UK jury-based law courts are unjust

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

And yet is that something that should be to treated?

I think that's a post for another day.

The development of tests in mental health

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

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

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

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

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

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

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

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

A note on the mental health system 2 and religion

or perhaps mental health system 3.

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

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

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

some notes on a conversation about mental health

This is part of a fascinating conversation last night.

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

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

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

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

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

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

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

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

(need to find the reference for this)

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

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

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

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

Its a bloody interesting thing eh?!

The argument for the denial of the right to mental illness

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

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

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

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

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

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

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

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

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

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

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

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

Native American mumbo jumbo doesn't get around that.

People have a right to be mentally ill

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

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

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

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

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

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

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

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

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

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

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

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

We have a right to be mad.