People recover from states of depression mostly through regaining a sense of positivity in their lives and hope in the future (Leamy, Bird, Boutillier, Williams, & Slade, Reference Leamy, Bird, Boutillier, Williams and Slade2011). They do so through a diverse range of pathways, from therapy and art to exercise and cold-water swimming (van Tulleken, Tipton, Massey, & Harper, Reference van Tulleken, Tipton, Massey and Harper2018). Very often, making (or remaking) connections with other human beings is important; at the heart of good mental health work is the development of a sense of solidarity and trust. If we have learnt anything about mental health recovery in the past 20 years, it is that values, meanings and relationships are where the real action lies (Leamy et al., Reference Leamy, Bird, Boutillier, Williams and Slade2011). Unlike orthopaedics or plastic surgery, in psychiatry we are not in the business of simply fixing things that are broken.
However, anyone who has worked at the acute end of mental health work will know that sometimes people can become ‘stuck’ in a depressive state, and it can be difficult to make any therapeutic connection. Even in the absence of any overt evidence of a medical condition, it can feel to the person themselves, and to family members and professionals, that their suffering has to have a biological cause – some kind of neurological or endocrine disturbance. The corollary is that some kind of physical intervention is needed to help the person get better. This idea is not new, and the history of psychiatry holds many accounts of different physical interventions for states of melancholia and other forms of mental disorder, from spinning stools to purgatives, cold baths and the induction of states of coma. Remarkably, perhaps, given the uncanny diversity of such interventions, many patients who seemed unreachable responded positively. Presumably, this is why physicians continued to use such techniques. Nowadays, we would probably view such recoveries as the result of the placebo effect. The power of this effect is seen, not just in psychiatry, but across most medical disciplines and seems to involve a complex mix of cultural, psychological and biological elements.
In a similar way, many people respond positively to antidepressants and ECT. Read and Moncrieff do not deny this. However, the case they are making is that when these interventions work, they are most likely also drawing on an enhanced placebo response. This is what the empirical evidence points to. The idea that these interventions are fixing a primary disturbance of brain function is simply untenable in the light of such evidence. However, many academic psychiatrists still cling to this idea. As Read and Moncrieff point out, they are trying to defend the indefensible, and effectively represent a form of psychiatry that is based on dogma, not science.
Furthermore, while support is waning for the idea that antidepressants and ECT offer anything other than an enhanced placebo effect, evidence of the damage that they can cause is growing. The negative impact of ECT on autobiographical memory is now generally accepted in the psychiatric literature, and psychiatrists using this intervention are advised to inform patients that ‘permanent amnesia’ is a ‘common’ effect that impacts ‘at least one-third of patients’ (Robertson & Pryor, Reference Robertson and Pryor2006, p. 234). In 2020, the immediate past president of the Royal College of Psychiatrists admitted that she, and many other psychiatrists, had ‘underestimated the number of people experiencing difficulties in stopping antidepressants and that the problem was widely under-recognised across healthcare’ (Burn, Reference Burn2020). Writing about antidepressants in the BMJ in 2020, the Director of Medicines Assessment, John Warren, concluded: ‘Given limited efficacy and long term safety concerns, the current level of UK prescribing is a major public health concern’ (Warren, Reference Warren2020, p. 3).
One implication of the evidence presented by Read and Moncrieff relates to the issue of informed consent. If patients are being asked to take antidepressants or undergo ECT, they should be openly informed that these treatments are controversial, that the scientific evidence does not support the idea that they are fixing any sort of biological deficit, and that their negative effects can be substantial and life-disabling. As Blease (Reference Blease2013, p. 169) notes: ‘the failure to reflect the full current status of theories and medical knowledge in critical clinical encounters can be considered a deception’. Doctors who do not share such information with their patients risk being sued, and Read and Moncrieff point to the fact that this is already happening.
Another implication concerns the nature of mental illness itself. A psychiatry that does not grapple with the ontological and epistemological consequences of putting the word ‘mental’ in front of the word ‘illness’ will never be fit for purpose. The mind cannot be grasped as just another organ of the body; ignoring the fact that ‘disorders of the mind’ present a completely different set of challenges to disorders of the liver or the lungs is medically, philosophically and professionally bankrupt.
Nevertheless, in its quest to assert its biological and medical identity, our discipline has often simply ignored the substantial difficulties involved in the use of a medical lexicon to frame the suffering it encounters. Furthermore, while ‘new styles of thought are beginning to emerge in neuroscience that recognize the need to move beyond reductionism as an explanatory tool’ (Rose & Abi-Rached, Reference Rose and Abi-Rached2013, p. 23), psychiatry has allowed itself to be guided by a philosophy best characterised as firmly reductionist and positivist. It has assumed that, in order to be a branch of medicine, it would have to model its epistemology and its expertise on approaches used in other medical specialties.
This position is no longer viable for three major reasons. First, 40 years of intensive biological research has delivered very little of any practical benefit to those who come to psychiatry for help, and there is growing concern that what Robin Murray calls the ‘fashion of the herd’ (Murray, Reference Murray2017, p. 255) has rendered many psychiatrists blind to the downsides of our interventions. Read and Moncrieff's review of physical treatments for depression adds considerable weight to this concern. Secondly, reductionism and positivism are becoming increasingly insupportable foundations for any serious attempt to understand the mind and its problems. Thirdly, the rise of the international service user movement is now challenging psychiatry to reimagine the way that medicine can be of use to those who struggle with states of distress, madness, and dislocation. This movement is asking for a psychiatry that is mature enough to engage in a genuine dialogue about what is helpful and what is harmful in mental health work. To respond to these challenges, psychiatrists will have to radically rethink what is meant by a ‘medicine of the mind’, and what kind of practitioners they should aspire to become.
In 2021, the World Health Organisation launched its Guidance on community mental health services: Promoting person-centred and rights-based approaches as part of its QualityRights Initiative (WHO, 2021). This calls on psychiatrists, other mental health professionals and the wider mental health community to move away from an ‘entrenched overreliance on the biomedical model in which the predominant focus of care is on diagnosis, medication and symptom reduction while the full range of social determinants that impact people's mental health are overlooked (Page XVii)’. Many psychiatrists are responding positively to such calls. Engaging in a non-defensive manner to the sort of evidence summarised by Read and Moncrieff will be a move in the right direction for the profession.
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People recover from states of depression mostly through regaining a sense of positivity in their lives and hope in the future (Leamy, Bird, Boutillier, Williams, & Slade, Reference Leamy, Bird, Boutillier, Williams and Slade2011). They do so through a diverse range of pathways, from therapy and art to exercise and cold-water swimming (van Tulleken, Tipton, Massey, & Harper, Reference van Tulleken, Tipton, Massey and Harper2018). Very often, making (or remaking) connections with other human beings is important; at the heart of good mental health work is the development of a sense of solidarity and trust. If we have learnt anything about mental health recovery in the past 20 years, it is that values, meanings and relationships are where the real action lies (Leamy et al., Reference Leamy, Bird, Boutillier, Williams and Slade2011). Unlike orthopaedics or plastic surgery, in psychiatry we are not in the business of simply fixing things that are broken.
However, anyone who has worked at the acute end of mental health work will know that sometimes people can become ‘stuck’ in a depressive state, and it can be difficult to make any therapeutic connection. Even in the absence of any overt evidence of a medical condition, it can feel to the person themselves, and to family members and professionals, that their suffering has to have a biological cause – some kind of neurological or endocrine disturbance. The corollary is that some kind of physical intervention is needed to help the person get better. This idea is not new, and the history of psychiatry holds many accounts of different physical interventions for states of melancholia and other forms of mental disorder, from spinning stools to purgatives, cold baths and the induction of states of coma. Remarkably, perhaps, given the uncanny diversity of such interventions, many patients who seemed unreachable responded positively. Presumably, this is why physicians continued to use such techniques. Nowadays, we would probably view such recoveries as the result of the placebo effect. The power of this effect is seen, not just in psychiatry, but across most medical disciplines and seems to involve a complex mix of cultural, psychological and biological elements.
In a similar way, many people respond positively to antidepressants and ECT. Read and Moncrieff do not deny this. However, the case they are making is that when these interventions work, they are most likely also drawing on an enhanced placebo response. This is what the empirical evidence points to. The idea that these interventions are fixing a primary disturbance of brain function is simply untenable in the light of such evidence. However, many academic psychiatrists still cling to this idea. As Read and Moncrieff point out, they are trying to defend the indefensible, and effectively represent a form of psychiatry that is based on dogma, not science.
Furthermore, while support is waning for the idea that antidepressants and ECT offer anything other than an enhanced placebo effect, evidence of the damage that they can cause is growing. The negative impact of ECT on autobiographical memory is now generally accepted in the psychiatric literature, and psychiatrists using this intervention are advised to inform patients that ‘permanent amnesia’ is a ‘common’ effect that impacts ‘at least one-third of patients’ (Robertson & Pryor, Reference Robertson and Pryor2006, p. 234). In 2020, the immediate past president of the Royal College of Psychiatrists admitted that she, and many other psychiatrists, had ‘underestimated the number of people experiencing difficulties in stopping antidepressants and that the problem was widely under-recognised across healthcare’ (Burn, Reference Burn2020). Writing about antidepressants in the BMJ in 2020, the Director of Medicines Assessment, John Warren, concluded: ‘Given limited efficacy and long term safety concerns, the current level of UK prescribing is a major public health concern’ (Warren, Reference Warren2020, p. 3).
One implication of the evidence presented by Read and Moncrieff relates to the issue of informed consent. If patients are being asked to take antidepressants or undergo ECT, they should be openly informed that these treatments are controversial, that the scientific evidence does not support the idea that they are fixing any sort of biological deficit, and that their negative effects can be substantial and life-disabling. As Blease (Reference Blease2013, p. 169) notes: ‘the failure to reflect the full current status of theories and medical knowledge in critical clinical encounters can be considered a deception’. Doctors who do not share such information with their patients risk being sued, and Read and Moncrieff point to the fact that this is already happening.
Another implication concerns the nature of mental illness itself. A psychiatry that does not grapple with the ontological and epistemological consequences of putting the word ‘mental’ in front of the word ‘illness’ will never be fit for purpose. The mind cannot be grasped as just another organ of the body; ignoring the fact that ‘disorders of the mind’ present a completely different set of challenges to disorders of the liver or the lungs is medically, philosophically and professionally bankrupt.
Nevertheless, in its quest to assert its biological and medical identity, our discipline has often simply ignored the substantial difficulties involved in the use of a medical lexicon to frame the suffering it encounters. Furthermore, while ‘new styles of thought are beginning to emerge in neuroscience that recognize the need to move beyond reductionism as an explanatory tool’ (Rose & Abi-Rached, Reference Rose and Abi-Rached2013, p. 23), psychiatry has allowed itself to be guided by a philosophy best characterised as firmly reductionist and positivist. It has assumed that, in order to be a branch of medicine, it would have to model its epistemology and its expertise on approaches used in other medical specialties.
This position is no longer viable for three major reasons. First, 40 years of intensive biological research has delivered very little of any practical benefit to those who come to psychiatry for help, and there is growing concern that what Robin Murray calls the ‘fashion of the herd’ (Murray, Reference Murray2017, p. 255) has rendered many psychiatrists blind to the downsides of our interventions. Read and Moncrieff's review of physical treatments for depression adds considerable weight to this concern. Secondly, reductionism and positivism are becoming increasingly insupportable foundations for any serious attempt to understand the mind and its problems. Thirdly, the rise of the international service user movement is now challenging psychiatry to reimagine the way that medicine can be of use to those who struggle with states of distress, madness, and dislocation. This movement is asking for a psychiatry that is mature enough to engage in a genuine dialogue about what is helpful and what is harmful in mental health work. To respond to these challenges, psychiatrists will have to radically rethink what is meant by a ‘medicine of the mind’, and what kind of practitioners they should aspire to become.
In 2021, the World Health Organisation launched its Guidance on community mental health services: Promoting person-centred and rights-based approaches as part of its QualityRights Initiative (WHO, 2021). This calls on psychiatrists, other mental health professionals and the wider mental health community to move away from an ‘entrenched overreliance on the biomedical model in which the predominant focus of care is on diagnosis, medication and symptom reduction while the full range of social determinants that impact people's mental health are overlooked (Page XVii)’. Many psychiatrists are responding positively to such calls. Engaging in a non-defensive manner to the sort of evidence summarised by Read and Moncrieff will be a move in the right direction for the profession.