Electronic Letters to:
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eLetters: Electronic letters published:
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Wake up or change?
- David Kingdon (2 July 2008)
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No easy answer
- Adarsh Shetty (17 July 2008)
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Vision for the Future, not harking back to the past
- Christine M Vize, list of 26 authors of all professions including service users is too long for this box please email me for it (17 July 2008)
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One cheer wake-up call
- jeremy a holmes (17 July 2008)
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Wake-up call for British psychiatry
- Walter M Braude. MD, FRCPsych, Andrew F. Blakey. MRCP, FRCPsych (17 July 2008)
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PTC response to Wake-up Call
- Ollie White (17 July 2008)
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The keys to a successful outcome
- Martin A. Gee, Gillian L. Rees (17 July 2008)
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Wake-up call for British psychiatry
- Peter L Cornwall, Angus Bell, Joe Reilly (17 July 2008)
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Psychiatry was broke - people are fixing it
- Phil Barker, Poppy Buchanan-Barker, Fran Biley, David Cooper, Phil Cooper, Lawrie Elliott, Alec Grant, Hugh Masters, Hugh McKenna, Shaun McNeil, Miriam Morgan, Steve Onyett, Richard Peacocke, David Pilgrim, Mark Radcliffe, Shula Ramon, Angela Simpson, Peter Wilkin (17 July 2008)
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A new anti-psychiatry movement?
- Derek B Dickson (17 July 2008)
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Re: A new anti-psychiatry movement?
- Louise Pembroke, Peter Campbell, Roberta Graley, Shaun Johnson, Louise Pembroke, Sara Stanton, Catherine Tate, Andrew Wetherall (30 July 2008)
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A medical student's perspective
- Rhiannon Allen (30 July 2008)
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Interim response from authors
- Nick Craddock, Co-authors of Wake up call artilce (30 July 2008)
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Re: Craddock et al - Wake Up Call for British Psychiatry
- Duncan Double (30 July 2008)
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Against Psychiatric Fundamentalism
- Andrew E Blewett (30 July 2008)
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One junior trainee's response...
- RJ Stamatakis (30 July 2008)
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Re: Wake-up call for British psychiatry
- Alejandro Corsico (30 July 2008)
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Psychiatry has more than medicines to offer
- Michael J Smith (30 July 2008)
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Getting Back to Basics
- Mark Agius (30 July 2008)
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Wake-up call for British psychiatry : a response to Craddock et al
- David Cunningham Owens, Eve C. Johnstone (31 July 2008)
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There’s more to psychiatry than medicine
- Joanna Moncrieff, Carl Beuster, Jonathan Bindman, Pat Bracken, Tim Calton, Miles Clapham, Rachel Freeth, John Heaton, William Hopkins, Rodhri Huws, Bob Johnson, Kwame Mckenzie, Jeyapaul Premkumar, Philip Thomas, Charles Whitfield, Michael Crawford (31 July 2008)
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Wake-up call for British Psychiatry
- Colm McDonald (31 July 2008)
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Wake up call - Who can take the responsibility?
- Karthik Thangavelu (31 July 2008)
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Making the biomedical case
- David Yeomans (1 August 2008)
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Wake-up call
- Jed Boardman, Michele Hampson, Consultant Psychiatrist, Queen's Medical Centre Nottingham (1 August 2008)
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Time for the College to act!
- David J Nutt (1 August 2008)
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Trainees' perspective
- Andrew C. Stanfield, Benjamin J. Baig (21 August 2008)
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Is Psychiatry a Medical Discipline? An International Perspective
- Johannes Thome (21 August 2008)
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Wake-up call for British Psychiatry
- Leon Rozewicz, Dr Paul St John Smith, Consultant Psychiatrist, Hertfordshire Partnership NHS Foundation Trust (21 August 2008)
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Change for the sake of change?
- Sameer Jauhar (27 August 2008)
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NWW: New Ways of What?
- Mamdouh EL-Adl (27 August 2008)
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A Primary Care View
- Alan Cohen, Andre Tylee and Chris Manning (3 September 2008)
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Re: Vision for the Future, not harking back to the past
- Christine Vize, see below (24 September 2008)
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wake up call for British Psychiatry
- Kamini Vasudev (24 September 2008)
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Wake up call: Response from authors
- Nick Craddock, see end of letter for list of authors (19 October 2008)
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Considering psychiatry as a career
- N J O Jacobsen (31 October 2008)
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Putting it all together.
- Mark Agius, Claranne Micallef Department of Anthropology University of Malta (31 October 2008)
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Why Psychiatrists Can’t Afford To Be Neurophobic
- Peter B Jones, Edward T Bullmore, Paul C Fletcher (9 September 2009)
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David Kingdon, Professor of Mental Health Care Delivery University of Southampton
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dgk{at}soton.ac.uk David Kingdon
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Emerging rather like the mythological Hydra, Craddock et al1 appeal to British Psychiatry to wake up. Their case seems to be that we should ‘..act as medical expert(s) in mental health services and work with the multi-disciplinary team to ensure a comprehensive, expert assessment of need, formulation, implementation of a therapeutic care plan ….’ ensuring that ‘… there is continuing need for expert contributions that recognise and address the contributions of the genetic, biochemical, physical, and neuro-developmental dimensions of mental health difficulties’ - exactly as these quotes from New Ways of Working2 state. They also seem to suggest that all patients with mental disorders referred to secondary care should be assessed by a psychiatrist unless the referrer specifies otherwise. But is this practical where psychiatrists' caseloads are already excessive? Effective collaboration and consultation with team members can ensure direct medical assessments occur when indicated. This allows us to focus on people with the most severe mental disorders, as Craddock et al advocate. If we are to survive as a profession, we certainly should not neglect traditional medical roles but we need to go beyond them. As described previously3 our diagnostic abilities are constrained by an inadequate classification system. The limitations of some of the treatments we use are becoming increasingly evident4 albeit often because we cannot persuade patients to consistently take them. Unless we develop new ways of working, the same fate that befell the heads of the Hydra is likely to happen to us, one by one. 1. Craddock N, Antebi D, Attenburrow MJ, Bailey A, Carson A, Cowen P et al. Wake-up call for British psychiatry. Br J Psychiatry 2008; 193(1):6 -9. 2. Royal College of Psychiatrists and National Institute for Mental Health in England. New Ways of Working for Psychiatrists: Enhancing Effective, Person-centred Services through New Ways of Working in Multidisciplinary and Multi-agency Contexts. Final Report ‘But Not the End of the Story’. Department of Health, 2005 (http://www.newwaysofworking.org.uk/psychiatry/psychiatry_documents.aspx). 3. Kingdon DG, Young A. Research into putative biological mechanisms of mental disorders has been of no value to clinical psychiatry. Br J Psychiatry 2007; 191(4):285-290. 4. Lieberman JA, Stroup TS, McEvoy JP, Swartz MS, Rosenheck RA, Perkins DO et al. Effectiveness of Antipsychotic Drugs in Patients with Chronic Schizophrenia. New England Journal of Medicine 2005; 353(12):1209-1223. |
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Adarsh Shetty, Specialist Registrar in Adult Psychiatry Crisis Team, Queen's Medical Centre, Derby Road, Nottingham NG7 2UH.
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dradarshshetty{at}yahoo.co.in Adarsh Shetty
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Craddock et al (2008) present a compelling argument for retaining the biomedical model of psychiatric illness, while acknowledging that evidence -based psychosocial interventions do have an important place in management and treatment. It is their discussion about New Ways of Working that particularly struck a chord with me. As a third year Specialist Registrar who will soon be looking for consultant jobs, I find myself in a dilemma: am I for New Ways of Working, or against it? Caseloads of 300 patients seen briefly in 15-minute ‘routine’ outpatient clinics; one urgent appointment after another; the community team, day unit and general practitioners all wanting their patients to be seen only by the consultant (Hampson, 2003); shouldering responsibility for patients not seen or advised on by me; to me, all of this sounds like a certain recipe for early burnout. Is it any surprise that I do not want any of this? On the other hand, my medical training has taught me to diagnose and treat appropriately and I do this well. When other members of the team ask me to see someone who they think may be depressed, my training enables me to not only exclude depression but to pick up the drowsiness, slurred speech and small pupils of morphine addiction, and to then manage the patient appropriately. As Craddock et al point out, having a broad-based assessment by a doctor at the first point of contact is likely to ensure that the patient gets the most appropriate treatment. Craddock et al think we should be arguing for better resources and increased workforce. This is very reasonable but is it realistic, given that the number of consultant posts has now effectively plateaued (Pidd, 2006)? Is the choice then, between one’s personal well-being and that of one’s patients? I have not found the answer to this dilemma yet. It is reassuring to see that experienced psychiatrists have strong views on both sides, illustrated by the heated debate over the last few months. Perhaps I should sit on the fence just a little while longer (Vize et al, 2008). REFERENCES 1 Craddock N, Antebi D, Attenburrow MJ, Bailey A, Carson A, Cowen P et al. Wake-up call for British psychiatry. Br J Psychiatry 2008; 193:6-9. 2 Hampson M. It just took a blank piece of paper: changing the job plan of an adult psychiatrist. Psychiatr Bull 2003; 27:309-11. 3 Pidd S. Workforce figures for psychiatrists: census results for 2006. Royal College of Psychiatrists. 4 Vize C, Humphries S, Brandling J, Mistral W. New Ways of Working: time to get off the fence. Psychiatr Bull 2008; 32:44-5. |
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Christine M Vize, Consultant Psychiatrist Associate Director for New Ways of Working, CSIP, list of 26 authors of all professions including service users is too long for this box please email me for it
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christine.vize{at}btinternet.com Christine M Vize, et al.
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The interpretation in The Times (Mentally Ill patients are 'jollied along' rather than treated by a psychatrist 27.06.08) of Craddock et al (Wake-up call for British Psychiatry Br J Psych 2008 193, 6-9) risks alienating multidisciplinary colleagues and patients alike, turning a call for quality services into an appeal for primacy for the psychiatric profession. New Ways of Working (NWW) is similarly open to misinterpretation, including by Craddock and colleagues. A fundamental principle of NWW is freeing up the appropriate staff to work with the patient. That means consultant practitioners working with those with the most complex needs - exactly what these doctors ordered. Yet Craddock et al appear defensive, undermining their own call for self-confident progress. Why get exercised about use of the term 'mental health' rather than 'mental illness'? The Government has stressed repeatedly in the National Health Service Next Stage Review that maintenance of health and wellbeing is its job just as much as treatment of illness. Performance management, outcome measures and payment by results drive vague 'support' out of the system, promoting more structured, evidence-based care delivery. The Future Vision Coalition, comprising leading mental health charities, Directors of Social Services, the Mental Health Foundation and, crucially, the Network of our employer Trusts, has just published ‘A New Vision for Mental Health’: bringing health and social models together, focusing more on health promotion, and on quality of life rather than illness, and redefining relationships between services and users. If the psychiatric profession endorses Craddock et al’s vision instead, who is likely to end up out of step and disregarded? The current investment in Improving Access to Psychological Therapies demonstrates how those evidence-based services have not been over-provided or over-used to date, whereas 93% of patients have been prescribed medication. NICE stresses the efficacy of both psychological and psychosocial interventions. The relevant expert should lead discussions where biomedical approaches are key, but where that is not the case or whole story, which is often, the other experts are similarly important. ‘Jollying along’ was seen when other professions were the handmaidens of psychiatrists, only trusted to give ‘support’; now they may be prescribing as well as delivering other therapeutic interventions. Politically correct terms like service user have arisen because of stigma, which psychiatrists have played their part in perpetuating, being accused of low expectations, making assumptions about behaviour based on diagnostic labels, patronising or unhelpful letters, using patients as ‘cases’ for training, and promoting the ‘medical’ model whilst dismissing side effects as ‘psychological.’ Our answer to their 'thought experiment question' - would you opt for a distributed responsibility model if a member of your family was the patient - is a resounding 'Yes please'. Going back to a psychiatrist with a caseload of hundreds, or awaiting the arrival of yet another locum for a decision, is neither safe nor satisfactory. Lord Darzi heralds a 'new professionalism' based on teamwork; teams can only be efficient and effective if members are appropriately skilled, competent and take responsibility for what they do. We agree with Craddock et al that psychiatry can have a great future, but only by embracing teamwork, abandoning hegemony, and accepting the importance of social and psychological as well as biological determinants of mental ill health, rather than harking back to a past which was actually far from ideal. |
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jeremy a holmes, visiting rofessor of psychological therapies University of Exeter UK
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j.a.holmes{at}btinternet.com jeremy a holmes
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Sir – One cheer at least for Craddock et al1’s polemic. Critical of the de-medicalisation and role-diffusion which they see as characterising contemporary British psychiatry, they argue that those with severe mental illnesses are best served by an initial consultation with a professional with the diagnostic skills of the Consultant Psychiatrist. Without such an intervention, they claim, the patient is likely to be psycho-pharmacologically disadvantaged, possible physical disorders may be overlooked, and scientific advances not brought to bear on their illness. Nevertheless a neutral observer might be tempted to see their ‘wake-up call’ as a tendentious attempt to regain hegemony by the psychiatric establishment. Their ad hominem ‘thought experiment’ – inviting readers to ask themselves whether they would be happy for ‘a member of their family’ to be cared for under the ‘distributed responsibility’ model’ – seems unworthy of such illustrious academics, a hostage to the possibility that many will take contrary view. The two absent cheers are for the missing psychosocial components of Mayer’s biopsychosocial triad, first proposed by a century ago, midway between Reil and Craddock et al. Indeed that lack exemplifies the narrowness of vision which has arguably led to the very crisis which they bemoan. Nowhere do the authors consider the social forces driving de-professionalisation: the need to contain burgeoning healthcare budgets; flattening of social hierarchies, with leadership to be earned rather than role-bestowed; and technology-driven fragmentation of care. Understanding these processes, and knowing how to work productively with the rivalries and distortions they create, is as essential to the psychiatrist’s repertoire as the latest psychopharmacology update. Nor are these issues confined to psychiatry, not excluding the cardiology model so dear to their hearts. The good general physician who takes an overview of a whole patient, including psychological aspects, and is not merely a technical expert in the minutiae of a malfunctioning organ, is as rare a species as the putative ‘superlative’ psychiatrist. Cradock et al’s view of the science relevant to psychiatry is similarly limited, confining itself to molecular biology and neuroscience. There is no mention of recent advances in developmental psychopathology2 which illuminate the psychological deficits of psychiatric illness, and the interpersonal skills needed by therapists of ameliorate them, or of psychotherapy process-outcome research which is beginning to tell us which kinds of therapy work best for which kinds of condition and personality. ‘Waking up’ is the moment when dreams momentarily enter consciousness. Behind their grumpy growling, Craddock et al’s reverie sounds like regressive nostalgia for an idealised past with which it is hard not to feel sympathetic, but is devoid of plans – as opposed to wishes – for the future. A more hopeful straw in the wind is the recent Royal Colleges of Psychiatry and General Practice joint document on psychological therapies3. This argues the case for the case for structured training in psychosocial skills for psychiatrists and GPs. Craddock et al might consider the possibility that a psychotherapeutically-informed psychiatrist – whose abilities include dream interpretation! -- is more likely regain a key role in the surely-here-to-stay Multidisciplinary Team than one whose expertise is narrowly confined to ‘excellence’ in prescribing, desirable though that no doubt is. Jeremy Holmes Department of Psychology, University of Exeter, EX 4 4QG, UK. j.a.holmes@btinternet.com Jeremy Holmes | |||
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Walter M Braude. MD, FRCPsych, Consultant Psychiatrist Hollins Park Hospital, Andrew F. Blakey. MRCP, FRCPsych
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walter.braude{at}5bp.nhs.uk Walter M Braude. MD, FRCPsych, et al.
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We strongly support the views expressed by Craddock et al in their 'Wake-up call for British psychiatry' (1). In our opinion their perspective is shared by many NHS consultant colleagues and is not limited to academic psychiatry. At the heart of the debate is the progressive downgrading of the role of the consultant psychiatrist to diagnose and manage severe mental illness as opposed to 'mental health problems'. The latter may not require specialist psychiatric input as medicalising problems of living is clearly undesirable. The centrally-driven 'one-size fits all' approach to 'modern' service delivery has left many patients with serious psychiatric illness bereft of the clinical expertise and leadership to effectively manage their condition. Notions of complexity (undefined) and risk have superseded diagnostic context. The 'diffusion of responsibility' as conceptualised in New Ways of Working often leads to unfocussed care plans and risk management assessments without the one element essential to modifying any risks - that is effective psychiatric treament based on a comprehensive diagnostic formulation and understanding of the nature of the illness. Accurate diagnosis not only allows appropriate treatments for individual patients but also prioritisation of resources in service delivery. Furthermore, a diagnostic threshold is an essential requirement of the Mental Capacity Act in the assessment of capacity of our most vulnerable patients. Major changes in psychiatric management and service structure have been introduced mostly not evidence-based and certainly not consequent upon real advances in treatment. The political dimension to this process makes constructive criticism difficult. The letter to the Times from Kinderman and members of the New Ways of Working Care Services Improvement Partnership and National Institute of Mental Health exemplifies this (2). In response to the article by Craddock et al they refer disparagingly to the 'traditional medical model' in contrast to 'modern mental health care' which is a 'collaborative team effort' as if the medical model concerns itself only with medical matters in the most narrow sense. They also suggest some psychiatrists are unable to 'cope with the loss of hegemony' and refer by implication to Professor Craddock and colleagues as demonstrating 'intellectual arrogance ... and assumptions of superiority'. Their response to put it mildly offers little basis for constructive debate and has previously been described as 'messianic' in tone (3). Like many psychiatrists engaged in the treatment of serious mental illness and organic brain disease we look to our professional body the Royal College for a lead but find our views are not adequately represented. References. 1. Craddock N, et al. Wake-up call for British psychiatry. Br J Psychiatry 2008; 193: 6-9. 2. Kinderman P, et al. Modern mental healthcare is a team effort. The Times (letter); 3 July 2008. 3. Lelliot P. Time for honest debate and critical friends. Commentary on ... New Ways of Working. Psychiatr Bull 2008; 32: 47-48. Declaration of interest: None. |
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Ollie White, Specialist Registrar Psychiatric Trainees' Committee, Royal College of Psychiatrists.
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olliewhite{at}mac.com Ollie White
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Craddock et al’s ‘Wake up call for British Psychiatry’1 is a timely reminder of the need for our profession to reassert its essential qualities, particularly in view of the current low recruitment rate into psychiatry from UK graduates. The Psychiatric Trainees’ Committee (PTC) agrees with the observation that the medical component of psychiatry is being devalued. Indeed, this is apparent in many of the recent changes associated with psychiatric training. The European Working Time Directive (EWTD) has in part contributed to reduced exposure to emergency psychiatry. This has resulted in a reduction in the recognition and management of biomedical aspects which are often key in acute psychiatric presentations. This has been exacerbated by financially stretched Trusts gradually reducing the out of hours contribution from trainee psychiatrists in favour of cheaper alternatives. New Ways of Working (NWW) remains a contentious issue. Specific consideration is required to ensure that postgraduate training adapts both in substance and delivery to ensure that future psychiatrists have the necessary skills to fulfil the changing role of a consultant. Trainees are increasingly anxious that the rapid evolution of NWW has become a driver for preventing essential continued expansion in the numbers of consultant psychiatrists. Indeed there is a growing political atmosphere suggesting that consultants will be needed less abundantly than at present2. The PTC firmly believes that the introduction of a sub-consultant grade will diminish the end-point of training, further devalue the profession, and not serve the needs of patients. These issues, alongside the changes resulting from Modernising Medical Careers (MMC) and the significant stresses of the Medical Training Application Service (MTAS) are contributing to a cohort of trainees who perceive that they are not in a valued profession. We believe that the new competency-based framework of psychiatric training, if robustly quality-assured, offers a solid opportunity to reassert the training needs of the future psychiatrist, especially in regard to their unique medical expertise in the assessment and treatment of mental disorder. However, the current changes within mental health services threaten to undervalue our role as medical specialists. This is likely to further alienate medical undergraduates and compound the current recruitment crisis. Urgent work needs to be done by our profession to reengage with both the government and the public as a whole to ensure that the essential contribution psychiatrists make in providing a high quality mental health service to our patients is not further devalued. 1. Craddock N, Antebi D, Attenburrow MJ, Bailey A, Carson A, Cowen P et al. Wake-up call for British psychiatry. Br J Psychiatry 2008; 193(1):6 -9. 2.NHS Employers. The future of the medical workforce http://www.nhsemployers.org/workforce/workforce-2193.cfm (2007) |
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Martin A. Gee, General Adult Psychiatrist NHS North Staffordshire, Gillian L. Rees
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m.a.gee{at}doctors.org.uk Martin A. Gee, et al.
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Craddock et al are to be applauded for trying to stem the tide of demedicalisation. This has been introduced into British Psychiatry through a Trojan horse called "New Ways of Working". Psychiatrists have been lured by promises of reduced but higher quality patient contact and more time for reflection¹ with no drop in status or pay. Patients, their families and GPs look on with bewilderment as Psychiatry gets itself into a tangle of obstructing traditional referral patterns (Single Point of Access), discontinuity (excessive functional teams) and lack of ownership (no one taking on longer term responsibilty). NWW was built on an allegory² and some myths. Consultants have never taken responsibilty for everything, recruitment diffulties did not arise from dysfunctional multidisciplinary teams and Out Patient clinics are vital component of care to the masses. One wonders how traditional Community Mental Health Teams would have performed had they been given the same level of resources afforded to our functional teams. They were certainly easier to refer to, more accountable and had simpler professional boundries. As we move to a quality and outcome agenda³ we hope that Psychiatry rediscovers that robust assessment by someone trained to diagnose and continuity are the keys to a successful outcome. 1.www.rcpsych.ac.uk/members/presidentspage/newwaysofworking.aspx - 20k 2.Kennedy, P. & Griffiths, H. (2001) General Psychiatrists discovering new roles for a new era...and removing work stress. British Journal of Psychiatry, 179, 283 - 285 3. BMJ 2008;337:a646 (p 11) Dr Martin Gee FRPsych Ashcombe Centre Wall Lane Terrace Cheddleton Staffs ST13 7ED Tel: 01538 481200 Fax: 01538 481218 Email: m.a.gee@doctors.org.uk Dr Gillian Rees DRCOG, FPCert Stoke Health Centre Honeywall Stoke on Trent ST4 7JB Tel: 01782 413596 Email: GillRees@doctors.org.uk Declaration of interest: Dr Gee is a General Adult Consultant Psychiatrist and Dr Rees is a Senior Partner in General Practice. They are married to each other. |
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Peter L Cornwall, Tees, Esk & Wear Valleys NHS Trust Consultant Psychiatrist, Angus Bell, Joe Reilly
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lenny.cornwall{at}tewv.nhs.uk Peter L Cornwall, et al.
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The role of the psychiatrist in the 21st century NHS is a topic much in need of research, and we welcome the engagement of the ‘Wake up call for British psychiatry’ authors, who are mainly from academic departments. How many are regularly taking direct referrals from GPs and writing from direct recent experience? The suggestion that all patients referred to secondary care should be assessed by a psychiatrist unless the referrer suggests otherwise was debated and settled in much of the NHS long before the emergence of New Ways of Working. Most community mental health teams moved away from leaving it to the general practitioner to determine the best professional to assess the patient many years ago. This was in part due to the great variation in GP referral practices, but also because the single point of access facilitated true multi-disciplinary assessment and treatment through having a psychiatrist fully integrated in the community team. In our teams, the psychiatrist participates in the discussion of all new assessments and can ensure prompt medical assessment of all those presenting with severe symptoms or complex problems. This approach focuses medical expertise where it is most needed, whilst traditional out- patient clinics have often done the opposite. In response to the question that if a member of your family were a patient, would a distributed responsibility model be the one for which you would opt, the answer is yes - although this is really a question we should be asking our patients and carers. We would expect the initial assessment to have a multi-disciplinary review, irrespective of the discipline of the assessor, so that further assessment and appropriate treatment would follow, with medical expertise readily available at all stages. |
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Phil Barker, Honorary Professor Faculty of Medicine, Dentistry and Nursing, University of Dundee, Scotland, Poppy Buchanan-Barker, Fran Biley, David Cooper, Phil Cooper, Lawrie Elliott, Alec Grant, Hugh Masters, Hugh McKenna, Shaun McNeil, Miriam Morgan, Steve Onyett, Richard Peacocke, David Pilgrim, Mark Radcliffe, Shula Ramon, Angela Simpson, Peter Wilkin
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phil.j.barker{at}btinternet.com Phil Barker, et al.
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Craddock et al1 call for the restoration of the ‘core values’ of biomedicine - diagnosis, aetiology and prognosis – despite evidence that such concepts have delivered little more than stigma and helplessness2. A generation ago Mosher demonstrated that, contrary to received opinion, the recovery of people with schizophrenia could be enabled with no more than sophisticated psychosocial support3. Since then the role of personal, social and environmental factors in generating ‘breakdowns’ and ‘fostering recovery’ has become widely accepted. The ‘mental well-being’ train has left the station and in many places is close to its destination. Craddock et al advocate a “more positive and self-confident view of psychiatry”, but complain that “many people …have developed exaggerated and unrealistic expectations”. Clearly, psychiatry’s reification of diagnosis, with the implication of effective ‘treatment’, fostered such expectations. The comparison of “mood disorders” with heart disease serves as an illustration. Much of the emergent distress within developed nations has more to do with lifestyle, values and other ‘psychosocial’ factors, than anything resembling biomedical ‘pathology’. If the global burden of ‘depression’ is to be lifted it will require more than specifying more “clearly the key (sic) role of psychiatrists”. Although Craddock et al were clearly offended by talk of ‘mental health’ and ‘well-being’, this focus is long overdue. Talk of “mental illness” and “our (sic) patients” is regressive and paternalistic. On the 60th anniversary of the NHS it should be unnecessary to advocate ‘well- being’ as the purpose of health care. Mental health advocacy joins the abolition of slavery, votes for women, feminism and gay rights as another example of emancipation within Western society. The ‘service user’ title may be unsatisfactory, but is another linguistic step towards acknowledging that ‘people’ are the agents of their lives. They must be addressed as persons if genuine emancipatory mental health care is to become a reality. The ‘learning disabilities’ field provides a precedent. A generation ago, most people with significant forms of ‘mental subnormality/deficiency’ lived in hospitals under the care of psychiatrists. Today, despite the influence of ‘genetic anomalies’ or ‘organic disorders’ such people live in natural communities, albeit with broad based psychosocial support. Some may have occasional need to consult physicians, but their lives no longer revolve around their diagnosis. This change in philosophy did not devalue psychiatry but did acknowledge that all problems in human living affect persons. All talk of psychiatric ‘treatment’ should follow suit, embracing the word’s original meaning: the ‘manner of behaving towards or dealing with a person” (OED). Regrettably Craddock et al’s rallying call will be offensive to many ‘service users’ who have struggled to detach themselves from the more unfortunate aspects of traditional psychiatry. It will also be dispiriting to many of their colleagues. Craddock et al may be surprised to discover that nurses have already joined psychiatrists as statutory prescribers of medication4, and some clinical teams recognise the virtue of electing the professional best qualified to inspire and nurture the team5. Time perhaps to wake up and smell the coffee. 1 Craddock N et al Wake-up call for British psychiatry Br J Psychiatry 2008; 193: 6-9 2 Kutchins H and Kirk S Making us Crazy: DSM – The psychiatric bible and the creation of mental disorders. NY: Free Press 1997 3 Bola J and Mosher L Treatment of acute psychosis without neuroleptics: two-year outcomes from the Soteria project. J Nerv Ment Disease 191: 219- 29 4 Department of Health. Improving patients’ access to medicines. A guide to implementing nurse and pharmacist prescribing within the NHS in England. DOH. London. 2007. 5 Rosen A and Callaly T Interdisciplinary teamwork and leadership: issues for psychiatrists Australasian Psychiatry 2005; 13: 234-40 |
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Derek B Dickson, consultant psychiatrist none
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derek.dickson{at}borders.scot.nhs.uk Derek B Dickson
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And so it goes.... the century long debate within the confines of psychiatry, the natural sciences against the human sciences which stirred Jaspers into emerging with his General Psychopathology(1).I am afraid this article, Craddock et al(2), offers nothing new to the debate and seems to be a rearguard response to the inevitability of balanced multi- disciplinary teams and the perceived threat this poses to psychiatry.My view would be that by not recognising the limitations of what we do, and minimising the role of fellow skilled practitioners and their contributions to patient care, that this maybe a modern anti-psychiatry stance. I would view the responsibility of psychiatrists as being skilled formulation and phenomenology practitioners,as only by reaching thorough understanding and defining others subjective mental life can we know when the use of physical treatments maybe required. It is just as skillful knowing when not to use these treatments or indeed when to stop them. Consultant psychiatrists, being trained doctors, are in a position to diagnose more organic drven illness that presents but this is a small percentage of our caseload, and being constantly aware of the limitations of diagnosis/treatments/definitions within psychiatry are part of our obligations and not allowing certainty (based on false knowledge ) to define our practice is vital. 1.Jaspers,General Psychopathology,John Hopkins 1997.2.Craddock et al,wake up call for british psychiatry ,BJP2008,6-9. |
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Louise Pembroke, service users/survivors/patients/experts by experience , Peter Campbell, Roberta Graley, Shaun Johnson, Louise Pembroke, Sara Stanton, Catherine Tate, Andrew Wetherall
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loopy{at}thepsychotic.org.uk Louise Pembroke, et al.
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Dear Editor, There is much talk of ‘stigma’ nowadays but little appreciation that stigma emanates from within the health services, particularly psychiatric diagnosis, which is never addressed in ‘anti-stigma’ campaigns. Are psychiatrists always accurate when it comes to diagnosis? In our experience, some psychiatrists don’t even follow the stated diagnostic criteria. It’s not a hard science, it’s subjective. Some diagnostic categories are little more than a value judgement. Sadly, no social support can be accessed without a psychiatric diagnosis, so in fact these threatened, fearful individuals are not currently at risk of losing their power base, which appears to be largely what this discourse is actually about. Distress is being reframed by service users and forward thinking psychiatrists whether one likes it or not. The work of Romme & Escher, Knight, Kingdon and Turkington to name a few, as well as the Hearing Voices movement, proves we can be assisted without being systemically medicated and that diagnosis in itself does not illuminate individual pathways. If anyone has “devalued” psychiatry, the profession has itself. A ‘medical’ approach is reductionist when a package of support is absolutely contingent on accepting medication. The justifications sometimes used are too glib. This is a recent statement from a nursing journal, “The risk of heart disease, diabetes and stroke is well documented as a potential consequence of regular use of the newer types of neuroleptic medication, whose side effects include extreme weight gain. Nevertheless, the mental health benefits of the medication arguably outweigh these stigmatising and even potentially life threatening side effects”. The question is who benefits, what are the benefits and how do the benefits outweigh death ? We don’t really care whether we are called ‘patients’ ‘service users’ or ‘loonies’, it’s the human connection and respect for our individual beliefs and needs that matter. ‘Mental health nurse ’ or ‘psychiatric nurse’ makes no great difference to us. NICE guidelines are wholly medically biased and pay lip service to non- medical or psychological approaches, and psychosocial approaches have been specific - specific to CBT. Nurses cannot progress without training specifically in CBT. As for ‘monitoring of mental state’ this is all that can occur for some service users with out-patient appointments timed at 4 minutes and the same 3 questions asked each time [eating/sleeping/compliance with medication]. Likewise Crisis Intervention can mean little more than ‘doorstep delivered medication’ with little human and meaningful interaction. It is sobering that Craddock et al. refer to appropriate use of interventions when evidence shows medication use and dosages have increased exponentially. Psychiatry is not a medical speciality that can be equally compared to orthopaedics because there are no diagnostic tests with clear demonstrable results. Psychiatry must broaden its knowledge base and include subjects it currently ignores otherwise it will continue to be part of the problem and not part of the solution. Psychiatric patients deserve what we actually want, not what psychiatrists are prepared to give from an ego-fragile position. Peter Campbell, Roberta Graley, Shaun Johnson, Louise Pembroke, Sara Stanton Catherine Tate, Andrew Wetherall *service users/survivors/patients/experts by experience* |
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Rhiannon Allen, Medical Student Cardiff University
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rhiannonallen321{at}hotmail.com Rhiannon Allen
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I’d like to provide a medical student’s perspective on the recent paper “Wake-up Call for Psychiatry” (Craddock et al, 2008). I am about to enter my 4th year of medicine (having just completed an intercalated BSc in Psychology and Medicine) and will soon have my first real exposure to clinical psychiatry. Although I’m keen on psychiatry, the majority of my fellow students are happy to express disdain at the thought of a psychiatric career. It’s obviously difficult to say why this might be the case but something is clearly amiss in the way that psychiatry is being presented to tomorrow’s doctors. During my BSc, it was interesting to gain insight into the opinion that psychologists have of psychiatry, which unfortunately was one of ‘over-medicalisation’ and neglect of psychosocial factors. For me, this reiterated the importance of early positive interaction between the two professions and a need for better understanding of each others strengths. Perhaps this interaction is best initiated during undergraduate training? More importantly, and from the angle of a card-carrying wannabe psychiatrist, this paper has confirmed for me that clinical psychiatry is attractive not because it is excessively reductionist but because it deals with the complex interplay between psychiatric (and non-psychiatric illness) and countless important psychosocial factors. Furthermore - and this may be the blind optimism of youth talking - I hope to become an excellent physician who is trusted and respected by her patients. Because of this, I am not discouraged by those who fail to consider psychiatrists as ‘proper doctors’, although it is clear to me that this negative view by other doctors acts as a deterrent for some of my colleagues who might have been interested in a psychiatric career. Finally, on a more anecdotal note, I have the perspective of someone who has lost a relative due to failure in psychiatric and non-psychiatric care and social support. Had an appropriate (and properly functioning) multidisciplinary team been in place, both in assessment and management, I believe that the outcome would have been very different. So in response to the question “if a member of your family were a patient, is a distributed responsibility model the one for which you would opt?” my answer would be an uncertain “ummm, I think so”, so long as this included the appropriate level of assessment and involvement of a senior psychiatrist alongside other professionals. Declaration of interests: Cardiff Medical School undergraduate who has completed research within the Department of Psychological Medicine. Reference: Craddock, N., Antebi, D., Attenburrow, M.-J., et al (2008) Wake-up call for British psychiatry. British Journal of Psychiatry, 193, 6-9. |
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Nick Craddock, Honoary Consultant Psychiatrist Cardiff University, Co-authors of Wake up call artilce
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craddockn{at}cardiff.ac.uk Nick Craddock, et al.
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We are pleased that our article has stimulated debate. This was our intention. We are, however, disappointed that some correspondents have sought to dismiss our article by attacking a stereotype of who they think we are or a caricature of what they think we might have said, rather than addressing what we actually did say. Such correspondents seem to have missed, or perhaps ignored, the whole point of the article – namely, to ask whether the demedicalistion that has taken place over recent years in British psychiatry is bad for the health of patients and the specialty? We believe this is a question that is worth taking seriously. As we stressed at several places within the article, we (a) embrace the importance of the full range of biological, psychological and social interventions for psychiatric illness, (b) fully respect our non- psychiatric fellow professionals, and (c) value their contributions as an integral part of mental health care. We believe that services should be informed by the experiences of patients, their relatives and carers and that multidisciplinary team work is crucial for optimal management of psychiatric illness. We do not advocate a return to, nor mourn the loss of, a bygone era of medical supremacy. We are looking ahead. Of the wide range of views being expressed by respondents, we believe the voice of trainees and those contemplating a career in psychiatry should carry particular weight and we would like to hear more from them. They are the future of British psychiatry. |
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Duncan Double, Consultant Psychiatrist Norfolk & Waveney Mental Health NHS Foundation Trust
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d.double{at}uea.ac.uk Duncan Double
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As a psychosocial psychiatrist, I welcome the article by Craddock et al (2008). As they themselves indicate, I do not think their position should be seen as defending a rigid biomedical model. Their focus is on deprofessionalisation, which is an issue which has been taken up by the Royal College of Psychiatrists (Bhugra, 2007). For some of us, new ways of working is not really new. What is distinctive is its systematic implementation across services (New Ways of Working in Mental Health for Everyone website). The Department of Health (2007) does not yet seem to have fully acknowledged how new ways of working has encouraged a fragmentation and loss of continuity of services through specialisation of teams, perhaps especially because of the splitting of acute and community services. It is also important not to forget the lesson of research on home treatment that there are dangers in an ideological avoidance of inpatient admission (Marks et al, 1994). Mental health services need to recognise mental illness and manage mental health problems well. These skills must be developed, not necessarily just by psychiatrists, and psychiatrists have an essential input that has to be recognised by services. High quality care can only be provided through a partnership of patient and professional expertise. @ Bhugra D (2007) The deanfs medical education newsletter, October 2007 http://www.rcpsych.ac.uk/Docs/Newsletter%20October%202007.doc Craddock N and 36 other signatories (2008) Wake up call for British psychiatry. British Journal of Psychiatry 193: 6-9. doi: 10.1192/bjp.bp.108.053561 Department of Health (2007) Mental health: New ways of working for everyone, Progress report April 2007. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_074490?IdcService=GET_FILE&dID=139505&Rendition=Web Marks IM, Connolly J, Muijen M, Audini B, McNamee G, Lawrence RE (1994) Home-based versus hospital-based care for people with serious mental illness. British Journal of Psychiatry. 165:179-94. New ways of working in mental health for everyone website. http://www.newwaysofworking.org.uk/ |
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Andrew E Blewett, Consultant Psychiatrist Devon Partnership NHS Trust
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andrew.blewett{at}devonptnrs.nhs.uk Andrew E Blewett
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Craddock et al (1) make largely rhetorical defence of their vision of biomedical psychiatry, which deserves a gentle critique. They seem to be haunted by a number of fears: that soft non-medics on low salaries are taking over thanks to a government plot, that biomedical psychiatry is subject to unfair linguistic discrimination, that New Ways of Working is a device for psychiatrists interested in an easy life whilst faced with short term staffing problems, and that crisis teams are over-focused on crisis management, (perhaps a bit more psychiatric participation would help here). On the other hand, Craddock et al are confident that alleged “major advances” in biomedical psychiatric understanding and technology are already having an impact on people seeing psychiatrists, and will continue apace. The projected massive inflation in worldwide rates of depression paralleled by biological research findings ought to create a less wimpy type of psychiatrist confidently pointing out the depressive lesion on a brain image, (assuming it doesn’t turn out to be somewhere else) to a relieved patient who only wants to be defined as such. The sad reality is that following the arrival of useful psychopharmacology 50 years ago, most biomedical achievement has been in safely limiting the use of old technologies. Examples include the correct use of clozapine, not making people dependant on benzodiazepines, and not destabilising bipolar disorder with antidepressants and episodic lithium. As for legitimation based on disease models, the authors cite Goodwin and Geddes (2) who proposed that after 100 years it is time to abandon the schizophrenia paradigm. Here there is a coming to terms with the weakness of founding professional credibility on a diagnosis of exclusion comprising arbitrarily defined conditions lacking pathognomonic signs, no clinically useful physical investigations, and a largely unpredictable long-term course and outcome (3). This real problem for the profession is that our core objective, a desire to empathically and sympathetically help those afflicted with madness, is no longer our exclusive domain consequent to moving out of large hospitals. It is true that psychiatry made a successful land grab from the clergy and the philosophers during the latter stages of the enlightenment, but we have now lost our monopoly. We have been democratised and we don’t like it. We are out of step with a world suspicious of linear fundamentalism, rightly so given the use of science to justify mass persecution, especially in psychiatry (4). The authors rather generously concede that, “psychological and social interventions will, of course, continue to be crucially important.” What a relief. An alternative view would be that psychosocial endeavours such as deliberate institutionalisation or indeed commitment to its ideological opposite in the recovery movement have always been at the heart of what psychiatrists exist for, and always will. Perhaps we should spend the next century making sure that we don’t repeat the errors of the last, whilst if we are very lucky someone might chance upon a completely new biomedical approach to psychosis. Meanwhile investment in public education about the effects of stigma, promotion of vocational rehabilitation, and a massive overhaul of the system used to deal with mentally disordered offenders might be a safer option in the interests of civilisation. Psychiatry has now struggled for 200 years to tame its subject matter. The nineteenth century founding fathers were stoutly biomedical, but the psychiatric bid to convert human mental experience into a Newtonian machine has been unsuccessful. Craddock et al are clearly diehards in this respect; the shame is that they regard the venture as the prerequisite to restoring lost prestige. The belief that despite all the cunning of central government and its managerial agents, psychiatry can be reborn and become “increasingly important” sounds like a manic defence against their existential despair over eroded status. The learning point is that if Craddock et al feel marginalized as biomedical reductionists, their experience echoes the stigmatisation of the mentally ill which they wave away as a “generic” problem. In fact it is specific and powerful. 1. Craddock N, et al. Wake-up call for British psychiatry. Br J Psychiatry 2008; 193: 6-9. 2. Goodwin GM, Geddes JR. What is the heartland of psychiatry? Br J Psychiatry 2007; 191: 189-91. 3. Bottero A. Un Autre Regard sur la Schizophrenie. Odile Jacob, 2008. 4. Lifton RJ. The Nazi Doctors: Medical Killing and the Psychology of Genocide. Basic Books, 1986. Andrew Blewett, Wonford House Hospital, Exeter EX2 5AF, UK. Email: andrew.blewett@devonptnrs.nhs.uk |
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RJ Stamatakis, ST1 Psychiatry
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robstamatakis{at}mac.com RJ Stamatakis
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This is perhaps the most excited I have been since starting psychiatry 12 months ago. I understand that I am in the early stages of psychiatric training, and that my opinion may be proportionally relevant. However, I do also have some experience of psychology and 5 years in the acute medical specialities. During this time, I have become increasingly uneasy with the apparent demedicalisation of mental illness, and for the continued medicalisation of psychological malaise. A colleague recently summed-up a feeling common to many trainees by commenting that she wished she hadn't spent so much time and effort studying medicine, as she can feel now-redundant but essential core knowledge and skills being palpably lost. Some feel this is being encouraged by the new ways in which we work and the roles we have in the multidisciplinary team. I am concerned that whilst I am currently keen to take on more responsibility for physical medicine within psychiatry, this is being discouraged by the approach our speciality seems to be adopting. I fear of learning from and becoming like those senior colleagues who are resisting a move towards the remedicalisation of psychiatry. It also worries me that good psychiatrists who recognise the problem can still not find the motivation to affect change. "Change will never happen" was one typical comment. We learn from our seniors. I strongly believe that remedicalising psychiatry and a sculpting a clearer role for psychiatrists within the MDT is the only way to protect the future of the profession and attract the necessary calibre of applicant into the speciality. I am glad that there are those amongst the leaders of our profession not so affected by apathy, and look forward to the oncoming debate optimistic that there are enough like-minded individuals to initiate a collective change in how we approach our work. I am also curious to see whether my views change as I progress through my training. |
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Alejandro Corsico, Consultant Psychiatrist
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Alejandro.Corsico{at}cpt.cornwall.nhs.uk Alejandro Corsico
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As Consultants in General Adult Psychiatry, we deal on a daily basis with patients who are severely ill. In most cases they live under restrained financial circumstances and suffer unsuitable housing. Contact with our patients is an invaluable tool for robust assessment and continuity of care. I agree with Prof. Craddock et al in many points. Community Mental Health Teams (CMHTs) are by definition designed to treat severe and enduring Mental illness of a Moderate to Severe degree of presentation. Expectations on psychiatric services are completely unrealistic; CMHTs shouldn’t deal with people displaying mild psychiatric symptoms. These would keep our eyes off the ones in greater need and who are the centre of our profession, those with a mental illness. Avoiding to name identified conditions to attempt dilute the stigma related to their severity and endurance will only lead to more confusion, which as a result would be detrimental for the patients. What happens to a patient needs to be communicated as accurately as possible for its description implies a prognosis and is linked to the best available treatment. Psychiatry, as any branch of medicine and as a science, should be based on the best available evidence able to comply with the parameters of the scientific method, and that should be the standard quality of knowledge we should offer to our patients. Reading other correspondents, I find people are frustrated and dismissive about the advances in psychiatry. In my opinion, Psychiatry has gone a long way in the past 50 years and has managed to improve the quality of life of our patients thanks to our better understanding of mental illness with its impact on functioning partly thanks to the development of biomedical research. A good example is how we have learnt to manage some groups of pathologies such as affective disorders with less and less need to hospitalize these patients. These achievements are not fruit of chance, but the application of a systematic approach so called “medical model” which includes the three dimensions, biological, psychological and social. Beyond inter professional rivalry, we do no favour to our patients thinking about saving costs when designing the best available care. I congratulate professionals like Prof Craddock et al who are able to bring two worlds together, a strong academic development and a solid clinical background. I wish this provocative article could bring all of us out of the stupor of ideological differences. |
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Michael J Smith, Consultant Psychiatrist NHS Greater Glasgow and Clyde
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m.j.smith{at}clinmed.gla.ac.uk Michael J Smith
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The authors of this paper make a contentious assertion: “many people with mild psychiatric symptoms have developed exaggerated and unrealistic expectations of psychiatry.” Rather than blame the patient for an inappropriate idealisation of our profession, it might be more accurate and more respectful to say that “psychiatry has not been able to respond adequately to the perceived needs of people who would otherwise seek help from psychiatrists.” Why should psychiatry complain that our patients are not ill enough? Most GPs work in “Health” Centres, committed to the prevention of illness and promotion of good health. Nonetheless, they spend most of their working day taking histories, conducting clinical examinations, ordering investigations and prescribing. GPs are proud- rightly- that broad concepts of health and wellbeing should form the bedrock of their profession. Several of the authors work in Scotland, where consultant psychiatrist numbers increased 40% in the decade to 2006. There are almost 13 times as many WTE consultant psychiatrists (1,013) in Scotland as there are neurologists (79) (http://www.isdscotland.org/isd/1348.html). Epilepsy has a prevalence similar to that of schizophrenia (0.5-1.0% http://tinyurl.com/5fykej). If psychiatry would like to become more like neurology, we should arguably be proposing a substantial reduction in consultant numbers. Psychiatry obviously needs to have the capacity to provide a medical perspective on mental health problems. But we are resourced to provide far more than that. Retreating into a limited biomedical model isn’t good for our patients, and is potentially disastrous for the profession. NWW isn’t part of the problem, but part of the solution. Psychiatrists working in teams have an ideal opportunity to extend our biopsychosocial and evidence-based professional influence. What better way to “de-medicalise” emotional problems than to have the potential- as leaders of teams- to direct those difficulties to colleagues with the expertise to resolve them in non-clinical ways? Sir William Osler once said, “If you listen to your patient, they will tell you their diagnosis.” Patients are right to turn to psychiatry for help, but also right to feel baffled and disillusioned when we turn them away, or respond with inappropriate interventions. We need not limit our clinical usefulness to scans and medicines, important as they are. We should have far more to offer than that. Psychiatric knowledge and experience should have an active role in influencing health services policy, public health approaches and the public understanding of mental health problems. If psychiatry defensively retreats from these areas, the vacuum will be filled by mental health policies determined by economists, or a scientifically illiterate media in thrall to useless alternative therapies. This isn’t a zero-sum game. Psychiatrists should be effective biomedical doctors while also being able to talk and act effectively about the broader contexts in which our patients’ problems occur. Defensive redefinitions of our purpose and scope will limit our effectiveness rather than enhance it. |
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Mark Agius, Visiting Research Associate Academic Department of Psychiatry University of Cambridge
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ma393{at}cam.ac.uk Mark Agius
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There are a number of key issues which those who have criticised the Wakeup call to British Psychiatry have failed to address; They are; 1. In order that any illness be treated, proper assessment and diagnosis is necessary. Is there definitive evidence that complex problems such as very early psychotic illness [‘at risk mental states’] or ‘type II’ bipolar disorder can be properly identified by non-medical staff without specific training? Is there a possibility that cases may be missed – and how big is this risk? 2. How certain can any doctor- or indeed any person- be that they can assess ‘service users’ appropriately based only on the reported assessment of others?- this is different from asking other respected professionals for their considered opinion in a multidisciplinary meeting. 3. Why is psychiatry the only medical speciality where many seen to feel that we can accept ‘patient choice’ to take or not take medication with entire equanimity, even though we know that Anti-psychotic medication and antidepressants do actually help treat symptoms…..and then why do we suddenly become concerned when tragedy happens because of non-concordance with medication? 4. Why do we in the UK expect other professions to deliver all psychological interventions, while we simply seem to provide biological treatment? Why do we not provide psychotherapy as well as medication, as many of our colleagues in Europe do? Should there not be one standard for how psychiatric help is delivered across the continent of Europe….and should this not obviously be holistic? 5. Having been a GP for many years, before going into psychiatry, I would ask, why are psychiatrists and their teams happy to dispense with the common courtesy of expecting the person addressed to answer a GP referral; In what other profession is ‘sending the referral back because it is inappropriate’ after a brief discussion in a multidisciplinary meeting considered an appropriate response ? When this happens, is it not the service user who suffers because his problem is not dealt with? 6. On the other hand, as a GP, I would certainly consider carefully who to refer to Secondary care, and would use all my skills, as acquired in my GP training, before referral. I would also consult my liason community psychiatric nurse or other attached mental health professional if I had one, and if necessary consult the Consultant Psychiatrist on the phone. However, a good GP will expect to be able to refer problems which he cannot solve to secondary care, and then expect his referral to be treated with respect by his Consultant Psychiatrist colleague with an adequate response; for a GP is a specialist in his own right. 7. Finally, in all of this debate, we have entirely forgotten that the reason ‘service users’ consult Doctors is the Doctor Patient relationship, which is a relationship based on trust in another person, who may or may not have a greater or lesser knowledge of Psychology and Neuroscience, but who most of all is a person to be confided in during difficult times . This is what we must be as doctors, and all our discussions about ‘the role of the consultant’ pales into insignificance before this. We must remember how Sir James Spence defined the Consultation…. ‘The occasion when ,in the intimacy of the consulting room, a person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he trusts. This is a consultation’ If we forget this, then what indeed is the point of our being doctors? |
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David Cunningham Owens, Professor of Clinical Psychiatry University of Edinburgh, Eve C. Johnstone
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david.owens{at}ed.ac.uk David Cunningham Owens, et al.
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Wake-up call to British psychiatry : a response to Craddock and colleagues Craddock et al (1) express concerns many share but their solutions seem to highlight the problem. Firstly diagnosis, still seen as justifying psychiatrists regard as ‘experts’. Would it were so! Standardised operational diagnostic principles have achieved reliability, which is laudable, but at a cost largely unacknowledged, which is reprehensible. Emphasis on where one classifies has been at the expense of what is classified – with psychopathology ignored as a taught subject, phenomenology a relic. Diagnosis by criterion-driven ‘tick-box’ is no marker of expertise. Those who pioneered standardisation never foresaw the consequences of ‘vernacularising’ a language offered pre-eminently to research and teaching communities (2). Now, inappropriate ‘diagnosis’ of ‘depression’ in the hundreds is justified by appropriate diagnosis of the tens (3). Why blame society for demanding more of the things the authors decry when doctors are the ones screaming ‘Armageddon’? Secondly, can evidence-based practice form a foundation for ‘expertise’? One need only say ‘CATIE’ (4) (or ‘CUtLASS’)! One cannot but be amazed at our evidence-led profession’s ability to absorb such blows, ignore the evidence and soldier on regardless, though with teaching of psychopharmacology, in the UK at least, so dependent on purchased expertise from ‘opinion leaders’ beloved by industry, this should perhaps not surprise. The quantitative ‘bottom lines’ of EBM are ill-suited to qualitative problems inherent to psychiatric research, allowing divergent conclusions from similar ‘evidence’ (cf CBT in schizophrenia). For psychiatry, EBM remains more the AA handbook than the Ordinance Survey! Craddock’s aspirations may be noble but doomed to dilution within a profession preferring breadth to depth. Psychiatrists have not had their position stolen. They have given it away – wilfully with a smile on their faces, sleep-walking to redundancy, as generic mental health workers with ‘diagnostic’ check-lists, local prescribing algorithms and Crown Clios become attractive (= cheaper) alternatives. It would be reassuring to look to our College for medical leadership but that is a commodity in short supply in Belgrave Square. Solutions lie in our own hands, individually, but at a level before those championed by Craddock. It may be no accident Edinburgh attracts a greater proportion of undergraduates into psychiatry than other UK universities (5) for it offers greater undergraduate exposure. So here’s a start – lobbying for sufficient dedicated undergraduate teaching time and reward for those who teach well. And for trainees, commitment to the principle of learning by apprenticeship, ensuring time for its central place in training. And dedicated psychopharmacology training matching psychotherapy. To paraphrase Clinton and Blair : “It’s education, stupid!” We may not have long. UK graduates passing the MRCPsych, the backbone of future services, are a dwindling breed (at the end of 2007, 12.5%) and a recruitment crisis could force our paymasters to reconsider just how much of the sorry state that is ‘the human condition’ can - and should - be managed medically from health budgets. Without the sort of radical change Craddock and colleagues plead for, some doctors might start wondering whether they might not be more comfortable whence we came – back with the physicians! References 1. Craddock N, Antebi D, Attenburrow M-J, Bailey A et al. Wake-up call for British psychiatry. Br J Psychiatr 2008; 193: 6 – 9. 2. Andreasen NC. DSM and the death of phenomenology in America : an example of unintended consequences. Schizophr Bull 2007; 33: 108-112. 3. Parker G & Hickie I. Is depression overdiagnosed? Br Med J 2007; 335: 328-329. 4. Lieberman JA, Stroup TS, McEvoy JP et al. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Eng J Med 2005; 353: 1209-1223. 5. Goldacre MJ, Turner G, Fazel S, Lambert TW. Career choices for psychiatry : national surveys of graduates 1974-2000 from UK medical schools. Br J Psychiatr 2005; 186: 158-164. Declaration : No competing interests. David Cunningham Owens Professor of Clinical Psychiatry (e-mail: david.owens@ed.ac.uk) tele : 0131 537 6262 fax : 0131 537 6291 Eve C Johnstone Professor of Psychiatry (e-mail : e.johnstone@ed.ac.uk) University of Edinburgh, Royal Edinburgh Hospital, Edinburgh EH10 5HF. |
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Joanna Moncrieff, psychiatrist Department of Mental Health Sciences, University College London, Carl Beuster, Jonathan Bindman, Pat Bracken, Tim Calton, Miles Clapham, Rachel Freeth, John Heaton, William Hopkins, Rodhri Huws, Bob Johnson, Kwame Mckenzie, Jeyapaul Premkumar, Philip Thomas, Charles Whitfield, Michael Crawford
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j.moncrieff{at}ucl.ac.uk Joanna Moncrieff, et al.
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Craddock et al (2008) recently expressed concerns that psychiatry is being diverted from its proper focus on mental disorders as medical conditions requiring proper medical assessment and treatment. These concerns are not new. The British Journal of Psychiatry has a long history of publishing commentaries by those arguing for a closer alignment to general medicine (1) and psychiatrists made similar points in response to the antipsychiatry movement in the 1970s (2). Since that time diagnostic manuals have been introduced, biological research has mushroomed and psychiatric drugs have become best sellers so it is curious to encounter the same expressions of vulnerability. The explanation may be that the medical model of madness and distress is always likely to be vulnerable, because of the dubious, and at best indirect, relationship between psychiatric disorders and medical diseases. Retreating into a more rigidly medical paradigm arguably makes psychiatry more vulnerable, by stressing the very feature that is at stake. In contrast, we suggest that what makes psychiatry distinct from medicine is also its strength. Psychiatrists are not simply dealing with people who have diseases, as other doctors usually do. They are dealing with issues that are by definition human problems: problems of rationality, of dependency, of loneliness and despair, problems of how we relate to other people in an increasingly complex world. This is what makes madness a source of interest for so many artists and cultural critics. The methods of physical science will never be enough to understand such complex phenomena, but this does not mean that psychiatry is inferior, just that other approaches such as philosophy, literature, art and social science are also necessary to understand the nature of psychiatric problems. The criticisms levelled at psychiatry highlight the ambiguous position of psychiatrists. We have a medical training to deal with problems that are not primarily of a medical nature. That is not to say there is no role for medicine. There is a place for drug treatment, which requires medical expertise, and a pressing need for decent physical health care for those with the most severe mental disorders. But there is no logical reason why doctors should be the ultimate arbiters of how best to help someone with psychiatric problems, although there is no particular reason why they should not be either. Psychiatrists need to be able to tolerate this ambiguity. Retreating into a narrowly medical approach makes psychiatry more easily exploited by governments and drug companies, because it obscures the political and commercial pressures that shape psychiatric practice. Medical students are attracted to psychiatry for what makes it different from medicine, not for what makes it the same. They are attracted because it is an area of broad cultural interest, because it concerns real human, social and political issues, and not just bodily tissues. Psychiatry should celebrate what makes it unique, not attempt to squeeze itself into a model of disease that it does not fit. Reference List 1. Moncrieff J, Crawford MJ: British psychiatry in the 20th century- -observations from a psychiatric journal. Soc Sci Med 2001; 53(3):349-356 2. Spitzer RL: On pseudoscience in science, logic in remission, and psychiatric diagnosis: a critique of Rosenhan's "On being sane in insane places". J Abnorm Psychol 1975; 84(5):442-452 |
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Colm McDonald, Professor of Psychiatry and Consultant Psychiatrist National University of Ireland Galway and HSE West , Ireland
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colm.mcdonald{at}nuigalway.ie Colm McDonald
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Having recently trained and worked for several years in the UK, it is an experience of considerable dismay to observe the current persistent undermining of the profession of psychiatry in Britain. Craddock et al’s (1) call to emphasize the boundaries of mental illness, focus on delivering evidence based treatments and assert psychiatry as a secondary care specialty with psychiatrists at the core of assessment and leadership of multidisciplinary teams is very welcome. It is clear that the implementation of a biomedical model in recent decades has brought great benefit to patients by enabling the application of quantitative scientific methodology to the field of psychiatry. This application has facilitated the demonstration of which pharmacological and psychosocial interventions are helpful and, crucially given the sometimes grim history of our profession, which are not. It is equally clear that psychiatry cannot be reduced to such a model and that within diagnostic boundaries an individualised approach which strives to identify the risk and protective factors throughout biological, psychological and social layers of an individual in order to formulate a multidisciplinary management plan is in our patients’ best interests. The nonsensical pitting of biomedical against psychosocial models by some correspondents serves our profession poorly and creates division unnecessarily, since these are really only different levels of scale in understanding illness from molecules through individuals to communities. Protecting psychiatry as a secondary care medical specialty for assessment of mental illness and psychiatrists as lead clinicians in multidisciplinary teams which can deliver a range of biological, psychological and social interventions is the model that will provide optimal care for current and future patients and optimal recruitment and retention of psychiatrists. It is to be hoped Craddock et al’s wake up call with jolt the silent majority of psychiatrists out of slumber to advocate for their patients and profession. |
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Karthik Thangavelu, Specialty registrar in adult psychiatry
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mcxkt2{at}nottingham.ac.uk Karthik Thangavelu
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The article ‘Wake up call for British Psychiatry’ by Craddock et al (BJP July 2008) is certainly an awe inspiring one. It had the power of a neurochemical that shook everyone up. It is indeed a reflection of several psychiatrists’ opinion including mine. However,in my opinion the pride of a psychiatrist lies in not taking a particular stance as to “I am a biological or psychosocial psychiatrist” but perhaps as the one and probably the only among physicians who can have different viewpoints and yet can best integrate them. It is still a commonplace to face difficulty recruiting trainees into psychiatry. Why? Who can take responsibility? Of course us the psychiatrist of today. What happened to the psychiatrists that I know who inspired me? The one who can talk through the patient’s phenomenology as if he has entered into the patient’s mind. He can analyse the patient’s behaviour just like a parent who only can decipher what the child says. He was the first physician I knew who can think about what might be happening to the patient beyond the clinic room . Yet he can whiz through the neurology examination , correlate the abnormal behaviour with the EEG abnormality . He acts with utmost zeal and confidence in making a diagnostic formulation. He puts his feet down as an expert who takes a holistic approach. The students look upon him in the grand grounds as an inspiring model. They take pride in being able to think biologically and psychosocially. It made people like me to develop interest and passion towards psychiatry. But where are they now? Are they a lost tribe ?They are not with the students but being bogged down with work to meet policy targets, cutting down costs and manage meetings or being pressurised to come up with publications and get study grants Certainly these things did not exist to fit in with Reil’s equation of the ‘role’ of a psychiatrist. We are running a risk of loosing out on the number of inspiring teachers. Let’s wake up now it is still not too late! Karthik Thangavelu ST4 in General Adult psychiatry Nottinghamshire Healthcare NHS trust Reference: Wake – up call for British Psychiatry, Nick Craddock et al, BJP (2008) 193, 6-9. |
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David Yeomans, consultant psychiatrist trustee leeds Mind
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david.yeomans{at}leedspft.nhs.uk David Yeomans
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The paper by Craddock et. al. and the subsequent e-letters illustrate the variety of opinions that attracted me to psychiatry. I work in a multi-agency service and our assessments and interventions can be carried out by professionals in Mind, in social services and in the NHS. In our service we share responsibilities. This allows me (a consultant psychiatrist) to pursue a resurgent interest in psychopharmacology, treatment adherence and the harm caused by side effects of medication. Although I appreciate the academic endeavours in biomedical science, I believe it is very important to contextualise them for non-academics. Randomised controlled trials don’t speak to clinicians as well as naturalistic studies. I have noticed that some of my psychiatric colleagues (and myself at times) shy away from precise diagnosis, acutely aware of how diagnoses are deliberately used to stigmatise people by individuals outside mental health services (as well as within). This is happening at a time when case definitions are becoming important to health service managers. Perhaps some psychiatrists are uncomfortable in their traditional territory. However, if psychiatrists step back too far, then others will move in. I expect that senior managers, rather than other clinicians or service users are likely to move into the spaces that we vacate. Psychiatrists should not support the replacement of “Doctor knows best” with “Manager knows best.” New Ways of Working may end up doing exactly that. Instead of being a shot in the arm, it may be a shot in the foot. Four trusts in the north of England are already constructing their own diagnostic systems to use alongside or instead of existing diagnostic schemes as a currency for payment by results. Assigning patients to pseudo-diagnostic “care clusters” could be something all staff do, not just the doctors. If psychiatrists step back from diagnosis, then diagnosis may change from a clinical concept with an associated evidence base, to a financial planning tool. There are other drivers of change too. In the prevalent atmosphere of anxiety and blame, risk assessment, not diagnosis, is now arguably the main gateway into acute mental health services. This means that some very ill people may have to wait for treatment while people who seem to be at acute risk are attended to first. Times change and if psychiatrists of any persuasion want to retain some influence they have to put up, not shut up; so well done for making the biomedical case. Biomedical psychiatry complements psychosocial psychiatry and is uniquely part of medical doctors’ expertise. The Royal College of psychiatrists should take this issue up with members. | |||
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Jed Boardman, Consultant Psychiatrist South London and Maudsley Foundation NHS Trust, Michele Hampson, Consultant Psychiatrist, Queen's Medical Centre Nottingham
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jedboard{at}atlas.co.uk Jed Boardman, et al.
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We welcome the debate initiated by Professor Craddock and colleagues in their “Wake-up call for British psychiatry” [1] and agree that the role of the psychiatrist is key to the delivery of high quality services, and may be currently threatened. However, we believe that their proposals would be restrictive and counter-productive. If the psychiatrist has to assess all those referred to secondary services access to such care would be restricted increasing the burden of unmet need. To deploy services effectively the psychiatrist should assess only those who require their direct input, freeing the psychiatrist up to have an overview of the clinical work of all the team members: from allocation, initial assessment and management through to discharge as well as a training and development role. This was the ambition of New Ways of Working,[2] although not realised in its implementation, partly due to the lack of training of the other team members for their extended role and the development of teams without adequate medical input for them to work effectively. These issues should be addressed directly. To return to a position of the consultant taking full clinical responsibility for all the team caseload is not only retrogressive, but unworkable. Allowing staff to take the personal responsibility that they already have improves the quality of care delivered and works best when the consultant is readily available for consultation and review rather than running over-booked out–patient clinics as occurred hitherto. The authors, in focussing on the importance of biomedical approaches appear to underestimate the important contribution of other approaches, psychological and social, to psychiatry which have been shown to lead to effective interventions. The profession of medicine is changing, with our physician colleagues taking up many of the challenges of a psychosocial approach. We appreciate that psychiatry is a medical speciality and that psychiatrists are physicians, but who have an expertise in psycho- and socio-dynamics in their broadest forms. In reconsidering our roles and values on the 200th anniversary of our speciality we should consider what we should be doing in the 21st century and how we adapt to this. The mental health services have far to go to improve standards, quality and the delivery of evidence-based practice. The users of these services should expect to encounter experts in the field of mental disorders, but these experts need a wide range of skills and knowledge to guide their assessment (including diagnosis) and management (including treatment). But, in addition, they need to utilise the ideas of recovery [3, 4] (a term regrettably omitted from Cradock et als paper) to negotiate and facilitate the types of goals and outcomes valued by service users and to allow people with mental disorders to participate more fully in their communities and society. It is important not to polarise this crucial debate, nor to retreat into restrictive medical modes of thinking. To meet the challenges of the 21st century will mean an important shift in our ways of working, which can be of enormous value to our professional roles and to the service users that we work with. Dr Jed Boardman Consultant Psychiatrist South London and Maudsley NHS Foundation Trust Dr Michele Hampson Consultant Psychiatrist Acute Care Network Queen's Medical Centre Nottingham References 1. Craddock, N. et al (2008) Wake-up call for British Psychiatry. British Journal of Psychiatry 193, 6-9. 2. Department of Health (2005) New Ways of Working for Psychiatrists. Enhancing effective, person centered services through new ways of working in multi-disciplinary and multi-agency contexts. Final Report July 2005 “but not the end of the story”. London : Department of Health. 3. Royal College of Psychiatrists/SCIE/CSIP (2007) A common purpose: Recovery in future mental health services. London: Social Care Institute for Excellence (www.scie.org.uk) 4. Shepherd, G., Boardman, J., & Slade M (2008). Making Recovery a Reality. London: Sainsbury Centre for Mental Health. Declaration of interest – none |
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David J Nutt, Consultant Psychiatrist University of Bristol
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david.j.nutt{at}bristol.ac.uk David J Nutt
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I read with interest, and a great deal of sympathy, the editorial of Craddock et al [June issue]. However I was puzzled by the omission of any reference to the Royal College of psychiatrists in relation to both the reasons for this crisis in psychiatry and potential ways in which matters might be improved. Surely if there was a time for our professional body to demonstrate strong leadership it is now? Perhaps the College could formally reply to the issues raised in the editorial? |
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Andrew C. Stanfield, Clinical Lecturer University of Edinburgh, Benjamin J. Baig
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andrew.stanfield{at}ed.ac.uk Andrew C. Stanfield, et al.
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Sir, As psychiatric trainees, we strongly support the “wake-up call for British psychiatry.”1 A critique of our professional inheritance by senior colleagues is both welcome and necessary. Contrary to common misperceptions, psychiatric training is not solely based in biomedicine. The syllabus contains as much sociology as neuroanatomy and as much psychology as psychopharmacology.2 We are not only diagnosticians but students of the biological, psychological and social contributors to illness. Other members of the multidisciplinary team are not so widely trained and cannot be expected to carry out appropriately broad initial assessments. Similarly, psychiatrists should not pretend to perform complex psychological or social assessments to the depth of our colleagues. Instead we are best placed to identify when detailed assessment is necessary and refer to an appropriately qualified member of the team. Bypassing this step from primary care referral, cannot be beneficial to patients. This approach does not devalue the multi- disciplinary team but rather endorses the different skills of those who comprise it. As increasingly few candidates for the MRCPsych examination are British graduates, there is no better time for a wake up call to recruitment. While lack of a biological focus to psychiatry may dissuade potential recruits, it is notable that an interest in people (rather than disease) and the social aspects of medicine are also important draws to the specialty.3 Psychiatry will lose further appeal if it becomes limited to the care of only those people who require medication or detention under the mental health act. In light of this, it is interesting to ask why others increasingly view the psychiatrist as strictly biological in orientation with a narrow role to play in patient care. A critique of British psychiatry may force us to take responsibility for the shape of our speciality. An over-inclusive classification system and a desire to ameliorate distress have tempted psychiatrists into treating normal human experience. There is no doubt that distressed individuals require support, but it does them no favours to be labelled, medicated and subsumed into a psychiatric system ill-equipped to provide for their needs. We must acknowledge our limits, encourage the development of support services outwith the psychiatric context and concentrate our own efforts on the heartlands of psychiatry. In addition, although psychiatrists may recognise the importance of psychosocial factors in mental illness, there are a lack of well- resourced, evidence-based services, to address these issues. The trend towards equating three to five years of postgraduate training in clinical psychology with sixteen weeks of training in CBT is particularly worrying. In this context, it is too easy for the focus of treatment to shift to an almost exclusively biological approach. Psychiatric trainees must ultimately fashion a professional landscape built upon informed diagnosis and evidence based biopsychosocial care. Indeed, our patients deserve nothing less. References 1. Craddock N, et al. Wake-up call for British psychiatry. Br J Psychiatry 2008; 193:6-9. 2. http://www.rcpsych.ac.uk/training/curriculum.aspx 3. Brown TM et al. Recruitment into psychiatry: views of consultants in Scotland. Psychiatr Bull 2007; 31:411–3. Conflicts of interest Nil |
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Johannes Thome, Professor of Psychiatry Swansea University School of Medicine
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j.thome{at}swan.ac.uk Johannes Thome
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Dear Editor, With great interest, I have read the wake-up call by Craddock et al. about the demedicalisation of psychiatry. In this context, it may be useful to introduce an international perspective and to consider how psychiatry is conceptualised elsewhere. Perhaps, the marginalisation of the medical profession in psychiatry is less advanced in countries whose psychiatric traditions are strongly influenced by Griesinger’s dictum that all psychiatric disorders are brain disorders, and thus medical conditions. For example, having a strong rooting in medicine is a natural feature of the self-concept of my German colleagues. During their training as junior doctors, future psychiatrists spend at least one year in neurology. Conducting lumbar punctures and providing advanced medical care including intensive care is not uncommon for many psychiatrists in German hospitals. I remember that when I was a medical student, it was a consultant psychiatrist who explained to me how to perform intracardiac catheterisation and total parenteral nutrition in a delirant patient who was treated on a psychiatric ward, because he was diagnosed with a psychiatric condition (alcohol addiction). We also had weekly joint ward rounds with neuroradiologists, neurologists and neurosurgeons in order to discuss the brain scans of our patients. Craddock et al. describe the risks and dangers of giving up the medical background in psychiatry, a process which can also have very negative consequences regarding the stigmatisation of our patients. The tendency to avoid the use of words like “psychiatry” and “psychiatric” can be counterproductive in the attempt to help de-stigmatise psychiatric patients: The increasingly widely used term “service user” is by now much more stigmatising than the term “patient”, because it is mostly used in the context of mental illness suggesting fundamental differences between psychiatric patients and other patients who are no “service users”. In contrast, some anti-stigma campaigns in continental Europe emphasise that, in principle, there is no difference between a patient in psychiatry and a patient in any other medical discipline. By ensuring that psychiatric patients have the same rights and standing as all other patients and by underscoring that psychiatric conditions are medical conditions, the stigma attached to psychiatry could be substantially reduced. This, of course, does not mean that the important contributions of non- medical team members (psychologists, social workers, nurses, occupational therapists etc) in psychiatric services are not recognised. |
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Leon Rozewicz, Consultant Psychiatrist Barnet, Enfield & Haringey Mental Health NHS Trust, Dr Paul St John Smith, Consultant Psychiatrist, Hertfordshire Partnership NHS Foundation Trust
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leon{at}rozewicz.com Leon Rozewicz, et al.
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We agree with Craddock et al (1), that psychiatrists need to be confident in what they have to offer. As a profession, we need to offer excellence in assessment, prescribing and patient management. Our College needs to promote all these qualities in the profession. Psychiatric patients in a modern health service need to have all this available. There should be no distinction between recognising organic and psychosocial problems. Recovery cannot take place without optimal medical treatment. This applies to psychiatric patients as much as it applies to those seen by any other specialist. Recovery should be about treating the treatable and optimising function caused by disabilities that result from what is not treatable. New Ways of Working (NWW)(2), when initially introduced, appeared to recognise this. Its emphasis on distributed responsibility promised to retain the important input of psychiatrists whilst allowing them to do what they do best, thus maximising the efficiency of multidisciplinary teams. It was also coupled with a training programme, Creating Capable Teams Approach (CCTA)(3), which would allow non medical team members to function safely and effectively. However, if NWW is implemented without appropriate training, it can lead to poor and dangerous practice. This will mean that important psychological and social problems will be missed, as well as medical ones. This does not promote recovery, indeed it does the opposite. It is also important to recognise that GPs have training and experience in managing mental illness. Indeed, 25% of their workload comprises of those with psychiatric disorders. It is therefore very important for referral systems to allow GPs access to psychiatric opinions about their patients when GPs think this is required. It is possible to design care pathways using multidisciplinary teams based on NWW that allow this, without greatly increasing workload. The current trend to create teams that do not allow for this, often citing efficient use of resources or the benefits of having a single point of entry, is driven more by misguided ideology than by any benefits it achieves for patients or the use of resources. We therefore strongly support the thrust of the author’s argument. However, NWW has an important contribution to make to the provision of services to our patients, provided it is implemented appropriately and coupled with training. As full time NHS psychiatrists, we are very keen to make sure that expert psychiatric assessments are available to all who need them, regardless of the ability to pay. At present, in some parts of England, it will be only available to those who are able to pay for this in the private sector. Unfortunately, often those of my patients who need it most are least able to pay for this. 1. Craddock N, Antebi D, Attenburrow MJ, Bailey A, Carson A, Cowen P et al. Wake-up call for British psychiatry. Br J Psychiatry 2008; 193:6-9. 2. Royal College of Psychiatrists and National Institute for Mental Health in England. New Ways of Working for Psychiatrists: Enhancing Effective, Person-centred Services through New Ways of Working in Multidisciplinary and Multi-agency Contexts. Final Report ‘But Not the End of the Story’. Department of Health, 2005. 3. Creating Capable Teams Approach (CCTA) Best practice guidance to support the implementation of New Ways of Working (NWW) and New Roles. Department of Health 2007. |
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Sameer Jauhar, ST4 General Adult Psychiatry Gartnavel Royal Hospital Glasgow
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sameerjauhar{at}gmail.com Sameer Jauhar
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Dear Editor, I thoroughly enjoyed the Editorial by Craddock et al (1), and would like to address the following points; a) The perceived “lack of recruitment and retention in Psychiatry”; though there has been considerable mention of this, anyone involved in psychiatric training or workforce planning recently will be aware of the changes in numbers in the years since systems such as New Ways of Working (2) were conceptualised. What has not been mentioned (and what is more pertinent) is the effect of such changes on future recruitment and retention. b) The educational standards that we, as trainees, are expected to achieve are laudable, and (justifiably) a great deal of effort has been spent over the years by the College to refine these (a recent example being the Curriculum submitted by the College to PMETB). The delegation of assessment to multidisciplinary team members, without adequate, standardised assessment of competency, is worrying. Clinical experience has shown that GPs, when they refer patients, might not have conducted an exhaustive neurological examination or battery of tests to exclude “organic” causes, and would expect these to be picked up by secondary services. It is beyond the boundaries of reason (and “team supervision”) to expect multidisciplinary team members to be aware of organic presentations, neuro-endocrine signs and symptoms, and subtleties on history and mental state examination that come with the experience (and training) of a psychiatrist. The equivalent would be a Neurology service expecting a physiotherapist to assess patients referred with unexplained weakness and muscle atrophy; certainly the physiotherapist may have an important, specialised role in treatment, but the initial assessment should be by a physician, who will have a broad knowledge base, refined by training and experience. Our patients present in complex ways, and to reduce their assessment to rating scales, symptom checklists and “risk management” (as is currently the vogue) makes a mockery of the skills needed to practice psychiatry to an adequate standard. By delegating initial assessment to generic team members the art of psychiatry appears to have been reduced to a “paint by numbers” approach, that is anything but “patient-centred”, Looking at the fashion in which changes have been implemented, it is easy to make comparison with other Department of Health initiatives (such as the MTAS/MMC fiasco(3)). On this occasion, however, the College has the opportunity to effect change. The gauntlet has been thrown to the College to poll its membership on the implementation of New Ways of Working; this issue will not go away and needs to be resolved. References 1. Craddock, N. et al (2008) Wake-up call for British Psychiatry. British Journal of Psychiatry 193, 6-9. 2. Department of Health (2005) New Ways of Working for Psychiatrists. Enhancing effective, person centered services through new ways of working in multi-disciplinary and multi-agency contexts. Final Report July 2005 “but not the end of the story”. London : Department of Health 3. Tooke J (2007) Aspiring to excellence; findings and recommendations of the independent inquiry into Modernising Medical Careers. (http://www.mmcinquiry.org.uk/MMC_Inquiry_Launch_2.pdf 2.) |
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Mamdouh EL-Adl, Consultant Psychiatrist Northamptonshire Healthcare NHS Trust
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mamdouh.eladl{at}nht.northants.nhs.uk Mamdouh EL-Adl
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Dear editor The special article by a group of eminent professors and consultants’ psychiatrists entitled: Wake-up call for British Psychiatry is a very important call. Craddock et al highlighted the likely multiple damages of the so called New Ways of Working “NWW”(1). Many colleagues welcomed the wake-up call but some feel concerned that this wake-up call was too late. An important question to be raised: where is the Royal College of Psychiatrists from this? As we know the College was one of the main driving parties for the introduction of NWW. The main reasons outlined by the College were: Consultants’ heavy workload across the UK and the need for change. The problem of the overworked consultants could have been addressed by different approach including: improving recruitments, encouraging healthy retired consultants to continue to work either full or part time and encouraging new generations of medical students and trainees to join psychiatry. Change is a healthy process that none could object to although it is usually associated with challenges. However radical and uncalculated change could be damaging. The disaster of modernising medical career (MMC) has not been forgotten yet and the medical profession continues to suffer its flashbacks. In his response to being invited by Patricia Hewitt, Health Secretary, to conduct an independent inquiry on MMC, Professor Sir John Tooke stated: Seldom in my professional career has an issue provoked such an outcry from the profession and expressions of concern for the future of trainee doctors and the delivery of medical care and health service developments to which we hope they will contribute (2). The long term planning for medical workforce has never been an easy task (3). However passing many of the important responsibilities that require the skills and expertise of the medically trained psychiatrists to non-medical disciplines is not the solution! There is a growing believe that the NWW has made a negative effect on the profession, the psychiatric training and service quality. While patients’ best interest should be at the heart of the clinical operation and healthcare strategy, many mental health clinicians (psychiatrists & non-psychiatrists) do not feel that NWW considered this carefully. I feel it was probably more appropriate instead of introducing a new system (NWW) to examine an already existing system, promote its positives and address its negatives. Professor Tooke stated: The profession should develop a mechanism(s) for providing a coherent advice on matters that are of major significance to medicine and hence the health of the population in general (4). Therefore, I am urging the College and the Department of Health (DOH) to objectively review the situation. I suggest forming an independent group of experienced clinicians, academics and service developers to review the implementation of NWW in the trusts that adopted this model and study its impact on patients’ care, service quality and delivery and quality of training before it is too late. We need to do it for our patients, profession and for the mental healthcare of future generations. If the College does not do this, who else will do? Declaration of interest: none. Mamdouh EL-Adl Consultant Psychiatrist, Campbell House, Northamptonshire Healthcare NHS Trust Mamdouh.eladl@nht.northants.nhs.uk References: 1.Craddock N, Antebi D, Attenburrow M et al. Wake-up call for British Psychiatry. Br J Psychiatry 2008;193: 6–9 2.Tooke J.: MMC Inquiry. Why an Inquiry? www.mmcinquiry.org.uk. Accessed on 07.08.08 3.Pidd S. The Royal College of Psychiatrists: response to the health committee’s inquiry into workforce needs and planning for the health service (2006). www.rcpsych.ac.uk/pdf/accessed on 07.08.08 4.Tooke J.: Final report of the Independent Inquiry into Modernising Medical Careers. www.mmcinquiry.org.uk/MMC_FINAL_REVD_4Jan.pdf. Accessed on 07.08.08 |
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Alan Cohen, General Practitioner Sainsbury Centre for Mental Health, Andre Tylee and Chris Manning
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alan.cohen{at}scmh.org.uk Alan Cohen, et al.
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Sir Craddock et al (Wake up call for British Psychiatry (2008) 193, 6-9) make some interesting points about the role of the psychiatrist. It is unashamedly made from a psychiatrist’s perspective. We would like to comment from a primary care perspective, since many of the issues raised have a significant bearing on the way primary care works currently, and how it may work in the future. The authors make the point that “psychiatry is a medical speciality” and that general practitioners should have the opportunity to refer patients for an opinion when they are unclear about the diagnosis or treatment. Sadly, in our experience, this rarely happens, as patients who have a mood disorder such as depression or anxiety are often told that they do not fulfil the criteria for referral (understood by the patient to mean that they are not “ill enough”) to see a psychiatrist. It is a rare occurrence where a psychiatrist will intervene in the administrative chore of “bouncing the patient” back to the GP, so that the patient does benefit from their opinion. Such referrals are often pejoratively labelled as “inappropriate” implying a lack of competence by the referrer. This behaviour, of screening out people with certain conditions, is justified on the grounds that psychiatrists should concentrate on the most ill, that is the psychoses, and they quote the National Service Framework for Mental Health (NSF) as supporting this stance. No other medical speciality diverts patients away from a medical opinion in the same way. It is a sad testament to both primary and secondary care clinicians that the person who was able to negotiate an improved level of care for people with a significant mental illness such as depression or anxiety, was an economist, making an economic argument at the highest level of government. The authors also make the case that they should be responsible for managing the physical health care needs of the people for whom they care. They are, according to the authors, first and foremost highly trained doctors. What has stopped psychiatrists providing this care in the past? Are the authors really making the case that they should manage not only the psychiatric needs of a person suffering from schizophrenia, but also manage that person’s diabetes, hypertension, obesity and osteoarthritis? Surely not? Readers were offered a thought experiment; we offer another thought experiment to the authors: “if you had diabetes, hypertension, obesity and osteoarthritis, would you want these conditions managed by a psychiatrist, or a GP?” If there is a real concern that psychiatrists no longer have the opportunity to practice the speciality in which they trained, then they should do something about it. The NSF is coming to an end – so should the restrictions on who psychiatrists will see should also come to an end. If psychiatrists wish to behave as other medical consultants, then they should see the referrals made to their teams – as team leaders it is in their gift to do so. It may well be that some form of screening may be necessary, but do so based on patient need, not on the basis of a diagnosis. |
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Christine Vize, Consultant Psychiatrist , see below
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christine.vize{at}btinternet.com Christine Vize, et al.
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Full list of authors for this letter Please could this be added Peter Atkinson Vice Chair UNISON National Nursing Committee, Simon Baugh Medical Director Bradford District Care Trust, Angus Bell Consultant Psychiatrist and Clinical Director Tees Esk and Wear Valleys Mental Health Trust, Desmond Benn Consultant Psychiatrist Tees Esk and Wear Valleys Mental Health Trust, Neil Brimblecombe Director of Nursing Research and Development South Staffordshire and Shropshire Healthcare NHS Foundation Trust, Tim Cate Associate Director of Psychology Tees Esk and Wear Valleys Mental Health Trust, Martin Crawshaw Chair British Psychological Society Professional Practice Board, Bill Davidson Service User Lead NIMHE National Workforce Programme, Barry Foley New Ways of Working Programme Lead NIMHE, Stuart Hatton Director of Service Delivery Bradford District Care Trust, Elizabeth Holford mental health services patient, Nicki Hollingsworth National Creating Capable Teams lead, Roslyn Hope Director NIMHE National Workforce Programme, Ian Hulatt RCN Mental Health Adviser, Steve Humphries Consultant Psychiatrist Associate Director for New Ways of Working CSIP, Jen Kilyon Carer Lead NIMHE National Workforce Programme, Peter Kinderman Professor of Clinical Psychology University of Liverpool, Tony Lavender Professor of Psychology and Pro Vice Chancellor/Dean Canterbury Christ Church University, Liz Lightbown Deputy Director Operational Services (Mental Health) Barnsley PCT, Laura McGraw Nurse Consultant Tees Esk and Wear Valleys Mental Health Trust, Malcolm Rae Joint Lead Acute Care Programme NIMHE, Hugh Middleton Consultant Psychiatrist Nottinghamshire Healthcare NHS Trust and School of Sociology and Social Policy University of Nottingham, Wendy Osborn Allied Health Professions Consultant and member National Steering Group for New Ways of Working, Sally Pidd Consultant Psychiatrist Lancashire Care Foundation Trust, Paul Rooney Joint Lead NIMHE National Acute Care Programme, Kim Shamash Executive Medical Director Sussex Partnership NHS Trust, Yvonne Stoddart Director National Acute Mental Health Project NIMHE, Graham Turpin Professor of Clinical Psychology University of Sheffield. |
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Kamini Vasudev, Specialist Registrar, Adult Psychiatry EIP Service, Monkwearmouth Hospital, Sunderland, SR5 1NB
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kaminivasudev{at}hotmail.com Kamini Vasudev
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I read with keen interest the article ‘Wake-up call for British Psychiatry’ by Craddock et al., BJPsych July 2008. I completely agree with the concerns raised by the authors. As a trainee psychiatrist working in United Kingdom for the last few years, I have had an opportunity of working with several community mental health teams (CMHTs). I have observed implementation of ‘new ways of working’ in different teams and its impact on patient care. Unfortunately, at some places the psychiatrists themselves have misinterpreted the meaning of their ‘consultative role’ in the ‘new ways of working’ model. They seem to be reluctant to assess new referrals. They tend to rely on the assessments conducted by other members of the team, who present the new cases at the team meeting, to decide if the patient needs to be reviewed by them. It might be that this reluctance stems from the need to carry out time- consuming paper work including the care co-ordination document and risk assessment document for the new referrals. However, this deprives the patient of the benefit of being assessed by ‘the most experienced and skilled professional of the team’, as rightly pointed by the authors. In the best interest of the patients, it is important that most, if not all the new referrals to the CMHTs should be assessed by the consultant psychiatrists or the trainee doctors under their supervision along with/without another member of the team, as appropriate. The management plan thus formulated could be implemented with involvement of other members of the team and sometimes in the primary care. The psychiatrists thus would have minimal number of patients in their follow- up clinic. After providing their ‘consultation’ the consultant psychiatrists should be able to discharge the care of the patients back to primary care. Alternatively, the more complicated patients could be followed up by other members of the CMHT with once or twice yearly review by the psychiatrists. This would free-up their time to make themselves available for urgent or new referrals. It is understandable that GPs might have their reservations to take the burden of care of all the stable psychiatric patients unless they get reassurance that the consultant psychiatrists would be able to review the patients as soon as possible should the need arise. There is a need for the psychiatrists to be forthcoming and take the initiative to implement the ‘new ways of working’ for patient-centred care. They would, however, need co-operation of other members of the team to make this happen, which can be challenging. |
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Nick Craddock Department of Psychological Medicine, Cardiff University, see end of letter for list of authors
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craddockn{at}Cardiff.ac.uk Nick Craddock, et al.
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Sir We are pleased that our article has stimulated debate. This was our intention. We are disappointed that some correspondents dismiss our argument by attacking a stereotype of who they think we are or a caricature of what they think we might have said, rather than addressing what we actually did say. Such correspondents have missed, or ignored, the point of the article – namely, to ask whether the de-medicalisation that has taken place over recent years in British psychiatry is bad for the health of patients and the specialty. We believe this is a question that is worth taking seriously. It is clear from the substantial eletter correspondence and other feedback that many psychiatrists share our concerns and wish for constructive debate. This primary concern with the decline in medical standards of care and the deliberate politicization of debates about service delivery does not imply that we cannot (a) embrace the importance of the full range of biological, psychological and social interventions for psychiatric illness and (b) value our non-psychiatric fellow professionals, and their integral contributions to mental health care. We also believe to be self-evident that services should be informed by the experiences of patients, their relatives and carers and that multidisciplinary team work is crucial for optimal management of psychiatric illness. We are not terribly interested in what is past. We are much more interested to look ahead. Of the wide range of views expressed by respondents, we believe the voice of trainees and those contemplating a career in psychiatry should carry particular weight and we should like to hear more from them. They are the future of British psychiatry. Declaration of interest: None Authors Nick Craddock1*, Danny Antebi2, Mary-Jane Attenburrow3, Tony Bailey3, Alan Carson4, Phil Cowen3, Bridget Craddock5, John Eagles6, Klaus Ebmeier3, Anne Farmer7, Seena Fazel3, Nicol Ferrier8, John Geddes3, Guy Goodwin3, Paul Harrison3, Keith Hawton3, Stephen Hunter9, Robin Jacoby3 Ian Jones1, Paul Keedwell1, Mike Kerr1, Paul Mackin8, Peter McGuffin7, Donald McIntyre4, Pauline McConville4, Deborah Mountain4, Michael C. O’Donovan1, Michael J. Owen1, Femi Oyebode10, Mary Phillips1,11, Jonathan Price3, Prem Shah3, Danny J. Smith1, James Walters1, Peter Woodruff12, Allan Young13, Stan Zammit1 1Department of Psychological Medicine, Medical School, Cardiff University, Heath Park, Cardiff CF14 4XN; 2Gwent Healthcare NHS Trust , 6 Goldtops, Newport, NP20 4PG; 3University of Oxford Department of Psychiatry, The Warneford Hospital, Oxford OX3 7JX; 4Royal Edinburgh Hospital, Morningside terrace , Edinburgh, EH10 5HF; 5ABM University NHS Trust, 71 Quarella Rd, Bridgend; 6 Royal Cornhill Hospital, Cornhill Road, Aberdeen AB25 2ZH; 7 Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF; 8Institute of Neuroscience (Psychiatry), Newcastle University, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP; 9 Gwent Healthcare NHS Trust, range House, Llanfrechfa Grange, Cwmbran, Torfaen NP44 8YN; 10 Department of Psychiatry, University of Birmingham, Queen Elizabeth Psychiatric Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2QZ; 11 Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Loeffler Building,121, Meyran Avenue, Pittsburgh. PA 15213, USA; 12 Department of Academic Clinical Psychiatry, Sheffield University, The Longley Centre, Norwood Grange Drive, Sheffield S5 7JT; 13 Dept. of Psychiatry, University of British Columbia, Suite 430 - 5950 University Blvd., Vancouver, BC V6T 1Z3, Canada. *Correspondence: Department of Psychological Medicine, Medical School, Cardiff University, Heath Park, Cardiff CF14 4XN; Email: craddockn@cardiff.ac.uk |
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N J O Jacobsen, F2 / SHO
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nickjacobsen{at}yahoo.co.uk N J O Jacobsen
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I came into medicine as a mature student of thirty two with a PhD and did a four year graduate entry medical degree. I am now a Foundation Programme trainee currently in my F2 year and am now at the point of decision about specialist training. I am fascinated by psychiatry and have been seriously considering it as a career for many years. As a consequence I have done two four month postings in general adult psychiatry, and old age psychiatry. This is a fairly unique position in terms of the level of exposure to psychiatry prior to specialist training entry. My two postings in psychiatry have been interspersed with medical and surgical positions and it is this mix that has created a perspective that made Professor Craddock’s article resonate for me. I spent many years at medical school acquiring the medical knowledge and skills necessary to do my job correctly. In my short experience of psychiatry, especially general adult psychiatry, the lack of emphasis on medical approaches was at times very concerning. Although I am a great advocate of psychological and social intervention, at times I felt that the medical side was side lined and devalued and I felt at times that the patient was not given the best possible treatment as a consequence. Much of the time I felt that the service in my locality is more nursing and MDT lead with the psychiatrist being present merely as an advisor or prescriber. As a consequence, my principle concerns when contemplating a career in psychiatry is that my core medical knowledge and skills will be eroded over time and this makes me feel decidedly uncomfortable and sad. My decision to enter a career in psychiatry is therefore no longer straight forward. This should not be the case because I anticipate opportunities for major improvements in understanding and patient care over the course of my career and with the correct medical approaches I know that I would contribute a great deal to British psychiatry. |
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Mark Agius, Visiting Research Associate Department of Psychiatry University of Cambridge, Claranne Micallef Department of Anthropology University of Malta
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ma393{at}cam.ac.uk Mark Agius, et al.
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Michael Balint has described the Doctor-Patient Relationship as follows; ‘The terapist’s tasks [are] ‘listening’,‘understanding’, ‘using the understanding so that it should have a therapeutic effect’.[Balint 1964]. I will always remember an old GP trainer who always used to tell us , quoting Balint, ‘Remember, the first drug the doctor prescribes to the patient is himself’. This , in psycho-dynamic terms is the core of medical practice. We must consider why doctors are such an effective ‘drug’. Clearly it is because patients assume that doctors are on their side and that they have knowledge about their condition which they will use to the patient’s benefit. Suggestion that doctors do not have knowledge which can be used to the patient’s advantage undermines the doctor-patient relationship and leads to such statements as have been made in this debate ‘It’s not a hard science, it’s subjective. Some diagnostic categories are little more than a value judgement.’[Penbroke 2008], and ‘Psychiatry is not a medical speciality that can be equally compared to orthopaedics because there are no diagnostic tests with clear demonstrable results’ [Penbroke 2008]. Other letters have undervalued , probably unintentionally, modern understanding of the pathophysiology of mental illness brought about by present techniques, thus for instance ‘Consultant psychiatrists, being trained doctors, are in a position to diagnose more organic driven illness that presents but this is a small percentage of our caseload’.[Dickson 2008] This ironically neglects the fact that modern technology is giving us greater insight, through such new techniques as neuroimaging and genetics of how mental illness occurs- a knowledge which it behoves consultant psychiatrists to contribute to their teams, and which should give doctors the support to give proper explanations to their patients. It is not for nothing that many of our leading Geneticists and Neuroimaging Experts have involved themselves in this debate. Elsewhere , it has been said ‘Neuroimaging has provided irrefutable evidence for a biological basis for psychiatric disorders’. [Frangou 2008]. So Psychiatry is changing, and, though we have far to go , is becoming more of an exact science, not just an attempt to apply arguably questionable ICD and DSM driven diagnostic criteria. This knowledge must be used to support the Doctor-Patient Relationship, giving patients more confidence that the doctors have some understanding of the causes of their illness. One problem is that clinicians in the field and managers have lost touch with the scientific developments, and are not using this new knowledge to guide their work and their services. Another way of undermining the doctor-patient relationship , clearly inadvertently, is the statement ‘If the psychiatrist has to assess all those referred to secondary services access to such care would be restricted increasing the burden of unmet need.’ [Boardman 2008]. This implies an unwillingness of the doctor to be available to his potential patients…..and availability is one attribute of the doctor which the patient values above all others. How the issue may be solved without overburdening doctors is a difficulty which society must ponder, and which ‘New Ways of Working ‘ has had difficulty solving for the reasons that Boardman has himself described. There is only one satisfactory answer to this; to increase the number of available doctors . Alternatives to this lead inevitably to ‘the substitution of “Doctor knows best” with “Manager knows best.” And New Ways of Working may end up doing exactly that’. [ Yeomans 2008] Recently a senior manager in a trust asked publicly ‘what extra value is there in a consultant psychiatrist seeing a patient for fifteen minutes every three months?’ But the answer to this question is precisely the doctor –patient relationship supported by the new biological knowledge and the doctor’s communication skills applied to the advantage of the patient…..this is genuine ‘new ways of working’. The lack of managers’ understanding of this is well illustrated by the recent simultaneous imposition by managers on the profession of both ‘Revalidation’, which ‘Balint like’ wishes to test us on our communication skills with patients, and ‘New ways of working’, which attempts to interpose other persons and professions between the doctor and the patient. Ultimately it is crucial that the ‘Wake up call for British Psychiatry’ must triumph, because it provides the basis in terms of our new knowledge of Psychopathology of the aetiology of mental illness- that knowledge, which allied with a caring attitude , is key to a Doctor-Patient Relationship devoid of inappropriate Paternalism, and which, by providing clear explanatory models of mental illness will help combat stigma. This does not at all exclude other professions; their different approaches help complement our relationship with patients and enable us to provide for all the patients’ needs. Recently the Royal College President called for a renewal of the Psychiatrist’s contract with society [Bugra 2008]. It is on the Doctor- Patient Relationship and the new Biomedical knowledge that this contract must be based. References Balint M 1964 The doctor, his patient, and the illness Churchill Livingstone London Boardman J, Hampson M 2008 Wake up call. BJPsych electronic letters Bugra D 2008. Renewing psychiatry’s contract with society. Psychiatric Bulletin 32;281-283. Dickson D 2008 2008 A new anti-psychiatry movement? BJPsych electronic letters Frangou S et al 2008 European Psychiatry Editorial 23;223. Penbroke L et al 2008 A new anti-psychiatry movement? BJPsych electronic letters Yeomans D 2008 Making the biomedical case BJPsych electronic letters |
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Peter B Jones, Head of Department of Psychiatry, Professor of Psychiatry, Consultant Psychiatrist University of Cambridge, Edward T Bullmore, Paul C Fletcher
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pbj21{at}cam.ac.uk Peter B Jones, et al.
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We thank the correspondents for their interest in our article[1] that, following Craddock’s polemic [2], we hoped would provoke some responses and debate. While we would dearly like to agree with the Editor’s suggestion [3] that a belief in the importance of the brain marks us out as Cavaliers, we fear that the neuroscientific enterprise, marked by slow, painstaking data collection, hypothesis testing and incremental advances doesn’t quite suit his analogy. Nor do we, in championing neuroscience, dismiss the importance of other levels of explanation as some of our respondents suggest. Our original editorial was clear on this. As for the suggestion that neuroscience is a form of behaviourism and must thereby deny the mind, we do hope that a brief survey of the last decade’s cognitive neuroscientific literature refutes that concern. McQueen [4] is right to take us to task for forgetting emotion: this is an oversight in our article but not, we are happy to say, in the field where affective and social neurosciences thrive. Blewett [5] is also correct when he points out that major impacts on the lives of patients have arisen, and continue to flow from phenomena that are meaningless when conceived solely within a neuroscientific framework. We certainly do not demur from a bio-psycho-social formulation; these are the three primary colours in which we paint our discipline and which make it more vibrant than other medical specialities. Rather, we point out that the “bio-” aspect of psychiatry is getting brighter, stronger and, in our opinion, more useful such that, as a profession, we cannot afford to ignore it lest we do a disservice to our patients. To argue, as does Datta [6], that if we embrace this change then we shall be taken over by neurology is surely, as Johansson [7] indicates, unfalteringly absurd. After all, patients need good doctors first and foremost, and we believe that Reil conceived psychiatry as a broad discipline reflecting his own polymathematical abilities. When we manage someone’s arachnophobia with an appropriately eclectic mix of graded exposure, SSRI for co-morbid depression, psycho-education and family support we do not aim for them to live in world populated by tarantulas, let alone become one. So, too, for psychiatry: in pointing out its neurophobic tendencies we aim to restore good function and allow it to move-on. To us, this doesn’t appear to be rocket-science, just neuroscience. Yours faithfully, Professor Peter B. Jones, FRCPsych, FMedSci Professor Ed Bullmore, MRCPsych, FMedSci, Professor Paul Fletcher, MRCPsych, PhD Herchel Smith Building for Brain and Mind Sciences Forvie Site, Robinson Way Cambridge Biomedical Campus Cambridge CB2 0SZ 01223 336961 |
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