On being different

I am a cheat. On Saturday night/Sunday morning I was speaking to some protestors who'd set up camp in Hyde Park overnight. I told them I campaigned in mental health. I was asked "so you have the mental health" by this lady. Yes. I have the mental health.

I explained to her it wasn't an illness. Its just being different. I was drunk and this was how I communicated my thinking to a person naive to the advanced concepts in mental health.

I cheated because she was a protestor. A liberal and a passionate one. Though not a conscious thought to achieve influence by aiming at something she'd understand from a personal perspective the result was it was powerful, I think, to see the alternative way of thinking about mental illness.

If I were a psyhiatrist i'd have been like a peadophile at a baby pageant. There was mental illness all around were I to see people who are different as being mentally ill. That is, after all, what psychiatry does. The schoolyard exclusion enforced with science.

Difference in this sense is as much of a construct as mental illness.

Tolerance as a treatment for mental ill health

Tolerance, compassion, unconditional love. Call it what you want.
There's a thing which could be the solution to the problem of mental ill
health.

This thought comes not from considering the idea as an illness. It comes
from recognising that the idea of illness is a mistake and a mistruth. I
prefer the term "the human condition" because it is a step closer to the
absolute truth of what mental illness is describing. A quick flick
through the history of psychiatry and some of the information which is
outside the biomedical paradigm, e.g. Foucault's Madness and
Civilisation, quickly eludcidates that the idea of illness is a construct.

The consideration of the problems covered my the mental health system as
problems of the human condition changes the persepctive in a way which I
hope produces better answers.

Tolerance is one of them. Psychiatry seeks to change individuals. It
used behavioural modification or drugs little different from illegal
narcotics in their purpose. It seeks to remove and hide behaviours so
people do better in a society which sees a blinkered view of the human
condition. Society accepts psychiatry's method because it allows the
ever tightening of what is normal so individuals become homogeneous and
easily function in the modern work and social environments. Psychiatry
seeks to reduce diversity in a time when this is an aim accepted by
society as a good thing.

Tolerance comes from a different angle. It seeks to see the problem as
complex as the human condition. It sees problems in individuals like
psychiatry does but with a different lean. It sees people first, not
illness which are automatically a negative thing. It sees the value of
phenotypes rather than attempts their extinction like a doctor would do
if it were a virus. It's not a virus and it's not an illness but there's
no replacement system. I've chosen the idea of human condition because
it makes sense to me and this idea means there's no perjorative
immediately assumed. There is with mental illness and that's why there's
fundamentally a stigma.

Tolerance for the symptoms of the human condition, for the spectrum of
behaviours individual's express when distresses or whatever else comes
under the massive umbrella of the human internal experience. This is one
of the reasons why people with supposed mental illness - or behavioural
and emotional disorders as the psychiatric textbooks refer to them - do
better in developing world nations. People in those nations are tolerant
of diversity. They still have the social and cultural knowledge that
human beings have a variety of expressions. We're not always happy and
we're not always peaceful. We're not always docile nor quiet. We go
through crazy times and show crazy behaviours. That's normal.

People in the West forgot what normal was after crazy was confined into
the asylum system. Inadvertently in an act of compassion this redoubled
the problems of the human condition and society. All that were mad
disappeared into these asylums for generations, an era known as The
Great Confinement in Foucault's insightful work in the area (which I've
still not read properly but have gleaned a lot from people who have and
used it to inform my thinking).

A part of the human condition became hidden so people forgot the human
condition is pretty weird at times. The confinement of madness hasn't
ended. Medication allowed many of the mad to leave the asylums where
they were incarcerated but they remained incarcerated using chemicals to
restrain and hide the madness. The behaviours of madness had become so
intolerable by this stage that the partially mad became the new mad as
slight divergence from this false idea of a robot-like normal became
considered an illness which should be removed. Step by step, generation
by generation the idea of illness allow the significant reduction of the
diversity of the human race and the blindfolding of the people to a part
of the human condition, a part which is not a negative thing except in
psychiatric thinking which has become enforced upon the people through
subtle means they themselves don't realise (Hanlon's razor is seen here).

Western society lost the ability to tolerate the wide and beautiful
expanse which is the human condition. It is beautiful because of it's
diversity but psychiatry, like some painter who judged the colour red to
be a sin, saw some of it should be pathologised and seen as ugly. They
allowed the tools which allowed the consensus of society - the largest
tribe - to be less tolerant. They allowed the greater exclusion and poor
social outcomes which aren't seen in nations where the psychiatric dogma
has had little influence.

If we can relearn to tolerate the human condition in it's fullest then
we heal mental illness. We also have a far greater concept to apply
science to: the true exploration of the human condition.

The treatment of severe mental illness in children

Childhood is a complex process to understand. The diagnosis of mental illness in childhood is a strong predictor of a worse life on many measures. The social and clinical outcomes are amplified if the diagnosis is in childhood. Those children may never go to university or be able to work in traditional office settings.

There's also the problems wrought by the system which attempts to help these children: mental healthcare and psychiatry. Since the mid-20th century the favoured treatment was drugs. For manic depression the mood stabiliser offered a way to reduce a person's emotions, flattening their affect and stinting their emotional development in the process but it does offer better social and clinical outcomes; our society likes docile people who are like robots and people who experience the full gamut of emotion are disadvantaged in modern Western society. For schizophrenia it's as bad. Most people going through first episode psychosis want one thing: the reduction of the hallucinations and delusions. The cost to their life is massive: the prophylactic use of antipsychotic medication takes so much away from these individuals.

Either of these drugs used in childhood means strong neurochemicals are being used on a developing brain and personality. Daily drugging with these strong chemicals might affect a child's brain development in ways not yet understood or accepted. Studies using MRI scans seem inclusive because of the small sample size in the paper I read however the effect on life expectancy in people with dementia - antipsychotics reduce life expectancy by 50% in one significant observational study compared to those who weren't treated with them for the symptoms of dementia - leads me to believe a doctor shouldn't be prescribing this drugs for long term use in children.

The problem of the antipsychotic drug

The terrible truth about the antipsychotic drug is it may not actually treat the hallucinations and delusions. In fact it doesn't for many people. This effect hasn't been studied in depth. The measures used in trials of antipsychotic medication don't focus on what patients want: the reduction of the hallucinations and delusions. This are represented in two of the sub-measures in PANSS. There are 6 if I remember right. OTher scales are also used. The other elements are nothing to do with what patients want. They're what psychiatrists want and pathologise.

I read a lot into the drug clozapine. This was the first a of a new generation of antipsychotics, the atypical antipsychotics. In early trials it produced exceptional results. The drug was released onto the market and heralded as a saviour for schizophrenics. This is still how it's thought of even though shortly after it was introduced it was discovered the drug was killing patients. The drug causes a condition called agranulocytosis where the immune system becomes compromised. This wasn't detected in the trials which lead to it being licensed. After the problem was discovered Sandoz, the manufacturer, voluntarily withdrew it. Many people died before it was withdrawn.

The psychiatric hegemony valued it so much they lobbied for its return. They discovered that using blood monitoring during the first six months they could halve the risk of death by agranulocytosis. They couldn't eliminate the risk of death but the drug was reintroduced as the best practice treatment for treaatment resistant schizophrenia. Even in the latest NICE Schziophrenia clinical guidelines it is listed as the treatment of choice after two trials of other antipsychotics at standard doses. They do not recommend anything else for treatment-resistant schizophrenia.

In a critical review paper Dr Joanna Moncrieff criticised the evidence for the drug's effectiveness. In the paper she mentions other reports and papers which also call into question the drug's effectiveness. This is based on the psychiatric paradigm of schizophrenia, i.e. the measure of schizophrenia which also includes things like aggression and excitability, which is not solely focused on the primary treatment expectation of the patient. What most patients want is the cessation of the internal experience which has ended them up in a psychiatric ward.

Unfortunately even the most dangerous and supposedly effective drug is not effective enough on the patient's measure. The only qualitative review on clozapine, written by people who work at the Clozapine Patient Monitoring Service which is funded by the manufacturer. published in the British Journal of Psychiatry the authors state the drug reduces the delusions and hallucinations in "some" patients. In another paper from America which detailed case studies t seemed this drug could be used for other reasons, reasons important to psychiatrists but not of primary interest to schizophrenic patients, which related to behavioural control. These are associated with the syndrome but not present in everyone. (search this blog for "clozapine" for the references)

Simply put the treatment may not treat what patients and the public think is the illness. The risks of reducing life expectancy and hindering psychological development when they're used in children is something which is a guess on my part. Antipsychotics have a strong sedative effect which was the primary reason for their invention. They used to be know as major tranquilisers. I think using this sort of treatment on someone for their whole life - from childhood to their early grave - is not the best treatment available.

On another note

Psychiatrists don't really understand what the internal experience is like being on and off these medications. There are many adults who, like myself, chose to remain off medication. It is assumed to be a lack of insight or a foolishness of somekind for a mentally ill person not to want to take medication.

In my opinion this is a lack of insight and competence on the part of the psychiatric hegemony. Let's take manic depression. People experience a wide range of emotions. The highs are fantastic but the lows are awful. The highs can also contribute to the social disability and mortality rate. Having this extraordinary range of emotions also comes with other things. Positive benefits. It's the same with schizophrenia. Dopamine neurotransmitter sites (D2 if I remember right) have been associated with creativity and more sexual partners. The latter has been suggested is an evolutionary reason for the propagation of schizophrenia through the generations. Though in today's society schizophrenia and bipolar (which may have the same genetic root) result in poorer outcomes the 'disease' itself is somehow wanted by evolutiionary processes and has survived even through the most recent shift in civilisation during which the idea that this type of human being was an illness was invented.

On the outside the antipsychotic and the mood stabiliser is highly effective at turning a human being into a docile, socially acceptable average person devoid of any of the good things which come with those experiences of consciousness or emotion.

I have experienced psychiatric medication. I've experienced high doses and polypharmacy. It got to a concurrent dose of 700mg of quetapine fulminate (an atypical antipsychotic used near the maximum dose), 3000mg sodium valporate (a mood stabiliser used at above maximum range), 225mg sodium venlaflaxine (an high dose of an antidepressant for treatment resisitant depression), 50mcg thyroxine (for the massive weight gain) and 10mg of propananol (for the shakes). I also drank a lot and smoked skunk. I was also advised to take an adjunct of 10 1g fish oil pills a day too.

I didn't like that period in my life. I was unhappy pretty much throughout. I am unhappy now but it is a better unhappiness. During the period of drugging I wasn't myself. I was dead inside and dead outside too. All the colour had gone from my internal life and I functioned through my daily life hoping death would come soon.

The medication took away the part of my life I enjoyed. I became a docile and inert lump of flesh ready to work and function without any form of existence or expression. The phrase "dead man walking" (misappropriated from cowboy movies) resonates with me about how I was at the time.

I am a person who values my emotions and creativity and passion and all the other things which comes with mental illness which the drugs take away or inhibit. Little research is done into the value to the individual of what psychiatrists call a mental illness. Yes. It means a worse life for the individual, but the methods of psychiatry are not the right way to deal with them. Psychiatric drugs don't really help the individual much and for many individuals the drugs remove too much of their individuality.

The truth is there are people who know the research and live the experience but chose to remain off psychiatric medication. I am not the only one. I remember one of those serendipitous moments which, if I were paranoid, would freak me out. After a talk on the asylum system I popped into a pub to write my thoughts. Sat a a table opposite was a few students. I asked for a light and they asked me to sit with them. I chatted about what I was writing and thinking. Most of them weren't interested but one or two were. One of them was a girl who was older than the rest of the group. They were on a day trip from university and were all studying arts courses. I speak honestly about my experience of mental illness in public and it can cause people to self-disclose when they ordinarily wouldn't.  She'd had schizophrenia as a child and was hospitalised for a couple of years. She'd been on medication and she'd been through the whole psychiatric system bullshit. Now she was at university. A little late but she'd made. She was excellent at what she did. Her peers spoke of how she picked up a brush and was an expert instantly. They were younger than her of course but she had had a lot of barriers in front of her path. She was happy. She was satisfied. In her life, at that moment in time, she was doing well. She was also off medication. She was proud of it and she felt being off them contributed to her happiness and her talent.

I wish I could remember her name. I gave her my Facebook details but she never contacted me. I hope her life is better than mine at the moment. Let her story be the sort of thing that doctors aim for when they're treating schizophrenia in children. They shouldn't take all the good stuff from the lives of children with severe mental illnesses using drugs. The aim should be to help them to survive and help remake this world so all types of people can succeed.

With support people can learn to self-manage without medication. It is a hard processes but it is what some patients want. I don't need to cite the few studies which show that low and no dose medication approaches with alternative paradigms of treatment may offer better outcomes. The WHO IPSS is enough for anyone to question the validity of Western psychiatric treatment as a good solution for the lives of people with schizophrenia.

The fact is the drugs contribute to the reduced life expectancy. They may cause brain damage. Certainly if they're used while the brain is developing there is an increased risk. There is the risk for the individual's psychological development if they are drugged out of important personal childhood experiences. The current solution proposes a drug addiction for life as a treatment. The treatment for schizophrenia at least may not achieve what the patient wants which is the reduction of the delusions and hallucinations. Till drug companies and psychiatrists start prioritising what patients want there may be no solution to this other than psychological therapies which help the person deal with them. There are alternative forms of support too and interventions where society and social structures need to be changed.

The priority is greatest in the treatment of children because fucking it up with them has far greater impacts in the long term.

Psychiatric science seeks heavy handed tools

Doctors have been prescribing narcotics to people since the mid-20th
century. There was a divide between legal and illegal drugs but this
wasn't a real divide, just a construct. The line between the two has
become blurred. There's been a resurgence in research into the potential
of LSD as a mental health treatment. After years of suppression a few
studies have been allowed and these have shown promising results.
Ketamine is another illegal drug which is showing very good results in
psychiatric research trials. I believe there's investigation of MDMA too
- it was experimented with as a therapeutic tool in the 70s too.

They've not looked into cannabis much. The research has focused on
powerful illegal drugs. Cannabis is a pretty mild one compared to LSD
and letamine but lots of people use it to get happy. There's a lot of
psychiatric research about the dangerous of cannabis. Those who use it
rarely read those papers and have better tools to understand the drug:
they've tried it. There's preliminary data from an RCT showing certain
components of cannabis are antipsychotic. Delta-9-THC has been shown to
induce psychosis-like symptoms in lab settings but this mild
hallucinogen is why people smoke high grade skunk - it makes them happy
when they're in natural settings with their smoking buddies. Delta-9-THC
is licensed in America as an appetite stimulant but I've not come across
the paper which investigates how and how much this component makes users
happier.

Delta-9-THC is no where near as strong a hallucinogen as LSD. It can be
used in the right way to help certain people with their unhappiness. It
is clear that many people already self-medicate using cannabis more than
any other illegal drug. Psychiatry and society dismiss this while they
accept the SSRI as the ok high. It may work for some people but the THC
antidepressant effect is different. If psychiatrists and psychiatric
researchers tried these drugs - the legal and the illegal ones - they'd
have a much better understanding.

Instead they research on subjects and that's what they publish. I'm sure
some of the researchers and professors have probably tried the drugs but
won't admit it for fear of their reputation. I know many doctors who
have tried drugs and people in other professions. Anyone who's tried
these drugs would see that LSD, ketamine and MDMA are strong drugs
compared to cannabis. Yet the research into the application of illegal
drugs in mental health has focused on these strong chemicals instead of
a relatively mild plant. Though research into cannabis has offered leaps
forward in the understanding of the human body and nervous system (the
endocannabinoid system was found through cannabis research if I remember
right) and offered new treatments for physical health problems (Sativex
and Marinol are the two licensed drugs. There's also cannabis for the
symptoms of MS) I've yet to see the research on the application of THC
in mental health.

It's a shame because it's a bloody good antidepressant. Perhaps not as
strong as LSD and psychiatrists prefer to use heavy handed tools.

At this moment this blog is inauthentic. I have removed part of my life

IT is hard. This is so important to me. But I have readers. I made the
mistake of letting people who read this know who I was.

because it wouldn't work otherwise

Democracy is not a process which begins and ends and is in totality an
election.

Democracy is about the people speaking. Fuck the referendum. We have the
right to protest.

The right to peaceful protest is an essential right of democracy

--
Don't let justice be the privilege of the elite. Support the Justice for All campaign
http://www.justice-for-all.org.uk/

Just because there's a neurobiological basis doesn't make it an illness

Love and I'm sure happiness could all be shown to have a neurobiological basis and an extreme level of one or more neurotransmitters associated with them. If society decided love was a bad thing, for example if some psychiatrist pointed out that people do terrible things in the name of love, then it would be possible to pathologise it in the same way that unhappiness or anger are pathologised. Richard Bentall, a critical psychiatrist, has written a paper to show how happiness could easily be pathologised using psychiatric methods just as depression...I mean msery is.

The biochemical thing is the only thing which allows the use of the word illness for the human condition. But it is wrong and the paradigm has shifted away from pure biomedical explanations anyway.

It's not a fucking illness and never was in other words.

A ramble about nothing in particular

I think doctors understand that some of mental health is about the medicalisation of unhappiness. I think they're wrong in their pathiologisation. I think part of this mistake comes from the modern nuclear family unit.

In the last two hundred years there has been a shift from having three generations in a household to having two. This really happened most in the 20th century hence the term nuclear family.

Doctors, obviously, were brought up in and propagate the nuclear family. The wisdom of the oldest generation has been lost.

This generation might tell them that misery is a part of life and they're handing out drugs little different from illegal narcotics. They might have been there in a doctor's childhood to teach them that pain is part of life and have the time to spend with them that their parents who work a 9-5 week can't offer them.

The three generation household's disintegration may be one of the factors of why people do better in developing world nations as well as, of course, the communities which are more accepting of different human emotions and states which include those which in the West mean incarceration in a psychiatric ward. Psychiatric crisis still happens in the developing world but is accepted by the community.

These cultures have ways to deal with unhappiness. They don't call it an illness. I'm not sure my grandparents would call it an illness either. They'd seen the breadth of the human condition in their long lives living in a third world country. Then they moved to the UK to recomplete the family unit.

I had the privilege of being brought up in a 3 generation household. Living with grandparents was not a good experience for my parents. It was the cultural norm for them though and had benefits. In a way it wasn't great for me either but there were many positives.

The polypill - a medical treatment aimed at reducing heart disease and increasing life expectancy

A single pill which could be taken by everyone and would significantly
reduce strokes and heart attacks.

Here's the paper
Wald, N. et al. 2003, A strategy to reduce cardiovascular disease by
more than 80%, BMJ 326 : 1419 doi: 10.1136/bmj.326.7404.1419 (Published
25 June 2003)
http://www.bmj.com/content/326/7404/1419.full

Here's the editorial which calls the BMJ issue the most important in 50
years.
http://www.bmj.com/content/326/7404/0.7.full

And here's some information on the ongoing work. It's interesting stuff.
Combining a few medications into a single pill which everyone takes
could significantly reduce heart disease and strokes.
http://www.bmj.com/content/326/7404/0.7.full

Let's hope the psychiatrists don't try this as they try to eradicate
unhappiness. It's not a fucking illness.

--
Don't let justice be the privilege of the elite. Support the Justice for All campaign
http://www.justice-for-all.org.uk/

A response to a friend of mine on Soteria and alternative treatment for psychosis

I've posted up a study on my Facebook profile. It's a systematic review
of the Soteria houses. These are an alternative treatment for first
episode psychosis and I'm a massive fan of the possibility of this and
other ways of progress in mental healthcare.

I've not yet read the study so I haven't posted the details up. My mate
read it though. He's a GP. He's in America now. He studied at Harvard
and has a Master in Public Health Policy. It's one of the most respected
degrees in the world for commissioning healthcare services at a national
level.

He asked me about the cost effectiveness of Soteria. Here's my response.
Lengthy as usual.

"
Yeah. It's a really useful study. Systematic review in a high quality
journal.

Cost effectiveness is poor compared to standard treatment. I think the
initial hospitalisation period is much longer - 6 months.

It's not the only paradigm of progressive treatment. There's a review by
John Bola which looks at data from other sites. The problem is it's
published in Psychosis which is new and has lno reputation.

The problem is looking at it from a economics perspective. I know
there's limited resources but what happens in first epssode is inhumane.
Soteria and other ways to deal with first episode without incarceration
and coercion and medication are the future but they do cost more.

The UK doesn't have anything like this. For two years I've been banging
on about the need for a progressive facility in the UK. Other nations
are trying these out, for example the Finnish Parachute Project (in
Bola's review).

When I get my shit together I'll be campaign for a progressive psychosis
treatment facility/prgram in London. Rates of diagnosis of schizophrenia
are something like double in London. There's 7 million people. It's a
long shot and it means persuading a lot of GPs but hopefully there'll be
a large consortia or two covering much of London.

Soteria may not be the best way but it has a lot of backing in the
movement. In the Bola review there were 2 suicides at the Soteria place.
None in the other facilities.

There is a real possibility to offer better outcomes but also to reduce
the trauma. I have my own thoughts on what could be done during first
episode, for example use it as an opportunity to train the person to
manage their symptoms. They can learn from others who've been through
the experience - this is part of the Soteria principle and others. They
can make an informed choice on which treatments they accept and don't
accept. This is key. This is what's denied to us and this is oppression.

http://psychrights.org/Research/Digest/Effective/PsychoSocialMoreEffective2009Psychosis.pdf
"

There's no such things as women's equality. There's just equality

This is what I uttered to some lass at a conference a few weeks ago.

She admitted to me she was a feminist. It's strange to me. It's like
admitting you're a racist but people are ok about it.

I take a very dangerous position when it comes to gender politics. I
think people are equal. Feminists and the women's 'equality' movement
work against that. It's not just a thing of semantics or language though
there's an element. What I mean is that people should be equalitist -
there's porbably a better word - rather than promoting women.

I am a full support of women's liberation and am aware of the
misdemeanour's of the male power holders. I am strongly against the
suppression of men by women and male ideas.

Many feminists and people who promote women's equality are actually
little different from racists when they subjugate male ideas and ways of
being. In conversation with people who call themselves feminist they're
clearly misandropists - people against the male way of being. They're
people who have negative views of men and who say things like, "oh it's
just because he's a man..." or "typical man" or similar utterances which
were the subject a woman the speaker would be accused of being a misogynist.

There There is just equality for all. I have met a handful of good
feminists who are equalitists rather people who take the best of
traditional values and modern values. They're women who open the door
for me. They're women wh are interested in equality.

is no male equality just as there is no women's equality.

Madness is a democratic right

They just don't know it yet.

Like freedom of speech or ther guaranteed liberties madness is the same. We have the right to be different. We have the right to think differently. We have the right to be mentally disordered. As long as people aren't harmed.

Isn't that your right? It's not a right that a mental health services-accessing individal has. Their being can be removed. Why? Because their individuality is called an illness. Who they are is not an illness but if you use that paradigm then you can change that person and call any resistance to the idea a lack of insight.

Diagnosis, treatment and effect size (and something else)

Doctors have spent a lot of time making diagnosis in research reliable and valid. The cluster of symptoms approach backed by evidence is both a marvel of science and a mockery. The latter is because of the pathologisation rather than the objective view of the phenotypes described by the labels.

What doctors do as treatment is where there's a problem. There's many areas. The measures and the systems are still far away from assessing the right variablews. There are more interactions and there is more individuality than is understood by the system. This is perhaps part of the reason why effect sizes in systematic reviews in mental health often show effect sizes which are smaller than what's considered good evidence in a trial in physical health.

The diagnostic system and the link to the treatment options is not able to accurately refer a person to the right treatment. Physicians aren't equipped with the tools or the learning to do this. It affects their ability to be effective in suppressing phenotypes. I mean ensuring good social and clinical outcomes.

On another note....

The system has never attempted to be able to fix the thing which patients come to it for: subjective unwellness. This will be the future mental health system and I guess it will evolve from psychiatry. The measures will be different. The measure will be subjective unwellness based on patient report. There is the problem of resilience but only because resources are limited. There is a greater resource, the people, from where mental healthcare in a distress based system can come from.

Subjugating a people

The human race is made rich through its diversity, not its conformity.
It is made poor by systems which seek to make us homogeneous or oppress
and subjugate those who are judged to be different.

From religious persecution to the oppression of gender or races or
sexuality to the subjugation of slavery to the modern methods of
psychiatry. This is all wrong and humanity's progress is marked not by
the advancement of these systems but their demise.

Today they subjugate people with the idea that behaviour patterns are an
illness. Anything which deviates from a robotic idea of a human being, a
child's idea of what a human being is perhaps, is considered mentally
ill. Extreme sadness is meant to be an illness as is extreme happiness
(mania). Unusual perceptions of reality are the result of a brain
dysfunction and not a gift.

There are extremes of consciousness and behaviour which Western
civilisations have sought to understand and suppress for generations. It
doesn't make these illnesses and it doesn't make the individuals
mentally ill.

We are all made from many things. Genetic predispositions and variances
encoded from our parent's genetic code. Our early learning in whatever
family setting and country we grow up in. Then our experiences in later
life interplay with our biology and psychology and our continuing life
experiences to make us who we are.

The truth is the application of psychiatric science could be used to
establish anything agreed with by the psychiatric hegemony was a mental
illness. This usually happens when the diagnostic criteria is updated,

It first started with the diagnosis and suppression of madness. It was
society which outcast us. It was psychiatry which incarcerated us. It
has continued to do that even with the liberation from the asylum
system. It still hides psychiatric crisis in hospitals and using the
chemical cosh, a powerful behavioural modification tool in pill form.

The drug affects areas of the brain associated with creativity and more
sexual partners. It subdues. It changes behaviour to an acceptable
automoton docility. It is a tool of subjugation in pill form handed out
by doctors.

It suppresses a type of people. It removes their right to exist with
ideas of capacity and insight. This clever trick means no schizophrenic
can say they are not ill and they have a right to exist. That
perspective would be symptom of the illness. They might have the same
thing to a homosexual in the UK in the mid 20th century. Or a black
slave two centuries before.

Drugged and excluded. Psychiatry and society's way to oppress the
mentally ill. They never thought that perhaps accepting that the human
condition includes strange, weird or even people you might not like
might be a better solution. Instead they do the job of a schoolyard
bully enforcing the unwritten laws of children.

Oh god I'm up

My first thought as I awoke

It's sort of funny

In truth I have a high expectation and a high ideal of what is medicine and what it is to be a doctor. That red cross on a white vehile is a target in a war but the convention, often upheld even when other conventions aren't, is those vehicles are not part of the war. They are proected because those men and women in them are healers. They are not part of the war. They treat people regardless of if they are friend or foe.

They are given that privilege because that's what good doctors do.

There are other ideals I have of doctors and that's what informs the rest of the length rants against the profession. They are better than what they achieve in psychiatry in practice. All laws are suspended because they're doctors. The medico-legal framework circumvents the basic tenets of crime, punishment and justice because doctors rule.

They're given all those privileges of autonomy because they're expected to live to the ideals of the profession.

First, do no harm. I think those use to be the first words any doctor spoke. In latin though.

Those are amazing ideals so in a bizarre sense all my rants are driven by the love of the ideal, and it basdardisation with things I have little time for when they're associated with the privilege or the paradigm of medicine.

Well...it's not funny really. Depends what your personal sense of understanding humour is like.

How inability to understand or agree with a behaviour become an illness.

Psychiatry's history. Religion explained and understood much of what psychiatry does and was the equivalent of mental healthcare pre-Industrial Age. Psychiatry uses medical science instead of god but is just as dogmatic.

Digital exclusion

Digital exclusion might be an alien concept to some. To me it means a new form of disadvantage and poverty.

Simply, people who don't use computers because they can't afford them or they don't know how to use them are worse off. Our world modern, for my generation at least, is all about computing and digital. I first experienced the internet over 18 years ago. Today it's become an essential part of my life.

The price of technology has dropped significantly. Netbooks offer enough to allow most users to improve their quality of life. They can use the WWW to find information, shop for cheaper deals, communicate for free with friends, find services, play games. read books and news stories, even publish their own works and all using a relatively cheap device.

The problem is the devices still aren't cheap enough. There are many poor people who may not be able to stretch to the captial outlay and running costs of even some of the cheapest options. The smartphone is becoming an viable option with the hope that a $100 Android smartphone will be released this year. As the sole way a person might access the internet the smartphone is limited because of the screen size and the processor on cheap smartphones but it allows access to computing with a lower capital outlay.

I already use the equivalent of a $100 Android smartphone. I use a T-Mobile G1 rooted with the latest Cyanogen Mod Android OS. It cost me £62 on Ebay and was a good bargain even by Ebay's standards. I get 3G internet access for £20 for 6 months on T-Mobile's pay-as-you-go tariff.

It allows me to do so much. Sadly it's a little slow for every day use but I'm used to fast computing. It serves the purpose of allowing me to read web pages and news stories, write and tag. I can use most webpages apart from those which use Flash. There are some excellent and very simple applications, for example the Pocket Auctions for Ebay, which are better than the website for most users. It has the significant advantage of a hardware keyboard but many people are satisfied with their virtual keyboards.

As you may gather I know how to live cheap. I also know about how to use technology. I've been using computers since I was a kid. I was a total computer geek. I wrote my first game (adapted from code in a programming magazine) at the age of 9 and wrote software for a European Space Agency project when I was 18. Other people don't have that sort of expertise.

This is another aspect of digital exclusion. Technology is something people can have a barrier towards because they have to learn. Their learning capacity is usually reserved for other things which they perceive have value to them whereas computing isn't. They have to learn and computers don't make a lot of sense.

The older generation, people who don't work in offices, people who work menial jobs with low pay, immigrants and asylum seekers, the mentally ill and the physically disabled, the homeless, the jobless....there are other groups too....could all be excluded from the advantage which digital provides to those who know how to use it.

This creates a disadvantage which doesn't need to exist. It's a disadvantage created by progress in technology but progress not designed for the human being. I think the smartphone will be the enabling tool to overcome the problem of digital exclusion not for the price, size, weight or power consumption benefits. I think the biggest hurdle for many people is the interface (as well as seeing the utility but that's something I'm explore in a bit).

A thought which resonated with me was spoken by a producer at the BBC. "I don't want to learn." It sounds like a horrible thing to hear as someone who likes to learn but I didn't take it that way. What she meant was that she can't be arsed with all the lack of usability which is common in new applications. She had an iPhone. They're amazing because they're so easy to use. There's very little learning involved and the benefits can be appreciated easier without the barrier of poor interfaces. It is the beauty of Google too. Their search engine homepage is exquisite because it is very easy to use and looks right.

People have better things to do than learn how to use the latest computer platform. Thankfully Apple are bringing out fantastic products with a high degree of focus on the ease of use. It's why so many people buy Apple products though they cost more. Windows by comparison isn't as easy to start using straight away until the more recent revisions of their operating system.

The smartphone takes it one step further. It is a consumer device now and applications are written for the consumer. The Pocket Auction for Ebay application is one of the finest examples of interface elegance. They've dropped a lot of the clutter of the main Ebay site and reduced the available features to those which are essential. Power users might prefer Ebay's own application or the full site experience but many people will find Ebay easier to learn to use through Pocket Auction for Ebay.

The impact

I've spoken at length now about barriers and this idea of digital exclusion. It's the disadvantage of barriers of cost and other factors such as fear of learning or poor interface design slowing the time to get to the benefits or not even seeing the benefits.

The impact covers many domains. I could only cover a few I can think of now. The impact may indirectly contribute to other factors in disability too.

Information
This is the force-multiplier (to take a term from the military vernacular for a technology or weapon of war which significantly increases the attack power of an army) in many areas of modern life. Knowledge and the dissemination of standardised knowledge was one of the core aspects where technology empowered the last major revolution in human civilisation, the Industrial Age. The printing press allowed standardised teaching. It was invented for religion but is used every day for teaching in schools, universities and other education establishments.

This is one of the reasons behind the One Laptop Per Child Project. In this blog post I'm talking about the Western world but the OLPC project sought to end the far greater digital exclusion in the developing world. The value of free access to information - mostly free written content available on just about anything available in seconds through a simple search of the web or Wikipedia - has benefits no matter how wealthy a society or how 'developed' the nation.

Being able to learn and have questions answered using the internet is empowering experience which some people can't get access to at all. It reduces what they can get out of this life compared to people who have the opportunity to access computing at home.

Shopping
Money is a major factor in exclusion of call kinds. People with disabilites, the disadvantages and otherwise financially poor have less choice, less freedom, die earlier, are more ill and generally have worse lifes than those who are moderately wealthy.

There are a number of factors involved in this and a significant body of research evidence behind the conclusions. One of them is the ability to buy cheap goods online. A person without internet access can't use Ebay. They'd have to use an internet cafe or a library. Access is not always suitable or secure in those places. They may not have the time to full research a purchase like a person with internet access at home could. They're also not able to keep regularly accessing Ebay without the costs rising because of more frequent use of public computing facilities. The key barrier is they won't be able to spend the time to learn how to use Ebay without paying for internet access at a public computing facility. These costs for people who are on state benefits, either the jobless or the disabled, are significant.

Ebay is just one place where people can buy cheaper goods online. There are many other goods and services which can be sourced cheaper using an internet search. There are websites dedicated to bargain hunting, for example Martin's Money tips or Hotdeals UK, and for people who get £50 or £60 a week those can make their money go much further.

There are other advantages. People with disabilities may not have high mobility. People who are poor or don't drive can't carry a lot so they can't take advantage of bulk buying heavy or large items; a person with a cat who doesn't have a car can't buy a few months of cat food when it's on promotion because they can't carry it. Online shopping and cheap or free delivery charges mean poor people can take advantage of these promotions to allow their money to go further.

Being able to consume more with the same amount of money reduces the impact of poverty. I've learned to live with less disposable income than people might believe. I manage to buy nice clothes because I get them second hand. I do the same for the electronic devices I buy. I bargain hunt. I scrimp on things which aren't of interest to me and save for the things I enjoy. Any large expenses are well researched and decisions made with a high onus on value versus performance (though I still buy good stuff sometimes).

It is all possible thanks to digital inclusion.


Other ways
I'm sure we can all think of other ways having regular access to a computer and the internet make our lives better and give us an advantage over someone who doesn't. Communication and keeping in touch is an obvious one. Isolation is often associated with negative impacts for some people. The exclusion which comes from experiencing symptoms of mental illness can be reduced through online communities and networks. Find your way around is easier so people can feel more comfortable to travel. News and blogs can be read. Books can be downloaded. Photos, music and movies too.

Fuck it. You can finish this one of yourself. There's a million and one ways in which digital exclusion makes life worse for those who are already disadvantaged by other factors.

These aspects of disadvantage can be fixed.

One step forward is cheap devices with suitable specification for basic needs and cheap internet access.

Another is better interfaces. And perhaps training.

Another is cheap or free public internet facilities.

There's an aspect which is about helping those excluded overcome the barriers and join us in the digital revolution. That's the sort of overall goal.

Knucking Futs: Street slang and schizophrenia

While hunting for another paper I came across this case study. It wasn't
what I expected. It's short and has an interesting exercise in how
without good understanding of the individual's culture and incorrect
diagnosis can be made. Admittedly the individual ended up with a
schizophrenia-like experience.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2151166/

What I take from this case is how this could be used by doctors to treat
what's called here the "prodome of schizophrenia" which is assume means
a syndrome before schizophrenia. The clinical argot can sometimes make
understand what they're saying in papers a challenge.

As doctors writing a case study they're focusing on the individual.
They've shown a rare degree of cultural sensitivity to determine what's
natural language for the patient and their culture before automatically
deciding the unknown words are a sign of what they call a pathological
process, a symptom of illness. Nonetheless they're looking just a
thought disorder and slang as though they're not interconnected.

Thought disorder and the creation of new words seems intertwined, though
psychiatrists would probably argue that thought disorder is definitely
pathological. It could also be a creative facet which is hard to control
at times. I sometimes get a form of tying dislexia or something.
Something which means I mistype words I know how to type. I once wrote
the word "spychaitry" by accident. The person I wrote to was a creative
coach. She saw it and didn't see a mistype. She saw a word that meant
spying on psychiatry, something which I sort of do in the sense that
read lots of papers and pick out information which people didn't know
about psychiatry.

This isn't specifically thought disorder. This is just an example of how
these vagries of creativity could be seen differently to people who
don't know what creativity was. This wasn't even two people formally
engaging in a creative process but an accident helped us both stumble
upon a word which was apt for a personal concept. Admittedly I've not
used that word.

I've used the word "automoton" frequently on this blog. It's a
neologism. There's a reason though. It serves as a perjorative word to
describe the opposite of the mentally ill, a concept which is often
(incorrectly) described by the word normal.

Thought disorder is an extreme. The authors of the paper haven't gone
into enough detail about what formal thought disorder is like though I
think the articule is enough to suggest that most diagnosis of thought
disorder is highly subjective if the psychiatrist is not aware of the
language used in the culture.

Thought disorder and other creative extremes are essential to the
creation of the slang of the street too. This may be schizoptypy rather
than schizophrenia. Schizophrenia is an extreme and society often
rejects extremes.

What to do with the information that a lot of psychological therapies aren't effective? (and a bit on mental health science) (research as a therapy) (and the need for more support groups)

Effective means they work better than the control group in a trial. For
medication this is a placebo pill. This doesn't have no effect. For a
number of reasons placebo pills work. Trials have even shown that
placebo antidepressants activate different areas of the brain to achieve
their effect. In psychological therapies there are forms of treatment
which are inert in any sort of science or form of therapy. The variable
tested is the mode of the therapy, for example Cognitive Behavioural
Therapy, and the comparison is something without a science or thinking
behind it other than offering social contact.

In high quality reviews psychological therapies fair badly. A high
quality review means a review of good trials. The data is taken from the
trials and averaged using the meta-analytic technique. This combines the
effects of lots of small studies and averages them to see the effect for
a large population. There are problems with this technique, namely the
individual trials can be different in their design so might use
different measures which mean they're measuring slightly different things.

Another benefit of the meta-analytic technique is the capability to
detect publication bias. This is another problem for the meta-analytic
technique. If you take an average but leave out some data then the
average will be skewed. Publication bias is when results, often negative
results, aren't published and this can make a treatment seem better when
it's not. A clever technique called a funnel plot can be used to quickly
identify the existence of publication bias. There's more on the
Wikipedia page on how it works. Essentially small studies have larger
errors than large sample size studies. Those will fall closest to the
average. The small studies will fall randomly above and below the
average. They should be evenly distributed unless publication bias exists.

How big is this problem? Well trials of antidepressants which include
unpublished data show SSRIs aren't as effective as once thought. In fact
a placebo pill comes very close - so close that the active treatment
can't be said to be effective. The Kirsch 2007 meta-analysis is one
example but there are others.

In psychological therapies in a meta-analysis which looked directly into
publication bias there was significant publication bias. It accounts for
about one third of the average effect size in the thousand studies
reviewed in this paper published last year or the year before in the
British Journal of Psychiatry.

Many reviews of high quality trials show psychological therapies to
offer small or no benefit compared to the interventions without a mode
or prescriptive teaching. A review which uses low quality trials and a
broad definition of what's been measured is not a good application of
science. There is a mega-meta-analyisis published in 2006 which shows
CBT to be effective for many mental illnesses but used these poor
application of science. It may have also suffered from bias in other
ways. One of the authors is a major proponent of CBT. A 2009 analysis of
CBT for schizophrenia which only included high quality trails showed a
significantly smaller effect to the point where CBT was shown to be
ineffective.

This measure of effect size and the idea of clinical significance is
also important. The levels required for an effect size to be called
clinically significant in mental health is much smaller than in physical
health. So the studies which show that psychological therapies are
effective have a lower criteria of success. It's my understanding that
an effect size of 3 or 4 is considered significant in physical health
treatment whereas 1 and above is considered significant in psychiatric
research. I'm not 100% on this. It was something I gathered from a
review of job satisfaction and physical and mental health.

The power of inert psychosocial treatments and placebo pills is high. In
the non-pharmocological stuff the theory is that it's social contact
which achieves the effect as well as variance in therapist qualities
which ameliorate the effect size shown by 'super therapists'. I also
think the research process is important by which I mean that being part
of a research trial has a positive treatment benefit on measures of
subjective well being.

Of course research can come in many forms. It can be in the form of
forms and tickboxes. It can also be face to face interviews. It's the
latter I'm talking about.

What I'm talking about is using face to face research as a treatment for
subjective well being. It offers the added value of the research
information itself. Unlike therapy the researchers have no aims but to
understand the person. They are not in contact with the healthcare team
and they are not their as professionals to do anything else but try to
understand the person. It's totally non-directive. The body of work it
produces is a study into the human condition.

This is a very small thumbnail sketch of the idea. The goal in this
thought process has not been to justify a significant study into the
human condition and people's lives in modern times. It has been a result
of pondering the problem of the small effect of psychological therapies
for schizophrenia. It's been over a year's work so it's a bit of a pants
conclusion that research should be used as a therapy for schizophrenia.
It's a mad oddball idea too. That's why I like it. It's a better
solution than what NICE are currently recommending and has significant
health economics arguments because of the added value of the research
itself.

My other suggestion is much more sane but might not get much support.
It's support groups. These have an even better health economics argument
to them because they're cheaper and they're also used as the controls in
trials of psychological therapies. Hundreds of these already exist
unsupported and unaided by the NHS.

The idea wouldn't get much support because patients might feel cheated
that they were being referred to a support group instead of a
therapists. Some people might initially be dissuaded from using a
support group because it's not socially acceptable. Therapists don't
like the diea of being put out of a job by untrained people with no
professional training, even if the evidence they don't want to read
shows that many therapies are ineffective when good scientific
techniques are used.

It is bloody cheap though. And the NHS are currently not offering enough
psychotherapy for people with schizophrenia (and probably bipolar too).

Truly I am an idealist but I reveal different colours when I come up
with ideas like this. My ideal is a solution, an effective mode which
can be selected as appropriate for the individual with a high degree of
success. What I mean is a more refined 'diagnosis' of individuality with
which to tailor a series of interventions designed around the person and
who they are. This would be done scientifically and with compassion in a
society which accepted people with schizophrenia as normal individuals.
Because they are.

But neither NICE nor the NHS think at that level. They think about
research and health economics and evidence-based medicine techniques.
And that's where this mad idea fits. The research one. Not the support
groups one. The support groups one is a good idea.

Kill the artists, said psychiatry!

Well. It's not quite true. Perhaps.

Schizotypy are traits asociated with schizophrenia. Creativity is one of them. Schizotypy is not an illness. It is a wellness. It's study is a rare example of psychosanology, the antithesis of psychiatry and a fundamental level.

Artists may not be valued, at least not the mad ones. Van Gogh never was and he was mad as a hatter. He was never successful in his own time either.

Thankfully he was spared psychiatry. He never was medicated with anitpsychotic medication, a medication which works to inhibit schizotypy behaviour. One of those is creativity.

These drugs are often used on artists for life. They reduce life expectancy but, even worse, they are designed to annihalte the being. The are the death of art and creativity.

They would kill religion too. Though they are careful when dealing with people with religious beliefs they use their chemcials to try to stop spiritual experiences and regulate people's interaction with their divinities.

The diagnosis of schizophrenia is spreading to cover at risk people. These people are those that show schizotypy traits as well as other behaviours and human experiences. They would rely on their favourite tool to cease the existence of the phenotypes. The antipsychotic.

Kill the artists, said psychiatry.

Evidence-based campaigns

When a study or report comes out it usually serves to reinforce a campaign or it is ignored.

That's the barren truth of campaigns and perhaps of campaigners.

I am thinking of something different. It's applying campaign techniques to important papers.

For example the result that in high quality trials ECT has no effect compared to placebo on followup.

There's more significance than simply the cessation of ECT, forced or with consent. There's the accountability for the crime against humanity.

Doctors can get away with some terrible things by using a simple "doh!" and I feel this isn't acceptable. There is clearly an error in psychiatric practice and evidence practices.

The worst and unrecognised wholesale slaughter in the UK was by doctors treating elderly patients with antipsychotics. They didn't need to. The symptms of dementia have been accepted for many generations. They allowed the possibility of their removal using a behavioural change agent. It was only after the study showiing life expectancy was halved then the susequent report from the RCPsych which estimated 1,800 unnecessary deaths were caused every year. This is significantly higher than the homicide rate.

In a sense this was an evidence based change driven by research. The fact is doctords got away with it and the change was not effected by a campaigning organisation.

I'm doing alright. Why am I fighting?

I have more choices in life than most. I don't get what I really want though. I've eschewed careers in finance and computing because I have a passion for something more.

I've lived a life of different privileges. I have learned a lot. I may be a cold, lonely drunk because of it but the learning experience was worth more than anyone can afford, or handle.

I'm still fighting. To my last dying breath. I used to be a rebel without a clue. I guess progress for me is not about wealth or status per se. It is about effect. I really hope I've earned the status of rebel without a cause. Not that I don't have a cause. It's just James Dean said it better.

"What are you rebelling against?"

To which I'll offer the summary which was his retort:

"What da you got?"

It's all relative though, ain't it?

Thoughts on utopia

This is obviously quite abstract thinking but it informs the direction of travel. In a way this is how dieologies and abstracts have power over time. Pure thought is always relevant.

Some might see the future as some technological heaven. I think they forget we're already there. Ain't that great is it.

I am sitting in a park writing this. Ducks circle me. I sit at the base of an oak which has been here far longer than I have had breathe. This is all possible with a mobile phone. To me, a person who thinks and writes and publishes, this is a future I couldn't have believed possible within a decade.

I have a desire for an independent lifestyle and my liberalism may be a factor. I believe utopia is societies and cultures which are for all. I believe it is not when humankind first reaches the moon which is our progress. It's when poor or disadvantaged, by whatever definition exists then, are living there too.

I believe utopia is not some paradise of an easy life. Hard though it is for me, suffering and struggle probably have an essential part in the progress of the human race. For many reasons.

if anyone else is this insane we need to work in harmony and without, in discourse and internal struggle. But there is no right nor no wrong. Just the ideals of utopia marred by our present conditioning. The exploration is all. No valuation.

Factors in overdiagnosis

Schizophrenia is meant to be a thing. It is meant to be definable and measureable. An individual who is not schizophrenic but is given the label is overdiagnosed by the labelling psychiatrist.

There is significant debate about what it is and what is the factor which makes it an illness. In fact the only factor is a biological componenet. In fact in an article on best practice for schizophrenia written by a Hong Kong psychiatrist they specify using brain scans. I didn't think this was possible yet because brain imaging in mental illness was not able to accurately identfy everyone. I'm not sure if it is a problem of over or underdiagnosis or both. I'm aware the problem is not there in neurological illnesses diagnosed using tests such as MRI scans.

Regardless of this the modern system is based on report of behaviour and understanding of patient communication by ther psychiatrist. Other factors are involved if a psychiatrist is doing their job properly, for example taking a patient and family history. Cultural and religious information are important too if making a high quality diagnosis which would have high inter-rated reliability was important in UK clinical practice.

It's not. Not in psychiatry anyway. The methods used by psychiatrists are borderline lunacy. One of them borders on using fashion sense as a diagnostic measure. I kid you not.

Every psychiatrist has a different understanding of what a diagnosis looks like. Many don't use the reference criteria. These are adhered to dogmatically in research studies but not in clinical practice.

What happens in clinical practice is rife under and overdiagnosis. It's all misdiagnosis the likes of which would not be tolerated in physical medicine.

Just one tiny example is how studies screen out patients with schizophrenia who have family members with schizophrenia when looking at clinical data. Though the evidence exists to show there is a hereditary/genetic component the pervasive knowledge of the effect in the psychiatric community has meant siblings of people with schizophrenia are more often diagnosed with schizophrenia when they shouldn't be. The results of the science have powerful effects on diagnosis trends, trends which shouldn't exist in real illnesses.

There are many other factors in this variance. A surprising result is a strong factor is where the psychiatrists studied psychiatry. After their learning period each alumini group continued the dogma of the individual teaching institution because at these institutions where psychiatrists actually spend time learning the stuff they learn isn't totally standardised. They don't stick to the research criteria's rigour in clinical practice and they're not taught standardised definitions of the concept.

And so onto the frequent overuse of the diagnosis of schizophrenia in black people and black men. They're also sectioned, drugged and forced into treatment than their white counterparts. This doesn't happen in their cultures native countries.

The model if schizophrenia has shifted significantly from the original biomedical one. NICE in the UK favour a stress vulnerability idea. They stick rigourosly to the standard model of pathologisation, one which I've ranted about in other posts. This model is meant to be robust to ethnic variation. At least PANSS is meant to be.

Psychiatry has accessed of being racist because of the disproportionate use of extreme treatments on black people. But many white psychiatrists reliably diagnose schizophrenia and concur with black psychiatrists.

These diagnoses wouldn't be concurrent with what a black or white psychiatrist from the Caribbean would diagnose and there is a reason.

Individual social learning is important in mental health. It's important to the mentally ill but an unrecognised importance is that of the person giving the label, the person who makes the judgement upon someone else's sanity and individuality's abberance.

By social learning I mean what we come to know from the environments of our growth. The cultures where we went to school and hung out. The people we met in life. What we learned about people from the people we've met in our lives.

Ask yourself? How do you come to experience people? How do you label them? What factors do you apply based on your own norms?

These social judgements are nothing which doctors should have anything to do with. Their meant to be bound by an oath of do no harm first. Medicine is not here to empower the whims of temporary fashions of behaviour as judged by some dominant clique.

That litte segue was me taking a little breather from what's an important point. A small rant to provide a little background to inform the relevance of what I'm trying to say.

Psychiatrists are doctors. This means they need to get into medical school. They need to get good grades and excel. They often to go private schools. They often come from rich, sheltered backgrounds. Those rare ones from poor backgrounds who make it as doctors are usually insanely driven and have no life.

As a group they live protected existences for their lives up until getting to medical school. It gets worse there. They are unlikely to see any black people. Especially at Oxford or Cambridge.

What's worse is those few black people and the lots of brown people they do meet are coconuts. This is a dereogatory term I am comfortable with. It is a person who is Westernised and far from their cultural roots in behaviour, norms and beliefs.

They never meet black, brown or people of any other skin colour from the ghetto. Not unless they do drugs, but that's a whole nuther story.

I've lived an unusual life in diverse communities. What I mean is my social learning is surprisingly high given my lack of social graces. I have experienced a privilege of wide experiences of people and cultures in the UK.

This social learning means I see a problem or the reason for a problem.

I'll be blunt. Much of the overdiagnosis is based on risk. This translates synonymously with fear of the angry black man or person. This isn't about racism though.

I have no fear of psychiatric patients just as I have no fear of black men and their hostility. I have had the privilege to live in poor areas where Afro-Caribbean (ugh. I hate that term. Propaganda bullshit.) Eastern European and Irish people live. I've seen aggressive people regularly. I've got no fear because they're of no harm to me. No more than any other person. They may be intimidating or look hostile but they pose no risk unless you give them a good reason.

I've met some very ...criminal people mostly in my youth. I never got involved in it but I learned about what poor people are like. They're more basic in many ways and it can be a quality. They still have the part of humanity which survives from the Savannah plains to the urban jungle, a mentality devoid in many affluent people who end up having kids who become doctors and psychiatrists.

The overdiagnosis problem in part is because psychiatrists lack the wisdom of having lived a full life with expansive social learning from the university of life and the school of hard knocks.

Me? I 'as got me PhD from there. Innit.

Thoughts on external flashes

Many amateur photographers eschew the external flash. Some do it on
principle. They chose to shoot only using natural light.

Professional photography is also about light and an external flash used
well is an essential part of their arsenal. Some use a few external
flashes to create studio-quality lighting setups on location. Others use
flash to soften shadows or to create interesting light in poor situatuions.

I admit I tend to shoot without flash most of the time. Natural light is
usually the best. Live music photography demands shooting without flash
to catch the interesting colours and the venue lighting's effect. There
are venues when even fast lenses and high ISOs aren't enough but the
photographer still needs to get the shot so flash is the only option.

Flash light can also be used creatively. One of the effects I
experimented is in the mode of light painting but uses tricks with the
lens. Using an external flash and a slow shutter speed I can create a
zoom blur effect by carefully zooming the lens while the shutter is
open. I went a bit further and tried rotating the camera while zooming
with the shutter open which produced highly unpredictable but
interesting and unusual results.

On a practical level an external flash is essential because most of the
photos required for paid work need well lit faces in difficult lighting
conditions. They can be wedding shots or corporate events. They all need
sharp shots. There's scope for artistic shots too but there's what the
customer expects which needs to be delivered upon. Sports and
photojournalism also require a flash. A flash bathes the subject in
light and ensures enough light to use lower ISO settings.

For commercial photography a flash is a must. There are a few options.
As always the manufacturer own-brand offers the best option. A Canon
580EX MkI, a flash I've owned, is very useful. It's powerful and can
zoom the flash in sync with the focal length of the lens. It connects
with the camera metering systems to offer superb flash metering accuracy
in the right hands.

The key advantage of any external flash is the tilt and swivel
capability. This allows the photographer to bounce the flash of other
surfaces. Direct flash is why flash photography gets a bad name. It
doesn't look right. Indirect flash, for example bounced off the ceiling,
can give a soft quality to the light. There are tricks to it, for
example recognising the colour and texture of the surface which is used
to bounce. Dark surfaces eat flash light.

When using direct flash external flashguns have an advantage over camera
flashes because they have larger flash areas further away from the lens.
The distance from the lens reduces the problem of red eye and the larger
area for the flash offers smoother light. There are many aftermarket
flash adapter devices which can soften the light even further, for
example portable softboxes for off-camera flashes.

A major advantage of an external flash is power and, for professionals,
fast recycle time. Power means a flash can reach half way across a
football pitch with a good lens and a moderate ISO. It means high
ceilings can be used to bounce the flash light or dark surfaces can
still be used to reflect flash light. Recycle time means the time
between flashes. The recycle time is important whether using fill in
flash during the day and rapidly shooting to ensure the perfect
expression or moment is captured or shooting live action sports and
needing that fast flash keeping up with the camera's fast shooting speed.

Some flashes feature a very useful ability - high shutter speed
synchronisation. This is usually only available on manufacturer branded
flashes, i.e. only Canon flashes on Canon cameras have this feature.
There is one exception from the independent manufacturer Metz and this
was released a few years ago so more independent manufacturer flashes
may have this capability too but it is standard with the own brand flashes.

All cameras have a maximum flash shutter speed. This is in the region of
1/200s and above on modern cameras. It sounds pretty high but modern
cameras have shutter speeds in excess of 1/8000s. To get these
ultra-high shutter speeds the shutter operates a different way.
Essentially rather than a single shutter moving across the film plane
the camera creates a window moving across. This window moves quickly but
flash light happens in the region of 1/50,000s and faster so only a
small part of the frame exposed by the moving window shutter will be
exposed by the flash.

The high speed sync system fires the flash repeatedly very quickly to
ensure the moving window is exposed evenly as it moves across the
film/sensor plane. It relies on the cmaera and the flash electronics
talking to each other. I think there was the problem that camera
manufacturers charge a lot to get the specification of the communication
system. The independent manufacturers reverse engineer the signals but
can't work out what the internal system is so when camera manufacturers
change it the advanced features stop working. Metz have overcome this
with a flash gun which can connect to a computer if the
software/electronics needs to be upgraded. It uses an EEPROM or an FPGA
or something so when the brand communication system is updated it can be
updated too.

As always price is a large factor in any buying process. I bought the
Canon 580EX MkI in a shop for about £350 a few years ago. It's a very
good flash. It has all the features and it's also very easy to use in
real world conditions. The minor problem with it is weakness in
construction and It broke at one point. Luckily the extended warranty
paid for a replacement. The 580EX Mk II is an excellent flash with all
the bells and whistles but it's very expensive.

The 4xxEX series offer many of the benefits with lower power and recycle
time. Offerings from Metz also compete because they offer all the
features of a Canon-brand flash. Some of their older designs and those
of Sigma don't offer high speed flash synchronisation. This may seem
like a minor problem but it's big one for commercial photography. There
are days when the sun is very bright so fill-in flash is essential to
reduce the harsh shadows. For portraits a wide aperture may still be
desirable to put the background out of focus but this is unattainable
even at the slowest ISO because the of the limited shutter speed without
high speed synchronisation. This is probably the only use I can think
of: soften shadows on bright days. It's useful for sports as well as
weddings and outdoor portraits. It means full control of aperture and
light is possible.

The Sigma flashes are considerably cheaper than the Canon ones. Their
flashes can compete with Canon's flagship in most aspect for the price
of a mid-range model like a 4xxEZ-series flash. They lack that one
quality of being able to be used in any lighting conditions. That's it.
The value of this is quite high though for photographers who know how to
use fill in flash to make take shots and how flash is useful for certain
applications.

For some people a cheap Sigma flash would offer a signifcant benefit to
their photography. The option to bounce the flash off surfaces makes for
much better flash light. It can also be used with much more creativity
than the flash units built into cameras. They offer a lot of value.

The one thing they don't offer is what the pros want. The little things
like recycle time make a difference. The better controls on the 580EX
make it a pleasure to use. The possibility to use the flash in all
situations where it might be needed means high speed flash sync is very
important and worth the premium. Metz now provide an alternative which
has better build quality too. There will be fewer available on Ebay than
the Canons. The professional models also offer other options, ones which
I've rarely used, such as stroboscopic flash. For creative photographers
these features offer new opportunities to experiment.

Further information on this extensive webpage
http://photonotes.org/articles/eos-flash/#controlling

And part 2
http://photonotes.org/articles/eos-flash/index2.html

Some information on Canon's range
http://en.wikipedia.org/wiki/Canon_EOS_flash_system#Speedlite_products

The cheapest alternative from Metz with high shutter speed synchronisation
http://www.metz.de/en/photo-electronics/product-families/system-flash-units/mecablitz-50-af-1-digital/product-information.html

New ones with high speed sync
http://www.dpreview.com/news/1008/10082005metz58af250af1.asp

Measures are importand as are language and concepts

If you tell a lay person it is an antipsychotic their expectation, like any other learned person outside the field of endeavour, is that it removes the delusions and hallucinations of psychosis.

If this is not true then the use of the term is highly inappropriate. As is the use of the drug.

The neuroleptic was commonly known as a major tranquilser, a 'medication' which did not function to heal true biological differences but to effect behavioural change. In the modern day where the word antipsychotic is used to describe the major tranquiliser there is another; the chemical cosh.

The fundamental point is about words and language and concepts. The antipsychotic is not about reducing the aspect which patients want and the public percieve. It is a tool driven by the power to sedate.

It may or may not have a significant effect compared to placebo responses but no review of current data is available. It is possible without a new experiment though things like these ultimately answer scientific questions.

On the question of whether the antipsychotic actually, definitely reduces the delusions and hallucinations themselves or merely sedates the individual into a conveient form of limited expression is an important question for patients, and I hope doctors too.

To the doctors I will explain using evidence which may be questioned if you are critical of evidence. A study which showed life expectancy in elderly people with dementia was reduced by 50% when antipsychotics were used shows a powerful effect but as an observational study it explains little but the existence of the effect. The criticisms which can ameliorate the effect are to do with selection of patients to get antipsychotics. Their behaviour may have been the result of a more advanced stage of a neurodegenerative illness. The effect has high sensitivity because patients were near death too. The untranquilised lived 3 years on average. The medicated 1.5.

An obvious review which needs to be done

Right. I've had a few beers and smokes. Bear with me.

PANSS and BPRS are two of the measures of effectiveness of treatment in trials for schizophrenia. Only one of the measures within those supra-measures is delusions and hallucinations.

I think so anyway. I have to double check PANSS and check BPRS.

This idea may be obvious to a psychiatrist wh understands the multifaceted treatments and what they actually achieve based on the research evidence.

It's a guess on my part and perhaps their part that if a review of trials was done which drilled into the measures to pick out the sole measure patients who accept psychiatric treatment for mental illness want - the reduction of the specific symptom of hallucinations, delusions or alterntive experiences of consciousness - it would show consdierably less effectiveness to the point of insignificance comapred to placebo.

Why I'm so sure is I've read two stufies which I'm sort of join together as an effect. Medication works on a biomedical model backed by placebo controlled high quality studies. One piece of evidence is clozapine, the most dangerous psychiatric medication, only reduces the delusions in some patients. This is from a qualitative paper, hence the quantification using the word sum, written by the company which makes the drug and was published in the British Journal of Psychiatry.

The other bit of evidence is the Rosenthal study into expectations and teacher effects. What I took from the study is not what's commonly known. What's disseminated about this study is the author's conclusions. The effect of telling teachers kids were smart made them smarter. This is true. Except in older kids in the study. They seemed to be indifferent to this effect.

What if the effect on delusions is not what's achieved by major tranquilisers. What if this effect is only achieved by the effects of expectation by doctor and patient? What if it is a placebo effect and the sole purpose of 'antipsychotic' medication is to subdue a person to remove behaviour rather than treat the concept people know as psychosis?

And where are my chocolate salty balls? Oh. Sorry. Firmly in the mouths of the RCPsych.

I remember childhood depression and perhaps SAD

For about 9 or 10 months I worked as an assistant engineer at the National Remote Sensing Centre on a European Space Agency satellite called ENVISAT. I was 18 years old and got the role through the Year In Industry gap year scheme.

I worked far away from home. All the rest of my friends were at university. When I started I used to travel from home. It would be pitch black at 5am when I woke up and pitch black at 7 or 8 when I got home as the winter months set it. I moved down there for a couple of months but it was even worse than the commute so I moved back to this punishing routine.

I remember walking home in darkness, going straight to my room and putting some music on. I would sit in there only lit by candlelight. I would cry but for no reason. I'd shut myself away and cry then get out of my room and put on my mask of normality.

It used to feel bad in ways which are different to now. In those days that was just normal. I didn't even see it as misery let alone an illness. I went to posh schools and they teach resilience. The pain was something I accepted and continued to function. There were thankfully low expectations of an 18 year old but I exceeded them beyond their expectations.

I never felt suicidal. I never contemplated it. I just got through every day. I found my release back then was music. My only luxury was going on a Friday night to the record shop and buying the latest releases when they had just come out. Then i'd go home and listen to them on my own.

I didn't no any different. I'd lead a sheltered childhood till being thrown out of how briefly at the age of 15. I'd spent two subsequent years at boarding school. I'd done another job before helping a researcher sift through medical data. This was my first proper job though.

My dad had done a similar routine most of his working life. When I was growing up he worked his arse off to give me a good education. He used to rise at 5 or 5:30 and return at 7 in the evening or later. The poor guy had one luxury to get him through it all. He drank Johnnie Walker Black Label. he medicated through years of misery the likes of which I briefly tasted when I was 18.

He's a GP.

Are good photographers obsessive

Yes and no. There must be some who aren't but the attention to fine detail and perfectionism required of professional photgraphers means the photographers naturally obsess.

I've spend a long time thinking about the value of an f2.8 lens. The value is beyond the premium except when getting the shot is a priority. Sports photographers spend several thousands on digital SLRs which meet this need and if they're not good enough they change brand. Sometime the perfect light and moment appear briefly and if the camera or the photographer are too slow the moment's missed.

There are little things about the equipment which might not make sense to average users. Another thing I'm thinking about is high sync flash. What this means is an external flash can be used at any shutter speed. In practice this means flash can be used in daylight to soften shadows. Really that's the only purpose - total creative freedom no matter what the situation. The problem is it's a small difference in apparent and real value for some forms of photography. Live music photographers rarely use flash.

Spec-ing a photographers desktop PC

I've already written a post about this so I'll summarise the information.

Photographers have unique requirements for a desktop computer setup. Computing is now an essential part of the photographer's standard equipment. The desktop, for many, has been replaced by powerful laptop machines however these are not able to offer the performance or the specification for the perfect professional machine.

Image quality
Performance is in different areas. One of them is image quality. No flat panel screen at a reasonable price can beat the quality of output from an old cathode ray tube (CRT) monitor. These are large but even the cheapest ones offer superlative image quality required for professional work.

Of course a large screen monitor is useful too. I'd suggest a dual screen setup with a large flat panel and a CRT. The CRT is used to see the whole image - a feature easily achieved in most good photo editing packages. The large screen can be used for the detail work and where all the tool docks are shown. Good quality, large CRT screens are pretty cheap second hand though delivery is expensive. Over the years some may have lost the quality of focus. Their image quality - colours, contrast, resolution - will still usually be excellent. A modern flat panel with a 14" CRT makes a lot of sense though.

Large widescreen flat panels have dropped significantly in price. There are three technologies: TN, PVA (and the variants) and IPS. The are increasingly more expensive going from TN to IPS technology and in quality too. Large OLED monitors are not a commercial option. The three TFT technologies have dropped a lot in price and the quality of commerically available TN screens has risen significantly using colour profiles which can adjust the graphics output to counter the problems of TN screens. With the added bonus of a CRT screen a 24" TN-type panel with a 14" CRT screen provides a good value option. A PVA screen would be a better option but the differences are small. The price of these has also dropped significantly. IPS screens are still a significant premium and they're the benchmark for high end screens dedicated to photography, video and 3D.

Calibration is also important. This can significantly improve the value of a screen. The CRT screen provides an exceptionally high quality output however a custom calibrated flat panel can perhaps beat the quality of a CRT screen. It can come very close anyway. Calibration is signifcantly more expensive than a 14" CRT screen though (note the viewing area of these screens will be about 12").

One feature often little considered is the graphics card. Most people would assume that a fast graphics card isn't required for photography work. They're right. Even integrated motherboard graphics cards can handle the output of image manipulation. What people don't know is there's a difference in image quality between different cards. There's no way to measure this and it's rarely discussed in reviews of graphics cards.

I stumbled across this when I had two graphics cards installed in my system. One was running a cheap but modern graphics card from a little know brand. The other was an ancient Matrox Millenium.  People may not recognise the brand any more but a decade ago they were very well regarded in the graphics card industry. This was in the time before people considered 3D processing a reason to buy an expensive graphics card. The Matrox cards were designed for image makers. They offered other features like inexpensive access to two monitor setups with one card - something which is standard today. Hooked up to the same monitor the Matrox displayed significantly better image quality across all domains. It was a clearly visible difference which anyone could see.

This reason alone is why Apple are good computers. Though they don't offer the choice of components or the ease of tinkering with the hardware as well as being significantly more expensive they're worth it if you don't want to have to know which graphics card offers the right quality. Their monitors are a significant premium over other equivalents too. It is possible to make a £1,500 non-Apple computer setup which would perform about as well as a £4,000 Apple setup and offer other benefits.

Computer spec
The chips in desktop machines are faster than laptops and importantly they can be overclocked. This is a way to get more performance out of the same processor. Given how quickly processor prices can rise with increasing speed the option to overclock a chip quickly becomes a money saving solution. Photography doesn't need ultra-fast processing like 3D or video which can benefit from multi-processor and multicore designs. Dual core or processor is the maxium requirement and an overclocked low-to-mid processor should be enough for a year or two. It can also be replaced by a faster processor next year which offers much better value.

RAM, of course, is important for easy editing of multilayered high resolution files. Modern file sizes are massive. RAW files are 25MB+ from my Canon 50D and something like the 7D will output even higher quality files which need more RAM. I like to step up my RAM gradually and this is much easier with a desktop than a laptop. Quick RAM is useful for overclocking and can offer small speed benefits too but it's important to chose carefully because some of the more exotic forms of memory don't offer significant benefits for photography applications.

Someone who's used consumer cameras and consumer photo editing software may not have experienced a need for a quick processor or lots of RAM. In professional digital photography the file sizes and more demanding algorithms which offer the highest quality output and maximum control mean a decent processor is required. The images from a professional digital camera aren't just higher megapixels. The files have more detail and much wider dynamic range. They're usually processed from RAW - the digital negative - rather than JPEG. Professional photographers spent a lot of time working with the filters, tools and controls offfered in programs such as Photoshop or GIMP. There's a lot of tweaking involved and this can mean rerunning a filter. One of my favourites, selective guassian blur, can take 15-30mins to run on a laptop.

Keeping data safe
Apart from performance there's one key aspect of the design of a content producer's PC: the disk system. I've had 3 hard drives fail in my years of computing. That's three too many and I lost a lot of important data. It's very expensive to recover data from a disk where the head has crashed. RAID is the primary solution for people who use large files and lots of them. These can use many disks with one to protect the data from a single drive failure. These systems are available in ultra-highend laptops but come as standard on good motherboards. They're often no implemented on consumer or even standard business PCs because there's little demand for them or knowledge about them. The system is used in any server worth its salt. Not just for better reliability and fault tolerance but because it can offer more speed too. A few disks are relatively cheap and can create a work area which will last for a couple of years of digital photography.

I think 3 or 4 1TB disks in a RAID 5 configuration should be enough for that requirement but 2 1TB disks in RAID 1 (mirroring not striping) would suffice at a push. It sounds like a lot of data but I shoot RAW and use the highest quality for all my processed image files. A 16GB card on a modern camera can quickly fill up on a day long shoot. I don't waste a lot of time clearing out old photos. I like to go back to them and work on them again. I need a very large hard drive for that workflow.

On top of this there also needs to be geographical backup which for most people means backup to an online server. I used an Idrive account to backup all the uncompressed JPEG versions of my best images. If my computer is stolen or the house burns down my images are still safe. For people who use their computer for writing documents or anything which has small file sizes the Idrive solution is enough. It's easy to use and it's free. The information is stored on their computers and can be retrieved with the right details from any computer just like web-based email.

Peripherals
A keyboard and mouse are obviously essential but a graphics tablet can be a very useful addition. It makes editing the image a lot easier though I've learned to get by with a mouse and even a trackpad. The computer forms the basis of the photographer's lightroom and it still requires good physical tools.

Obviously a memory card reader, a few USB ports (and Firewire can be useful too) and wireless are important. These are cheap or come as standard.

Budget
It's possible to build a bespoke photographer's PC for about £1,000. £1,500 would be optimum. At a squeeze one can be built for £800 with all the above considerations taken into account. A £1,000 PC with a £500 investment in upgrades over a two year period would be suitable for professional photography at the lower end though £1,500 with £1,000 spent over the next two years would be better with cameras offering really large files and for photographers used to compositiing several images together, using focusing stacking or HDR techniques.

A laptop is yet another necessity for modern professional photography. More on that in another post.