Foreign Correspondents

Just this week, a report written by a task force advising on new dietary guidelines commissioned by the US departments of Health and Human Service and Agriculture recognized the importance of nutrition in mental health outcomes for the first time. Is the public ready to accept the importance of nutrition for mental health?

It isn’t easy coming to a point in your career where you begin to question widely held beliefs about the nature of mental illness, and how it should be treated. Indeed it becomes starkly obvious that, no matter what you think and believe, even know in your heart to be true, the world runs along different lines. Sometimes I can be full of hope for change, but frequently it angers and frustrates; often I am rendered melancholic by the mountain that lies ahead. Let me explain.

When a pharmaceutical company discovers a potential new drug, they undertake a mammoth project. The aim is to amass sufficient evidence that national organizations such as the FDA will approve sale of the drug, and the type of disorders for which it can be openly prescribed – the so-called “on-label” uses. In order to encourage companies to undertake this risk, governments place a pot of gold at the end of the rainbow.

In a belated new-year blog, I thought it would be useful to set out what I think someone needs to think about if they are considering taking a drug for a mental health problem, especially if they think they might end up taking the drug for a long time. These are the questions you might want to ask your doctor if you take a ‘drug-centred’ approach to the use of drugs in mental health.

The Scottish Anthropologist Ioan Lewis, wrote the book Ecstatic Religion in 1971, in which he suggested a ‘shaman is not less than a psychiatrist, he is more.’   He claimed psychiatry was just one of the functions of the shaman, and he invited comparison between shamans and psychiatrists.  Some diagnostic criteria for schizophrenia appeared rather similar to the desired conditions of shamans in an altered state of consciousness.  Other terms used (and misused) for therapeutic practitioners included: native or traditional healer, medicine man, witch doctor, soul doctor, sorcerer, magician, spirit medium, exorcist, curer, diviner and diagnostician.

From 1951, a system designed for heroin and cocaine addicts – prescription-only status – was applied to all new drugs. Why? These were after all the first truly effective drugs in medicine. But the ability to do good came with a likelihood of doing harm. There was a trade-off to be made between risks and benefits. The new complex trade-offs could not be put on to the label of a drug or even captured in a forty page package insert. They needed to be individual to each person.

The version of psychiatry that many professionals, politicians and laypeople would like to be true is that mental illnesses are specific brain disorders with specific drug treatments, to which they are very responsive if identified early. In reality, the way we categorise mental illnesses is arbitrary, and the diagnostic criteria are over inclusive. Whilst psychiatric drugs can be helpful, the dream of a quick fix by targeted drugs has become a nightmare where we often do more harm than good in the way we use drugs, e.g. against depression, schizophrenia and ADHD.

In Paris today we have a lot of people mouthing words that come easily: "Je Suis Charlie." For anyone who wants to be Charlie, who wants to get to know what modern politics is all about, by feeling it in your marrow, try reporting an adverse event on treatment to your doctor. Outside your doctor’s surgery/clinic/ consultation room you can believe you are operating in a democracy. Inside the room you may be treated with courtesy and apparent friendliness but you are being treated in an arrangement set in place to police addicts. This is not a domain in which ideals of Liberty, Equality or Fraternity are welcome.

So here we go again; another meeting with another young person who describes how he is in an acute crisis - you may call it - and is diagnosed and prescribed neuroleptics. He is told by the doctor that he suffers from a life-long illness and he will from now on be dependent on his “medication.” As long as people are met this way I see no alternative than showing that there are alternatives. If that means being "antipsychiatry," then I am more than happy to define myself and our work in that way.

Do you still need your psychiatric diagnosis? The answer for practical purposes is probably ‘Yes.’ In the current system, diagnosis is essential for accessing services and benefits and, particularly in the USA, for covering your treatment costs. But do you need to believe in your diagnosis? Do you have to accept this particular attempt to explain your difficulties, and to take it on as part of your identity by becoming one of the ‘mentally ill’? since psychiatric diagnoses have been admitted to be non-valid even by the people who drew them up, professionals should not be offering people the ‘choice’ of describing their difficulties in diagnostic terms in the first place. That would still leave people with the right to adopt whatever explanation suits them as private individuals.

The Finnish Psychological Association held a meeting in Helsinki on 1 Sept 2014 titled “Mental Health and Medicalization.” I spoke at the meeting and four days later I sent a letter to another speaker, psychiatrist Erkki Isometsä. Professor Isometsä replied: “I will respond to it in detail within a few days..." As "Open Dialogue" is essential in science, I have published my letter to Isometsä here as well as on my own website, although I didn’t succeed in starting a dialogue.

Through the ISPS listserve, I read a blog this morning written by Thomas Insel, director of the NIMH. The way he described people I daily meet in work and in my own life created a rising pulse, so I decided to find out some more about his thoughts and practice. I am not saying that what I read on his blog is unknown to me, but still it made me wonder how on earth is it possible to invest so much money - and resources - in research which is so distant from practice, and so far away from humanistic and holistic ideas and theories.

Fifteen years ago this month we were sitting together in the basement of Peter’s house. We had felt a sense of despair at the widespread misinformation and atrocious stereotypes that were dominating media coverage of mental health at the time. We felt that our profession had a responsibility to challenge these stereotypes, and that as psychologists we had something unique to contribute. That was the time when research into the psychology of psychosis was beginning to burgeon, and many of our findings challenged not only the stereotypes but – perhaps more significantly - much ‘accepted wisdom’ within mental health services as well.

In many respects it is difficult to fault the report Understanding Psychosis and Schizophrenia, recently published by the British Psychological Society (BPS) and the Division of Clinical Psychology (DCP)[i]; indeed, as recent posts on Mad in America have observed, there is much to admire in it. Whilst not overtly attacking biomedical interpretations of psychosis, it rightly draws attention to the limitations and problems of this model, and points instead to the importance of contexts of adversity, oppression and abuse in understanding psychosis. But the report makes only scant, fleeting references to the role of cultural differences and the complex relationships that are apparent between such differences and individual experiences of psychosis.

Often it is a relief to get an understanding of how we have developed a psychological problem, and it is especially good if we can feel that there is a reason for the problem that it is understandable. When I suffered from a phobia, it was a relief to understand that I probably had linked fear to an insect when I was a child. And it was even more satisfying when I understood that there was nothing wrong with my brain — that the problem was in what I had experienced. It was in my “software.”

Some readers of Mad in America may be aware that Scientific American published a short blog by me on 17^th November 2014 - Why We Need to Abandon the Disease-Model of Mental Health Care. This blog was rather wonderfully (and slightly embarrassingly) described by Phil Hickey on his website, Behaviorism and Mental Health, as “an important milestone.” My blog attempts to summarise many of the key points of a perspective widely shared on Mad in America: 

The fundamental stance of bio-medical psychiatry remains unchanged since my grandfather’s time – “mentally ill” people managed like stock portfolios, reduced to diseased brains and bundles of genes and biochemicals that can be quantified, manipulated and cured “scientifically” by bio-tech and surgical interventions. Magic bullets as magical thinking.

A new generation of multilateral and bilateral trade agreements is likely to significantly threaten access and cost of healthcare, and limit signatory Governments sovereignty to prioritise health care policy to protect and improve the health of citizens. The Trans Pacific Partnership Agreement (TPPA), a Pacific Rim regional trade agreement involving 12 countries — including New Zealand, Australia and the US — is one such agreement, and it has the potential to significantly alter the domestic environment for health policy-making.

Conflict is a pervasive human phenomenon that is at the heart of much distress and misery. Unfortunately, it is also seldom recognised; obscured by categories of disorder spelled out in systems such as the DSM, or brushed aside by other, fancier (but less accurate) ways of describing psychological turmoil and discontent. The source of psychological distress is not an ill, a disordered, or a dysfunctional mind but a conflicted one.

Based on any data from any country it is clear that we have a problem. Mental illness is on the rise. Researchers in the emerging field of nutritional psychiatry have documented the benefits of micronutrients to treat mental illness, showing that micronutrients help treat depression, stress, anxiety and autism and ADHD. Not a single study shows that the Western diet is good for our mental health. Many questions remain to be answered, but we can make some recommendations.

In a recent blog, we talked about the fact that nutrition and poverty are linked, and how poor nutrition is likely a mediator variable in the relationship between poverty and illness. In other words, it is the suboptimal nutrition associated with low income which likely explains much of the vulnerability to mental and physical illness. Today we want to tell you about an amazing American program that is making great strides in addressing this issue.

Over the last decade, people have commonly made statements to me of the ilk — “What bugs me about antipsychiatry people is they only care about tearing down; there is no commitment to actually helping people” — Which suggests that there is a serious dearth of awareness about antipsychiatry.

One of the main arguments for continuing drug treatment for depression, psychosis and bipolar disorder is that you will get worse from stopping the drugs, especially if they are stopped abruptly. These are findings from mainstream psychiatry. However, if we combine this information with the methodology of the randomized controlled trial, we may see that these drug trials do not show efficacy of drugs, and may not be usable to show safety. The positive side to this is that the trials may actually demonstrate the healing power of our own minds.

I know that this might sound odd coming from a critical psychiatrist, but I believe that psychiatry has a future. Furthermore, I maintain that a good deal of psychiatry as practised now is helpful and that many psychiatrists manage to play a positive and therapeutic role in the lives of their patients. However, I also believe that we are at our most helpful when we depart from the current biomedical ideology that has come to dominate in our profession. As a first step, we need to get beyond the reductionism that currently guides most psychiatric research and education.

There are some things to applaud about the recently released update of the NICE bipolar guidelines, not least the recognition that the diagnosis has been inappropriately applied to children with behavioural problems. Hopefully this will help curtail the worrying trend of using toxic bipolar drugs in this age group. As usual, however, the Guidelines overlook glaring problems with the evidence base for drug treatment in general, and miss an opportunity to stem the diagnostic creep that has come to the UK and Europe via the United States.