UK jury-based law courts are unjust

I didn't realise that people with a diagnosis (or specifically those who have recieved treatment. I'm unsure of the law) were excluded from jury service.

The justice system is meant to be fair and it isn't when huge sections of the population are excluded from serving as jurists because at some point in their life they have experienced a certain condition that may or may not have impaired their decision making capabilities. Its one of those idiotic social stigmas that has made it into the legal system and caused disadvantage through incompetence rather than malice (Hanlon's Razor again).

This unintented way that mad people are disadvantaged by society is a black mark on the UK legal system. A jury that doesn't represent the full spectrum of humanity is like a sample of the population that isn't correctly stratified yet it is construed as being representative. It means that there is an implicit lack of understanding of emotional and behavioural health. It means that every legal decision made by jury against a person with a diagnosis is potentially unfair.

There already exists a stigma from reciept of a diagnosis. Depression may be less stigmatised now but schizophrenia carries a high public stigma. People who have suffered these experiences understand the complexities of the human experience better than those who have lived ordinary lives.

It means people who have shown the symptoms of mental illness or mental health problems are misunderstood and disadvantaged by a legal system that depends on the fairness of the decision-making system at its very core. Yet by excluding mad people - because that's where I assume the legislation came from, the fear of the mad or the expectation that a single incidence of mad behaviour somehow makes that person forever lack decision making capability and judgement - from jury service the legal system is biased towards the old paradigm of normality.

Practically it means that emotional problems, behavioural problems and psychosis are misunderstood by jurists. Its means that people who go through these symptoms which are described as illnesses are still treated the same way by the law, very much like in a recent case where the Chinese executed a man suffering from mental illness (http://www.reprieve.org.uk/akmalshaikh).

There are some instances where decision making systems used a jury of peers rather than a jury of laypeople. The proponents of trial by a jury by peers would be mortified at the idea that people with mental illnesses are tried by people who supposedly have never been through those difficult times in life's journey.

Perhaps the reason that people with mental health problems are excluded from jury service is because it is true that a person who loses their capacity once or even on a periodic basis is incapable of ever making a good decision, even when they are in a more stable frame of mind. I think that's utter bollocks but I guess that's because I'm a bit mad and am incapable of making a good judgement.

A rambling discourse that started on the meaning of misery and ended on what should mental health treat?

There are many types of pain, suffering and times when an individual says "I am unwell". These are complex and individual experiences. They are not the same for everyone and they do not look the same. Psychiatry and the medical model has developed to say they do look the same and essentially that's what's important.

Depression is the simple example where people experience a range of internal experiences, externalisations and other influences that could by understood as being "depressed". This is poorly recognised in the current definition. It has been observed that men are more likely to externalise their unhappiness in different ways. This may be partially covered by the a diagnosis of atypical depression though the very language shows that it is unusual or not typical when in fact it is simply poorly recognised. This would be even worse in clinical practice where primary care physicans may not be aware of what atypical depression looks like.

A high quality study in the US looked at the experience of people using the DSM-III (or DSM-IIIR) clusters and how often people fitted one or more symptom. The first criteria was a feeling of low or mental unwellness as reported by the individual. There was a surprisingly high number of people who reported this with a slightly higher prevalence in women. As the 8 symptoms that made up the cluster of symptoms (that are clinically signficant when 4 or more are present for a period of time (?2 weeks)) were gradually included the percentages decreased overall and faster in men. This very clearly showed how the cluster approach was 'feminsed' towards acting in symptoms and it also shows that in its question to be scientific it was missing large swathes of people who had the base criteria: a subjective feeling of unwellness.

The diagnostic criteria for depression is a good shot for a poor science. It doesn't cover the heterogeneity of the experience and the human condition, i.e. it thinks that depression is the same for everyone. The cluster system values the individual's report that they are unwell for a period of time but the research criteria ignores some who don't fit the pattern and this may be a large section of the depressed population.

In reality of course it may be quite different. I would expect that the implementation of the diagnostic criteria and the treatment protocols would vary between physicans. Another American study looked at the factor of bias in diagnosis amongst psychiatrists. Surprisingly the bias was not on gender of psychiatrist or patient, ethnicity or age but where the psychiatrists had trained. This is another of many examples of the problem where people will receive different diagnoses from different doctors, something that is much less so but still present in physical medicine.

There is likely a large difference between primary care diagnosis and psychiatrist diagnosis, though again this is likely (but less so) for physical illness. Psychiatric training for primary care physicians was the theme of World Mental Health Day 2009 and the point is a salient one. Better trained GPs who see the majority of people with mental health problems are underequiped to recognise the complexities of emotional and behavioural disorders. However psychiatrists are also poorly equipped by a diagnostic criteria that demands adherence to the cluster of symptoms approach rather than the report of the individual.

The problem of the unusual depression that is experienced without mood effects, e.g. withdrawal without mood fluctuation or usual externalisations, would mean individuals would not report their potential unwellness. This particular idea of depression though is a tricky one where the individual themselves doesn't feel the low of depression which is the most significant cultural definition of depression but exhibits either changes in behaviour, withdrawal or excess giving. It is a question whether this is a form of depression or a socially acceptable way to be depressed from an inner experience point of view. The individual may be unconsciously feeling the roots of where other people feel low feelings. Their externalisations could be based on excessive guilt or clinically low levels of self-esteem. Their behaviour may cause morbidity, changed life course and may reduce their 'flourishingness' (to make a noun of a recent rewording and perhaps reconceptualisation of what is mental health by the Department of Health) and this may be identifable as a prognosis below the average and below their expected life course.

And yet is that something that should be to treated?

I think that's a post for another day.

The development of tests in mental health

A signifcant evolution in the medical model of mental health is a use of tests. This is being spearheaded in America because their medical system is heavily based around tests whereas in the UK the reliance is on the skill of the diagnostician. Essentially UK doctors are possibly better doctors without tests but American doctors produce more accurate diagnoses and can thereby provide better medical care.

Inevitably the cutting edge of the medical model will influence those countries that have a less well funded medical system. It means that the paradigm of the medical model, i.e. that these behaviours and states of being need to be classified then changed, can be make a significant leap towards a science.

They test may not revolve around physical identifiers though there may be this possibility with the science of brain scans and behavioural genetics. Abnormalities in brain activity have been observed in many diagnoses. There is also the option of measurement of levels of brain chemcials using indirect routes such as a spinal tap, however these methods are perhaps not practical for general clinical practice because of they involve taking a spinal tap. (Having just checked out Wiki the psychosis or neurosis with back pain are contraindicated with this procedure)

The most likely tests used in clinical practice would the cognitive function tests. These have already been used in research and have shown cognitive deficits associated with conditions like schizophrenia and depression (those are the ones I've seen though I'm sure there'd be evidence for other states of mind). The evidence for detectable cognitive deficits for the diagnosis of schizophrenia are so strong that there is a school of thought that these should be included in the diagnostic criteria and the neurobattery of tests used to justify a diagnosis.

This is in stark contrast to today where a lot of unscientific guesswork is still used. There are tested used in practice, for example the MMSE (mini mental state examination), but these would be considered rudimentary to someone from the physical sciences. Again it is likely that these tests are used more often in America than in the UK. The recent BBC program "How mad are you?" illustrated once again the unreliability and lack of concurrence between psychiatrists who ended up giving no diagnosis to people with pre-existing conditions, diagnosing people who had no pre-existing condition and giving different diagnoses to the same person.

The use of tests in psychiatry is something I would advocate, except that psychiatry still lacks the awareness that these behaviours in classifies may not need to be 'treated' by medicine. As far too often I make the comparison with the diagnosis of homosexuality. There would be genetic, neurological and cognitive tests that may identify homosexuality one day but those with that diagnosis shouldn't be 'treated' i.e. they shouldn't be made 'normal' and heterosexual.

Another point from the case of homosexuality is that it is my belief that some people would get the 'diagnosis' either culturally or using a sophisticated, test-based psychiatric diagnostic system are not homosexual. As in all judgement systems based on a simple set of rules there are exceptions to the rule. The medical model depends on 95% confidence interval techniques to established reliability of an observation for 95% of the people studies but the 5% may fall far outside the expectations of the evidence.

Diagnostic reliability is an admirable goal but the ethics of treatment, the rights of the individual, the thought that treatment can involve behavioural modification and the observation that mental health also involves social stigmas justified by science means that progress in diagnostic science may not be the real priority for advancement. That said, for the paradigm of the medical model reliable and scientific, unbiased diagnosis is a major step forward to ensuring the right treatment protocol is applied. My personal bias considers safe, humane, effective and ethical treatment to be more important.

A note on the mental health system 2 and religion

or perhaps mental health system 3.

This is a quick note on a long thought process about what would be the next or a right (?or perfect) mental health system be.

An answer I came to was unending human compassion, unconditionally given to all by all, would be the solution where mental healthcare was done through people looking after each other. It extends to them know what to do so there would be a public awareness of the extremes and variety of the human condition. In practice this would be the ultimate aim of a true antistigma movement: to remove the stigma of the symptoms as well as the diagnoses.

This is a grand scheme of course, and this note is not really about that scheme. Its just about the realisation that the pre-mental health system that was religion preached a similar gospel. Love thy neighbour, etc.

some notes on a conversation about mental health

This is part of a fascinating conversation last night.

As always I should probably start with a caveat on the use of language. My use of language can be complicated. I consider there is precision in the meaning of the words but I consider the concepts the most important thing. I can be guilt of using the word madness or using the word mental health problems to describe the same concept but make differentiations between mental health problems and mental illness. I probably have a split personality or something. ; ) Its just a laziness of communication.

The conversation in the pub yesterday evening started with the misquoted 1 in 4 statistic. Its actually a reasonably high quality statistic though as all statistics in social science it is a ball park figure. Its 1 in 4 in a year but its often misquote as 1 in 4 in a lifetime by most of the people who use it.

The figure comes from the work of Huxley and Goldberg from a book they published in the 1980s. They established a period prevalence of 180/1000 people with a very high expectation of a clinical mental health problem sampled (if I remember right) in a one month period and using some complicated science estimated a multiplying factor to calculate the incidence (yearly prevalence) which came to exactly 250/1000, hence 1 in 4 in a year. In their later book in the 1990s they admitted that multiplying factor may have been miscalculated and underestimated. That's good scientists for you.

The figure is also backed up by the Adult Psychiatric Morbidity Survey using British Housepanels Survey data (if I remember right) uses a 2 week sampling period to establish a 1 in 6 figure at any one time. That sampling period is around half that used in the Huxley and Goldberg 180 in 1000 figure and 1 in 6 is approximately 167 in 1000. Using the same multiplying factor the 1 in 6 figure comes in slightly lower than 1 in 4 a year which is expected with the shorter sampling period. They're both in the same ball park. There's also no evidence I've ever found for a 1 in 4 in a lifetime measure of people with mental health problems.

Both those high quality examples produce a 1 in 4 figure but its important to know what that means and that's what's often contented by mental health scientists and statisticians when discussing 1 in 4. Does it mean mental illness (psychiatric illness), mental health problems (a broader definition) or experience of mental distress (as is used by one of the major UK charities in a lot of its marketing)?

Lets get rid of the last one first. In any sense of real use of language 1 in 4 is not to do with people who experience mental distress. Everyone in their lifetime experiences mental distress, or 99.95% do because there are always exceptions and different experiences of life. That may even be true for the incidence as well.

The second two options are where the debate gets interesting though takes something of a tangent. The idea of psychiatric mental illness is a concept based dogmatically on the strict fitting of symptoms to the cluster of systems defined in the accepted diagnostic criteria (usually DSM). High scores on the screening tool used in the APMS do not mean the same as a clinical interview or a diagnosis given by a psychiatrist, though it would indicate a high probability that the individual may be suffer from mental illness. "mental health problems" are often misconstrued as a euphimisation of mental illness whereas those who are precise with the language consider them to be lesser conditions or conditions based around distress specifically rather than the spectrum of psychiatric illness.

The conversation last night moved onto the point about homosexuality. After it was demedicalised first in America there was a debate about a diagnosis about homosexuality that was to remain in. I can't remember the name of the diagnosis but it covered the period of adjustment and the associated distress where a person goes from considering themselves hetereosexual (or 'normal') to accepting the homosexual feelings and desires. This diagnosis was not kept in DSM-III and future revisions. If I remember right the diagnosis was not included because the distress was thought to be a normal part of the process and therefore not to be medicalised.

(need to find the reference for this)

The conversation also moved onto grief as another example where 'normal' distress is not considered part of the mental health system. An often underused diagnosis in primary care is the adjustment disorder which relates to a life stressor creating symptoms defined as mental illness, however it carefully excludes anything related to grief. Bereavement and its consequences though they may be distressful and may induce social or psychological dsyfunction seems not to be part of the mental health systems compassion. (This has to be balanced by the fact that practice and academia are two very different worlds and it is likely that a GP may consider a referral for psychological therapies even if they suspect symptoms may be caused by a death and may consider medication).

Another digression moved into alternate mental health systems, specifically religion, and their consideration of grief. First of all this particular "alternate mental health systems" is a concept that needs further explaining is a separate post but for the moment its necessary to accept that the psychiatric system is not the only system that has ever controlled and helped people with emotional, behavioural or other forms of expressions of unusualness or distress. The example of a system of grief management was taken from the Islamic system (though in fact this may be a cultural system rather than specific to the religion). It is culturally accepted and it is even encouraged to wail and cry and 'freak out' and externalise as much as possible after a death. These behaviours are possibly considered "a bit much" in repressed societies but in other societies the holding in of grief and showing a bit of stuff upper lip is conisdered a poor way to deal with the aftermath of death. In the same system though there is a time limit on this grief. After one month the mourning period is over and it becomes time to get on with things.

Its surprising that there's nothing on grief in DSM-IV-TR. In fact there is. On page 756 of the 1323 page manual there's a short paragraph on the section about depressive disorders. It sets 2 months as the length of time before a diagnosis of major depressive disorder can be given and an individual offered short-term psychotherapy to deal with unresolved grief issues and pharmacotherapy. It also mentions that normal grief 'symptoms' usually happen within 2-3 weeks and resolve spontaneously over 6-8 weeks. That's it.

So the psychiatric system is clearly different from what most people would expect based on the ideal of a formalised system of human compassion. Its careful to select which forms of distress are normal and which aren't. It carefully attempts to tread that line between what is thought to be normal and what it considers an illness and abnormal, even though 1 in 4 people in a year are likely to receive a psychiatric diagnosis. The diagnostic criteria seems to leave certain types of distress out, specifically grief, lumping it in haphazardly into a paragraph in the length section on depressive disorders. And it used to 'treat' normal ways of being such as homosexuality.

Its a bloody interesting thing eh?!

The argument for the denial of the right to mental illness

I feel I have to write this because the previous post was unbalanced. Its necessary because without balance its just wrong. I hate doing this though.

The states which are described by mental illness come with prognosis, i.e. a fortelling of lower outcomes based on various measures and the coherent different levels of detriment to outcome based on the diagnosis. Schizophrenia has a predictable outcome worse than bipolar in many of these measures which are usually well validated.

Schizoaffective disorder is a controversial diagnosis (and different from cycloid psychosis which seems to have more acceptance in those who have heard of it but it not the equivalent of schizoaffective, bipolar type) but proven to be a valid diagnosis is research literature because of the different prognosis to schizophrenia and biploar (sitting somewhere inbetween for many and closer to bipolar for others if I remember the paper correctly).

These measured outcomes are a salient argument for the treatment of mental illnesses. Treatment means people have better, longer lives. They may not necessarily be fulfilling nor as good as life pre-treatment because these measure systems don't completely comprehend the true measures of life. The research as always shows the average picture and usually shows signficance using 95% confidence levels, so 5% outliers can have significantly better or worse outcomes (I make this point because I consider myself diagnoseable based on the research criteria and the operational critera (DSM and ICD is what I mean) but my level of function is relatively high and my ability to cope, while variable, is also high therefore I consider myself in the 2.5% possible positive outcome).

The experiences that end in crisis can be catastrophic to some individuals and it is better to prevent those catastrophies happening. Suicide is the worst outcome of crisis and that should be prevented at all costs. Other impacts like social exclusion through crisis, financial ruin, relationship breakdowns, family breakdown and exclusion, impact on physical health and a number of other serious negative events can also be prevented by disregard for the right to be mentally ill.

Mental illness also comes with a curse that decisions can be considered irrational and rational decisions might be tainted and dismissed by others because of the the stigma of madness or incomprehensible logic on previous occassions. The prevention of these mad moments means the individual can have a better reputation and social standing, something that many people value and some people who don't could get a diagnosis for not valuing (in the extreme).

Are people also capable of handling their mental illnesses yet? People who successfully self-managing without medication are an exception to the rule. Most people survive and are thankful to a mental health system that is compassionate to the extremes of human behaviour, that treats the outcasts and the despised and attempts to return them to society, that provides a safe place when they are in severe crisis and offers professional support to help them work better.

Many people are glad that they can be treated and their experiences reduced, their emotions dulled, their anger taken away and their sleep made easy. Many people want to be normal and not weird and those that don't have been proven by research to be more likely to be criminals or murders. Even those may be treated and they should be treated and changed so they don't murder.

A future possiblity for mental health is the treatment of criminals to change their thinking patterns and behaviour so that they don't reoffend. Its a chance for those people to return to a civilised way of function and its better that than a life of crime. The tools of brainwashing have already been used for good to treat depression, anxiety and psychosis. Why not crime? And why not the punishment for crime not be incarceration alone but enforced psychiatric behavioural modification. Its in the criminals best interests and its good for society too.

Is it possible to apply that argument to current psychiatric diagnoses. People do not always know whats best for them, i.e. people can lack capacity and when that happens other people can make decisions for them based on their personal idea of their best interests. They may lack the insight to understand that they are mad. That's part of the illness. How can a person have that right?

Mental illnesses are not the same as the rights of people with physical illness for that reason. A blind person has the right not to have their sight restored if the technology comes about that allows that. A person dying of cancer is soon likely to have the right to take their own life and this is possible now in the Dignitas clinic in Switzerland. A chronically depressed person doesn't have the right to kill themself, even if it is a rational decision based upon the enduring and treatment resistant experience of life, because that is part of the illness (perhaps until the test case, and perhaps not even then).

Suicide itself is part of the diagnositic criteria of depression and depression is the medicalisation of misery. Its fundamentally compassionate to take away the rational choice of an individual's experience of consciousness and of life in their best interests because the illness means they don't think normally and they can't know what's in their own best interests because they are ill.

Native American mumbo jumbo doesn't get around that.

People have a right to be mentally ill

Its a strange concept: the right to be ill. Its worth remembering that mental illness isn't actually an illness and but its a way of considering it. The same concept can be euphimised as mental health problems or mental distress, though the latter is an incorrect description of mental illness.

An individual has the right to go through depression, mania, anxiety, psychosis, personality disorders and every other manner of mental illness. That is a right but there is a counter argument based on the reality of that anarchic, liberal thinking which I espouse.

The mental health system is based on many things, one of which is dealing with the stigmatised. The stigmatising behaviours or the extremes of normal traits are not well accepted by the public so people became seen in healthcare settings. Mental crisis is also a real thing even though it is a result of society's maladaption to the complete human experience, i.e. a society in the future will be setup such that crisis happens in the community with no social harm and no risk to another person's life (I see suicide as something can be a rational choice but can also be an irrational one and the latter prevented, whereas murder and manslaughter should be prevented).

The maladaption of society is real but it is as changeable as the mental health and legal systems. Again I use the example of the demedicalisation of homosexuality. Or the huge change that is seen over the latter twentieth century in the application of a quasiscientific framework with the operational definitions of cluster of systems. Sadly the early twenty first century is seeming a psychiatric insanity in the development of premordibity operational definitions as part of the American psychiatric system.

It is with this change to diagnosing pre-illness states that this point about the right of the individual to refuse treatment, espeically psychopharmaceuticals, if they are definied as pre-mentally ill by the new system. Premorbid psychosis does not guarantee a person will experience full-blown psychosis or schizophrenia, but standardised treatment would likely be the chemical cosh which cause changes in a person's experience of life and have harmful physical side effects that will reduce their life expectancy.

Psychosis itself is highly misunderstood because it is understood by people who have never experienced it. The psychaitric dogma of pathologising this experience and offering treatments designed by people who have not had the experience (up until recently) are two of the reason the outcomes are so poor. It is well recognised that many cultures around the world have alternative explanations for this experience and stigmatise it considerably less than in the UK.

The new Community Treatment Order in the 2007 amendments of the mental health act meant medication could be forced on people who wanted to live free of the chemical cosh and was overused a considerable amount because of psychiatrists infringing on a person's right to free experience. Some of those people may be taking an antipsychotic called clozapine, one that is well established to induce life threatening conditions and dramatically shorter life expectancy. If I remember right one of the arguments for its introduction was to reduce the number of 'revolving doors' patients who were repeatedly hospitalised but became a tool to force medication (as is often what happens during hosptialisation anyway, even with a section 2 where there is no legal power to force treatment (if I remember right) though in practice nurses and doctors may not inform patients of that right or they will be exceptionally coercive in persuading a person that they must take medication).

The right of a person to be considered mentally ill and refuse treatment is a complex debate and I've only provided one side of the argument. I think its a strong one though and I'll make my final point.

Life may be more complex that what is understood by simplistic psychiatiry. These illnesses may not be illnesses. They may be a reaction to something that is wrong in society, and medicating them away is like dismissing criticism: its blinding oneself to a feedback channel. They may also be part of an individual's journey through life and that these experiences have purpose beyond Kraeplinean ideas of where these experiences come from. They may be part of change for the better, but if they are stopped by psychiatric treatment or mistreated by misunderstanding psychologists then the individual's journey suffers and their development may be stunted. And its all done for their best interests, of course....

"The soul would have no rainbow if the eyes had no tears."

Native American wisdom printed in Our Voice/Notre aux voix (Canadian consumer magazine).

That's an alternative view from an alternative mental health system. The spiritual wisdom handed down through the oral tradition of evolution of knowledge beats psychiatry's understanding of mental illness, in my opinion.

We have a right to be mad.

Evidence, prejudice and fucking do gooders doing bad things

This is prompted by a piece of promotion of gender prejudice that I'm afraid I was part of, all done for the greater good of course. I'm angry as hell right now and I'm venting.

There are many prejudices that are held beliefs based usually but not always on no truth whatsoever. The difference between ignorance and prejudice, or faith, is when evidence is presented it is ignored and the prejudice continued to be held.

I'm not going to fuck about. The example is the idea that men don't seek help for their mental health problems. Its a prejudice I held till I was tasked with the futile effort to find research to back this up. I searched high and low. I read information from a variety of studies and reviews and caused myself a large amount of distress for my incapability to find out where the evidence was behind the idea the men don't seek help for mental health problems.

I was guilty of that cardinal sin of research: bias. In fact it helped to drive me to search for this piece of evidence. Every time I found hard evidence instead of an unproven hypothesis based on anecdotes and more unproven hypotheses (yes, I read a lot of sociology) it drove me to look harder rather than sit in complacency.

Eventually the obvious hit me: I couldn't find any difference in the levels of help seeking for mental health between genders. Every piece of evidence that was suggested supported the idea, primarily the "men visit their GPs 50% less than women" from Living in Britain (and the British Housepanels Survey data) and the 3 times higher suicide rate could be explained away. The data from the 2001 BHPS was only true for working age (18-65) and the trend was the opposite above working age. It is easy to guess that in 2001 more men worked than women and fewer GP practices opened late and Living in Britain authors also acknowledged that women may visit more for family planning and pregnancy.

The suicide rate is well known. The attempted suicide rate is also well know. It has been noted that men choose more violent methods and this is why there is a difference in the completed rate (though I'm still not sure that this is true) but the rate of attempts is higher in women. The piece of evidence I did find on help seeking for suicide showed an interesting result. The Samaritans recieved about 2.8 million answered calls every year and have done so for about a decade. Every year for the last decade there have been approximately equal calls from men and women (in fact calls from men were fractionally higher).

The best quality study that used evidence to look at help seeking for mental health also showed similar results. A survey sent to 13,000 people with 11,000 returns asked for attitudes from a rural population The authors noted statistically insignificant differences in overall levels though there were some noteable differences when looking at the detail. This was a peer-reviewed study published in the British Journal of Psychiatry and was the only one of its kind in the UK.

Its not the quality of evidence I would hope for because it is based on intent rather than behaviour. The Samaritans data is actual behaviour. It was also of a rural population so may not reflect the average accurately. These two pieces of data alone are very strong and much moreso than the poorly understood examples used to justify the prejudice.

The prejudice was very strong. The organisation I worked for I used to believe in and this process broke than image. They conducted their own research by conducting a poll on people's help seeking behaviour. The prototyped survey was run to test the questions but the results from the experiment backed up the idea that there was little difference in the overall levels of help seeking for mental health problems between the genders. This caused much concern. I'm unaware if the questions were adjusted because of this or not but the full survey went out anyway to 2000 people. It returned showing the same thing: no significant differences in overall levels, though there was an difference in the levels of help seeking from GPs with men less likely to see a GP.

And yet a national campaign ran that told men they should seek help for mental health problems more. I should have quit at that point.

This was one of the worst things to happen to me that year. It broke my ideal of the organisation I worked for. Perhaps that was necessary but it was a brutal process.

And they're still fucking promoting that same fucking prejudice.

They did it for the right reasons which is why I didn't take more serious action because this sort of behaviour is exactly what gives science a bad reputation and its a thing I hate: evidence use to create lies. Eventually I let it be know to the organisation that this was something I thought was wrong but to no avail. They still promote that prejudice. They waste the donations of their members (I stopped my after this incident) and put it towards promoting their own bullshit, even when the evidence presented to them shows that their view is ignorance.

Today I've seen yet another example of them promoting this prejudice. Its a small thing. Its in amongst a page detailing other important work. But I'm still so clouded by this one failure of theirs that I was part of that I find it hard to see the rest of their good work.

There's a quote that goes something along the lines of "Tyranny will continue if good men stay silent." I've failed that. I could speak up about this now but my sense has taken hold. Its not worth it. Its a small issue. They do a lot of other good work. Its a storm in a teacup. The lives of the mentally ill are more important the damage public action could do to the organisations brand is far too great a cost because they do a lot of good work and help thousands of people.

I suppose I know my future better or what I need to change. I need to have the backbone and the wisdom to know which battles to fight. The latter makes me think that I should leave this one alone. The former makes me think that next time I will say my piece stronger and more effectively so that prejudice will not stand.

What to do if someone is suicidal?

This is an extremely difficult piece to write for many reasons, not least because of my own views. This is an area where no one is an expert and the text below is less a guide and more of a thought process.

Many people have no idea what to do if someone is suicidal. Its rare that people talk about suicide though its not rare to want to die or think how to kill themself.

I'm lucky because I've been through a few suicide attempts over the years (that must be one of the strangest sentences I've ever written...). Wanting to die is normal for me and has been for the majority of the past few years. I have the lived experience of the things that have worked and the huge barriers.

For me the first thing for someone who is suicidal to know that they shouldn't go through it alone. I'm not sure I can think of a greater hell except psychosis/ego death itself. Ensuring they have someone they can always go to no matter what is vital because often its those closest to the person that the person will not talk about their deathwishes to, for obvious reasons.

My personal view is that I won't directly talk someone out of doing anything. I won't criticise their desire to die. I won't help them but I won't condone them and I'll allow them to speak about it as if it was the weather. That's really important I feel because many people won't talk about it for many reasons and those that do really don't want to be told not to do it. That's the natural reaction though and its one that I've always listen to with a polite smile and ignored. Its what I expect that person's friends and loved ones to say like a mental health key message so I don't need to say and frankly I think I'd be a liar if I said it.

My amorality aside, it means a suicidal person will keep talking to me when they won't talk to anyone else about it. It means that person always has someone they can talk to no matter how bad the situation, no matter how worthless or hopeless they feel, no matter what they're thinking of doing. This is absolutely essential because I've noticed in my own life the pattern where the reduction in social contact can quickly lead to thinking about suicide to planning or actual attempts. There are many examples of people being saved from suicide by the random kindness or interaction of strangers or friends. I'll admit that to some people I have explicitly said, "if you're going to do it please give me a call and I'll join you." which sounds horrific but I can say it with a degree of honesty and it means that, perhaps, they maybe they'll take up that offer of a last contact before they go.

The value of my personal experience of the hells of life and my openness means that I have a certain credibility or authority that might make the words, "it'll get better" or "its not always like this" have a fractionally chance of actually getting through to a person who can't see that to be possibly true. Getting a chink of hope into a person's mind is vital. Often its unending and pure hopelessness that drives people to kill themselves. Its not easy though and done badly it may distance the suicidal person from talking about it again with that person.

In my personal experience many people feel like they want to die on a regular basis but never, ever mention it and they can be the happiest person on the outside. This state can change and become a very, very dark place and this can happen without warning. In this dark place the nature of the individual's relationship with those suicidal thoughts is different. In the mild state it can be a useful coping mechanism to dispel life's problems and it a thought that can be pushed away. In the dark place its not so simple. It can be all pervading and the solution of ending things becomes a reasonable, practical way to end the hopelessness. (Even as I write now I can feel the tug of desire for the peacefulness of eternal slumber.) They can rationalise the social effect of suicide or simply hate themselves more to get past the effects on friends and family, or it may be something they don't consider because their minds have become inward focused.

Herein lies the value of trying to get the that tiny, teeny sense of hope. In my mind I see it as a thin, barely perceptible ray of light breaking into a darkened room. But it is the tiny difference between the pitch black that the mind can not handle and the black it can see. The pitch black analogy is experienced by people who use a photographic darkroom for the first time as their mind tries to adjust to the total blackness they have never experienced before even on the darkest, cloudiest nights. Everywhere outside the darkroom there is a small, sometimes imperceptible amount of light that the mind requires to 'see' black. In the darkroom the mind is out of its depth.

Some forms of suicide are about loss of hope but there are other reasons and its important to understand that a person may not reveal their true reasons and those reasons may not fit a generalisable picture. But the offering of hope that the situation can change I think can get through.

The problem is that its the obvious thing to say and that 'intelligent' (whatever that means) people know that there is hope even when they feel hopeless. Its the thought that may or may not get said. "Yes, I know there's hope but I don't feel it now and my present state is wanting to end it, so fuck off with your positive attitude."

An alternative can use distraction, fun and whatever else to indirectly work with the individual. I'm always in the pub and its an excellent environment to deal with someone who is suicidial if there is a suitably secluded spot away from prying ears. There are antidepressant-depressants available on tap and these also help people to open up. I. The environment is socially safe and it is a place that many people have fond memories of. Alcohol loosens people up, relieves stress and makes people happier when they're drunk and its a widely accept social medication. The hangover is the ideal form of depression - the cause is easily identified as a consequence of the night before. There is the risk of recklessness induced by alcohol and redoubled by recklessness behaviour induced by suicide (not wanting to live can change a person's attitudes to risk) leading to a drunken attempt. Its important to note that risk.

What I'm saying is a couple of pints and a chat can, perhaps, do more than seeing a professional who the suicidal person knows is going to try and talk them out of it and psychiatric antidepressant medication which is also given to stop them killing themselves. Its important that the chat isn't about suicide unless the person wants to talk about it. Maintaining social contact, distraction and ensuring that there is a bit of fun is the important aspect in my opinion. They are natural, temporary ways to relieve suicidal thoughts. Even if the suicidal person is smiling and laughing but still crying on the inside the effect of them pretending to smile and laugh can have the effect of making them genuinely express that way. That memory of simple fun can wake up that bit of a person's psyche that says, "well I like having fun. At least I can keep on doing that" or whatever other inner thought process happens such that a person moves out of the dark.

Engaging in a conversation about suicide is very difficult for anyone who is not an experienced professional or someone without extensive lived experience. For the inexperienced listening is the key and allowing the person the opportunity to accept they are suffering may also be important (many don't understand the significance of the distress that brought them to the point of suicide). Also getting them to talk more is useful because it can be a way for them to offload and in my opinion I think it is an effective way of reducing their suicidality in the short term.

Experienced people can have a more meaningful conversation. I'm not sure I'm capable of elucidating on how this would go but I'm making a differentiation between the experience levels of the samaritan because an inexperienced person can be treading in murky territory and it can be bad for their mental health if they feel like they've said the wrong thing and the person ends up killing themself. The best way to avoid that future guilt is to tread lightly.

I feel experienced people can take a different approach because they realise that often there's nothing positive or negative another person can do directly for someone who is truly suicidal (I'm making a distinction but one that I feel doesn't need explanation). They may also be more capable of taking the risks in communication and conversation necessary to get that person to listen to even a small amount of what is said, so they may be able to confront the issue that the person wants to kill themself about rather than side step it for safety.

Confidentiality is vital though I'm aware that it my case confidentiality has been broken. I've accepted that but other people wouldn't and it can be deleterious to a personal relationship. Revealing suicidal ideation is a massive step for someone. Breaking that trust can be catastrophic. Many people may want to talk to that person's close friends or their family or loved ones about it but my opinion is that it is up to that individual. The worst thing anyone can do is make the foolish mistake (as has been done to me in the past) of contacting mental health services who's knee-jerk reaction is far too often hospitalisation.

This is a very, very, very tricky area and my opinion is only that. I'm sure other people will make their own decisions but the loss of trust can be something that can be catastrophic to a distressed individual. There is little that mental health services can do except section and from personal experience that makes things worse. It is better to discuss your intention with the individual and if they firmly say "no" then it see if they will speak to someone anonymously or speak to the Samaritans helpline or speak to a person with lived experience or professional expertise outside the NHS system.

I strongly value suicide survivors in helping the suicidal because they are able to give real personal accounts. A survivor's life is usually full of useful tales that can help the newly suicidal see that they're not alone and they're not abnormal, that life can be strange and that their suicidal desire will go away. For those without that 'gift' and curse dealing with someone who is suicidal feels very out of their depth I would guess.

As a surivor there's something I can say with confidence (at this present time). Its gets better and there's hope. Those messages are much better coming from someone know to have been in the same dark place in their past that the suicidal person is in their present. Its perhaps why ending up in a psychiatric ward can be a good thing (though this is not part of the design of that system). Being able to speak to other veterans of suicidal ideation is better than speaking to any mental health professional.

I want to end on an important thing to remember as a conclusion and the important thing I can think of is to recognise the difficulty and the unending futility before engaging with someone who is suicidal. It is very hard for most people and the rewards are often not seen directly except in their continued existence. When I've been suicidal and talking about it there have been times when I've been an arsehole and that's why I'm making this point. Its an important point because it will help the samaritan through the difficulty so they can help the suicidal more.

Just a line of thought

Lets imagine a hypothetical study is published that shows lightboxes increase productivity during winter. The measure was the increase in the number of calls and the quality of calls (measured using mystery shopper calls) from the same time the year before and there was a control group. The study was conducted over a twoyear period which made it more difficult because of the high turnover of call centre staff that meant that a 1000 advisors had to have light boxes on their desks to get complete information on 500 of them. The study showed an increase in the number of calls taken but was inconclusive on the quality of the calls.

This study was well publicised and many businesses saw the opportunity to inexpensively increase productivity with a modest investment that quickly paid for itself over time. Across the UK and in the US more and more businesses fitted light boxes as standard and ran them over the winter period. Subsequent studies confirmed the increase in productivity. The mental health campaigning fraternity saw it as a way to prevent Seasonal Affective Disorder and their became a national requirement for all workplaces to ensure that lightboxes were fitted.

A decade afterwards new data arose. Comparisons were done including the summer months and over a five year period. It was found that annual productivity went up at the start of the use of lightboxes but started an evermore rapid decline over five years. At the end of the five year sampling range annual productivity was lower than at the start when no lightboxes were being used.

Not wanting to U-turn the government ignored the new data and said more data was needed. Another decade passed. Some people had started to switch off their lightboxes but many didn't see the research. Many who read it dismissed it because it was regarded as poor quality and there was no funding to run a high quality study.

Three decades after the introduction of the mandatory lightbox in the workplace a shocking study was published that looked at life expectancy. The researchers were looking at life expectancy by job type across the world. In the US and the UK, and in other countries where the lightbox was adopted enmasse, life expectancy was reduced. The strongest indicator was the change in life expectancy was due to lightboxes was the comparison with the life expectancies of those who worked outside the office. Their life expectancy had risen dramatically as would be expected over a thirty year period whereas office workers' life expectancy had stayed constant though had been rising faster than the average before the introduction of the lightbox.

This is just a boring story about unintended consequences of the things done for productivity and preventing mental illness. There's a moral in there somewhere. I'm not sure what it is.

A rant on the motto of the Royal College of Psychiatry

The Royal College of Psychiatry's motto is something like Let wisdom guide. I chuckled hard when I heard that. There's as much wisdom there as there's snow in the Sahara.

Psychiatry creates the divide between normal and illness and calls it a science. It uses sophisticated tools of evidence to justify social stigma and it does it so well that its fooled itself. I always refer to the example of homosexuality because its such a good example. It was stigmatised and so became psychopathologised. Yet how often does the wise psychiatrist question the other diagnoses and ask whether they're really illnesses or just normal.

Psychiatry is a profession that uses clusters of external symptoms to map experiences which are often internal. There is no concept of the lived experience psychiatrist (more on this later) which is an idea I have that would be the future of good psychiatry. Its very simple: people with lived experience go through psychiatric training - only they will possess the full knowledge of the experience and the knowledge of the textbooks. Depression would be treated by people who know what depression is. Treatment of psychosis, mania and all the other dimensions and domains currently medicalised by people who lack the real knowledge of these experiences would be revolutionised to become effective and ethical.

Their great lack of wisdom is most seen in the use of medication. The prophylactic use of psychiatric medication, i.e. the lifetime of taking medication for the mind after one crisis or episode, is foolish. Trust me, I'm a fool so I should know. A person can become unnecessarily drugged as an unintended punishment for a single hospitalisation and repeated hospitalisations can mean this regime is enforced through the medico-legal framework because of the introduction of Community Treatment Orders in the amended Mental Health Act (and in other legislation outside the UK).

Its not meant to be a punishment but the removal of certain emotions, range of emotions or expression of emotions is punishment. These are the very things that make us human and make the human experience liveable. To mess with them is dangerous and should be done with a care, and very differently to the current sledgehammer approach favoured by psychiatry's foolish wisdom.

Perhaps its greatest error is to disregard the pre- and extrapsychiatry mental health systems. Its an ignorant assumption that the only people capable of understanding mental health are psychiatrists. The converse is likely to be true. Spiritual, religious, cultural and other forms of extrapsychiatric mental healthcare have existed for generations. As far back as Roman times mood stabilisers were used for madness but these were very low doses of lithium found in certain spring waters. There are many examples of mind healers outside psychiatry and psychiatry is becoming influenced by them in the 21st century, for example Mindfulness Cognitive Behavioural Therapy is in part Buddhism.

And the last two 'wise' idiocies come together in another absurdity: the medicines for the mind prescribed by doctors and psychiatrists are usually given by people who have never tried nor would try them. There are some anecdotal stories of consultant psychiatrists making trainees try psychopharmaceuticals but this is very rare. There are more stories of doctors and other mental health professionals being averse to taking medication because of the stigma of mental illness and medication of mental illness in their profession. Last year a local doctor in Enfield was struck off for self-prescribing antidepressants; he could have got another doctor to write the prescription but that would be admission of illness, or weakness.

I think perhaps the motto is aspirational rather than a description of the RCPsych and the collective consensus of thought they represent. I really hope that it will describe them one day but they really should have an accurate motto.

"We're way out of our depth but we've got loads of science to justify our foolishness. Just try not to remind us of the mistakes of the past because those were wise mistakes."

or

"The legal drug dealers."

Or perhaps you can think of something more snappy?

Add them below in the comments box

DSM V: The debate

The next revision of DSM is stirring a huge debate.

It started with this article by Allen Frances, chair of the DSM-IV taskforce.

http://www.psychiatrictimes.com/display/article/10168/1493263

and this article

http://www.psychiatrictimes.com/display/article/10168/1425378

which had a reply from the chair of the DSM-V taskforce

http://www.psychiatrictimes.com/display/article/10168/1426507

The debate surrounds many areas, one of which is the idea of premorbid psychiatric illness. It goes without saying that such a situation is possible, i.e a state of being with a high probability of incurring a 'real' psychiatric diagnosis of mental illness. America's insurance-backed healthcare system means this makes even more sense because it means people can get treatment without having severe illness. There's research that backups the idea that premorbid psychosis can be treated as a preventative measure.

That's all well and good, except the reality is that academia's understanding of premorbidity will be different to clinicians. The concerns of the old guard are that there will be a repeat of the overdiagnosis of ADHD and the use of medication on huge swathes of the population who were once considered 'normal' will ensue. The operational diagnostic cluster of symptoms will also not accurately predict a premorbid state, i.e. some people will receive a diagnosis who have no chance or very little chance of full blown psychosis.

These false positives will be treated when treatment is unnecessary. Treatment usually means antipsychotics and these have profound effects on an individual. Unintended or not they can cause a lack of volition as well as a number of physical disorders. Medicine hasn't got the balance of harm of medication versus outcome correct without premorbid psychiatric illness to confuse the picture further.

Another interesting development in DSM-V is the use of the dimensional model. I'm afraid I know little about this except that it is a radical change to the diagnostic paradigm. Schizoaffective disorder can be seen on three dimensions of psychotic, mood and depression (check this) whereas schizophrenia may be on one or two. It means rather than lump different behaviours into one diagnosis the individual behaviours are separated out. This means treatment happens for each dimension and it solves the problem of comorbidity.

The old guard have suggested this is a welcomed shift and that the dimensional model of mental illness is the future, however it is not ready to be included in a major revision of the psychiatric bible. DSM bases itself on epidemiological studies and other forms of research that provide the robust scientific justifcation of the different illnesses, their course and treatments. This simply doesn't exist for the dimensional model and it is seen as a huge risk by the DSM-V taskforce.

A large part of the criticism of the DSM-V process has been its secrecy. The debate is happened behind closed doors, or it was till Frances and Spitzer made their criticisms vocal from informal conversations with taskforce members (they were not on the DSM-V taskforce). I find myself having to agree with the old guard that this has the highest potential to make DSM-V a dangerous revision.

1

we each have too short a time. we get washed with the sea of those endless nescessities, things that aren't real and we never, ever want to be real (in our 'idealism') and end up stuck in the same fucking filth of the past.

no matter what I do this is the reality I face. death is better than that certainty. so what? that's all that keeps me alive. all that keeps me from this leaving this frigid, rigid sickness is the thought that I'm going to change it.

i just wish I could bear this. I can't.

Augmented Reality - an overview at the start of 2010

Augmented Reality is the latest revolution in the tech age of revolution after revolution, many of which start with dreams of a world dominated by whatever the visionaries see as the future. Unlike other bleeding edge ideas from the high tech world AR is tempered with a degree of realism.

AR is the blending of computer information with our sense. Its not quite cybernetics. In practice its applications on smartphones that use the video camera and overlay electronic information. There are also so called audio AR browsers that allow sound input. The technology is hindered because high end smartphones are still few and far between and none have the hardware to really make AR a reality. The precision of the current sensors onboard iPhones and Android devices isn't good enough for applications that are beyond gimmicks and proof of concept.

New devices and cheaper smartphones capable of running advanced AR apps will make the AR future happen quicker though perhaps it won't be quite how the visionaries saw it. I don't mean to criticise them: I like to think I'm one myself in a different field. I think visionaries fit into the picture by dreaming their dreams and publishing them, whereas ordinary folk get on with enjoying the fruits of those dreams.

Exciting developments from students at MIT and their Six Sense project are showing what creative minds can do with the limitations of current technology to produce a working prototype of a device that has a camera, projector and wireless interface to connect to a smartphone all in a small and portable though aesthetically impractical package. VR and AR-dedicated headset devices are becoming products that the public may consider buying though mass market products are still a way off in the future.

AR success as a revolution and the new Web 3.0 is dependent on a predictable and smooth advance of current technology but there's a high dependence on technology that's not ready for the real world and that means AR will advance at the rate of its least advanced technology necessary for (low unit cost) mass manufacture.

This is true for many technological advances. The development of high capacity disc systems like Blu Ray was limited by semiconductor material science. The major enabling breakthrough came from developing semiconductors robust enough to create high frequency (therefore high energy) light without destabilising the atomic structure. Without this modern high definition drives would have needed the laser replaced every six months which would have been commerically impractical.

Like the high def discs, the current tranche of AR devices may be obviated by another technology. As ADSL2 brings high speed broadband to the masses and the increasing success of online media the need for high capacity media systems has diminished. High definition audio is listed as one of the fails of the decade. Blu Ray won the format wars but takeup is still slow and it may never see the return on investment expected.

The AR industry seems somewhat aware of this potential and many companies are patenting ideas for the future. Its likely there's been an increase in patent applications for AR devices in the last few months of 2009 and a significant increase throughout 2010. This trend is another danger to the future of AR as it is for any technological advance but seems to be an accepted necessity of the information revolution, much to my personal dislike.

AR will happen. Its already happening in America and I expect the Far East to be leading the trend. Marketing and gaming have become to two growth areas in 2009 and there's high expectations for this to continue in 2010, even in the UK where AR has made little impact.

Wellbeing: same shit, different era?

Well being is possibly misunderstood by the people pushing through the policies.

Its a dimension of mental health outside psychiatry and the current diagnostic system. It is the other continuum of mental health, as I understand it, and is a paradigm shift for it to be used in practice.

It is sa that it is the current mental health system and psychiatry that will be driving this new way of thinking about people's mental health. It will fall back into thinking along the psychiatric disorders continuum because that's all that psychiatrists know and where the majority of research is.

The real expertise in this area lies outside psychiatry. The world's expert on well being is most likely to be the Dalai Lama or the Bhutanese king rather than someone who's spent most of their life learning a system of disorder based on a mix of people's experiences of severe distress, society's stigmatised groups medicalised and social stigmas falsely made into illnesses (e.g homosexuality, communism, hearing voices).

I believe that the new operational definitions of well being will end up being very much like the psychiatric mental health system so much so that in a few years people will ask whether there was any point. It may even end up looking very similar to premorbidity developments in DSM-V because the people working on these definitions have been educated in the same paradigm: psychopathology.

Few of them would know the continua model of mental health that has been promoted through the last century by organisations such as the National Association for Mental Health. Mind (as its know today) still haven't realised just what a significant victory it is that the UK, French and other international governments are putting what the original meaning of mental health was on the national policy agenda. This is the paradigm that separates psychiatric diagnosis from mental health, so a person can be very 'ill' but have good mental health or well being.

Commissioners, policy makers, researchers and the general public still don't understand this. This will show in the processing through which the operational definitions are constructed such that they show strong similarities to psychopathology's system and future critics will lambast the wellbeing system for being psychiatry all over again.

This is why it is essential for their to be a wider group of people involved in the development of wellbeing. Importantly the psychiatric movement should be on a equal par with the alternative and fringe. In practice this will not happen because psychiatry has such a high regard, it is embedded as a way of thinking about mental health in too many people and few are openminded enough to quickly leap to an alternative, untested paradigm.

If this happens it is still not a failure. The change brought about to psychiatry and the perception of what is mental health may be the more significant. The continua model serves most to separate diagnosis from distress or wellbeing. It is not well understood. The discussions surrounding wellbeing will mean that the idea of individual distress will permeate into the mind's of clinicians who often consider only the academic diagnostic criteria as the be all and end all of mental health.

Wellbeing should also bring a cornucopia of new treatments. These will be humane and safer than medication though this will still remain and become a last resort. Again, this will perhaps be more important than the separation of well being and mental illness. It will mean better, safer treatments for the mentally ill alongside continued antistigma work and this will make their lives better.

Mu utmost hope is that true sages will become involved in medical mental healthcare and national policy. The factory-made sages (psychiatrists and their ilk) can only repeat what they have been taught by their common system. Those that have learnt the wisdom of life through their own journey in life have the most to offer to any movement, and most of all to one that hopes to make the word a genuinely better place.

a little on cannabis

A few useful links. This shows weed should be legalised definitely. The arguments are harder for skunk but possible given the rationale of regulation rather than anarchy.

The UKs decision to classify cannabis in all its forms as a class B is wrong from this evidence. There result is irrelevant: the classification has little impact on user practices. The profit margins are so high that the trade would continue were it to be a class A drug. Users continue to suffer as does society through any form of criminalisation. There is no regulation and profits go to the illegal drugs industry and crime unless cannabis is legalised.

A change in policing policy to target users would make a difference though that is a draconian measure that serves to criminalise and punish large sectors of the population who don't deserve it. Such a measure would bring the reality of cannabis use to the fore: many people from all walks of life use cannabis safely and responsibly. They are not engaged in the debate and often are in favour of its continued criminalisation though they use it and would not consider it criminal.

Some great pro-weed legalisation evidence from this study showing the antipsychotic effects of CBD and referencing many useful studies. There are also comparisons with other antipsychotic showing similarities to the properties of atypical antipsychotics

http://www.scielo.br/pdf/bjmbr/v39n4/6164.pdf

A good counter-piece criticising David Nutt's criticisms and highlighting evidencethat makes the prolegalisation argument difficult

http://www.guardian.co.uk/commentisfree/2009/oct/29/cannabis-schizophrenia-classification

UK psychiatrist who's a specialist in the area

http://www.zerrinatakan.com/index.html