Thursday, June 14, 2012

Ireland reviews psych laws; radical critiques emerge

Ireland’s been in the news over the past few years as people there have tried to come to grips with the abuses committed by various institutions. This year, the government is reviewing the country’s mental health law, including “capacity” legislation. It’s promising that Amnesty International Ireland, which has made the mental health system a priority since 2003, is active in the discussions, while psych rights groups are also clamoring to be heard.

In this context, some psychiatrists are offering some radical criticism. Mad in America links to an interesting opinion piece by Pat Bracken in the Irish Journal of Psychiatric Medicine, focusing on the weighty question of whether there is a sufficient scientific basis to justify the (often coercive) power of psychiatry. Bracken writes:

In their defense of involuntary commitment, in The Reality of Mental Illness, Martin Roth and Jerome Kroll make an important point:

‘Since most people agree that civil commitment, i.e. involuntary incarceration of a person who has not committed a crime, and involuntary treatment (based upon what others believe is best for a person) represent massive [their emphasis] infringements of that person’s civil liberties and personal integrity, it follows that the factual basis and the ethico-legal justification for such a course must be suitably strong and unambiguous’.6

According to Roth and Kroll, if psychiatrists are ever going to be able to justify their role in such ‘massive infringements’ of civil liberty we will need to be very confident that our science is disinterested and robust and that our treatments are transparently effective. We will need to be confident that we can predict outcomes, and happy that we understand how our treatments work and for whom. Furthermore, we will need to be very clear that the benefit of these treatments completely outweighs their negative effects. Remember, no other branch of medicine has the power that psychiatry possesses. We will need to be at least as confident as the rest of medicine about the veracity of our science if we are to justify this power. Do we have such a science?

…[R]ecent metaanalyses [of research on antidepressants] represent not only a challenge to our prescribing but also question the foundations of contemporary psychiatric science itself. Rather than embrace the therapeutic reality and the theoretical implications of the placebo phenomenon and explore ways of incorporating these positively and transparently, a number of prominent psychiatrists have sought to justify current prescribing practices by dismissing the results of these meta-analyses. Some of them have done so by arguing that we should abandon the evidence-based medicine (EBM) approach. They say something like: ‘actually science isn’t that important in debates about psychopharmacology, what is really important is the experience of the doctor’. So we hear one prominent psychopharmacologist, MacAllister Williams, insisting that: ‘it matters little whether the patient responds due to the placebo effect or the specific pharmacological actions of the drug, as long as they get better’.11

But the whole logic of EBM, of double blind controlled trials, is to identify what part of therapeutic improvement is due to the placebo response. MacAllister Williams is telling us that this is not important: we know how to get our patients better with antidepressants and that is all that matters.

The psychiatric discourse around antidepressants is far from the ‘strong and unambiguous science’ demanded by Roth and Kroll. Is the science of anti-psychotics any more robust? The development of second generation antipsychotics was heralded as one of the great achievements of modern psychopharmacology. For many years after their introduction, psychiatrists told patients and relatives how safe and effective these drugs were. There was talk about a ‘breakthrough’ in the treatment of schizophrenia. Several years on, and the picture does not look so rosy. We now know that these drugs are possibly more toxic than the earlier ones and there is no evidence that they are more effective. Furthermore, in a major paper in the Lancet last year, evidence was presented to show that even the notion that these drugs represented a significantly different grouping was false.12 In an editorial comment on this paper, Peter Tyrer and Tim Kendall wrote: ‘The spurious invention of the atypicals can now be regarded as invention only, cleverly manipulated by the drug industry for marketing purposes and only now being exposed. But how is it that for nearly two decades we have, as some have put it, “been beguiled” into thinking they were superior?’.13

Antidepressants and antipsychotics are cornerstones of psychopharmacology. These are the drugs that are administered to patients when they are detained. Psychopharmacology is the usual form of treatment given to patients on an involuntary basis.

My argument is that the science we have available to us now, with its explanations and treatments, is simply not of the standard set by Roth and Kroll to justify the power that psychiatrists have been given. [emphasis added]

No comments:

Post a Comment