In a lecture he gave in October 2008 Consultant Psychiatrist Dr Pat Bracken spoke strongly in favour of engagement of psychiatrists with consumers of mental health services.  He put it rather strongly actually:

‘If we say that we are working to develop user-centred services, training and research programmes then is it simply unethical to carry on as if the user movement did not exist’.

True to this insight, during my time as a psychiatric trainee I’ve had very little to do with user organisations, and they have therefore had little or no impact on my thinking or clinical practice*.  Just like Bracken says, for me they have not existed.  I am unable to say if this is the experience of all psychiatric trainees, or whether my training establishment is particularly indifferent, but I fear that I am not a unique case.  This must be a regrettable oversight.  Any sensible commercial entity (to which health services are becoming increasingly compared) listens to people who take the time to lodge a concern, knowing that if they do not, not only will their disgruntled customer brief others of their dissatisfaction, but also that they will be missing an opportunity to improve.  Within psychiatry, patients can make complaints and are sometimes asked to participate, but they act predominantly as advisors and expertise still resides with professionals.

Why, you might say, does this matter, and why should we single psychiatry out on this?  Perhaps we should not; I personally have seen from working in other medical specialties that psychiatry’s reluctance to engage with user groups is shared by other branches of medicine where there reside doctors who are very unwilling to engage with patients.  Many people return from a stay in a hospital medical or surgical ward with reports of offhand medical staff and have been so uninvolved in their care that they are barely aware of what has happened to them.  However, whilst psychiatric disorders resemble those of physical medicine in many ways, their formulation cannot easily be captured with the same lexicon and the interaction between psychiatrists and their patients is different.  You can, at least in theory treat, a patient’s coronary arteries without so much as exchanging the time of day with them.  A cardiologist who takes into account their patients’ community role and psychological well being may have more satisfied patients, but it is not their primary business.  Psychiatry, on the other hand, deals with thoughts, feelings and behaviours and is entirely cited in the social world.  Our outcomes are less mechanical and more nuanced than those of other parts of medicine.  We have power to define normality, to bestow stigmatizing labels and to take freedoms where we think fit**.

Psychiatric disease is often chronic, so a beneficial relationship between doctors and patients can only be to mutual benefit.  The fuller dialogue with patients and with user groups could lead us to devise services that genuinely engage people with mental health problems and inform our theories as to the nature and boundaries of psychiatric illness.  Such engagement will lead to responsibilities for our patients too; they, as well as the wider public need to be will to be understanding over the particular areas of difficulty in our practice, such as the use of the mental health act.  Recognition will also be needed of the fact that user groups do not speak with one voice and potentially have contradictory messages.

If you have worked with user groups in any capacity, please leave a comment below and tell of your experience.

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*Criticism of psychiatry from former users is, of course, not new.  In 1620 for instance the House of Lords received the ‘Petition of the Poor Distracted People in the House of Bedlam’ a complaint against the inhumane treatment of the Bedlam Asylum inmates.

** Not that I was there, but this transcript of a 2006 debate organised by the James Naylor Trust gives an idea of how upset some people are with psychiatrists.

Links:

Users’ movement and the challenge to psychiatrists – 1998 British Journal of Psychiatry

Addendum 5 July 2009

An interesting new publication by Pat Bracken and Phil Thomas on the user groups subject:

Beyond consultation: the challenge of working with user/survivor and carer groups

Common sense, nonsense and the new culture wars within psychiatry. Invited commentary on . . Beyond consultation

Authors’ response. Invited commentary on … Beyond consultation

Addendum 8 February 2010

Louise Pembroke has written for Openmind magazine about the relationship between psychiatrists and user groups and this is well worth a read.

Today I saw a female patient who has problems with use of multiple recreational drugs and alcohol.  I was the first psychiatrist that she has ever seen, she has however for the past two years been taking mirtazapine – an antidepressant – and this is prescribed by her hospital physician.  I almost never prescribe medications outside a psychiatric remit, however antidepressants are regularly prescribed by doctors whose area of expertise is not psychiatry.  GPs, ITUs and stroke wards often start their patients on these medications, and hospital physicians can also be very fond of them. 

The notion that there is a very common disease called ‘depression’ that can be addressed with the use of antidepressants is very prevalent in our society and although psychiatrists are ‘experts’ in it, the general abandon doctors show with antidepressant prescribing would suggest that its treatment is something on which all doctors have purchase and is not just the preserve of shrinks.  Yet can this be a good idea?  Many doctors’ insight into this area may be no more nuanced than that gleaned from their teaching at medical school, which from my recollection was simplistic and dogmatic.  Is low mood such a problem that we cannot but afford to have all doctors tackling the problem, or has the diagnosis gone feral and now needs to be tamed by expert tamers with chairs and whips?

In truth ‘depression’ is a very difficult thing to define and any doctor who says that they can reliably differentiate it from sadness is deluding themselves.  Our current best shots at a definition, or at least the one that most people agree on, are the vague aggregation of symptoms offered by DSM-IV and ICD-10.  These definitions are so broad however that they stand accused of pathologizing everyday sadness and have in part lead to the ridiculous notion, useful to some, that one in four of our population suffers from a disorder of their mental health. 

Standing aside whether widely used criteria are worthy, most doctors – including psychiatrists – pay little heed to operational criteria, and instead simply going to a doctor once or twice and stating that you’re ‘not quite yourself’ is most often sufficient for a prescription of antidepressants, which is a de facto diagnosis of depression.  It’s illuminating often to ask people who say that they are ‘depressed’ what meaning they attach to this; the selection of responses I have had range from those equating to mild dysphoria to those expressing unremitting misery.  It is also not unusual for a question about someone’s supposed mental distress to be framed in more concrete terms: ‘I’ve got a lot of trouble with my housing’ being an unfortunate favourite.  If the first doctor won’t provide you with antidepressants, the second surely will.  Doctors we feel they must help and antidepressants allow them to avoid admitting the boundaries of their efficacy.

Thus a patient who entered a consulting room simply sad, and often unfortunate, leaves anointed as ‘depressed’ having now a stigmatizing mental health disorder, and as this is a disease that sits independent from a life narrative, other avenues of relief which might have otherwise been explored are tacitly discouraged.  Now take the patient we started with.  Anyone standing next to you at a bus stop would tell you that if someone was already taking four psychoactive substances on a daily basis, then addressing these might be the first place to start.    This is what I’d have said to them, but in this rights-based society if I think this and a patient thinks differently, who’s right?

You might think then that this is a call for psychiatrists to act as gatekeepers to the prescribing of antidepressants.  Actually no, depression and antidepressants are one of the stories of our age, which means that they effect everybody and everyone has a part to play in their sensible use.  I’m not going to go so far as to say that there is no such thing as ‘mood disorder’ but in recently years we have all reimagined humans as intensely vulnerable beings, which inevitably means that people will view themselves in this light.  As the prominence of religion in European communities fades and market capitalism continues to propagate the excluded, medicine has become the place to turn for suffering of all kinds, social, physical and mental but this is no substitute for a supportive community.  They don’t teach us at medical school how to know the limits of our business, so we’ve been simply blundering on.  If all doctors can prescribe antidepressants, then all doctors should be part of the conversation about when we’ve gone too far and we should tell people that they’re a lot tougher than they think.

Also published on bmj.com blogs

One of the constant criticisms of psychiatry that it is heavily influenced by pharmaceutical companies in whose interest it is to encourage as many people as possible to take medication.  This is not to say that the benefit to society from the products of drugs companies has not been massive, but we should not, simply on this basis, assume that the interest of drug companies and the desires of doctors and patients are identical.  There are significant overlaps, but in one fundamental respect they come into conflict: pharmaceutical companies are answerable to their shareholders and thus above all need to maximize profit and their market share.   Put another way, human beings can survive without endless drugs to cure every possible ill but the companies that provide them cannot.

Psychiatric prescribing has been a particularly rich picking for pharmaceutical companies.  A large proportion of the global drugs spend is on psychoactive drug and in the UK between 1991 and 2001 prescriptions of antidepressants rose by 173%.  Partly off the back of this drug companies have become some of the most profitable organizations in the world.  In 2002 the combined profits for the ten drug companies ($35.9bn) in the Fortune 500 were more than the profits for the other 490 listed businesses put together ($33.7bn).  As their profits have increased, so have the amount governments and individuals have spent on their products.  In the UK the per-person government health care spending went up from $84 in 1960 (3.9%GDP) to $977 in 1980 (5.6%GDP) and reached $2160 in 2002 (7.7% GDP – all figures adjusted for inflation). The global spend on drugs increased from $20bn in 1972 to $500bn in 2004 (not adjusted for inflation).

Drugs are central to modern psychiatric practice and also to thinking about the nature and aetiology of mental disorders.  Arguably the primacy of concepts such as depression, social phobia, attention deficit and hyperactivity disorder owe much to pharmaceutical company intervention and psychiatric disorders provide opportunities for increasing product sales as, being poorly understood, they allow scope for expanding definitions of sickness to include more and more areas of social and personal difficulty not previously within the medical realm.  In addition the influence that the pharmaceutical industry wields has helped to create and reinforce a narrow biological approach to the explanation and treatment of mental disorders and has led to the exclusion of alternative explanatory paradigms. Furthermore the coercive function of psychiatry has also been strengthened by the continued promotion of the idea that that psychiatric disorders are akin to medical conditions and therefore amenable to technical solutions in the form of drugs the benefits of which we have a duty to impose.

Pharmaceutical companies spend a vast amount of money on marketing, an activity which is often aimed at doctors, on whom they must rely in large part for the distribution of their products.  Sponsorship is given to academic meetings providing access to the leading doctors of the future.  Although a representative’s gifts may be relatively small, even ones of negligible value can influence the behavior of the recipient in ways the recipient does not always realize.  There is also disquiet about various aspects of research and the licensing process.  Drug companies have repeatedly been shown to bury unflattering data.  Even drug trials can be considered as a form of marketing as they introduce physicians to drugs early.

Any invective on this subject should not of course just be levelled at psychiatrists, as it effects all branches of medicine but psychiatry has arguably been one of the most vulnerable specialties.  We are rapidly becoming, or indeed have become, a society that seeks a ‘pill for every ill’ and one that looks for simplistic, technical solutions to complex social problems. This helps to divert attention away from the profound social and political changes that have occurred during the last few decades. But for our part as psychiatrists and doctors we should, whilst recognizing the contribution that pharmaceutical companies make, seek not to collude with practices that are against the best interests of patients and of the wider society.

For further information on this subject the following are excellent:

Is Psychiatry for sale? – the astute reader will see that I’ve pinched some of her arguments.  It’s a short closely argued polemic.  But be warned – I once presented it in a journal club and found few supporters.

Big Pharma by Jackie Law.  An entire book on this subject.  Here she talks about it on R4’s Start the Week.  Here’s her blog

Bad Science by Ben Goldacre.  Everyone’s favourite exposer of folly has a chapter on this in his book.  I note with some envy that it’s the 13th best seller on Amazon.  I’d be lucky to get 13 comments on this blog in a month.  One can but dream….

No free lunch

There was a page advert in the Metro this week for a three days seminar with TV hypnotist Paul McKenna and pals which promised to ‘Change your life in three days’. 

In just 3 days, you will learn quick and lasting techniques to change your life, allowing you to:

Let go of your old emotional baggage
Have supreme self-confidence
Move past the obstacles to change
Supercharge your creativity
Deal with the past, once and for all
Become the person you’ve always wanted to be

If these claims could be substantiated, then this is pretty impressive work.  As someone who tries to address at least some of these problems with my patients on a daily basis, for me changing someone’s life permanently in three days would be nothing short of a miracle.  Is the self help industry really helping people or merely offering over simplified solutions to complicated personal and social problems?

The wise woman in the cave has been providing guidance since the beginning of time, but the pioneer of the modern self help movement was Dale Carnegie who published his book How to win friends and influence people in 1936.  It sold 15 million copies and continues to sell in an updated version today.  The industry it spawned is estimated to be worth $11bn.  These riches are not surprising; in a world where dissatisfaction is rife and those without personal contentment or possessions are failures, the best self-help materials appear to make the keys to a successful life appear within reach and the world deliciously simple.  ‘Self-help’ and the reward it promises therefore represent an undoubtedly attractive proposition.

Closer scrutiny reveals a more mixed picture.  In order to promote their product, the marketing for self help materials must necessarily engender or at least encourage personal deficit within potential clients which their product then promises to satisfy.  Not only is this (like most advertising) socially corrosive, but represents a circular proposition.  Furthermore the self help industry is the product of, but also fans the flames of, the West’s culture of individualism.  In this way they work so as to discourage people from acting as part of collective movements to solve their problems but to see them as individually based.  Attention and scrutiny is thereby attracted away from gross social inequalities and the myth promoted that health and wealth are largely self generated.

The initial and perhaps laudible aim that one should reach one’s full potential be has been replaced by a continuing demand that maximize oneself as ‘human capital’.  Self help can be considered as colluding in a cultural trap cultural trap whereby people are in endless cycles of self-invention and overwork as they struggle to stay ahead of the rapidly restructuring economic order.  The tacit assumption that people need help, until proven otherwise, is also troubling and can only exacerbate our burgeoning culture of victimization.

In terms of content self-help can be seen as equally wanting and has a tendency to present ancient clichés as revolutionary new strategies.  The majority of the wisdom self help books provide is actually repackaged common sense and platitudes.  This repackaging is necessary as any author is unable to lay claim to ideas that might be considered common property and with ownership in mind therefore seeks sophistication via the appearance of scientific method and intellectual rigor.  Anthony Robbins has, for instance, called one of his most successful books Unlimited power: the new science of personal relations.  As well as the message, the medium is also vital as with relatively little insight to impart, a theatrics will help (just like a brightly coloured sugar pill acts as a placebo).  If your friend tells you something you might not listen.  However if you’ve paid £400 for the honour then the situation may be quite different and large expensive personal development seminars are widespread.  Anthony Robbins is famed for using firewalking demonstrations to illustrate that the main quality shared by those who achieve greatness is the ability to take action.

When the dust settles, my concern about self help overlaps with my concerns about the worst excesses of psychology and psychiatry practice.  It promises to do much more than it can ultimately deliver, the financial motivation behind it is rarely scrutinized and its individualistic focus draws attention from socially based solutions that might ultimately provide more permanent succour.  I would however concede that it is far preferable that people spend their money on McKenna’s show than on, say, a three day booze and drug fuelled bender – an altogether more dysfunctional coping strategy.

I leave you with two further thoughts:

“The only way to get rich from a self-help book is to write one” – Christopher Buckley in God is my Broker

“The part I really don’t understand is if you’re looking for self-help, why would you read a book written by somebody else? That’s not self-help, that’s help” – George Carlin comedian

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Also

Wikipedia article – which needs a bit of work if anyone’s interested….

SHAM – How the Gurus of self help made us helpless – Steve Salerno
- the first chapter is available here and this is well worth a read
- he has a blog too

Self Help Inc – Makeover culture in American life by Micki McKee
- Blog
- Excerpt

How mumbo jumbo conquered the world by Francis Wheen has an ascerbic chapter on this subject

Orthodox view:

In the ICD-10 PTSD is listed under ICD-10 as F43.1; here find a summary of the PTSD information available on the Royal College of Psychiatrists website:

In our everyday lives, any of us can have an experience that is overwhelming, frightening, and beyond our control. We could find ourselves in a car crash, the victim of an assault, or see an accident. Police, fire brigade or ambulance workers are more likely to have such experiences – they often have to deal with horrifying scenes. Soldiers may be shot or blown up, and see friends killed or injured.
Most people, in time, get over experiences like this without needing help. In some people though, traumatic experiences set off a reaction that can last for many months or years. This is called Post-Traumatic Stress Disorder (PTSD).

PTSD can start after any traumatic event. A traumatic event is one where we can see that we are in danger, our life is threatened, or where we see other people dying or being injured. Some typical traumatic events would be military combat or a serious road accident or being taken hostage or being diagnosed with a life threatening illness.  Even hearing about the unexpected injury or violent death of a family member or close friend* can start PTSD.

The symptoms of PTSD can start after a delay of weeks, or even months. They usually appear within 6 months of a traumatic event.  Many people feel grief-stricken, depressed, anxious, guilty and angry. As well as these understandable emotional reactions, there are three main types of symptoms produced by such an experience:

• Flashbacks & Nightmares – where people find themselves reliving an event again and again.  Ordinary things can trigger ‘flashbacks’.
• Avoidance & Numbing – where sufferers avoid places and people that remind you of the trauma, and try not to talk about it.  Numbing is where people deal with the pain of their feelings by trying to feel nothing at all.
• Hypervigilance – this is like being “on guard” all the time.

These symptoms can be accompanied by: muscle aches and pains, diarrhoea, irregular heartbeats, headaches, feelings of panic and fear, depression, drinking too much alcohol and using drugs.
Traumatic events are so shocking as they undermine our sense that life is fair, reasonably safe, and that we are secure. The symptoms of PTSD are part of a normal reaction to narrowly avoided death.  However not everyone will get PTSD after a traumatic experience.  Over a few weeks, most people slowly come to terms with what has happened, and their stress symptoms start to disappear.  However about 1 in 3 people will find that their symptoms just carry on and that they can’t come to terms with what has happened.  The more disturbing the experience, the more likely you are to develop PTSD.

Possible explanations for why PTSD occurs:
The first of these is psychological.  When we are frightened, we remember things very clearly. Although it can be distressing to remember these things, it can help us to understand what happened and, in the long run, help us to survive.  The flashbacks, or replays, force us to think about what has happened; we can decide what to do if it happens again. After a while, we learn to think about it without becoming upset.  Being ‘on guard’ means that we can react quickly if another crisis happens.
In terms of the body and its mechanisms, adrenaline is a hormone our bodies produce when we are under stress. It ‘pumps up’ the body to prepare it for action.  When the stress disappears, the level of adrenaline should go back to normal.  In PTSD, it may be that the vivid memories of the trauma keep the levels of adrenaline high.  This will make a person tense, irritable, and unable to relax or sleep well.

The hippocampus is a part of the brain that processes memories. High levels of stress hormones, like adrenaline, can stop it from working properly – like ‘blowing a fuse’. This means that flashbacks and nightmares continue because the memories of the trauma can’t be processed. If the stress goes away and the adrenaline levels get back to normal, the brain is able to repair the damage itself, like other natural healing processes in the body. The disturbing memories can then be processed and the flashbacks and nightmares will slowly disappear.

PTSD Critical view:

Rather than being something with an objective existence, whether identified by psychiatrists or not, the origins of PTSD are actually grounded in the political and social, emerging as it did during the fallout from the Vietnam War.  At this time returning American soldiers found themselves pilloried and marginalised.  The new diagnosis of PTSD shifted the emphasis from the brutal actions of soldiers towards the essentially traumatic experience of war.  The diagnosis bestowed victimhood and thereby moral exculpation.  Originally envisaged as being appropriate for application to only extreme and unlikely experiences, the diagnosis has come to encompass relatively common, albeit unfortunate, events (see * above).  Vulnerability, rather than resilience is now considered to be the norm.

Modern western culture has taken a direction whereby a nation is judged as an economy rather than as a society and where great disparities of wealth are tolerated and even argued necessary.  ‘Psychological thinking’, individualism and personal rights are increasingly prominent.  Grievances for life’s injustices under such circumstances are common and individuals largely tailor their behaviour to fit expectations.   In this way PTSD allows compensation to be granted in a socially acceptable way.
PTSD is also weak as a diagnostic category.  A psychiatric disorder is not necessarily a disease, but rather a way of seeing; throughout history people have had disturbing recollections and despair, but the idea of traumatic memory as a fixed, circumscribed, pathological entity separate from other varieties of psychological distress is recent.  Rather than representing, as one might expect from its separate categorisation , a entirely independent disease process, PTSD is grounded in phenomena which are shared by other psychiatric disorders.  It also lacks specificity as it fails to distinguish what is ‘pathological’ from ordinary distress.  Furthermore, its conception that the condition’s aetiology involves a single traumatic event from which all else follows is dubious given the influence that other factors must have over the development of the disorder, for example coping styles and previous psychiatric history.

PTSD is made rather than discovered, but once invented, it is hard to uninvent; each time a diagnosis of PTSD is made its existence is further solidified.

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Further reading:

The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category BMJ 2001;322:95-98

PTSD: a critical appraisal

Article on Dr Pat Bracken and his book Trauma: Culture, meaning and philosophy

On the concept of trauma BMJ2009;339:B4577 – access restricted

One in four of us have a mental health disorder. Ruby says it (and Stephen Fry too), so then it must be true. But has one in four people I pass in the street really got a diagnosable mental health problem? If this sounds like rather a lot, then it is: 15 243 750 people from the last estimate of the UK population.

I emailed the Time to Change Campaign to ask them where they got their numbers from and, seemingly unable to provide any hard evidence themselves, they pointed me toward the webpages of Mind, the Royal College of Psychiatrists and the Institute of Psychiatry. Pause for a minute to consider that a campaign that is happily promulgating ‘one in four’ via television advertisements and on London-wide posters is unable to produce simple evidence for it to an interested party on request. Of the three websites, that of Mind is the most helpful and points towards two surveys, the references of which are below. Both of them use population surveys to come their conclusions.

But before I get to that, think about this; in his book Blink: the power of thinking without thinking the eloquent Malcolm Gladwell essentially posits the following thesis: if you are faced with something and your first reaction is ‘that’s bollocks’ (my phraseology) then this inner voice should not be ignored; it well might be correct. I put it to you that ‘one in four’ statistic is just such instinctual bollocks and it is only because it is told to us by ‘experts’ and written all over our world that it is accepted as fact.

Because anyone like me who’s in the business of identifying mental health disorders knows one thing. Sometimes it’s very difficult to do and untangling symptoms of reasonable distress from those of functional mental illness is more often than not utterly impossible. I’ve written before about people whose ‘career’ as psychiatric patients involves being given a number of different classifications on which any two psychiatrists often disagree. What hope then for surveys whose aim is to tease out these same symptoms with scant regard to the whole person whose reasons meanings and circumstance will be complex and opaque? Thus ‘one in four’ is a vast overestimate reached in part as life is hard and distress but not ‘mental illness’ is widespread.

Sadly the more something is repeated, the more it is accepted as fact. And this is true doubly if it is coming from the mouth of a celebrity. But soberingly: even if these numbers are not real, they may be real in their consequences and in a world where 25% of the population is mentally ill, we get what we deserve. In the UK 2.5 million working age people are claiming disability benefits, and only 20% of people claiming these benefits will return to work within the next five years. This amounts to massive waste of potential and one which doctors are expected to police, despite often not even having received ten seconds tuition on the matter whilst at medical school or since.

Yes there is a significant number of people in the population with serious problems in their mental health, and yes, Time for Change’s aim to reduce mental health stigma is laudable. But their ‘one in four’ slogan is an untruth sold to them by foolish psychiatrists. Time for change indeed…

Links:

From the MInd site:

ONS 2000, Psychiatric morbidity among adults living in private households in Great Britain,
States that the number of people with a mental health disorder in the UK at any one time is 1 in 6 people. This number represents those with ‘significant’ mental health problems.

Goldberg, D. & Huxley Common mental disorders a bio-social model which uses a wider definition of mental illness and correspondingly provides us with a ‘one in four’

**

Derek Summerfield has written about similar especially with regard to the Layard proposals

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Addendum 27 May 2009 The excellent Neuroskeptic has begun looking into this.  In his first posting he looks into the basis of the ‘one in four’ claim, and was unable to find the basis of the claim