Something Rotten in the State of British Psychiatry
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.”
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.
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