A tweetpost about mental illness and psychiatry: I’ve been meaning to do this for some time but it has taken a while to find the time and the clarity. It is long and wide ranging thus the numbered points. It will hopefully have something for everyone to (dis)agree with.
1.This thread is a response to various Twitter discussions and arguments about psychiatry, mental illness, psychopharmacological agents, diagnosis, etc. I will acknowledge some friends and colleagues and include a detailed list at the end.
2. So credentials and disclosures first. I am a psychiatrist and work in an NHS early intervention in psychosis service. I am also a researcher with a wide range of research interests and a very narrow range of research achievements.
3.I am a member of the Wearing2Hats group in CPFT, headed by the amazing @sharongilfoyle1. With @Sarah_Rae58 and Iliana Rokkou, for the last 4 years I have run the Conversations with Experts by Experience (CEbE) programme.
4. The CEbE programme is teaching programme for researchers studying mental illness led by people with lived experience. The aim is to give researchers an opportunity to better understand the experience, reality and variability of mental illness experiences.
5. I have suffered with depression and have found antidepressants to be remarkably helpful and transformative and have been on them for many years. In the scheme of things my experiences were mild-moderate and I am mindful of my many privileges (education, gender, position).
6. One of the reasons I joined Wearing2Hats is that for various reasons (including privilege) I am both able and happy to talk about my experiences and be a visible medical member of the group.
7. I have a strong family history of serious mental illness though this only became manifest after I decided to be a psychiatrist at 17. I am fairly certain there is no causal relationship there.
8. Finally, as this is bound to come up at some point and I can save people looking through my papers to find this disclosure, I was jointly funded by GSK and the Wellcome Trust during my PhD and I have done consultancy work for GSK, all about anti-obesity drug development.
9. With that out of the way, let’s get on with the important stuff. There are numerous competing perspectives on psychiatry and related matters and we often end up countering/debating criticisms and attacks instead of actually explaining our positions.
10. This can (very) occasionally make for interesting debate but I don’t know how much it helps our field or people whose lives are affected by mental illness. So I am going to take a stab at explaining my position. I should warn you that there is little novel to follow.
11. And if you are someone who is not happy with the idea of the brain being involved in mental illness, please try and make it to point 20 before you leave.
12. Along the way I will highlight what I feel are some of our failings as a field and as clinicians and these will be indicated by FAILING. I use the term ‘we’ to refer to us psychiatrists a group. I think the majority of us are good and kind but we know colleagues who are not.
13. Btw, I am sticking to psychiatrists because I am already being too presumptuous pretending to speak for psychiatrists and not out of any disrespect to other mental health professionals.
14. Let’s begin with, what are mental illnesses? They are a complex set of illnesses that affect the higher brain functions such as creating a model of the body and world, memory, enjoyment, mood, mental organisation, planning, motivation, etc.
15. If you have to think about things that affect the brain, then you have to think about the brain in its natural habitat (see figure). The brain resides in a body that inhabits a world (with other brains in their own bodies and their relationships to your brain and each other). 
16. You will see from the figure that the brain has a component called the mind. Avoiding the philosophical complexities, I am sticking with @cdfrith's very elegant proposition that the mind is our conscious experience of our self and this is something that our brain creates.
17. See @cdfrith’s Making up the Mind for a very accessible and enjoyable account of this. Essentially our brain does most stuff without us being consciously aware of it and things work much better this way.
18. If you had to think about all the steps you needed to perform in terms of the nerve signals and muscle movements required to pick up a cup, you wouldn’t know where to start. Some people with psychosis do have such experiences.
19. The reason its important to consider the brain in its natural habitat is that all elements of the figure are vital to consider. You cannot think about the brain without considering the body and the world, or the mind without considering the brain, body and world.
20. At this point it is worth addressing a common contested point. Acknowledging the importance of any of these elements or focussing on one of them does not mean that one is automatically ignoring all the others. All the elements are important.
21. In fact one should be very suspicious of any perspective that says it is ok to ignore any of them. However the challenge is in ascertaining to what and how much of a, role each element is playing in a particular illness and a particular individual.
22. FAILING: at various points in our history we have not sufficiently acknowledged our lack of knowledge about these complex illnesses and shown sufficient humility.
23. The disturbances of these higher brain functions result in varied manifestations in distress, alterations in functioning and the experience of oneself and the world (particularly other people and their relationship to one).
24. Critically these manifestations are shaped by sociocultural processes, as German Berrios has eloquently said, there may be a clear biological signal but a manifestation or a symptom is sociocultural construct built around that signal.
25. Given the complexity of the system and processes involved in these higher brain functions, we still have a lot to understand about how the healthy system works, let alone how it goes awry in illness.
26. However at the point in the 19th century when these illnesses were being described, we had even less idea about how these illnesses arose.
An influential school of thought took the view that since we didn’t know what was causing these illnesses, The most sensible approach would be to describe the clinical picture and course and see if it was possible to reasonably accurately identify different kinds of illnesses.
28. This was a fairly longstanding approach in medicine by this point and not an unreasonable one. The idea of conceptualising mental illnesses as descriptive syndromes and describing their natural history (how they develop and progress) remains with us to the present.
29. It was in fact reinforced by a dark period in US psychiatry where psychoanalytic formulations of mental illness that were based on ideas of what was causing the illness (in psychoanalytic terms) created an awful mess that led to the development of the DSM-III.
30. FAILING: Like most human endeavours this has not been a neat process and there have been and continue to be numerous flaws and failings that we must acknowledge, learn from and where necessary, apologise for.
31. Our current diagnostic system is still based mainly on descriptive features of mental illnesses and there are continuing moves to get beyond this. It is worth remembering that the system has diagnostic criteria whose purpose is to allow people to make reliable diagnoses
32. By this I mean, the diagnostic criteria for depression do not define depression. Depression, like all psychiatric illnesses, comprises a mixed group of different illnesses that we are still to tease out and properly characterise.
33. What the diagnostic criteria for depression are meant to do is allow clinicians to reliably (i.e. two clinicians will/can make the same diagnosis in the same person) identify depression in an individual.
34. i.e. there are likely lots of kinds of depression but these criteria allow us to determine if a person has depression (as we understand it now).
35. This was and remains the way diagnostic criteria are intended to be used. However they are often seen as defining the conditions even when it is fairly obvious that they cannot be doing so.
36. Another criticism I have of them is that they are more biased towards how experiences look (to the observer) rather than how they feel (to the individual).
37. This brings us to the next important question, what is the purpose of diagnosis? In the clinical setting, there are only 2 purposes. One, a diagnosis should help the person and people looking after the person understand what they are going through.
38. Two, a diagnosis should help guide treatment. Apart from these, I think the main other purpose diagnosis serves is to help people access services and benefits that require a diagnosis.
39. To serve the first purpose, a diagnosis cannot be just a summary conclusion, it has to be part of some kind of formulation of the person’s experiences and difficulties.
40. Diagnosis is a major point of contention in the mental health field and I think some of this relates to the many failings related to it.
41. FAILING: I do not have quantitative data on this but my impression is that there have been too many times when the making of a diagnosis has not really served the first purpose.
42. FAILING: Diagnoses can be wrong, can change over time and with more information. We have not always been quick to acknowledge where we have been wrong or to explain how or why things have changed e.g. a common reason for change of diagnosis is that illnesses evolve over time
43. FAILING: Diagnoses have too often become labels. They have subsumed people’s identities and exposed them to terrible stigma and injustice.
44. FAILING: forgetting the person who has the diagnosis.
45. FAILING: people have been treated very badly in MH services.
44. FAILING: forgetting the person who has the diagnosis.
45. FAILING: people have been treated very badly in MH services.
46.However there is also the contention that diagnosis is medicalising normal experience and distress. Again, this does happen even though it shouldn’t. Mental illness is not normal experience and distress and not acknowledging this is deeply unfair to people with mental illness.
47. The failure or wilful refusal to acknowledge the reality of the suffering of people with mental illness is a pre-requisite for various shaming positions-pillshaming, lifestyle shaming, etc, and for holding intellectual positions that prize ideology over people.
48. @peterkinderman best exemplified this for me in the Q&A following his talk in Cambridge earlier this year. He was asked if he would be willing to consider the possibility of Ritalin being prescribed to a child with ADHD.
49. He said he would only countenance this if the various inequalities and structural problems in the school system were addressed and fixed. This struck me as absurd and cruel. Why hold a child hostage to the process of massive systemic overhaul?
50. Why does treating a child’s suffering and difficulties mean that one is somehow denying that there are problems with the system? Is it because you believe that the problems are solely caused by the system? Is it because you don’t believe in the condition or the treatment?
51. I am very grateful to various Twitter colleagues who have lived experience of mental illness and are doing a lot of good work here, who have to constantly deal with critical and belittling comments, yet keep up the fight.
52. What about treating mental illnesses? There are two key things to consider here: suffering and impairment (i.e. not being able to function as you previously did). The ultimate goal of treatment is to help people get their lives back.
53. There may be various intermediate goals including getting the medication right, completing a helpful course of therapy, preventing one’s options in life being limited, etc but the ultimate goal is getting your life back.
54. For me herein lie two vital aspects of understanding mental illnesses as illnesses: hope and humility. Instilling hope in people and at times holding hope for people, is a crucial part of what we have to do to help people suffering with illnesses.
55. There is also a need for humility in the face of illness: recognising what one can and can’t do for someone, that some illnesses are worse than others, that our treatments can only do so much. Sometimes its not about getting former lives back but building new lives.
56. FAILING: blaming people for failing to recover.
57. What about our treatments? At present we have effective evidence based pharmacological and psychological treatments for mental illnesses. We clearly need more than we have at present.
58. What we don’t have yet are ways to know which specific treatment will work for which person? This means that we have often have to go through a process of working out the right treatment. This applies more to drug treatments but also to psychological therapy.
59. Here are the key questions when it comes to drug treatments in order of priority: can the person tolerate taking it? Does it produce a meaningful benefit? Is it acceptable to take for the necessary duration? The last is about longer term side-effects.
60. The same questions can be but are not as commonly asked about psychological treatments.
61. How long do you need to take treatment for? There are evidence based answers for this by condition. As a general rule for at least 6 months after recovery, ideally a year. Some people will need longer term treatment and again we don’t have any way of telling who they will be.
62. I usually advise people to focus on getting their lives back and treat medication as a tool to achieve that goal, rather than thinking of (coming off) medication as a goal in itself.
63. However to allow people to do this, it is important to get side-effects sorted/improved so that people don’t feel like they are biding time till they can get rid of awful side-effects.
64. There are many critics of psychopharmacological treatment and I don't think I can address all the usual arguments here. All I would say is keep an eye out for ideology and look out for people who insist that one or more aspects of the figure above are all/not important.
65. There is a lot we have yet to learn about mental illnesses and various ideas will be revised over time. It is very possible that we will discover things that we were wrong about. At any point we can only do the best we can given what we know and what tools we have.
66. And two of the most important tools are compassion and empathy.
Here endeth the ‘lecture’.
And here are various people I would recommend following: @SameiHuda @sameerjauhar @PaulMor64695904 @AshCurryOcd @hotsexmadrigal @TomNwainwright @sharongilfoyle1
Here endeth the ‘lecture’.
And here are various people I would recommend following: @SameiHuda @sameerjauhar @PaulMor64695904 @AshCurryOcd @hotsexmadrigal @TomNwainwright @sharongilfoyle1
Here is pdf of the tweetpost for the people who asked and anyone else who wants it. The link will be active till the end of the year.
dropbox.com/s/yd4b2yvodhn4…
dropbox.com/s/yd4b2yvodhn4…
PS: this is the original version so the numbering is a pre-formatting for twitter.
