Archive for the ‘Thinking about psychiatry’ Category

‘Schizophrenically’

Friday, December 7th, 2012

http://upload.wikimedia.org/wikipedia/commons/c/c4/Eugen_bleuler.jpg

The term “schizophrenia” was coined by Swiss psychiatrist Eugen Bleuler in 1908.  With the term’s introduction, Bleuer ultimately replaced ‘dementia praecox‘, a term first used by Arnold Pick (of Pick’s disease) to categorize a similar disorder (or group of disorders).  The essence of schizophrenia as described by Bleuler is the ‘loosening of the associations’ between personality, thinking, memory and perception.  Dementia praecox has a different focus, describing patients having a global disruption of perceptual and cognitive processes (dementia) together with early onset (praecox).  I’ve written about different conceptions of schizophrenia in the past.

The word “schizophrenia” derives from Greek roots and translates approximately as “splitting of the mind”.  It is often written that, because of this, schizophrenia is misconstrued to mean having a split or multiple personality.  Otherwise known as ‘dissociative identity disorder‘ a ‘split personality’ is where a person has two or more distinct identities or personalities alternatively in control of his or her behaviour.  I’m not absolutely convinced this disorder exists in a straightforward sense but anyway, our current understanding of schizophrenia is that it’s nothing like that at all.

“Starbucks is a schizophrenic brand”

This brings me to the point I wish to make.  For effected people, and their families, schizophrenia can be pretty devastating.  But rather than simply used to refer to this, “schizophrenic” is also used quite commonly to mean “inconsistent and contradictory”.  Here’s an example from Radio 4’s Today programme and another from the Guardian.  Today’s presenter, Evan Davies, doesn’t hesitate at talk of Starbucks as a “schizophrenic brand”.  “Irish” used to be used in quite a similar way, but I doubt Davies could have let talk of Starbucks as an “Irish brand” pass without reproof.  “Schizophrenic” used in this way is a misappropriation, and one which perpetuates misunderstanding and disparages a vulnerable group of people.  I don’t know why it remains so acceptable.

* I’ve yet to actually meet anyone who thinks this, but this is perhaps because all my friends are psychiatrists.

***

Inquiry into the schizophrenia label is looking into whether we should use the term ‘schizophrenia’ at all

I haven’t read it, but this book – American Madness: the rise and fall of dementia praecox – looks v. interesting.  It charts how DP lost out to schizophrenia in the nosology arms race

Interview with writer Will Self part 2

Monday, April 16th, 2012

Will Self interview by Prof Femi Oyebode (part 1 with me found here) in November 2010

WS: I’ve been very interested in the psychiatric profession and though out my fiction and my nonfiction and have written on visions related to psychiatry, so in a way when it comes to reading to you I’m presented with an embarrassment of riches. So I’m going to confine myself to my latest book, available in all good bookshops at the seductive price of £17.99. No one, not even the most exalted mental health professionals would see this for a second as being in any way analogous to £18 but will see it as significantly cheaper. It’s called Walking to Hollywood and it’s a sort of fictionalized memoir which in itself arouses some interesting questions about relationships between mental states and what philosophers call ontology, the nature of reality in a wider sense.

Just by way of an introduction to a couple of short readings, as it’s a fictionalized memoir and the ‘I’ in the fictionalized text and me are the same person.

(Reading – I’ve not transcribed this for copyright reasons, but extracts are legitimately  available here and here)

FO: Thank you very much for that Will. One of the intriguing things about that reading was how it is both fiction and autobiography, and I was wondering how far the fiction had in it ‘real life’.

WS: Well my grandfather was a relentless autodidactic who, whist working as civil servant gained eight degrees by studying during his daily train commute to London. He did write a thesis called ‘The Divine Indwelling’, which was an attempt to reconcile Existentialism, Christianity and Western science. That’s true.

I was prescribed those drugs; I did decide not to take them and tied a knot in the bag and threw them on top of a shelf. Indeed they were up there until I wrote that passage, when I finally got them down and disposed of them in a suitably irresponsible fashion.

FO: And Dr Busner?

WS: Dr Busner doesn’t really exist but is a character who exists in a number of my different narratives. He’s a consultant psychiatrist in a place called Health hospital which doesn’t exist either, although it’s quite easy to guess which hospital it might be modelled on. He doesn’t exist, but he acquires an existence by being present in different narratives appearing in my novels and short stories; I think that gives him perhaps a greater level of reality than a lot of fictional characters.

He’s based to some parts on R D Laing and the anti-psychiatrists of the 1960s. I was very influenced by books like Thomas Szasz’s the Myth of mental illness and Laing’s The Divided Self and most specifically by Szasz’s concept of the ‘therapeutic state’ and the idea of the psychiatric profession being responsible in our culture for policing behaviour in ways that perhaps neither the profession itself nor the wider society are actively aware of. He’s also based in some other aspects on the neurologist Oliver Sacks as well as people I’ve known over the years. Busner is a way for me to examine in fictional terms the role of the psychiatrist in our culture and what the psychiatrist represents. He’s described in one of my books as a kind of almost religious figure, almost like some kind of shaman or witch doctor.

FO: Can I draw you out a little bit about the question of characterisation. One of the things I find wonderful in your writing is the way in which you create these very strong characters. They could easily be in plays and I was thinking of Ibsen, for example, saying that when he is writing a play, he thinks during the first draft that he knows his characters like he might someone he has met once. When he writes the second draft he feels like he’s spent a month with them on his farm. Then when he writes the third draft, he thinks that he knows him as well as he knows his friends.

With characters like Shiva Mukti and Zac Busner, how do you create them? Because they do feel real. I know they are fiction, but there is a sense in which you feel that they are real.

WS: Shiva Mukti is a protagonist in a novella I wrote called Dr Mukti. The second protagonist in that novella is Dr Zac Busner and these two psychiatrists find themselves engaged in a duel – or at any rate Shiva Mukti thinks they are engaged in a duel – where they attack each other using psychotic patients as weapons, whom they send to each other for diagnoses, with the knowledge that having appended falsities in the case notes, their colleague may well make a mistake in terms of diagnosis and then reap the consequences which could potentially be fatal. It’s in many ways an engaging – or non-engaging – fantasia, but it’s based in reality like of a lot of what I write.

It’s interesting that you should pick on Shiva Mukti as a character. I don’t think of myself as a writer of character in particular at all. I would say that he’s probably one of the few characters I’ve created who has a more or less conventional depth psychology. I don’t know how many of you here today read much fiction. There are certain assumptions in naturalistic fiction about how and what you can convey in prose narrative of individual psychology.

What you said Femi about Ibsen, though he’s a playwright, applies to what conventional writers of fiction at times do. I’m not a naturalisitic writer and the reason I think that most people, if they read a lot of fiction, find characters in fiction believable as people is because they have constructed their own persona from reading fiction. In other words I think it’s a self-fulfilling prophecy. However in that particular novella I needed a character to contrast with Zac Busner. We never really know Dr Busner in Dr Mukti except through Shiva Mukti’s perception and it becomes clear, without giving too much away, that Shiva Mukti is himself mentally ill. I needed him to have that kind of naturalistic humanity in that way. And how did I construct the character? I think that all fictional characters are kind of ‘us’. They are usually based on a number of people the writer knows, their characteristics cut up and sewn together into some sort of Frankensteinian figure.

FO: There’s a theme in your work where psychiatrists, I suppose through their patients, themselves have pathology in them. That’s quite an interesting way in which you’ve got the patients in the asylum but you’ve also created the similar problems in the psychiatrists I was wondering why you were doing that?

WS: Well, in terms of iatrogenic disease, psychiatry is well ahead of the pack. The phrase in the pharmaceutical industry I believe now is ‘conditioned branding’ whereby a certain psychiatric pathology is devised or defined in order to provide a market for a certain neuropharmaceutical product. That is an iatrogenic disease. This is going on all the time and it goes on more in psychiatry than arguably in any other branch of medicine. So in seeking to establish that the psychiatrists themselves are afflicted with a pathology I’m making a comment on the iatrogenic propensity of psychiatry itself. Primarily my use of psychiatry is supposed to establish what psychiatry is doing in our society which neither its practitioners nor the wider society may be aware of and then to satirise it.

Question from floor: You mentioned about Zac Busner that he can be a tool for exploring the role of psychiatrists in society today and their ‘policing’ of social behaviour, but what should be the role of psychiatrists be in society today?

WS: That’s a very interesting question. I started off at some point saying that when I was a young man I was very much influenced by RD Laing’s writings and very much viewed psychosis as a radical lifestyle choice. And then as a result of that I put my money where my mouth was and found myself living in my own version of Laing’s Kingsley Hall with a group of psychotic outpatients in a mental hospital and rapidly reached the understanding that in fact psychosis is not a lifestyle choice at all, it’s a mental illness. So don’t get me wrong. I’m not one of those people who say that there shouldn’t be psychiatrists or that mental illness doesn’t exist, I know it does. I think the job of psychiatrists is to treat mental illness, pure and simple. Far be it from me to tell you your job in its practical application but I think that the criteria used and the way in which we understand what mental illness is is in question. And nor do I think that the psychiatric profession necessarily are the worst offenders of the problem we have in understanding what mental illness is. If you’ll forgive the extended pun, there’s a folie à deux between the wider society and the psychiatric profession in regard to that and that’s where the problem is and where I think the confusion sets in.

Let’s not forget that this is an evolving thing. In the 1950’s and 60’s there were 120 000 people in this country in total institutions in one kind or another. So we have changed in our attitudes and we continue to change our attitudes. I don’t want to demonize the psychiatric profession because in a way you get loaded with society’s dirty work. But put simply psychiatry’s job is to treat mental illness, nothing more and nothing less.

Question from floor: Critiques about medicalisation of normal life leave psychiatrists between a rock and hard place and in our culture. On the one hand we are criticized if we are paternalistic. On the other hand if we don’t attempt to define the diseases we treat then patients are given the ‘keys to the shop’, which also has its problems. Where do we draw the line?

WS: There have been some colossal howlers within living memory in your profession. There are many many thousands of people with extra-pyramidal side effects who were classed as catatonic schizophrenics and held in total institutions for many years. Nobody is responsible for that except for paternalistic psychiatrists.

You could argue that medical science had not advanced far enough for the diagnosis to be made, that’s not actually true. You could also argue that society wished for a total institution programme to exist. I’m not sure. Of course when you come to people who are, to use probably an expression that is outmoded in the profession, engaged in inadequate reality testing and to actually hand over to them the keys to their own sins on the face of it is an absolutely mad thing to be doing. But on the other hand I’m very concerned and have been concerned throughout my writing career with kinds of collusion that particularly affect who are placed in positions of professional expertise. I don’t think that the psychiatric profession is by any means unique in this but I do think that all professions need to be very alive to these tendencies. The tendencies to create forms of arcane knowledge that are not accessible to lay people and to hide behind that. In as much as I agree with you that there is a real difference of kind between serious mental illness and what could be regarded epiphenomenal forms of that: neuroses of various kinds. I think again there is an unconscious collusion between the profession and the wider society to allow the profession to police that boundary.

Question from floor: Medicine generally is responsible for some ‘real howlers’ in the past – and psychiatry as well – and will continue to do so to a large extent because of the relationship we have with society as doctors. One of the problems is that the brain should be an organ that gets diseased as well, it shouldn’t be protected but it’s not the liver and it’s not the kidneys, it’s who we are, it’s our very essence, it’s the human condition. We all find it a problem when it goes wrong and I think one of the bigger problems is that none of us, especially lay persons, are clear about what constitutes a mental illness and what constitutes the rough and tumble of normal life and we in a sense sup with the devil on that one because there are some psychiatrists who are willing to go down that route and profess to make comments about all sorts of human endeavours, activities and behaviours as if they’re psychiatric conditions. If you ask a cardiologist on something that’s got nothing about cardiology he’ll say ‘I can’t answer that as a professional, but I’ll answer it as a lay person’. But many psychiatrists are unwilling to do that and they medicalize all of human behaviour. My concern with psychiatry is around the areas of depravation of liberty and the perceptions of dangerousness which is primarily driven by the public and by commentators. Those are the areas that worry me because that determines how we work.

WS: Yes I would agree with where you paint the problem. Interestingly that’s another aspect of my psychiatrist Zac Busner; he’s a kind of media doctor. So that is exactly what I was satirizing. But it’s easy to understand as well why, that of all things psychiatry is seen to be the right profession to be doing that. Here you are, the people qualified in science but you’re treating not of the brain but of the mind, so you seem to represent the interface between the mechanistic, physical explanation of the world and whatever other meanings we wish to ascribe to our existence. So it’s very easy to understand that if one of your kind goes to the dark side it’s going to be that much more dangerous than it might be for a cardiologist or a podiatrist.

The other thing that I’ve been most concerned is about, and I’ve written about a lot in my fiction, is the impact of neuropharmacology. That concerns me a great deal. I don’t necessarily think – and I’m aware that I’m in a room full of psychiatrists and I’m not looking to make a swift exit out the back – that psychiatrists are the worst offenders in terms of what we described as ‘conditioned branding’, I actually think that the foot soldiers in that tendency are General Practitioners. And also what can you do when we have now reached the situation where the public collectively now know how to approach a dispensing doctor in such a way as to solicit an anxiolytic medication of some kind or another? I think we need to maintain a very critical view of all of this, and I think the profession in and of itself, and maybe goaded on by people like me, needs to be involved in a continuous and evolving discourse.

Question from floor: I think that it’s interesting the shift you made from writing fiction where you can be in control of your characters and be quite sheltered to then a fictionized memoir in which you leave yourself open and reveal a lot about yourself, but still retain the power to change whatever elements you like because it’s fictionalized. I just wondered what made you choose to do that? And I think it’s interesting given what Ruby Wax was saying before, talking about stigma, and making herself a poster person for mental illness. She said that she didn’t volunteer to be a face for Time for Change.

WS: What pathology does Ruby Wax cleave to? I only ask this as a point of information.

Floor: She was talking about her experience of bipolar disorder.

WS: Bipolar, that’s a corker isn’t it? There was a very good article in the London Review of books’ last issue on bipolar disorder. I mean again following on from what you were saying: this idea that there are, these quite dangerous people from the profession who adopt this role of medicalizing conditions that are just part of the hurley-burley of life. The celebrity authorities are equally dangerous for almost exactly the same reason. One thinks immediately of Alastair Campbell as I do – on waking – with the feeling of deep and numbing rage – or indeed Stephen Fry who can make me feel quite nauseous at almost any hour of the day. People who witting – or not – are doing exactly the same thing, they are placing expectations on you as a profession that you will be able to provide some sort of pill for every ill.

I’m not really answering your question because the answer is inadvertent in a sense. I wanted to write about various things and I found I couldn’t write about them within the established rubric of factuality. So, like a lot of things I write it was a form as on-the-job experimentation using my own psyche as the test bed. So I didn’t set out to reveal or not reveal particular things about myself. It’s actually on the public record anyway some of the things I’ve said about my own history of either what you might call ‘mental illness’ or of being diagnosed with mental illness. I’ve written about it and spoken about it before, so that wasn’t why I choose to use myself as the protagonist.

There’s a connection with a film I recently saw called Hancock. It’s about a superhero living in modern LA, and there were some scenes in that, as there are in quite a lot of contemporary Hollywood films, I thought were psychotic, that they were like people’s experience of psychosis must be. They had a sense of great believability and you could suspend disbelief in them but in fact what was happening in these scenes was suspension of all kinds of natural laws and so on and so forth. So it was an interesting exercise to write from a protagonist’s point of view about experiencing that. So as mental health professionals next time you see one of these extravagant CGI sequences in a Hollywood blockbuster try and think about it as really happening and what that might be like and then snapping back to reality. That might be quite a good way into the mental states of some of your patients. And of course that’s something one can only do fictionally.

FO: I wanted to finish with one or two words. Will Self’s writing is absolutely incredible and I think we ended on what is quite so important about his writing from a psychiatrist’s point of view. Of course he’s commenting on the world we inhabit, on a day to day basis, as psychiatrists and commenting on the hospital environment, commenting on people’s emotional experiences and commenting how people might depart from their sense of reality that we all take for granted.

But he does something else we haven’t talked about today which is that he bends language so that he to express the world that he’s created for that particular story, or for that particular novel. And of course as psychiatrists we also have a day to day contact with patients who use language in an awkward, novel, original kind of a way. So I think there’s a lot to learn from what Will Self does and it’s been marvelous listening to him talk with his exposition and also for him to challenge us in his usual subtle way.

“One in four”: the anatomy of a statistic

Friday, February 24th, 2012

(From a bus stop Archway – if you look carefully you can see the reflection of me and my bike)

This written by me and Jamie Horder published this week in the BMJ

Despite a lack of supporting evidence, the claim that one in four people will have a mental health problem at some point in their lives is a popular one. Where does this figure come from, and why does it persist, ask Stephen Ginn and Jamie Horder


“It’s time to talk” is a campaign currently being promoted by Time to Change, a charity whose aim is to change attitudes to people with mental ill health. On the charity’s website a banner tells us:

“1 in 4 of us will experience a mental health problem at some point in our lives, but we still don’t talk about it. What are we afraid of?”

This “one in four” figure has also appeared in government speeches(1) and NHS publications.(2) It is the name of a short film and the title of a mental health magazine.

Yet it is not always clear to what the figure refers. Time to Change seems to be referring to lifetime prevalence, while a 2010 advertising campaign by Islington Primary Care Trust stated, “One in four people will experience mental health problems each year.” A statement on the Royal College of Psychiatrists’ website reads, “One in four people has a mental health problem,” implying point prevalence.

The evidence base

The number’s origin is unclear. When one of us (SG) contacted a selection of organisations that use “one in four” in their literature, they cited a number of different sources. The earliest seems to be a 2001 World Health Organization report, Mental Health: New Understanding New Hope, which stated, “During their entire lifetime, more than 25% of individuals develop one or more mental or behavioural disorders (Regier et al 1988; Wells et al 1989; Almeida-Filho et al 1997).”(3)

However, none of the three papers cited contains an estimate of 25% lifetime risk. One did not report on lifetime prevalence at all,(4) and the two that did provide a lifetime figure of rather more than 25% (66% for “all [mental] disorders” in New Zealand and 31-51% in Brazil).(5, 6)

Lifetime prevalence of mental disorder seems never to have been estimated in the United Kingdom. In 2007 the annual psychiatric morbidity survey (APMS) estimated a UK prevalence of 23% in the past week.(7) In numerous other countries lifetime estimates are reported as being in the region of 50%.(8)

We are unaware of any evidence that straightforwardly supports a UK lifetime prevalence of 25%. The APMS past week prevalence most robustly supports one in four as a statement of the UK’s 12 month prevalence,(7) but in this case the UK lifetime prevalence would be expected to be much higher.

Counting cases

A 2005 meta-analysis estimated a yearly prevalence of 27% for the European Union (including the UK),(9) but a 2010 update of this work revised this to 38% a year,10 as a result of including more disorders such as insomnia and attention-deficit/hyperactivity disorder. This highlights the fact that over the years the consensus on what constitutes mental disorder has often changed.

Different population surveys adopt different definitions, and there is no agreement about whether to treat, for example, a phobia such as arachnophobia as “mental illness.” No major study has considered nicotine dependence or male erectile disorder in their calculations, despite these disorders being widespread and listed in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Nicotine dependence is perhaps responsible for more deaths than any other psychiatric disorder.

Furthermore, surveys such as the APMS establish diagnosis in a very different way from how it is discerned clinically. In the clinic, a doctor works from a patient’s presenting complaint, through their history, and on to mental state examination. By contrast the APMS recruited a large representative sample and used a structured diagnostic interview to screen each participant for a range of disorders. Structured interviews involve a patient answering a fixed series of questions taken from published criteria.

Systematic checking of a symptom inventory in this way lacks the benefit of clinical judgment and simultaneously creates a risk of both over-diagnosis and under-diagnosis. Taken literally, the DSM-IV criteria for major depressive disorder would deem many people depressed after bereavement or the end of a relationship. Conversely, a patient’s imperfect recall or lack of insight into their own psychopathology could lead to under-reporting.

The popularity of “one in four”

Despite these drawbacks, why has this figure proved so popular? We would like to suggest some reasons.

Demonstrating relevance: For journalists, quoting a high prevalence of mental disorder helps illustrate the newsworthiness of stories about mental health.

Fighting stigma: The one in four statistic has been used extensively by charities to advocate the interests of people with mental illness. Much of their recent campaigning has focused on attempting to combat stigma and prejudice through providing a more inclusive vision of mental disorder—one in which it is nothing unusual and a threat to everyone.

Not too big, not too small: If the intent is to raise awareness of the burden of mental illness, why do organisations not cite the even higher, and better supported, figures of one in three or one in two lifetime prevalence? We suggest that one in four is high enough to gain people’s attention but not so high that it provokes incredulity, as claims that over 50% of people have had a mental illness indeed have.

Conclusion

The one in four figure for mental illness prevalence is widely quoted, related variously to lifetime, yearly, or point prevalence. The evidence indicates that it is best supported as an estimate of yearly prevalence. However, estimates of the population prevalence of mental disorder should be approached with caution, as the methods used often have shortcomings. It is important that people know that mental illness is common and that treatment of mental disorder is essential, but it is not clear that championing a poorly supported prevalence figure is the way to achieve this.

References

  1. Johnson A. Psychological therapies in the NHS: science, practice and policy (speech to the New Savoy Partnership Annual Conference). Department of Health, 2008.
  2. Tavistock and Portman NHS Foundation Trust. Mental health myths. 2011. www.tavistockandportman.nhs.uk/mentalhealth/myths.
  3. World Health Organization. Mental health: new understanding, new hope. WHO, 2001:23.
  4. Regier DA, Boyd JH, Burke JD Jr, Rae DS, Myers JK, Kramer M. One-month prevalence of mental disorders in the United States. Based on five epidemiologic catchment area sites. Arch Gen Psychiatry1988;45:977-86.
  5. Wells JE, Bushnell JA, Hornblow AR, Joyce PR, Oakley-Browne MA. Christchurch psychiatric epidemiology study, part I: methodology and lifetime prevalence for specific psychiatric disorders. Aust N Z J Psychiatry1989;23:315-26.
  6. Almeida-Filho, Mari Jde J, Coutinho E, França JF, Fernandes J, Andreoli SB, et al. Brazilian multicentric study of psychiatric morbidity: methodological features and prevalence estimates. Br J Psychiatry1997;171:524-9.
  7. Weich S, Brugha T, King M, McManus S, Bebbington P, Jenkins R, et al. Mental well-being and mental illness: findings from the adult psychiatric morbidity survey for England 2007. Br J Psychiatry2011;199:23-8.
  8. Kessler, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry2005;62:617-27.
  9. Wittchen HU, Jacobi F. Size and burden of mental disorders in Europe: a critical review and appraisal of 27 studies. Eur Neuropsychopharmacol2005;15:357-76.
  10. Wittchen HU, Jacobi F, Rehm J, Gustavsson A, Svensson M, Jönsson B, et al. The size and burden of mental disorders and other disorders of the brain in Europe 2010. Eur Neuropsychopharmacol2011;21:655-79.

Models of mental illness

Thursday, November 3rd, 2011

(Picture credit – taken with a tilt shift lens – looks like a model…)

It’s widely accepted that individuals can be disturbed or troubled of mind.  What is controversial is how we should understand this. 

Asides psychiatrists, many professional disciplines work and research in the field of mental disorder.  Each discipline approaches the subject from their own viewpoint, using their own conceptual model to explain what they find before them. 

Alas there is no single model that has complete explanatory power.  To fully understand an individual’s difficulties it is often necessary to borrow from several.  This would be the favoured approach from an eclectic practitioner.  In practice it’s easy to favour a pet model which most closely fits one’s world view and defend this against those supported by others. 

The on-going debate about the merits of drug treatments versus talking therapy can be viewed as a clash of models: biological versus psychodynamic/cognitive.

The disease or biological model

This model holds that any dysfunction that effects mental functioning can be regarded as ‘disease’ in a similar way to dysfunction that affects other parts of the body.

In the disease model, a disorder affecting mental functioning is assumed to be a consequence of physical and chemical changes which take place primarily in the brain.  Just like any other disease a mental disease can be recognised by specific and consistent signs, symptoms and test results.  These distinguish it from other diseases. 

Psychiatrists who adhere to the disease model are often referred to as ‘biological psychiatrists’ (as in ‘he’s very biological’).
With a biological approach comes a preference for physical treatment methods, primarily drugs, but also ECT. 

This model best applies to schizophrenia

The psychodynamic model

The central tenet of the psychodynamic model is that a patient’s feelings have lead to problematic thinking and behaviour.  These feelings may be unknown to the patient and have formed during critical times in their life, due to interpersonal relationships. 

These unknown (or unconscious) feelings are uncovered during therapy.  Therapy can take place over a large number of sessions and over a time period of a year and beyond. 

During therapy a relationship builds up between therapist and patient.  The emotions that the patient attaches to the therapist are collectively known as ‘transference’, and those the therapist attaches to the patient collectively as ‘counter transference’.  By understanding these feelings a patient may gain an understanding that they can take with them to future relationships. 
This model is applied broadly, but has limited applicability to the most severe mental disorders. 

The behavioural model

The behavioural model understands mental dysfunction in terms theory emerging from experimental psychology.

Symptoms, as understood by the behavioural model, are a patient’s behaviour.  This behaviour has come about by a process of learning, or conditioning.  Most learning is useful as it helps us to adapt to our environment, for example by learning new skills.  However some learning is maladaptive and behaviour therapy aims to reverse this learning (counter conditioning). 

This model best applies to phobias.

The cognitive model

The cognitive model understands mental disorder as being a result of errors or biases in thinking.  Our view of the world is determined by our thinking, and dysfunctional thinking can lead to mental disorder.  Therefore to correct mental disorder, what is necessary is a change in thinking. 

This model will be familiar to anyone who has trained or undergone cognitive behavioural therapy (CBT).  CBT aims to identify and correct ‘errors’ in thinking.  In this way, unlike psychodynamic therapy, it takes little interest in a patient’s past. 
This model is widely used, but classically applies to depression and anxiety.

The social model.

The social model regards social forces as the most important determinants of mental disorder.  The social model takes a broader view of psychiatric disorder than any other model.  It regards a patient’s environment and their behaviour as being intrinsically linked. 

In some ways it is like the psychodynamic model, which also sees patients as moulded by external events.  However whereas the psychodynamic model sees mental disorder as highly personalized and its determinants not immediately recognizable, the social model sees mental disorder as based on general theories of groups and caused by observable environmental factors. 

Example

For someone who develops persistent depression following the death of a close relative :

“This can be perceived in several ways by psychiatrists.  One sees the depression as a pathological event that is directly due to the biochemical changes occurring in the brain of someone who is predisposed to pathological depression through an accident of illness.  Another sees the depression as a reactivation of unresolved childhood conflicts over an early loss.  Another regards the depression as part of the normal mourning process that has got out of control because the person’s thoughts become fixed in a negative set which sees everything in the most pessimistic light.  Yet others conclude that the mourning response has been exaggerated primarily by society or see it as an abnormal form of learning which is no longer appropriate for the situation but is receiving encouragement from some quarter (positive reinforcement)”

From Models for mental disorder

“Happiness” and psychiatrists

Thursday, June 30th, 2011

There has been growing interest amongst social scientists in recent years in the ‘science of happiness’.  This has also found favour with politicians, and from April – via a ‘happiness index’ – the National Audit Office will seek to establish the key areas that matter most to British people’s wellbeing.  Should this approach take hold it threatens to redefine the role of government, which has traditionally directed much of its efforts towards the aim of promoting economic growth.

Listen to enthusiasts (Lord Layard or the ‘Action for happiness’ movement for instance) and one could be convinced.  Happiness (or ‘well-being’, the two words are often used synonymously) can be measured, and inferences can be drawn about what makes us happy or unhappy.  Individuals and governments can then be directed towards behaviour and policies which produce the greatest happiness and the least unhappiness.  As a result, overall, people are more content. 

What should psychiatrists make of this happiness agenda?  Even if they are not depressed, many of our patients are unhappy.  If we are in the business of reducing mental suffering then we could choose to enthusiastically promote actions that increase happiness.  This would be in the same way that a hepatologist might wish to endorse sensible drinking.

Happiness has a subjective nature and is a notoriously difficult thing to pin down.  What makes one person happy does not make everyone happy; indeed what makes one person happy may make another person unhappy – think of a child’s glee at tormenting a sibling.  These conceptual difficulties with happiness are not in themselves a reason not to try to increase happiness, but should at least inform us to proceed with caution. 

Is promoting subjective well-being anything but a personal matter?  A top-down approach may struggle to address the complexities at play.  One notes for instance that some types of happiness are ‘better’ than others.  Campaigners for happiness often observe that the ways in which we ostensibly seek pleasure – wanton consumption and recreational drugs to name but two – do not bring ‘real’ happiness. But can such a distinction actually be made? 

I also have more practical concerns.  Serious steps towards promoting happiness would require our politicians to change their priorities away from promoting consumerism and toward a more equable society.  These are actions they are likely to be unwilling to take.  The Action for Happiness campaign does talk about ‘actions to create a better society’.  Many of its recommendations for behaviour are laudable, but they are also bland and do not challenge the status quo.  The revolution offered is meek.  As an organising principle the happiness agenda has no direction, no meaning, and no mention of duty or sacrifice. 

Psychiatrists do need to be aware of how ‘happiness’ is rising up the agenda.  With happiness as a focus we may find that our patients increasingly feel that if they are not ‘happy’ they are failing.  One of our roles can be to promote perspective and to remind them that even generally happy lives are still liable to humiliations, disappointments and tragedies.  In fact looking on the bright side, unhappiness can be useful as it can spur us on towards changing our lives. 

Action for happiness’ Ten keys to happier living

1.    Do things for others
2.    Connect with people
3.    Take care of your body
4.    Notice the world around you
5.    New learning new things
6.    Have goals to look forward to
7.    Find ways to bounce back
8.    Take a positive approach
9.    Be comfortable with who you are
10.  Be part of something bigger

This article will shortly be published in the June RCPsych London Division Newsletter

Risk

Wednesday, October 13th, 2010

A history of ‘risk’

Most commentators link the emergence of the word and concept of ‘risk’ with maritime activity during the pre-modern period.  The early meaning referred to the perils of the natural world that could befall a voyage and therefore excluded the idea of human fault and responsibility. 

This way of considering risk changed with modernity and was influenced by the notion, emerging from the Enlightenment, that the key to human progress and social order is an objective knowledge of the world through scientific exploration and rational thinking.  This assumes that the social and natural worlds follow laws that may be measured, calculated and therefore predicted. 

The development of the mathematics of probability further promoted the idea that rationalized counting and ordering could bring disorder under control.  In this way ill defined hazards that previously affected only the individual became well defined ‘risks’ that could be statistically described and, theoretically at least, prevented.

Today the sociologists Beck and Giddens talk about the ‘risk society’.  They refer to a society that is obsessed with risk and debates on how risk should be managed at both the institutional and personal levels.  They also refer to the way that society organises itself to deal with these hazards which are caused by modernity itself.

Risk and psychiatry

The Lunatic Asylums Act 1845 made it mandatory for each borough and county to provide, at public expense, adequate asylum accommodation for its pauper lunatic population.  This lead to an asylum building programme and to an increase in the psychiatric inpatient population.  The peak of the asylum population was in the mid-1950s, after which this time asylums began to be closed and the overall number of inpatient beds reduced. 

One of the factors behind asylum closures was the recognition of the potential harm caused by psychiatric hospitalization following a number of scandals that had uncovered mistreatment of patients.  The policy of community care for psychiatric patients slowly emerged but with this the focus of concern also shifted from the restrictive nature of institutional care towards the seeming lack of control over mentally disordered patients in the community. 

Initially disquiet was about the potential for subsequent homelessness in discharged patients.  Since there was (and remains) a high level of mental illness amongst homeless people it was concluded that patients were being discharged ‘onto the street’.  This was not substantiated by research and focus then shifted to public safety due to psychiatric patients.  The murder of Jonathan Zito by Christopher Clunis in 1992 was particularly pivotal as it lead to the formation of the Zito Trust, an influential organisation that campaigned to improve community care. 

Since 1994 health authorities have been obliged to hold an independent inquiry in cases of homicide committed by those who have been in contact with psychiatric services.  And although the overall number of psychiatric beds has reduced, the number of compulsory and overall admissions has increased.  The emergence of the concept of ‘dangerous and severe personality disorder’ was criticized as representing a sociopolitical rather than psychiatric rationale for justifying psychiatric detention. 

Consideration of the quantification and prediction of the risk posed by patients has become a dominant force in the practice of clinical psychiatry and a public expectation has developed that mental health services should exert some influence over the individuals under their care.  Whilst psychiatrists do perform a protective role both towards their patients and towards the public, there is a media and political expectation that serious incidents are totally preventable.  This focus on mental health services on the prevention of untoward events means that other contributing factors are excluded. 

Although firmly entrenched in practice, it is not a given that psychiatrists should be responsible for the behaviour of their patients.  This is a situation unique in medicine, and places unhelpful restrictions on the therapeutic relationship as doctors are obliged to be responsible for the involuntary detention of patients whom they treat. 

Defensive and over cautious practice carried its own risks and does not lead to creative thinking.  Our focus on ‘risk’ we run the risk of following procedures that are more for the purpose of protecting staff than helping patients.

Links:

Risk (Key ideas) by Deborah Lupton
Risk society on Wikipedia
Challenging risk: a critique of defensive practice
BBC Radio 4 Thinking Allowed: Managment of risk in everyday life
‘Dangerous and severe personality disorder’: a psychiatric manifestation of the risk society

Photo credit
 

The Rosenhan experiment examined

Wednesday, September 1st, 2010

The ‘Rosenhan experiment’ is a well known experiment examining the validity of psychiatric diagnosis.  It was published in 1975 by David Rosenhan in a paper entitled ‘On being sane in insane places’

The study consisted of two parts.  The first involved ‘pseudopatients’ – people who had never had symptoms of serious mental disorder – who, as part of the study, briefly reported auditory hallucinations in order to gain admission to psychiatric hospitals across the United States. 

After admission, the pseudopatients no longer reported hallucinations and behaved as they ‘normally’ would.  Despite this many were confined as inpatients for substantial periods of time and all were discharged with the diagnosis of a psychiatric disorder. 

For the second part of the experiment staff at a teaching hospital, whose staff had learned of Rosenhan’s above results, were informed that one or more pseudopatients would attempt to be admitted to their hospital over an ensuing three month period.  Many patients were subsequently identified as likely pseudopatients but in fact no pseudopatient had been sent. 

‘On being sane…’ also examines, though the experience of the pseudopatients, the patient experience of psychiatric inpatient wards.  This part of the paper is discussed often only in passing.

Rosenhan’s conclusion was stark:  A psychiatric diagnosis is more a function of the situation in which the observer finds a patient and reveals little about a patient themselves. 

“It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals“

Despite being over thirty years old the Rosenhan experiment remains well known and is often cited.  Accounts of the experiment are widespread on the internet, but critiques are rarer and many people accept the study’s conclusions at face value. 

This was an audacious experiment and the subsequent paper had an extremely good title, but was Rosenhan justified in his conclusion?  Anthony Clare, amongst others, wrote that Rosenhan was ‘theorising in the absence of sufficient data’.  But if Rosenhan was correct then his experiment remains extremely important; as if diagnoses are in ‘the mind of the observer’ and do not reflect a quality inherent a patient, they are of little use. 

If you wish to read the original paper it can be found here.  Spitzer’s 1975 critique is available here (for a fee).  Davis’s critique here.  Clare’s ‘Psychiatry in dissent’ is available in preview here.

Circumstances of diagnosis and the detecting of sanity.

In the experiment eight pseudopatients presented at psychiatric hospitals complaining of hearing a voice.  Asked what the voices said, they replied that the voices were often unclear, but as far as they could tell, said “empty,” “hollow,” and “thud.”  Beyond alleging this symptom, and falsifying their names and vocations, no other falsehoods were told.  Upon admission to the ward the pseudopatients are reported to have ceased to claim symptoms and behaved as they ‘normally’ would. 

Length of hospitalization was an average of 19 days during which time no pseudopatients were identified as fraudulent. All pseudopatients except one (diagnosed with bipolar disorder) were discharged with a diagnosis of ‘schizophrenia in remission’.  In light of this Rosenhan regards there to have been ‘uniform failure to recognise sanity’.  Rosenhan refused to identify the hospitals used on the grounds of his concern for confidentiality.  This is laudable in some respects, but it makes it impossible for anyone at the hospitals in question to corroborate or refute this account of how the pseudopatients acted or were perceived. 

It is a difficulty that Rosenhan seeks to answer whether patients can be identified as ‘sane’ or ‘insane’, whilst psychiatrists, whose practice he wishes to scrutinize, do not make such distinctions in their practice but instead aim to identify and treat what they view as psychiatric disorders.  This objection aside, and working within this terminology, in his 1975 critique Spitzer identifies three possible meanings for ‘detecting of sanity’. 

  1. Recognition, when he is first seen, that the pseudopatient is feigning insanity as he attempts to gain admission to the hospital. This would be detecting sanity in a sane person simulating insanity.
  2. Recognition, after having observed him acting normally during his hospitalization, that the pseudopatient was initially feigning insanity. This would be detecting that the currently sane person never was insane.
  3. Recognition, during hospitalization, that the pseudopatient, though initially appearing to be ‘insane’ was no longer showing signs of psychiatric disturbance.

Only the first two involve identifying a pseudopatient as a fraud and Spitzer feels that it is these that Rosenhan implies are all that are relevant to the central research question.  He disagrees, writing that when the third definition of detecting of sanity is considered Rosenhan’s conclusions cannot be sustained. 

This assertion hinges on Rosenhan’s report that all the pseudopatients were diagnosed as being ‘in remission’, that is recognised as being, currently, without signs of mental disorder or ‘sane’.  By this view the data as reported by Rosenhan contradicts Rosenhan’s own conclusion.  Spitzer also writes that ‘schizophrenia in remission’ was a diagnosis rarely used by psychiatrists at the time of the experiment, and as such this indicates that the diagnoses given were a function of the patients’ behaviours and not simply of the environment in which they were made. 

Should a psychiatrist be able to able to detect that a patient is a fraud?  That is, should a psychiatrist be able to detect that, after observing a patient acting normally, that they were initially feigning insanity?  Rosenhan reports that this possibility was considered by the pseudopatients’ fellow patients but by no clinical staff:

“It was quite common for the patients to “detect” the pseudopatient’s sanity.  During the first three hospitalizations, when accurate counts were kept, 35 of a total of 118 patients on the admissions ward voiced their suspicions, some vigorously.  “You’re not crazy.  You’re a journalist, or a professor (referring to the continual note-taking).  You’re checking up on the hospital.” …. The fact that the patients often recognized normality when staff did not raises important questions.”

Rosenhan reports that the psychiatrists did not spend much time with the pseudopatients.  Other patients of course had ample time to formulate their own theories.  Whilst the medical staff’s lack of engagement with the pseudopatients is regrettable, it does point towards poor clinical skills rather than an indictment of psychiatric classification.  Clare again:

“Rosenhan and those many critics of psychiatry who have greeted his paper with enthusiasm seem in fact to be saying that, since the doctors did not appear to have the faintest idea as to what constitutes the operational concept of ‘schizophrenia’ and yet applied it with haste to people showing virtually no signs or symptoms whatsoever, the whole diagnostic approach should be scrapped!”

Rosenhan later wrote that he considered the patients apparent insight over that of the psychiatrists as due to the ‘experimenter effect’ or ‘expectation bias’.  The professionals expected to see a patient with a mental illness, so they looked for reasons to believe it, and eventually they convinced themselves that the pseudopatients were actually suffering from schizophrenia.

People do sometimes simulate mental illness for their own ends and this is a genuine diagnostic problem.  It is a situation not unique to psychiatry and how easily a disorder psychiatric or otherwise can be feigned tells us little about the worth of the psychiatric classification system.  Kety has something to say on this. 

“If I were to drink a quart of blood and, concealing what I had done, come to the emergency room of any hospital vomiting blood, the behavior of the staff would be quite predictable. If they labeled and treated me as having a bleeding peptic ulcer, I doubt that I could argue convincingly that medical science does not know how to diagnose that condition”

Clare makes a similar point using the example that the signs and symptoms of diabetes exist independently of whether they are correctly elicited or not. 

Rosenhan does consider in his paper that that a mental illness is a life sentence:

“A broken leg is something one recovers from, but mental illness allegedly endures forever”

If a disorder was known to be always chronic and unremitting, it would illogical not to question the original diagnosis if the patient was later found to be asymptomatic and it is at this that Rosenhan is presumably driving.  If the pseudopatients ‘recovered’ from an incurable illness whilst under the gaze of their psychiatrists and this did not alter the diagnosis then this would be an example, just as Rosenhan says, of the hospital environment influencing diagnostic decision making.  But in stating that mental illness is something that endures forever Rosenhan is taking a very selective view of the wide range of presentations all of which come under the umbrella of ‘schizophrenia’.  Schizophrenia has acute subtypes from which full recovery is possible and can also relapse and remit. 

As for the non-existent impostor experiment it is surprising that it was agreed to by the teaching hospital in question.  The poor reliability of psychiatric diagnoses means that the design of the experiment could only produce an outcome where actual patients were incorrectly identified as pseudopatients. 

Conditions on the ward

All of the pseudopatients took extensive notes.  Rosenhan makes much of this writing being "seen as an aspect of their pathological behaviour” on the grounds of the nursing entry that read “engages in writing behaviour”.  Spitzer argues that was routine for nursing staff to frequently and intentionally comment on non-pathological activities in which a patient engages to enable other staff members to have knowledge of how the patient spends his time.  As such, a comment about note taking is therefore inevitable and unremarkable.  He is struck by what he sees as Rosenhan’s actual failure to provide data demonstrating where normal hospital experiences were categorized as pathological. 

Rosenhan’s account of the conditions on the psychiatric wards is, for me, the most interesting part of the paper.  The staff and patients were strictly segregated, the professional staff and especially the psychiatrists being rarely seen and having little patient contact. 

“Staff and patients are strictly segregated. Staff have their own living space, including their dining facilities, bathrooms, and assembly places. The glassed quarters that contain the professional staff, which the pseudopatients came to call “the cage,” sit out on every dayroom. The staff emerge primarily for care-taking purposes – to give medication, to conduct therapy or group meeting, to instruct or reprimand a patient. Otherwise, staff keep to themselves, almost as if the disorder that afflicts their charges is somehow catching.”

This description bears resemblance to modern UK psychiatric wards.  Psychiatrists spend little time with the patients in their care and nurses are occupied for a great deal of their time sitting in a locked room doing paperwork.  The healthcare staff members with the most patient contact are the least qualified.  This is far from ideal, and a target for improvement, but it should be noted that within healthcare this distance between staff and patients is not restricted to psychiatric wards and the pressures on staff due to the number of patients in their care means that a more desirable personal service is something with which the NHS struggles in all its domains.

Rosenhan’s description of the depersonalising effect of a long stay on the wards is also powerful.  Despite their commitment to the experiment in which they are taking part, their wish to resist the powerlessness they experience leads several of them to jeopardise the study. 

“The patient is deprived of many of his legal rights by dint of his psychiatric commitment. He is shorn of credibility by virtue of his psychiatric label. His freedom of movement is restricted. He cannot initiate contact with the staff, but may only respond to such overtures as they make. Personal privacy is minimal. Patient quarters and possessions can be entered and examined by any staff member, for whatever reason. His personal history and anguish is available to any staff member (often including the “grey lady” and “candy striper” volunteer) who chooses to read his folder, regardless of their therapeutic relationship to him. His personal hygiene and waste evacuation are often monitored. The water closets have no doors.”

Attendants were reported to deliver verbal and occasional physical abuse to patients, something that can in no way be justified.  Rosenhan’s report of this leads to an interesting inconsistency.  Despite initial descriptions of abusive staff behaviour, in his conclusion Rosenhan describes the staff as overwhelmingly ‘committed and … uncommonly intelligent’.  Spitzer considers that this is because of Rosenhan does not wish to direct attention toward shortcomings of the staff, rather wishing to concentrate on diagnostic labels. 

Validity of diagnosis.

There are two issues here.  Where the psychiatrists who met his pseudopatients wrong to make a diagnosis of schizophrenia within the DSM II diagnostic framework? And are psychiatric diagnoses of use or should they be replaced by an alternative?

The ease with which the pseudopatients gained admission on the basis of what are reported to be mild symptoms was remarked upon by Anthony Clare in Psychiatry in Dissent. 

“It is a matter of some interest that a solitary complaint of a hallucinatory voice in the absence of any other unusual experience or personal discomfort should actually persuade certain American hospitals to open their doors.  Such is the current demand for a psychiatric bed within the National Health Service and the prevailing emphasis on treating patients outside hospitals and in the community that the average admitting doctor in Britain is likely to find himself under strict instructions to avoid admitting any patient who can see, speak, and do all of these things without bothering himself or others to an significant extent.  On suspects that, in Britain, Professor Rosenhan might well be advised to go home like a good man, get a decent night’s rest and come back again in the morning.” 

And many people have been critical of the way the pseudopatients were diagnosed with schizophrenia on the basis of hallucinations – a single symptom and not even essential for the diagnosis.  Anthony Clare again:

“…the doctors did not appear to have the faintest idea as to what constitutes the operational concept of ‘schizophrenia’ and yet applied it with haste to people showing virtually no signs or symptoms whatsoever…”

Spitzer remarks that the doctors should have been wary of making a diagnosis of schizophrenia in a previously unknown patient presenting without any history of insidious onset.  However he is more lenient toward the pseudopatients’ psychiatrists, writing that, given the information available, schizophrenia was the most reasonable diagnosis.  Davis and Weiner agree, respectively arguing from statistical and attribution theory standpoints that schizophrenia was the most likely diagnosis.  Rosenhan himself presents no differential diagnosis. 

Hunter takes exception to Rosenhan’s assertion that the pseudopatients acted ‘normally’ in the hospital:

“The pseudopatients did not behave normally in the hospital.  Had their behaviour been normal, they would have talked to the nurses’ station and said “Look, I am a normal person who tried to see if I could get into the hospital by behaving in a crazy way or saying crazy things.  It worked and I was admitted to the hospital but now I would like to be discharged from the hospital”.

We in fact learn very little about the diagnostic process beyond the initial presentations of the pseudopatients.  It should be noted that the pseudopatients would likely not have been, unlike Rosenhan’s assertion, admitted on the basis of their hallucinations solely.  Their presentation to hospital and request for admission may also have carried diagnostic weight as it suggested much greater distress.  However, whatever the fine detail, throughout their stay, the pseudopatients do not appear to have been assessed in detail.

The poor diagnostic skills and apparent lack of curiosity of the psychiatrists that the pseudopatients met is not an indictment of the classification per se, rather its application.   The Rosenhan paper offers no insight as to why psychiatric classification had developed into the shape that he found it in 1973. 

The purpose of a disease classification system is that it allows healthcare professionals to:

  • Communicate with each other about the subject of their concern
  • Avoid unacceptable variations in diagnostic practice
  • Predict their outcome disorders and suggest a treatment.
  • Conduct research

Amongst others Richard Bentall has made a career out of pointing out that psychiatric diagnosis is neither particularly valid nor reliable.  However in Spitzer’s view the historical precedent is that classification in medicine has always been preceded by clinicians using imperfect systems.  These have then improved on the basis of clinical and research experience.  The clinician is forced to do the best he/she can until something better comes along. 

In contrast to psychiatric disorders, the diagnosing of physical medical conditions is often portrayed as being solid and dependable.  This does not bear close inspection, as many medical conditions are at least as vaguely described as psychiatric disorders.  Although it is true that by-and-large a physical illnesses diagnosis rests on biological ‘facts’, the accompanying negative impact on person is the most important factor and this is highly subjective.  For instance we all have bacteria in the back of our throats, but do not consider ourselves to have an infection. 

In light of his experiment, rather than the syndromal classification system, Rosenhan would favour a classification system based on behaviours:

“It seems more useful … to limit our discussions to behaviours, the stimuli that provoke them, and their correlates”

Yet despite this early on in the paper he writes that “Anxiety and depression exist”, suggesting he favours an ad-hoc classification system at least. 

Conclusion

Rosenhan concludes:

“It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals. The hospital itself imposes a special environment in which the meaning of behavior can easily be misunderstood. The consequences to patients hospitalized in such an environment – the powerlessness, depersonalization, segregation, mortification, and self-labeling – seem undoubtedly counter-therapeutic.”

There are sufficient objections to the design of Rosenhan’s experiment – not least that his study consisted of only eight subjects- to doubt whether he is justified in writing his initial sentence.  Rosenhan’s observational study of conditions on psychiatric wards – to which the rest of the above paragraph alludes – still has relevance today and remains a note of caution for anyone who works in mental health.   

Links:

Mind changers 27 July 2009 Radio 4: The pseudopatient study

Scribd: On Being Sane in Insane Places A Critical Review

“Who wants to be a psychiatrist?” London Division academic day May 20 2010

Tuesday, June 8th, 2010

“Who wants to be a psychiatrist?” a London Division academic day, was an interesting day of talks, workshops and discussion examining reasons and solutions for the current problems of UK psychiatric recruitment. 

Prof Robert Howard, Dean of the Royal College of Psychiatrists, perhaps summed the current situation the most baldly.  "The recruitment crisis is the biggest challenge psychiatry faces".  Concerning, he also said that this is leading to an "unacceptable variation in quality amongst trainees and consultants".  

The situation does indeed appear to be dire.  This year the London Deanery received 250 applications for core training posts, down from 400 in previous years.  In the country as a whole the competition ratio of applicants to psychiatric training to jobs available is 1:1.  The result, as Michael Maier, head of the London Specialty School of Psychiatry put it, is that “psychiatry is a recruiting, not a selecting specialty”.  

Yet despite this, a recent Royal Society of Medicine study found that, alongside general practice, it was doctors who worked in psychiatry who found their lives the most satisfying.  The popularity of the study of psychology suggests that, amongst school leavers, a general lack of interest in the mind and its problems is not a problem; however again and again, upon leaving foundation jobs, doctors in training choose other specialities for a career.

 How could this have come about?  Prof Ania Korszun from Barts and the London suggested three culprits: psychiatry is seen as not ‘medical’ or ‘scientific’ enough; psychiatry recruitment suffers by association with the widespread popular stigma surrounding mental disorder; and medical students are discouraged from psychiatric careers by the negative views held by doctors working in other specialities with whom they spend much of their training.  

This relentless disparagement directed towards the ears of impressionable medical students appears to be particularly potent.  Dr Gianetta Rands, who talked about psychiatry as a part of foundation training, told us that the longer medical students spend in non-psychiatric specialities the less likely they are to choose a career in psychiatry.  The split between acute trusts and mental health trusts also means that psychiatrists are rarely present – be it at grand rounds or in the canteen – to put forward an alternative viewpoint.  It has been recognised that more psychiatry foundation year placements are required, especially in year one.  There are currently 500 placements over both years, but 2000 are needed.

Psychiatry undoubtedly has an image problem and Dr Peter Byrne, chairman of the Royal College of Psychiatry’s public education committee, presented a fascinating talk about the profile that psychiatrists have in the media and also our role as ‘evidence based public educators’.  An interesting insight was that whilst newspaper stories about physical health most often concerned the stereotype of ‘bad patient’, those concerning mental health focus on that of the ‘bad doctor’.  The recent BBC programme Mental: A history of the madhouse is an example of this.  Dr Byrne encouraged media engagement by psychiatrists and this theme was further examined in a workshop run by Dr Mark Salter, the event’s organiser.  Other workshops tackled writing skills, running student psychiatric societies and making a psychiatric documentary.  

Given the current situation, it might have been possible to find some of the messages of the day dispiriting.  Fortunately there were many moments of levity and an overall note of optimism.  Dr Chris Manning, a GP with experience of mental health services from both sides, praised psychiatrists and delivered an enthusiastic panegyric: “Minding the brain – the best job in the world”.  Dr Kate Stein, a foundation doctor, was equally enthusiastic when she told us about her plans for a psychiatric career.  The active role of medical students present as delegates was also welcome and encouraging.  

Of course it is not simply enough to identify a problem and there is a plan of action, in which – amongst others – Prof Howard, Dean of the College, is taking a special interest.  He wishes to raise the profile of psychiatry, especially with medical students, and to make medicine in general ‘more psychiatric’.

The day closed with a rabble rousing talk from Prof Simon Wessely “Why psychiatrists still need to be doctors”.  Prof Wessely convincingly argued that patients both want and need their mental health disorders to be treated by psychiatrists who are also doctors.  He spoke of the value of our ability to make a diagnosis and in our use of the biomedical model.  Psychiatrists’ ability to distinguish physical from psychiatric disease makes us indispensible to our physical medicine colleagues.  

Psychiatry has in fact never recruited as many UK trained doctors as it needs to fill its posts and in seeking to reverse this phenomenon we seek to overturn a historical precedent.  Improving the situation requires action on many fronts.  It particularly concerns me that we may be recruiting the wrong mix of students to medical school, as current science focused selection criteria favours technical knowledge over a candidate’s potential to flourish into the practitioner of holistic medicine that psychiatric practice requires and may preclude those who will eventually wish to take the path required by psychiatric practice.  A central message of “Who wants to be a psychiatrist?” is that we can all become involved in this debate and every day should regard ourselves as “walking, talking adverts for psychiatry”.

 

Also published in the June newsletter of the RCPsych London Division

 

Image credit Wikipedia

Pre-modern and modern early environments

Wednesday, March 24th, 2010

happy_family4

There are few people working in mental health who would argue that early childhood experience does not have a significant effect on one’s functioning in later life.  It’s easy to think up reasons why this should be so;  the architecture of the brain is under development during this time and  appears to be sensitive to impoverished or adverse circumstances. In his book The impact of inequality sociologist Richard Wilkinson discusses this point.  In pre-modern times he argues the distinct delineation between family and wider society did not exist and as a result the rearing atmosphere much more closely resembled that of later life.

Here’s what Wilkinson has to say (pg 266)

“The relationship between early experience and later social behaviour has often been seen as a process by which people’s relationship to societal authority is modelled on their childhood relationship to parental authority. This comes close to the idea that the function of early sensitivity is to use early social experience as an indicator of the nature of the social relationships we will have to deal with later in life: preparing us to be more or less confident, secure, aggressive, friendly, dependent, independent, trusting, or suspicious.

In modern societies, where children grow up in a nuclear family environment in which the quality of social relations might be quite different from those in the wider society, the results of early sensitivity can often look counterproductive. Many children are brought up amid great conflict and end up lacking the social skills, such as the ability to trust and cooperate, that are helpful during adult life in modern societies. Others grow up in a very secure and caring emotional atmosphere that leaves them ill-prepared for a world in which personal ambition, competition wealth, and position count for so much. But in the small groups in which our pre-human and prehistoric human ancestors lived, there was rarely such a sharp distinction between the separate social worlds of the nuclear family and the wider society as there is in modern societies. In the small foraging bands of our prehistory there was less scope for a mismatch between the social environment of childhood and adulthood. Rather than being brought up in separate nuclear families providing self-contained emotional environments distinct from the rest of society, children would have had direct exposure to the kind of community they would have to live in as adults.”

I don’t know much about this sort of thing, so if anyone knows any pertinent further reading, please leave a comment.

Reconcile, Prozac for dogs

Thursday, January 14th, 2010

prozacfordogs

Fluoxetine hydrochloride (3-(p-trifluoromethylphenoxy)-N-methyl-3-phenylpropylamine HCl) was first described in a scientific journal in 1974 as a selective serotonin -uptake inhibitor.  It was licenced for use in the treatment of depression in Belgium in 1986 and the USA in 1987.  Before its launch, to introduce it to the public, its manufacturer Eli Lilly funded eight million brochures (“Depression: what you need to know”) and 200 000 posters.  It would become one of the best selling pharmaceuticals of its age; by 1992 annual sales had reached US$1bn and by 1995 they had doubled to US$2bn.  In 1999 ‘Prozac’ – the trade name of fluoxetine – was named on of the ‘Products of the century’ by Fortune magazine.

The impact of the drug is hard to overstate, both in terms of the culture of the treatment of mental health disorders and in Western society at large.  Prior to the introduction of fluoxetine antidepressants had a reputation of having side effects and were cautiously prescribed as they were toxic in overdose.  Fluoxetine, on the other hand, was relatively benign and its introduction practically created a market in drugs for mood problems that could be safely prescribed to anyone who wanted them.

Other SSRIs followed in fluoxetine’s wake and the result has been an explosion in the diagnosing of depression and the prescribing of antidepressants.  This is all the more incredible when one considers that the revenue from antidepressants sales in 1975 was US$200million and the market was considered to be saturated.  ‘Prozac’ has since entered the popular lexicon and spawned its own sub-genre of literature.  Of these perhaps the best known is Prozac Nation, a bestselling – but in my view rather tedious – memoir of mental illness written by Elizabeth Wurtzel.

There have been some hiccups along the way.  Fluoxetine doesn’t have as few side effects as originally thought and, amongst those who are prescribed it, anorgasmia is quite common.  Nausea is often experienced initially and it can sometimes increase rather than reduce anxiety.  There have been concerns about other SSRI drugs, notably paroxetine, increasing suicide risk in young adults and in 1989, Joseph Wesbecker shot and killed eight people and injured 12 others in Kentucky before killing himself.  More recently a meta-analysis of 35 clinical trials of four antidepressants including fluoxetine concluded that the action of the medications was not clinical significance for any patient who was not severely depressed.

In 2007 Eli Lilly began to market fluoxetine for dogs under the name Reconcile.  In this incarnation it’s chewable, tastes like beef and is intended to treat something called ‘canine separation anxiety’.  This disorder amounts to a set of behaviours displayed by a dog when being left alone for too long.  A dog so affected may urinate in inappropriate places or chew furniture.  At the time of launch Lilly said that their research showed the up to 17% of dogs suffered from this behavioural disturbance.  Reconcile comes in a once a day chewable beef flavoured capsule.

I don’t know much about dogs, but other people seem to really like them.  I’ve been trying to think about what antidepressants for dogs tells us about ourselves.  Many people see dogs as part of their families and as such project onto them human attributes.  In their advertising Lilly avoid suggesting that Reconcile is a treatment for ‘canine depression’ but other articles written at the time of Reconcile’s launch are not so careful, here in the Times:

In Britain, research among pet-owners carried out for Sainsbury’s Bank in 2003 indicated that 632,000 dogs and cats had suffered from depression in the previous year.

Nearly three times as many pets had suffered from behavioural problems that which could be linked to depression, often resulting in the animal damaging its home or becoming moody or aggressive, according to the research.

The experience of a human disease such as depression involves complex human attributes such as thoughts, emotions and language.  To suggest that we can extend the concept of a specific human mental illnesses such as depression to dogs is to stretch the paradigm almost to breaking point and shows at once how loosely lay people apply the concept and how engrained widespread mental illness it is in everyday thinking.

Not that this association will worry the pharmaceutical companies.  Marketing antidepressants to dogs tacitly encourages dog owners to consider that their dogs have mental health conditions previously described in humans and this can only be good for sales.  Many pharmaceuticals develop mission creep whereby manufacturers endeavor to win them licences to allow their use to treat disorders distinct from those for which they were initially licenced.  Initially cleared for depression only, Fluoxetine is now used for anorexia and bulimia nervosa, obsessive compulsive disorder, panic disorder, premenstrual dysphoria and generalized anxiety disorder.  Viewed in this light, the launch of Reconcile, and fluoxetine’s crossing of the species barrier, is just part of the drugs product lifecycle.

This is not to say of course that fluoxetine doesn’t have its uses for animals.  In similarity to human subjects it may have impressive effects in some, moderate for others and no effect for a substantial number.  The emphasis is on the problem being in the dog and nowhere else,  just like in humans.

Links:

Animals can model psychiatric symptoms – Psychiatric news 2003
Pooches Pop Prozac to Treat Behavioral Problems
Prozac for your dog – Technology Review 2007
Eternal Sunshine – Observer May 2007

Emotions in animals – Wikipedia

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