CBT doesn't really work much and science in mental health

Lynch, D, 2010, Cognitive behavioural therapy for major psychiatricdisorder: does it really work? A meta-analytical review of well-controlled trials, Psychological Medicine
http://journals.cambridge.org/download.php?file=/PSM/PSM40_01/S003329170900590Xa.pdf&code=b62ffa4b898268608a9e7b504bdd5319

Cognitive behavioural therapy - changing the way people think and behave by using talking techniques from therapists - doesn't really work according to this high quality review.The review uses a different inclusion criteria to the 'mega-analysis' which is often used to show that CBT really does work.
Butler, A. et al. 2006, The empirical status of cognitive-behavioral therapy: A review of meta-analyses, Clinical Psychology Review
http://www.sciencedirect.com/science/article/pii/S0272735805001005

So which one is true? The massive review (the 2006 one) which includes loads of papers but has a weaker inclusion criteria and, if I remember right, doesn't include a funnel plot or the smaller review of higher quality trials (the 2009 one at the top of the page)?

I'm afraid it's the one of controlled trials. At least based on the current paradigm of evidence based medicine. Blindness is so important.

The double blind randomised controlled trial gained success when it showed insulin shock or insulin coma therapy to be as effective as other treatments at the toime for...think it was schizophrenia. At the time
the insulin treatment was considered best practice around the world but the introduction of random assignment to the control or active treatment group showed that, in fact, it wasn't the best treatment.

Time and again it's the reviews that select the highest quality trials which show treatments thought to work suddenly don't. The recent noteable example is electro-convulsive therapy or ECT. This barbaric
treatment is what I hope is the last in the line of psychiatric treatments which induce seizures. The history of inducing seizures to treat mental disorder can be traced back to the work of Hippocrates who
notices paitents who had malaria seizures also had behavioural changes. The recent Bentall and Read review on ECT picked high quality trials with long term follow. This treatment of last resort was shown to be as
effective on follow up as sham ECT (where no electricity is used to shock a person into a seizure) and slightly more effective during treatment.
http://www.mindfreedom.org/kb/mental-health-abuse/electroshock/ect-review-2010-read-bentall.pdf/view
(Link to paper at the bottom of the page.)

Many, many people have died because of this treatment. Some people who've had it done are major advocates of the treatment. This presentation on TED is an example.
http://www.ted.com/talks/sherwin_nuland_on_electroshock_therapy.html

The speaker may have gotten the same benefit from sham ECT and less damage to his brain.

And so back to CBT. The controls in the trials are as effective as this new dogma of treatment for all but depression where the evidence for it's effect is small. The effect size is far below what got the Improve
Access to Psychological Therapies scheme approved.then factoring in publication bias...that demon of good
research....which is the effect of trials with negative results being hidden...well it knows off about a third of the effect size of CBT studies.
http://bjp.rcpsych.org/content/196/3/173.full

In a sense it's saddening that there's few effective cures for mental disorder. Perhaps it's all the hedonic treadmill.
http://en.wikipedia.org/wiki/Hedonic_treadmill

Or perhaps it's the operational cluster of symptoms approach doesn't provide a good way to assign treatment to diagnosis?

Waterboarding as psychotherapy

http://psychiatryandhistory.blogspot.com/2009/05/waterboarding-as-psychotherapy.html
"
While we are properly horrified to learn about the use of deliberate near-drowning (waterboarding) as an interrogation technique, it is worth noting that for a period of nearly two hundred years the same procedure was regarded as a form of psychotherapy. The influential seventeenth century physician Jan Baptiste Van Helmont (1580-1644), originated this treatment after observing that a madman, who was revived following an accidental near-drowning, was relieved of his mental symptoms. The most influential eighteenth century physican Hermann Boerhaave. (1668-1738) mentions the use of submersion in the treatment of insanity but recommends it for only the most desperate cases. Boerhaave's student Jerome Gaub also discusses the treatment and attributes its efficacy to anxiety. "The most deeply seated mental defects and the most incurable forms of madness" he writes, "may sometimes be rooted out by anxiety." Perhaps, he speculates, this is "because the tormented and frightened mind is revived by the terrible punishment of her greatly depressed senses…." He cites "men with minds held captive by the violence of love or grief," who recovered their soundness of mind when revived after accidental near-drowning. He insists that the cause of this recovery is the "frightful torment that near loss of life from suffocation inflicts on the mind." Gaub acknowledges that "submersion therapy" is "a terrible remedy" but adds that it is "one hardly to be exceed in efficacy." Gaub took the trouble to attempt a medical explanation of "submersion therapy." He argued that "submersion therapy" worked by provoking anxiety, which he understood as a powerful emotion caused by bodily changes. The most frequent cause of anxiety, he felt, is interference with respiration, which hinders the passage of blood through the lungs and thus places life in jeopardy. These bodily events affect the "common sensorium" [where mind and body meet] so as to excite ideas in the mind that cannot be contemplated without horror and cannot be dispelled. The value of such shock therapy was widely recognized in the eighteenth century. "In mania," a Montpellier doctor wrote in Diderot and D'Alembert's encyclopédie, "therapy is directed to the body, in which it aims to produce a shock and a deep disturbance ." Such ideas even influenced Philippe Pinel, who cites Van Helmont. Although Pinel did not use "submersion therapy," he did include the role of powerful emotions like fear in dispelling fixed ideas as a component of his moral therapy.
"

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.

A rant on the motto of the Royal College of Psychiatry

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

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

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

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

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

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

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

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

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

or

"The legal drug dealers."

Or perhaps you can think of something more snappy?

Add them below in the comments box

Psychosanology, psychopathology and genius

Geniuses are invaluable to society. They are the diamonds amongst the mass of coal. They stand out in history because their achievements significantly impact the consensus. They are always different and original, though this may be a factor of recognition as much as difference (geniuses that work within the construct and impact it significantly but within the paradigm of consensus thought, systems and methods may be less likely to be recognised in history). Their value to society is without measure.

But they are usually mentally ill. Geniuses show the traits of a number of psychiatry disorders. Different ones in different catgories and to different levels of severity. It may be that their eccentric behaviours are allowable because of their talent but it is probably that their eccentric behaviours are part of their talent.

The loneliness of genius may be a factor. It takes a lot of time working and usually working alone for the work of genius. Perfectionism can lead to depression, anxiety and low self esteem however it is a necessary trait for certain areas where genius is expressed, for example in art. The dogged pursuit of their own ideas in the face of the consensus truth is almost a personality disorder in itself.

Upon diagnosis using the cluster of symptoms approach of modern psychiatry the behaviours, thoughts and moods become treated. This is the paradigm of physical medicine. An individual might therefore recieve medication or psychotherapy or another form of therapy. These will solve the illness, but will they spoil the good.

Very simply put the question we are discussing here is whether good things comes from bad things or bad things have a purpose.

Can the experiences that are pathologised by psychiatry have importance and value. Could treatment of the experiences observed by psychiatry to be illness and unwantd be part of genius? Could treating these experiences, changing them and reducing their intensity, without understand of their purpose and potential be detrimental and inhibit the development of indivudals, society and civilisation? Could psychiatry be reducing the production of better people through life's experiences? And is that also true of human compassion in general?