industry can believe concerns of child abuse, with medical evidence (or any / all real life problem), is a “chemical imbalance” in the mother’s brain. Psychiatry is either insane, or pure evil.

          • Someone Else,

            You wrote:

            “Psychiatry is either insane, or pure evil.”

            Unfortunately, you’re not the first to come to this conclusion.

            The good news is that *love* will win in the end. If not in this time and place, then in the next one.

            Keep the faith,

            Duane

          • Yes, Duane, I have a beautiful story of Love in my dreams. I just wish there were a little more love on the planet, and corporate America would realize intentionally harming people for profit is not acceptable behavior.

  3. I think Doctor Thomas and other psychiatrists critical of their profession deserve a lot of credit. But I am somewhat surprised, though pleased, that the official “leaders” of the profession seem to be in a panic.

    Psychiatry never has had any real scientific rationale for what they do, even before the days of mass drugging and mass bribes to its practitioners from the drug companies. In spite of that, our society has given psychiatry more and more power, both ideological and legal.

    For example, when people become unhappy because of what is happening in their lives, instead of perceiving it as part of life and trying to do something to change what is hurting them, they now believe it’s a “disease,” and take a drug. I’m obviously not saying anything revelatory to readers of MIA here, but my point is that psychiatry has become a religion to the average person. The criticisms of their profession by honest doctors haven’t reached the public yet.

    Even worse (to me as a lawyer), psychiatry has been given incredible legal power over people’s freedom. As I understand it, in most of Europe and the UK, people can still be locked up if one or two psychiatrists say they “need treatment.” In the United States, our Supreme Court ruled against this almost forty years ago, but in practice in most states, “need for treatment” is still followed. Note, for example the recent case of a woman in Vermont (one of our most liberal states) who was held for nearly six weeks without legal review.

    So what I am saying is that I find it strange that the official rulers of psychiatry are in a panic. Their power to lock people up at will, and their bizarre view of human nature that the public believes in, has still been untouched.

    I wish that their power was a lot closer to being taken away than it really is. But if I were them, I wouldn’t worry too much. They should just save some of the bribes they receive from the drug companies and retire to the country somewhere, perhaps to some former “asylum” where one hopes there will be lots of room for them.

    Meanwhile, I commend again decent and honest psychiatrists like Doctors Thomas, Moncrieff, and others, for having the courage to speak the truth to the leaders of their profession. As for those leaders, perhaps they should try some of the wonderful medications that are available and they will feel better.

  4. I’m reminded that virtually every program or practitioner asserts that all treatment is evidence based. Absent consideration of the Dutch First Episode study is it now more appropriate to assert that all treatment is based on the evidence we prefer?

    For too many psychiatrists patients have simply become maws for meds. Unfortunately, for too many patients meds alone will continue to be treatment in its entirety where so many needs and challenges can’t simply be addressed by medications alone.

    • You and I know that, and all the rest of people who come to MIA, but how do we get this out to the general public who believe in psychiatry and the false claims of the drug companies? I keep wracking my brain for something that can be done to bring the spotlight to bear on all of this so that the average person on the street realizes that the claims of psychiatry and the drug companies is nothing but large piles of bull feces. At least bull feces makes for good fertilizer and is useful while psychiatry and the drug companies are nothing but liars.

      • I don’t think America’s broke; I think it’s broken. Wealthy individuals and corporations are not paying their shares of taxes, and the spending of what tax money is collected is managed by marionettes owned by those same super wealthy individuals and corporations.

        They want everyone to believe that the nation is broke so that their austerity policies have a veneer of legitimacy rather than being viewed as the cruel relics of Gilded Age economic royalism and social Darwinism that they truly are.

        • @ uprising,

          As the debt clock points out, the unfunded liability for *each* taxpayer is over $1,000,000 (bottom of this link):

          http://www.usdebtclock.org/

          If the IRS took every dime from the wealthiest Americans, it would not be a drop in the bucket.

          This liability is in the areas of: Social Security, Medicare and prescription drugs.

          The U.S. could significantly reduce those costs (and future liabilities) by addressing mental health costs, with sane and affordable options.

          Instead, Congress passed an (Un)Affordable Health Care Act – guaranteeing, through so-called “parity” the so-called right to get a psychiatric label and mind-altering drugs, paid for by the taxpayer, who is already liable for a million bucks.

          Why?

          Because the politicians are kept in power by Pharma, in exhange for keeping Pharma in money:

          http://www.ijreview.com/2012/06/7143-president-to-recieve-80-billion-in-support-from-big-pharma-for-obamacare/l

          Duane

          • Duane,

            Well, I disagree with most of those points, but since I also reject the premise, as I said, the rest of it is academic to me.

            I admire your passion, however, and will content myself with enjoying your criticisms of psychiatry.

          • I agree with you, Duane. The entire world’s monetary system is a mess now. And it seems there may be some, at the top, who have this as a goal because they want to bring about a reworking of the monetary system for the entire world. And this is what the bible predicts will happen some day.

            Personally, I believe it is the Triune God who has the right to offer debt forgiveness, which we all need, so I am now praying for His return. Such prayers really shouldn’t be called “bipolar.” Psychiatrists are criminals for force medicating people for belief in the Holy Spirit and God. And fools for being obsessed with force medicating Jesus.

            What if the Holy Bible is correct, and He is to return some day? Playing on the radio right now, “This is my kingdom come, this is my kingdom come.” He is supposed to “come in the night like a thief” “singing a new tune,” and that’s the story of my dreams. And an American girl should be allowed to pray for the Lord’s Prayer to come true some day, without being defamed and tortured by Jewish psychiatrists, in the United States.

  5. I can tie in years of disability, 2 suicide attempts
    and 2 near misses to depot long acting injections and a return to good health as a result of stopping.

    These control medications do not improve health and safety they are psyco active and cause homicide.

  6. I think the use of the word “Something” in the article’s headline is unfortunate in its understatedness.

    The “rotten thing” in the play was “incest” and there’s an awful lot of incestuousness in the field of psychiatry. Actually, calling it a “field” is insulting to farmers. The uninhabitable island of psychiatry? The in vivo experimental camp of psychiatry?

    It’s not easy to get the words right.

  7. The other “rotten thing” in Hamlet’s ambiguous words was “murder” and there’s an awful lot of unspoken murder in the in vivo experimental camp of psychiatry.

    Just to add I enjoyed the article.

    Critical Psychiatry is, to a degree, the Oskar Schindler of British Psychiatry. Maybe I’m being too deferent. I’ll have to have a think about that.

    • I agree that Critical Psychiatry are a glimmer of hope and it’s a travesty that Dr. Joanna Moncrieff has been prevented from giving her address “Re-evaluating Antipsychotics – Time to Change Practice?” to the people that most need to be hear it.

      The rejection speaks volumes and underlines the mass delusion being experienced in British psychiatry.

      Given Moncrieff’s collation of evidence surely a case can be made to “section” psychiatrists that insist on prescribing so-called antipsychotics long-term, for surely they are pose a real and present and ongoing danger to others?

      Would the critical psychiatrists be willing to attend the 2014 International Congress in the company of social workers and police and “section” those dangerous psychiatrists?

  8. [I didn't realise self-editing facilities were withheld here; this is the correct and edited draft; rather than bang something out I'll write in a text editor priorly. please remove this stuff between the square brackets and the previous iteration with all the errors - thanks. it should read like this:]

    I agree that Critical Psychiatry are a glimmer of hope and it’s a travesty that Dr. Joanna Moncrieff has been prevented from giving her address “Re-evaluating Antipsychotics – Time to Change Practice?” to the people that most need to hear it.

    The rejection speaks volumes and underlines the mass delusion being experienced in British psychiatry.

    Given Moncrieff’s collation of evidence surely a case can be made to “section” psychiatrists that insist on prescribing so-called antipsychotics long-term, for surely they pose a real and present and ongoing danger to others?

    Would the critical psychiatrists be willing to attend the 2014 International Congress in the company of social workers and police and “section” those dangerous psychiatrists?

  9. “At best psychiatry appears indifferent and complacent. At worst it is subconsciously attempting to hush up inconvenient data, so that, along with its partner, the pharmaceutical industry, it can continue ‘business as usual.’ Either way, it appears that the critics are right: the profession has its head firmly in the sand.”
    (Moncrieff, 2013)

    Any Ethical Lawyers in the UK to represent one young man with possible Chronic Brain Impairment?

    Must be able to work on No win No fee Basis.