Monday, December 5, 2022

Comments by Jonathanledlarsen

Showing 68 of 68 comments.

  • He actually writes they can be ‘expected’ to be the same. And he does suggest replication in other countries. If he had specified ‘western countries’ it would probably have been a bit stronger. Still, it is a reasonable assumption. Psychiatric science is published in international journals, the diagnostic systems are used internationally, american research output is immense and influence psychiatry in all western countries. Paradigms for research and dissemination works across national borders. In a sense national textbooks can reasonably be expected to be local expressions of some transnational lore.

  • @Enrico
    Here’s former head of National Institute of Mental Health, Thomas Insel’s take on the benefit of genetic and neuroscience research:
    “I spent 13 years at NIMH really pushing on the neuroscience and genetics of mental disorders, and when I look back on that I realize that while I think I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs—I think $20 billion—I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness.” I can see, you think otherwise…

  • Well, you could also say that philosophy is implicit in science, no matter what you consider science to be. And that there are different ways of doing science that attempts to get a grip on a lively world through different means. One grip on mental health issues is the pharmacological grip, which comes with its set of theories and philosophical assumptions. Another grip is the psychosocial approach, which is underpinned by other theories and philosophical leanings. Thinking this way completely defuses claims of having found THE universal explanation for whatever the problem is. It considers knowledge as situated and local, not as decontextualized and universal. And different ‘grips’ can co-exist just fine as long as none of them develop megalomania and claim to be THE only sensible grip. The trouble really begins, I think, when one type of ‘grip’ or solution starts to reframe the problem in its own picture. Psychopharmacological solutions explain mental health issues as biological disturbances, psychosocial solutions explain them as problems with learning and relationships. And then we end up in different camps, clutching our precious ‘truthy’ knowledge, without realizing that knowledge really flows from practice, and that different forms of practice makes possible different kinds of knowledge. Both camps routinely oversell, in my view. The world and its problems are much weirder than either-or.
    (I can really recommend this article making the distinction between understanding knowledge either in a representational or in a performative idiom:

  • @Steve, Enrico
    Just a reference to a blog post with an interview with a philosopher. She distinguishes between two different approaches to intervening in case of mental health issues: local-to-global or global-to-local. This distinction exactly matches your positions. Local-to-global can be psychopharmacological interventions working on neurotransmitters locally before creating a global cascading effect, that influences experience and behavior in some way. Global-to-local can be environmental or psychotherapeutic interventions which through experiential processes creates changes locally by way of learning. It is a logical distinction. This way of thinking does not sit easy with naive-realist views of mental disorders or treatment modalities. Medication, e.g., is not assumed to ‘correct’ anything – rather it disturbs neural processes which then reacts back through their own dynamics. This may be helpful or not depending on person, circumstances etc.
    (sometimes psychiatrictimes does react when using google chrome as browser)

  • @DrStrait
    Old, I now, but somebody posted in the thread. You are right that some problems in medicine are ‘vague’ too. However, you cannot argue that because medical issues can be vague, and mental health issues are vague, then mental health issues are medical problems. It’s a faulty syllogism. What you need to show is that there are processes going on in your medical examples that are the same as the processes going on in particular mental health issues. What you are in some sense adamant about is that discomfort in a broad sense is a medical issue, regardless of the particular processes going on. In medicine, progress is often measured in survival. Cancer treatment has become immensely better in the last decades. However, the survival of psychiatric patients haven’t changed a bit. People with a mental health diagnosis live 15-20 years shorter. One interpretation of this is that the scientific models used in cancer research leads to clinical progress, while the models dominating psychiatric research does not.

    You can argue, as you do, that all medical issues involve politics and power. However, if I were diagnosed with cancer I would prefer the tumor be localized and treated, perhaps with chemotherapy, perhaps surgically removed or both. When the disease manifests I would not expect behavioral interventions to work. There are specific cells which multiply, regardless of how I think about them or how my surroundings treat me. In contrast, when a psychiatric diagnosis is made I would expect a much wider palette of treatment options: environmental, psychopharmacological, psychotherapeutic, support through friendships etc. While some of these would be nice to have during cancer treatment (e.g. friendships) they do not treat the localized tumor but rather helps endure the treatment and uncertainty.

    One way to understand this is to regard mental health issues as ‘global’ in the sense that they affect the way a person makes sense of and navigates his or her world. Cancer, on the other hand, is a local occurrence in a group of cells that can be delineated precisely. It is local, the opposite of global. Getting a diagnosis of cancer may have global effects in that it changes one’s view of life, the future etc. It is, however, not in itself a global phenomena. You may then suggest that mental disorders also have a local origin in a similar manner. However, you need to detail this not just postulate it, and you need to point to evidence showing that interventions based on this model improves survival or other relevant outcome both short- and longterm. I don’t think this is available.

    Perhaps most mental health issues are different from cancer in that it manifests on the global level without any localizable, local first-cause. I think you, DrStrait, in your way of arguing lose the ability to make this distinction between local and global.

  • At least in Europe there is a wider field, e, g. phenomenological psychopathology a la Karl Jaspers, which is more wary towards physiological explanations. From my point of view the most basic ‘model’ is that mental health is a medical specialty – whatever the psychiatric specialist take that to mean in a certain time and context. Also, I think the diagnostic approach using ICD-10/-11 is la bit less moronic/reflective than DSM – perhaps it has something to do with public healthcare systems too

  • Is there a consensual ‘psychiatric model’? Or is there rather both subtly and openly shifting models and interpretations which can be brought out when needed to rationalize some kind of prioritization or course of action? Theory is seldom made explicit in psychiatric thinking which makes it like steering a ship in the dark, I think. Re: model – you can also consider a model as something not concrete enough for doing predictions, but instead as something to bridge different perspectives with. That was probably to intent of the first biopsychosocial model as it was only very vaguely developed…

  • In her book length version of this article, the overall categories are something like: biological/physiological, social/cultural, psychological/experiential and reflective/existential. That gives room for spirituality, I think. No matter what kind of psychiatry or non-psychiatry one supports, or what kind of problems in the world one is concerned with, I think you need to reckon with the tension between thinking holistically vs. reductionistically.

  • Well, yes, among a lot of other things he actually says that. To my eyes, it is the narrative of the ‘lost art of psychiatry’ he leaps into. How the psychiatrist once was a more rounded authority, well read in the humanities, at least as interested in psychotherapy as in medication and so forth. But alas, now this refined professional has been degraded to pushing pills. However, the past had its problems too, of which the present knows very little, so perhaps it is a nice dream, nothing more. I’m pretty sure the future does not lie in the past in such a concrete sense.

  • So, dr. Timimi is hoping to recover the psychiatrists, who potentially “are the only mental health practitioners that can do it all, from prescribing to therapy” and who should “be leaders in mental health services, helping bring other professions along, as well as not being afraid of becoming embroiled in the politics and politicization of services.” Sounds comforting…

  • Hi Paula – Thx for weighing in. ICD as a WHO publication is available online for free. In my country, Denmark, the ICD is not sold by the WHO – it is sold in a versioned, Danish copy of chapter V which has been adjusted by a danish working group. It is then published by ‘Munksgaard’ – a Danish publisher who publishes lots of different genres. There must, I agree, be some financial incentives in this whole process. I’m not sure WHO are responsible for registering harms from psych-drugs. In Denmark it is the national health authorities who are responsible for this. In Denmark you can file a report online. This is in Danish, but this details the how reports of harm are handled:
    It says that the company, not the authorities are responsible that the medicine works as advertised – nevertheless the authorities do some weighing of evidence, e.g. harm-reports, reports from companies when making recommendations. This process seems somewhat opaque.
    It is a interesting that there is not the same kind of attention to interests and money flows involved with the ICD compared to the DSM where literature on this is readily available. Perhaps it has to do with the nationalization of how ICD is used. The areas are much smaller – and e.g. European psychiatry does not have the same impact as US psychiatry. As I understand it there is probably also a major impact due to the different ways the American vs. most European health systems are funded, how medicine can be advertised, how reimbursement and legal questions are handled and so forth.
    When I trained as a psychologist, the DSM was considered more precise (particular for research purposes) than ICD. But today attempts are more often made to distance the use of ICD from that of DSM. That does signal some change, I think.

  • Thx for the link. And I think you are right – DSM and ICD are overall coordinated so they are not that far apart. The reason I’m asking is that in the European context I’m in, it is often claimed that clinical practice using ICD is much better, more flexible and experience based than what is often described as the American cook-book like approach in the DSM. Nancy Andreasen of Broken-Brain-fame, for instance, writes that North American psychiatry has lost its connection with the phenomenological approach to diagnosing. This connection – which entails development of a nuanced repertoire of tacit knowledge on the part of the clinician – is sometimes used in defense of the ICD. Kind of like: Yes, but ICD is only a rough guide, what matters is the ‘art of psychiatry’. So I wondered if anyone in this thread knew of a more thorough analysis of ICD – because such a thing is hard to find. Probably because DSM usually is the target of critique. And the kind of defense for the ICD system mentioned above is in a way more subtle and is supported by a more philosophically savvy understanding of what constitutes disorders, e.g. self-disorders as central to the diagnosis of schizophrenia.

  • Can you provide some kind of assessment of ICD-11? While it is true that ICD is not commercial, and that it is used flexibly in many different countries, I’m not sure you can consider it at heart different from the DSM-system. They are both polythetic systems suffering from problems with validity. And applied within a biomedical frame of reference it still leads to the same sort of biologizing and individual pathologizing that the DSM is often critiqued for. However, the mental health part of ICD has to my knowledge not been the object of critical reflection in the same way as the ICD. If anybody knows of critical pieces concerning the ICD-10/11 it would be much appreciated with a link.

  • Does anybody know if a parallel review of ICD mental health-diagnoses exists? There exists a narrative that ICD is ‘less wrong’ than DSM because it leaves more to ‘clinical judgement’. This is supposed to be connected with how it is designed to be implementable in widely different health-systems around the world. Any links or references would be appreciated…

  • However, the story appears to be a bit more complex, because the biological cause does not materialize suddenly in a vacuum.

    I think what Borsboom et al are suggesting is to look for feedback loops in a kind of circular causality. Thus, pointing to one cause only makes partial sense, because you could partition the stream of events differently.

    In the short example by Rachel777, theories about the cause and treatment of ‘depression’ leads to an intervention with antidepressants, which leads to a new dynamic for maintaining the ‘depressive state’ by influencing processes in the gut. This, however, could not have been the initial cause for the ‘depression’ simply because it must be assumed the ‘depression’ preceded the antidepressants.

    Thus, the *cause* of the ‘depression’ could equally validly be processes resulting in the initial symptoms, the idea of treating ‘depression’ with antidepressants, the side effects of the antidepressant or the B12 deficiency.

    More correctly, I think, the whole sequence of events could be considered, and one or more strategic points of intervention pursued in a necessary collaboration with the person experiencing the difficulties.

    The work of Borsboom et al is very interesting, I think, and part of a renewed interest in using (holistic) systems thinking in the context of mental health, which could actually make a sensible difference.

    In a later comment you write, that it is untrue that ‘mental health concerns are not brain disorders’ because biological causation may lead to mental health concerns. However, from a systemic process point of view it is still true, I think, that ‘mental disorders’ cannot primary be understood as brain disorders, because the causality involved is much more complex and traverses different levels of description.

    Unfortunately this flies in the face of hopes for a ‘simple’, one-domain solution to mental health problem, which is what many are hoping for (and which would be nice if true). The Borsboom et al perspective paints a differently complex picture.

  • Very well written! Reminds me of this description by an ecological psychologist of Kurt Lewin’s thinking on causality:
    “It was Lewin’s conviction that actions are rarely understandable as being triggered by a single environmental precipitant or personal disposition; instead, converging influences from multiple sources are the rule. Moreover, an action is not caused by a stimulus; rather, an actor is situated in a field of multiple environmental and personal influences, and the observed pattern or direction of action is an outcome of their mutual convergence.” (Harry Heft, 2001, p. 205)

  • I have difficulty seeing how we can dispense with something like the biopsychosocial model when thinking about the human condition. It is probably right to criticize the BPS-model for not being a model per se, but I have difficulty believing that even dr. McLaren does not, in his work with patients, use some kind of categorization of the particulars of the patients life experiences, situation and complaints that resembles the categories of the BPS. And where Engel proposed his ‘model’ as a way to save psychiatry from its bio-tendencies (by providing a holistic framework for thinking) it is still not entirely clear how the BPS-framework can be enhanced in order be used as basis for research. I can recommend the psychologist/sociologist David Pilgrims talk on the BPS-model found here:

  • Hi Steve 🙂
    My 5 cent on empathy 🙂
    I would say that empathy potentially hurts while at the same time being integral to finding meaning in life. And although it would be nice to eradicate violence and cruelty, I don’t think that will happen, but experiences rooted in empathy may very well fuel the ambition to reduce violence and cruelty. Although it is commendable not trying to shield oneself from being exposed to the pain of others it – I think – is advisable to choose a path of gradual exposure. Not all exposure to the suffering of others is constructive either – think of how parts of the media as well as politicians and others use our proclivity for empathy to manipulate huge numbers of people…

  • @Holger
    Good example – they conflate a here-and-now description at the neurological level with the multifactorial etiological proces leading up to the here and now. It is unfortunately the norm. As I see it the reductive biological approach to mental health, which sees causality as solely bottom-up, lacks understanding of contextualized development. It still refers to environment though – only it is reduced to the umbrella-term ‘stress’ – which relates it to a second rate position.

    Although there are definitely power-structures behind this type of ‘flat thinking’ there are also, IMHO, intellectual reasons behind it. We humans are not very adept at understanding complexity and presented with cognitive shortcuts, such as simple linear models, we too readily accept them: “There’s A here, so that explains B there!” The biopsychosocial model is an attempt at grasping dynamic complexity better, but unfortunately it lacks specificity and influence.

    Another type of important reason could be the rise of the computer metaphor. A computer does not react to subtleties in the environment as long as it gets power. If you grab a picture of the program a faulty computer is presently running, you can correct its program directly too. Its history or relational embeddedness is not central to its local operation. It’s sad the computer has become the main metaphor for the brain. It would be better to consider the nervous system as more akin to a plant than a computer. In this regard biological psychiatry is strangely un-biological.

    Just as mental health is not determined by single one-factor causality, neither – I think – is the unfolding of psychiatry solely related to the pharmaceutical industry.

  • @Sylvain
    There exists a pragmatic approach to ‘truth’ as well. In this version thought, theories and so forth are tools for problem solving. Thoughts are not seen as things inside the head corresponding more or less correctly to some external reality but as at the core a relational matter. It goes against common intuition – but is – I think – a more correct description of what knowledge is than the simple correspondence theory.

    Our concepts and our thinking can help us in different ways – and, for example, a biomedical vs. a psychosocial frame of knowledge opens different avenues for action. None are true in a correspondence I-have-a-copy-of-the-world-in-my-head type of way. Some ways of conceptually slicing up the world nevertheless avoids making too much a mess of it – and it will probably be more useful and thus ‘more true’.

    Knowledge – in the pragmatic perspective – is constructed and is the product of the activity of the researcher. This does not refute the existence of reality because reality is setting the scene, so to speak, and infuses the entire process of knowledge.

    William James was a proponent of this approach to truth. The sadly predominant biomedical approach to mental health is – I think – in line with a correspondence approach to knowledge and claims access to it by use of the scientific method, the experiment, the fMRI etc.

    Hope it makes sense – somebody here probably knows a lot more about theories of knowledge, than I do 🙂 There is immense power in being the one who determines what is valid knowledge or ‘truth’ and what is not.

  • Sounds like an interesting conference you have coming up.
    It would be helpful, I think, to address the confusion in psychiatry about theories and models. At least here in Denmark psychiatric practice is supposedly based on an in theory holistic biopsychosocial approach to the whole person. And it probably also is the intention of many mental health professionals to ‘see the whole person’. In practice, though, there is very little guidance in the biopsychosocial model – so often the whole person enters the consultation room and after the consultation a diseased brain supported by an ignored body leaves the room to return to living in a not further specified environment.

    The lack of a sound, integrative model within psychiatry leaves space for bringing all sorts of arguments forth in public debates – so present practice can always be defended by referring eclectically to different recent findings in brain imaging, genetics etc., spiced up with humane-sounding psychosocial considerations and a nod to the amazing breakthrough waiting round the corner, without ever having any idea how it all fits together.

    The question is what sort of framework could be adopted to integrate the major parallel perspectives on mind? I think the so called 4E (Embodied, Embedded, Extended, Enactive) approach will be helpful – it both provides a strong critique of brain-centered views as well as grounding alternatives to both reductionism and dualism. And it requires radical re-thinking of psychiatric services as well, I think – probably in the direction of pluralism, ecological/local embeddedness and a more realistic approach to the use of medication.

    I can see from the conference program that you actually have a presenter suggesting an enactive approach – any chance the conference will be webcast?

  • It is probably stated elsewhere – but what model does dr. McLaren have of mental disorders? I’ve read a bit about his biocognitive model, which still appears to base disorders on a biological basis – although it suggest a move to a non-dualist position, which is generally a good thing. But it does not appear to be a coherent framework for talking about ‘mental dis-ease’ and he still points to psychiatrists as the main actors in mental health – but how is this supported?
    I’m skeptical if the solution we need is a new and improved bio-model that includes cognition. A problem with the individual-brain-centered view is that it disregards context and culture, and then assumes they can easily be added later on – which is like… studying dead fish in a desert without even a concept of water. I think we need to reconfigure the starting-point in a more radical fashion. Culture, feedback-loops, embodiment and experience seems like important concepts.
    I think dr. McLarens point about psychiatry’s extraordinary lack of self-criticism is spot-on.

  • No – I think CBT is so wide and poorly defined a term, and that the questions you ask are of a very generalizing nature, which makes it impossible to either completely agree or disagree.
    Question 1, for example, assumes a complete dichotomy between psyche and soma, and it assumes CBT is a completely discrete entity which can be applied and any side effects then neatly measured. Neither assumption holds true, I think.
    Question 4, another example: The use of CBT has been steadily increasing in the last decades. So has the use of for instance antidepressants. This does not support the assumption at a societal level.
    Question 6: ‘Optimal quality of life’ sounds nice! It sounds like a pretty self-defeating ideal to have, though, considering there isn’t really a stable place of ‘optimal quality of life’ you can reach.

  • @Kjetil
    Where you may be right that your way of thinking about and justifying CBT is in line with the views sided with in the article, CBT generally is not so straight forward as you idealistically propose. CBT proponents have in practice made a pact with the biological view on distress as brain illness. In competing for resources CBT-practitioners routinely refer to ‘the disease’, CBT is promoted as an intervention on par with medication and – although you may think about peoples life circumstances in therapy – there is no real activist side to CBT: No outcry about inequality, no engagement with creating niches for the burdened, and there is no endeavor to understand the complexities of the human mind. CBT is really a way of coaxing language that promote simplicities such as that thinking directly decides emotion, and it isolates the causes of people’s distress to somewhere inside their heads. As a therapist you may bring a wider view, but that’s not the CBT speaking.

    Just as psychiatry has done, I think that CBT has consistently oversold itself – often by attacking pluralism in its proponents attempt to achieve hegemony – by using outcome studies molded on medical interventions. Of course there are CBT-adherents who are more thoughtful – and you are probably among them – but generally CBT as a brand really is nicely in line with much of what is wrong with the dominant models in psychiatry.

  • Hi there
    Perhaps a bit dull compared to the other comments, but: Does anybody have a reference for the Goethe-quote:

    “Stephen: People are people; there isn’t anything that is abnormal. As the great German poet Goethe once put it, “If you want to understand the abnormal, assume it is normal.” Once you do that, things begin to fall into place rather quickly.”

    I’ve tried different permutations on Google, but no luck. Links to other thinking with the same take on normal-abnormal would also be very welcome! It’s interesting – I think – because the opposite mechanism often is in place: If something is strange, assume it is abnormal and look for a mechanism to explain it.

  • Good comments. I found the article and it brings together threads of evidence which is seldom presented together. There’s some tension in the paper still – perhaps because it is difficult to get a paper with these views published if it is too blunt. Or perhaps because of other interests. In the conclusion, for example, it says:

    “Many psychiatrists rely largely on antipsychotics, not because they dismiss the value of, for example, cognitive–behavioural therapy or vocational training, but rather because financial constraints limit the availability of such interventions.”

    I think it is very simplistic to blame the over-reliance on antipsychotics on financial constraints because there are so many different interests involved in how it came to be. They point to: “The Abandoned Illness. Rethink, 2012” as a reference – but it is an 80+ page report so it’s not very specific. Robin Murray is coauthor of both this paper and the 2012 report.

    Perhaps the authors are right – that it is financial constraints that have driven the use of antipsychotics. But I fear there are stronger interests at play, some of which have to do with power and hierarchy within mental health services. So although the paper is good news in that it brings the critique of AP use forward it is strangely lacking (or naive) in addressing the underlying incentives driving the prominence of using AP to handle psychosis.

    The question is if things can be changed without properly addressing the causes of the problem…

  • @DrStrait
    Thx for your answer on throwing away the DSM:
    “@jonathan, In the clinic, sure, but *something* would have to replace it that would provide a common language necessary to do research and to train residents (and clinical psychologists, social workers, nps, etc.). But the DSM is not terribly useful to anyone, and the APA doesn’t really understand what is at stake in various nosological controversies.”
    That is something of a bombshell. We use the ICD-10 in Denmark and it would be unthinkable to throw the diagnostic system away at least among leading figures in psychiatry. In the fight for funding and leverage in the health care system, mental health diagnoses are routinely referred to as discrete, identifiable, specific illnesses which requires specific medication. Research based on ICD (or DSM) categories are used to argue for for example forced treatment. The argument goes something like this: “This person has an illness, he is suffering terribly and it would be unethical not to treat him/her with the medication we know from research works on this brain disease.” The same people, however, at other times acknowledge that, “no, schizophrenia is probably not one disease, but several different conditions.” But they still do category-based research and use simplistic diagnostic arguments.
    If you do not find DSM-categories helpful, how do you decide how to treat patients? Different medications are usually researched through the administration to persons in a diagnostic category. If you consider this diagnostic system useless for anything than getting paid, how do you at the same time argue that psychiatry rests on a bona fide scientific body of knowledge?

  • Hi DrStrait,
    Your reasoning about the connection between brain and mind is not a proven fact. Epiphenomenalism, which states that the material organization of the brain causes experience, is a philosophical position not based on empirical science per se. There are alternatives to epiphenomenalism which nevertheless also retains a materialistic worldview. The area of systems theory holds several alternatives. For example work in the line of Gregory Bateson points to the interactional characteristics of complex systems – such as brain, body, culture, family, dyadic constellations etc. – and holds, that mind is immanent not in the brain per se but in the-organism-in-the-world. This of course is a challenging way of thinking because it involves not only the complexity of the brain but also of psychological, social and cultural occurrences and their patterns of interaction – and further more it entails a circular view of causality in contrast to the more simple linear view usually assumed.

    If you see your search for a clear definition of brain illness or brain pathology in this light, it might lead you to question how you delimit the object in the first place. I think few will disagree that psychiatry holds a special position compared to the different branches of medicine in that its way of delimiting ‘illness’ to a very high degree is a cultural process. But if the systemic, or bio-psycho-social, nature of psychiatry is denied in favor of a solely biomedical self-presentation then terms such as ‘brain disease’ risks serving an effort to leverage power – often by insinuating a deeper understanding than actually exists – rather than pursuing genuine understanding of the complexity involved.

    I understand from your comments that you are a physician, and that you find it abhorring not to prescribe stimulants to a person presenting him- or herself to you with symptoms similar to that described under the ADHD-diagnosis because not doing this would be to deny this person help. But there are other ways of helping – for example based on learning theories or by addressing the milieu – that may be more appropriate (either alone or in conjunction) but are often eclipsed by pharmacological solutions.

  • It is a good and difficult question.

    My five cents: The term ‘Illness’ is nothing in itself but becomes meaningful through the context and functional intent of its use. Sometimes illness is used to alleviate someone of (perhaps perceived) painful responsibility, sometimes it is used to ascertain power by professionals. Sometimes it is used carefully in order to indicate functional problems, sometimes it is used to market drugs or therapy and sometimes it is used to indicate the need to allocate resources to an individual. Sometimes it is used to (illusory or not) suggest that we understand the nature of some problem or other. Sometimes it is used to point out the inexplicable or alien.

    Illness is just a name – and what’s in a name, really? By any other context, it could mean something completely different.

  • Actually they do mention Wunderink. From the article:
    “The treatment recommendation in current consensus guidelines for patients with first episode of schizophrenia is an initial treatment with AM for 1–2 years (Buchanan et al. 2010; Barnes & Schizophrenia Consensus Group of British Association for Psychopharmacology, 2011). However, in clinical praxis AM is commonly prolonged for many years (Harrow & Jobe, 2007), which also becomes apparent in our sample, as medicated participants had been taking AM for 6.5 years on average, ranging from 3 months to 21 years. Together with the results of longitudinal trials that find better long-term outcomes in non-medicated compared with medicated patients (Harrow et al. 2012; Moilanen et al. 2013) and the findings on the severe risks of long-term use of AM (e.g. Newcomer & Haupt, 2006; Newcomer, 2007; Daumit et al. 2008;Ray et al. 2009;Ho et al. 2011), findings that show that patients who discontinue medication are doing equally well or better stress the necessity to be more courageous when it comes to discontinuing medication after a first acute phase. This conclusion is also clearly underpinned by the result of Wunderink et al.(2013) who found better long-term recovery rates in a group of first-episode patients with early dose reduction compared with a maintenance group after a 7 year follow-up.”

  • Hi Bradford

    Good point – it ties in with the general discussion about the efficacy of antipsychotic and other medication for mental health problems, i think. In a major danish newspaper there was an opinion-piece yesterday written by the sister of a mental health patient receiving forced treatment. The title was: ‘My sister has been sentenced to lethal medicine’ (In danish:

    I think it points to a central dilemma that – among others – the media should address more forcefully: What is really meant by the ‘treatment’-part of forced treatment: Is it a cure? Is it helpful for the patient or for the surroundings? What documentation is there for short-term benefit? For long-term benefit?

    In the online comments to the mentioned article commentators voiced the opinion, that forced treatment was not to make things better for the patient, but in order to protect society from the patient.

    As you point out this may be an illusion. But it also illuminates that ‘treatment’ in this context has a different meaning than we usually assume.

  • Hi oldhead

    You could be right in some instances. I think it is very difficult to be meaningfully categorical in these matters.

    In your post you write:
    “It sounds like they’re labelling criminals and violent people as “mentally ill” then putting them in “treatment” rather than incarcerating them until they no longer pose a threat.”

    Do we not again end with a similar problem to the question of forced treatment, because on what grounds can we incarcerate someone ‘until they no longer pose a threat’? Who would be qualified to judge this, and what rights should the prisoner have?

  • @Fiachra

    In Denmark there are a number of protocols that have to be fulfilled in order to have someone committed and forced treatment demands further procedures. But, as you point out, it still rests on a certain medical type of thinking.

    I think these types of situations are common – especially in larger cities, where people in extreme states are directed towards the acute psychiatric units. Sometimes it is connected to mental anguish/life events/life history, in some cases it is caused by drug use and in quite a few cases by a combination of both.

    I think it is very important to be clear about, how we envision these situations handled without force if possible. And with the most benign form of force if the first option is not possible. Because these situations exist, and they will be used as examples in order to give more room for forced treatment.

  • Hi Fiachra

    If you mean, that people in extreme mental states should be handled by the police, there are certain risks in that as well. Again here in Denmark we regularly have episodes where police officers hurt or kill mentally unstable people who react in supposedly threatening ways.

    In order to reduce these risks, som cities have made teams consisting of both police and mental health professionals – I’m not sure how it is working out in practice…

  • Hi Sa
    Thx for the reply – it makes sense to differentiate between ‘forced safety’ and ‘forced treatment’ I think, although, as you point out, it is no simple feat to offer ‘safety’ in a forced format…

    I think these nuances are important to bring out, but I fear it is too subtle to make these distinctions count in the public debate, unfortunately. There would certainly need to be clear alternatives to present practice to make an impact.

    Best of luck with your family situation!

  • Perhaps I can get this threads opinion on what I have come to see as something of an impasse in completely avoiding force/forced treatment?

    I live in Denmark where we at present have a rather turbulent discussion about forced treatment. The background is that there has been several instances recently, where employees at psychiatric units or semi-psychiatric housing facilities have been attacked and even killed by people (patients) receiving treatment or support for daily living.

    This has led to a call for a more uncomplicated access to the use of force in both psychiatry proper and especially in the semi-psychiatric housing facilities which often have severe problems with illegal drug use.

    I generally agree with dr. Breggin about the use of forced treatment. It is a really nasty experience for people undergoing it and ideally it should not take place. But I have difficulty seeing how any use of force can be completely avoided at all times. Sometimes people end up in states where they can do themselves or somebody else harm – and do things they will regret later if not stopped.

    How to tackle this problem? As I read dr. Breggin – he primarily writes about forced treatment with antipsychotics – a type of medication that is meant to be taken continuously, where there is risk of severe collateral damage (side effects…), and of which the long-term benefit has not been documented (perhaps even the contrary).

    Should it in some cases be allowed to use antipsychotics short-term? Should other drugs – perhaps sedatives – be used instead? Or some other solution?

    I hope I don’t offend anybody by posing these questions – but I think they are important, also if things are to improve gradually it will be important to point to the next good step to take in order to avoid the kind of forced treatment described in the post. The discussion here in Denmark also hinges on coming up with some good answers to these questions, because these are the kind of examples that the advocates of more forced treatment pull into the debate.


  • Thank you for the post – it is good, thougthful reading.

    I think the following sentence sums up a central point in the whole discussion on antipsychotics and short-term vs. long-term benefits:

    “It has been hard for me to fully grasp – and I doubt I am alone in this — that reduction of relapse is not synonymous with optimal outcome. The notion that people may overall fare better in their lives despite having one or multiple encounters with psychosis would never have been self-evident to me.”

    I can follow the above line of reasoning: That reduction of relapse is intuitively a good thing that must also have positive implications in the longer term. But I think it becomes less evident the moment you realise, that this only makes sense in a sort of (no insult intended!) naive view of mental distress: one which sees the distress as caused by something separate from the person. A view which sees antipsychotics as targeting a disease instead of a whole person.

    When you realise that the motivation to act on irrational fears, confused thoughts, voices and so on is the same motivation that helps the person strive to achieve important goals, to learn new things and to build positive relations it becomes much less obvious that (at least partly) shutting the engine of motivation down is necessarily helpful in the longer run.

    Seen this way, the dilemma of short vs. long-term benefit can be understood as an extreme and medicalized version of what we all try to find in our lives: The fine line between what we can endure and grow by, and what we, at least for the moment, need to tranquilize away in order to remain functional.

    Thanks again for an honest and quite fearless post.

  • Hi Sandra

    Thanks for en engaging read.

    The changed view on medication, that you propose, as a means to change conscious experience rather than as a specific treatment for a clearly delineated disease entity, raises a number of considerations, I think, in regard to the distinction between psychopharmacological drugs and recreational drugs – a distinction which especially in this perspective appears quite arbitrary.

    Do you have any thoughts on if this change to a drug-centered perspective on psychiatric medication is connected to a parallel need for a reevaluation of the way western culture treats drug-problems – mainly as a criminal rather than a mental health issue?

    And do you have any thoughts on how the medical part of psychiatric professionals could meaningfully position themselves in the field between what is psychopharmacological and what is recreational use of psychoactive substances?


  • Some lines of thought view the mind as something larger than and non-reducible to the brain.

    For example the brain is made up of atoms none of which show signs of being conscious or having any degree of free will. But somehow the whole brain-structure performs in surprising ways which are not possible for its constituent parts.

    Some would argue that for example the experience of free will, planning, thinking, creativity etc. does not solely rely on brain structure but requires a brain embedded in a wider network: social, physical, spiritual, cultural, informational etc. It follows that you cannot understand the mind by looking only at the brain.

    Some types of signalling can be described at brain level – for example a neuron firing – but other mental phenomena – such as experiencing fear – cannot be fully explained by a brain-only explanation.

    Yeah, well – that’s my take on it anyways 😉


  • Hi theloniusmunk

    Could you please clarify if there is any research pointing to the reverse causation you mention: That the dementia is caused by a neuropathological process of anxiety and is not exacerbated or in other ways causally connected to the use of benzodiazepines ?

    As a psychologist I’ve had some experience with elderly people who have been prescribed benzodiazepines for decades and who show steady cognitive decline, which is often also reflected in their life histories. In many ways it also appears that this treatment-path leads to lives which in many ways are impoverished. This also affects brain function longterm…

    When you point to the problem of association versus causation is this not a general problem? Here is for example the conclusion from another study:
    “This case-control study based on 8980 individuals representative of elderly people living in the community in Quebec showed that the risk of Alzheimer’s disease was increased by 43-51% among those who had used benzodiazepines in the past. Risk increased with density of exposure and when long acting benzodiazepines were used. Further adjustment on symptoms thought to be potential prodromes for dementia—such as depression, anxiety, or sleep disorders—did not meaningfully alter the results.”

    It appears this study also found a positive dosis-effect relation. Where some of the commenters on this study also raise the association versus cause problem, the more astute ones are quite thoughtful in their conclusions, for example:
    “It is important that we appreciate the clinical implications and relevance of the above study to our elderly population. There is growing evidence on the long-term cognitive effects of benzodiazepines(5-8) and although concerns around protopathic basis are valid, we should be aware our own limitations and look to future advancement of science and technology to help provide us with a clearer picture of this complex link.”

    Perhaps it is the case, that it is extremely difficult to conduct the ideal experiment. But this also makes it difficult to substantiate the claim, that benzodiazepines does not raise the risk of dementia, and that all correlation between benzodiazepin use and dementia are artifacts of protopathological processes.

  • Hi MT – I’m not sure you’re interpreting the article correctly. But I haven’t got the time at the present moment to reread it. Still, I read the following line:
    “[…] children still taking medication by 6 and 8 years fared no better than their nonmedicated counterparts.”
    … as indication (by the use of the word ‘still’) that they are referring to a group of children who have been more or less continuously on medication.

    It’s very unfortunate that, as you mention, there is a lack of longterm research in the whole field of psychopharmacological medications.

    I unfortunately cannot follow your links further than a registration-wall. Perhaps you could provide the titles so I can reach them in some other way?

    In your previous post you mention: “However, when you look at studies of children with ADHD who have been maintained on stimulants during childhood and adolescence, you find that their behaviors and academic performance are remarkably better.”

    Are these the studies you are linking to? Because by your description they certainly sound like they are fairly longterm and have strong conclusions.

  • Hi MT – I looked through your post (thanks for the effort) and decided to look up one of your objections to see, if it had any merit. I looked at your comment to #3, where you claim that the article by Molina et al only looks at the effect of 14 months of medication 8 years down the road. If that was what the article was actually saying it would, I think, be a good objection.

    But looking at the article this is not what it says. I quote:
    “[…] with one exception (math achievement), children still taking medication by 6 and 8 years fared no better than their nonmedicated counterparts, despite a 41% increase in the average total daily dose, failing to support continued medication treatment as salutary […]. Additionally, failure to find better outcomes associated with continued medication treatment occurred despite the arrival of improved long-acting stimulant medications […].”

    This pretty much goes against your assertions, MT. Can you point to one of the studies you mention about children who have been maintained on stimulants during childhood and adolescence and their academic performances?

  • Thanks for the article, Olga. Being a danish psychologist working for the 10th year at a psychiatric hospital I too am a bit surprised by the reactions you quote. It appears to be very much powered by an inferiority complex of some sort – wanting to be like a psychiatrist. Or at least have the wage of one… I have actually found it a huge help in my work, that I do not have to be a gatekeeper to medication or forced treatment.

    I find myself very much in agreement with the above comment by bpdtransformation: What is lacking in psychiatry is interpersonal capacity. Medication can be distributed very efficiently, in the present system, but not so much with care, support and love. Which is really sad because care, support and love has this almost magical quality: When used it does not get depleted or ineffective. It grows and multiplies.

    I fear that the more we as professionals focus on medication, force and control the more we risk loosing the know-how to transform fear, shame and anger into courage, self-worth and strength by way of interpersonal connection.

    The danish psychological association, of which I also find myself a member, seems to have lost track of the bigger picture along with at least some of its members.

  • It is difficult to comprehend how mr. Allen can both critizise diagnostic categorization:
    “Mental illness” is terribly misleading because the “mental disorders” we diagnose are no more than descriptions of what clinicians observe people do or say, not at all well established diseases.
    … and then proceed to call for accurate diagnostics:
    I don’t trust clinicians who […] can’t make an accurate diagnosis.
    It appears it is difficult for him to follow his own logic…

  • Thanks for an engaging read. I like the point about keeping the facts in focus in discussing these things, not the qualifications of the persons talking.

    Reading the Andreasen articles (2001, 2013) I get the impression, that there are different interpretations of them regarding the possible negative effects of antipsychotic medication on brain volume. Apparently they conclude that medication causes atrophy but so does relapse/psychosis, and therefore medication should be used at lowest possible dose but possibly for life?

    Can anybody point me to posts, sites, articles that tries to give an overview/a good discussion of the different ways of understanding these data – and what implications the different views have for treatment?


  • “I’m quite certain the psychiatric and medical communities should take another look at the actual effects of what they call “effective pharmacological treatments.”

    I think you’re quite right about the importance of being clear on the actual effects. In the referenced article (note #21, by the same first author) the phrasing: “in the absence of uncertainty about the diagnosis or concerns about the contribution of medication side effects to problems with health or functioning, a trial off of antipsychotic medications is associated with a very high risk of symptom recurrence and should thus not be recommended,” is a way of sidestepping two huge issues – because in real life there ARE issues of side effects and health as well as concerns about the validity of the diagnosis-construct.

  • Interesting excerpt from the article!

    Upon reading the full article, I stumbled upon one of its references (#21 “Risk of symptom recurrence with medication discontinuation in first-episode psychosis: a systematic review”), in which there is a strong bias towards continued medication in patients with schizophrenia. To quote from the abstract of this second article:

    “Six studies were identified that met our criteria and these reported a weighted mean one-year recurrence rate of 77% following discontinuation of antipsychotic medication. By two years, the risk of recurrence had increased to over 90%. By comparison, we estimated the one-year recurrence rate for patients who continued antipsychotic medication to be 3%. These findings suggest that in the absence of uncertainty about the diagnosis or concerns about the contribution of medication side effects to problems with health or functioning, a trial off of antipsychotic medications is associated with a very high risk of symptom recurrence and should thus not be recommended.”

    This stance is echoed in the primary article in this news item:

    “While we may be inclined to try to eventually discontinue
    antipsychotic medication for those patients who have the
    best response and remission, this may be misguided. It should
    not be surprising that those patients who respond most
    robustly to dopamine D2 antagonists may also be most likely
    to become ill when those same medications are discontinued.
    With antipsychotic medication, the large majority of individuals
    with a first episode of schizophrenia are able to achieve
    and sustain symptomatic remission. Without medication, few
    if any patients with a diagnosis of schizophrenia are likely to
    remain in remission.”

    Firstly it strikes me that these conclusions does not jibe very well with the overall findings on functional recovery and longterm maintenance treatment (Harrow etc…). And secondly I have difficulty reconciling the articles statement that schizophrenia is probably not a progressive neurodegenerative disorder and the same articles warning about trying to discontinue antipsychotic medication. Unless of course it is the authors point of view, that schizophrenia first and foremost is a stable and chronic brain disease.

    It is also a bit surprising that the article is so adamant about excluding the possibility of getting well and staying well without medication.

    Well, that was sort of a reflection on the article – it would be interesting to read other reflections… or reflections on the reflection 🙂