Wednesday, 30 July 2008

A wake-up call for British psychiatry?

There has been a bit of interest in my Institute in a recent short article by a group of UK psychiatrists in the BJPsych (Craddock, N. et al (2008) ‘Wake-up call for British psychiatry’ British Journal of Psychiatry, 193: 6-9) and responses to it. In the article, the authors argue in defence of a medical model for psychiatry in contrast to what they call 'non-specific psychosocial support'. (By the way, anyone arriving at this page via a search engine might wish to browse within this blog for further discussion of the philosophy of psychiatry and mental healthcare.) They begin:

British psychiatry faces an identity crisis. A major contributory factor has been the recent trend to downgrade the importance of the core aspects of medical care. In many instances, this has resulted in services that are better suited to delivering nonspecific, psychosocial support rather than a process of thorough, broad-based diagnostic assessment with formulation of aetiology, diagnosis and prognosis followed by specific treatments aimed at recovery with maintenance of functioning. These changes have been driven in part by government, but there has been both active collusion and passive acquiescence by psychiatrists themselves. Our contention is that this creeping devaluation of medicine is damaging our ability to deliver excellent psychiatric care. It is imperative that we specify clearly the key role of psychiatrists in the management of people with mental illnesses. [ibid: 6]

The authors argue, among other things, for preserving a focus on mental illness not health, on a role for psychiatry experts rather than multi-disciplinary teams with distributed responsibility, and on a medical approach to severe psychiatric disorders, at least.

Many recent NHS changes, including, for example, those outlined within the National Service Framework for Mental Health, have provided an extensive discussion of important generic issues, including social inclusiveness, stigma and access. What they have not done, however, is to place sufficient weight on medical fundamentals such as the need to distinguish the major forms of mental disorder, the implementation of appropriate evidence-based treatments, the subsequent monitoring of mental state for optimal outcome and the importance of addressing the physical morbidity and mortality associated with almost all types of psychiatric illness. [ibid: 7]

Taken in isolation, these seem reasonable points. It would be surprising if psychiatrists writing in the BJPsych were, in general, pessimistic about the prospects for their discipline, especially in what it takes to be its core areas. (That I think explains the hostility of psychiatrists to fellow psychiatrist Jo Moncrief last month.) And it seems reasonable for there to be disagreement within a profession about how best to organise its services, especially if proposals seem to weaken the profession’s authority.

But what seems very surprising to me is that the article makes no attempt to engage with its opponents’ motivations, not least the reaction against paternalistic approaches to mental illness and questions about who should count a condition as pathological, what role for mental health service users? Without saying something about why the alternatives to a medical model have come to be explored and the rise of the service user movement as a constituency in thinking about mental healthcare, this seems simply to reinforce the worry that psychiatry in general tends not even to begin to listen to the people it aims to help.

(See also this.)