Wake-up call for British psychiatry: responses

Craddock et al ¹ 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 helplessness. ² 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 support. ³ 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 high-income 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 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 patients’ is regressive and paternalistic. On the 60th anniversary of the NHS it should be unnecessary to advocate well-being as the purpose of healthcare. 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 healthcare is to become a reality.

The learning disabilities field provides a precedent. A generation ago, most people with significant forms of ‘mental sub-normality/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’. ⁴

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 medication, ⁵ and some clinical teams recognise the virtue of electing the professional best qualified to inspire and nurture the team. ⁶ Time, perhaps, to wake up and smell the coffee.