Criticism of the standard ways of treating people with psychosis is widespread (Love, Reference Love2020). Many psychiatrists simply shrug off the criticisms as evidence of anti-psychiatry bias. Sometimes this reaction is justified. Some critics are implacably opposed to psychiatry as a whole, and campaign to have the discipline abolished. This is the position of the Scientologists who disguise themselves as the Citizens Commission on Human Rights and accost us outside psychiatric meetings. As many readers will have experienced, it is difficult to have a fruitful dialogue with such believers. Similarly, there exists a small group of extremist psychologists who appear to think that psychiatrists delight in compulsorily detaining patients and will order electroconvulsive therapy (ECT) at the drop of a hat; they spend their energies railing against a type of psychiatry which became extinct in most Western countries decades ago.
However, there are also those who while extremely critical of psychiatry and the over-reliance on a pharmaceutical model of treatment, have the intention to improve it. That is the position of the ‘Critical Psychiatry Network’ in the UK (Double, Reference Double2019), most of whose members are themselves practicing psychiatrists. Other critics have themselves experienced psychosis and become mental health workers or researchers in an attempt to improve the care system (Jones, Reference Jones2020; Longden, Reference Longden2013). In the USA, by far the most important forum for critical discussions is the Website ‘Mad in America’ https://www.madinamerica.com. Those of us who are proud to be psychiatrists and appreciate the gratitude expressed by many of our patients, will be dismayed to read about the distress caused to some people by their experience of bad psychiatric care, and the resultant antagonism to the profession displayed in its columns.
Although one cannot agree with many of the comments made in Mad in America, if only a fraction is true, then it is clear that there must be a great deal wrong with psychiatry as it is practiced. Non-Americans may try and comfort themselves with the view that this reflects the huge disparities in the quality of care in the USA – as well as the reification of diagnostic and statistical manual of mental disorders (DSM) diagnoses as real diseases, and the apparent indifference to the thousands of psychotic patients in the streets or in jail (Braslow, Reference Braslow2020). However, we would be wise to reflect on the defects in our own care systems; in the UK, for instance the absence of choice of psychiatrist, the loss of continuity of care, the terrifying atmosphere on some in-patient units and the dumping of the long-term care of patients with psychosis onto general practitioners with little training in psychiatry (Schizophrenia Commission, 2011).
We need therefore to be open to learn from our critics. For example, a prominent critical psychiatrist (Moncrieff & Leo, Reference Moncrieff and Leo2010) was one of the first to point; in this Journal, to the evidence that some of the brain changes found in people with schizophrenia are a consequence of the long-term prescription of antipsychotics; although this view is now generally accepted, three out the four referees to this paper recommended its rejection! Again, it was a team of patient researchers who carried out a systematic review that resolved the longstanding dispute over whether ECT can cause memory loss; they demonstrated that when patients who have had ECT are given neuropsychological tests, they show no loss of ability to form new memories, but they frequently complain of loss of autobiographical memories concerning important moments of their life (Rose, Fleischmann, Wykes, Leese, & Bindman, Reference Rose, Fleischmann, Wykes, Leese and Bindman2003).
In this light, we publish in this issue an article by Robert Whitaker. Mr Whitaker has written several best-selling but extremely critical books about psychiatry, and was the Founder of the ‘Mad in America’ website. His article challenges the view, popular among some experts, that antipsychotics protect against early death in patients who have experienced psychosis. This is not the usual type of review we publish in which the pros and cons of a specific treatment are carefully balanced. Rather, Robert Whitaker has a particular point of view which he outlines as a campaigning journalist rather than as a scientist (Whitaker, Reference Whitaker2020). To balance his viewpoint, we publish a commentary from a group of well-known experts in the use of antipsychotics (Tiihonen, Taipale, & Correll, Reference Tiihonen, Taipale and Correll2020). Hopefully, this will initiate more cross-talk between clinicians and critics, including patients, concerning the benefits and hazards of long-term antipsychotics.
