Over 1 in 10 adults who go missing were depressed before they became estranged from their loved ones. This is a tragic statistic given that few return to their former lives. Depression distorts reality and leads to feelings of helplessness. The depressed person who is low in mood is desperate to feel better. In his desperation there exists a fantasy that removing himself from his situation, painted as it is with the miserable murk of depression, like looking through a dirty window, might do the trick. This is rarely the case - depression will follow the sufferer where he goes - just as was the case in Stephen Fry’s flight to Paris during his West End show. Fortunately Stephen Fry returned to his old life again but many do not, perhaps because they feel too much guilt and shame, which is wrapped up with the depression, or the memory of it. Given that a change of location does not necessarily bring about relief from depression it is best to stay put and get help from friends and family as well as the local professional services. There is no shame in asking for help as at least 1 in 5 of us will become depressed at some point in our lives. It is not a sign of weakness to own up to needing to help - it is a sign of humility. Depression is very treatable. Even without treatment most cases clear up within 12 months, time being a healer. It is better to stay and face up to one’s demons rather than attempt to escape from them by fleeing. Most who flee are not escaping from a situation that caused depression, especially if their depression followed a bereavement. Even if the prior life led to the depression this does not mean that the depressed person can not sort out these problems rather than running away from them. Depression is forcing some time out to reflect, but this does not mean that we have to cut ourselves off from all those more valuable sources of support that we have around us - this is denying us the support we need in the long term.

The demedicalisation of psychiatry – a step too far?

Rufus May, a clinical psychologist who experienced his first episode of schizophrenia at the age of 18, was forced to take medication while in hospital; although the drugs ultimately took his symptoms away this was a traumatic experience, and he had unpleasant side effects. Admirably, as a reaction to his experiences he decided to channel his energies in to trying to treat others. However, his recent addition to the debate about medical treatments for mental health problems has lacked balance. Channel Four’s strange programme “The Doctor Who Hears Voices” (aired on 21st April, 2008) featured May attempting to treat a young doctor, who was hearing voices, with his own brand of talking therapy. Intentionally or not, I believe the effect was to portray to a wide audience that psychotic disorder can be managed drug free by facing up to your ‘voices’ and exploring their origin in your childhood. This is a distorted view of psychosis, seen through rose tinted spectacles.

The programme seems to be part of an overall agenda to demedicalise psychiatry. Although it is good to keep the psychiatric profession in check it seems to me that the movement is going a little too far when it comes to the treatment of psychosis. This opinion comes from someone who has had a training in psychology and psychiatry (the latter enables you to prescribe medication, the former not), so should be able to see both sides. In my view, there could be dangers around the corner for an important number of mentally ill patients.

A holistic approach to mental disorder keeps an open mind to all factors at play in an individual: developmental experiences and life’s stresses interact with the genetic and biological influences. However, non-medically trained professionals can downplay biological influences due to ignorance, or in order to boost their own professional status in a tub-thumping way. Although I would not assume that Mr May falls in to either of these categories his refusal to accept that chemical imbalances can occur in the brain is bizarre. In this regard, he seems to be following in the wake of a great many closed-minded psychologists who do not seem to be able to break free of the biases inherent in their own training - a training which, while attacking the inherent limitations of the so-called ‘medical model’, often tries to pretend that genetic and biological influences on the brain, and hence the mind, do not exist. This ignores the advances that have been made in genetics and neuroscience over the last 20 or 30 years. It is misguided to think that all these discoveries have been led by pharmaceutical companies.

Dinesh Bhugra, the president of the Royal College of Psychiatrists has highlighted how recent government initiatives like “New Ways of Working” are devaluing the unique role of psychiatrists in the assessment of mental illness in favour of non-medically trained professionals. Similar sentiments are expressed in a leader entitled “A Wake Up Call for Psychiatrists”, which has just been accepted for publication in the British Journal of Psychiatry. I have added my name to a long list of co-authors. The article was originally conceived by Professor Craddock who is a leading MRC and Wellcome funded researcher in to the genetics of psychiatric disorders, including schizophrenia.

Schizophrenia is the most common form of psychosis, with symptoms typically including persistent hallucinations (e.g. voices or visions without external source) and delusions (persistently fixed beliefs not built on objective evidence). The heritability of schizophrenia is high and the evidence in favour of genetic vulnerability, abnormal brain chemistry and abnormal development of brain connections is rapidly expanding. Although the triggering of schizophrenia has an environmental component, we have moved on from the psychological theories of the genesis of schizophrenia which ignore the biological aspects. Although schizophrenia has been shown to be more common in people who have suffered child abuse, for example, there is no suggestion that this is a specific cause, but merely a trigger (child abuse is the precursor to many psychiatric illnesses, after all).

There are good, proven, psychological treatments for psychosis, which include logical reasoning techniques to fight delusions, family interventions to reduce hostile reactions, and focusing techniques to gain mastery over hallucinations. I should add that explorative approaches like those May employed in his programme are not among them. In fact, most psychologists would admit that such approaches can make a psychosis worse due to the fact that there is insufficient ego strength to deal with emotionally harrowing interpretations. Furthermore, I have never worked with clinical psychologists, including expert proponents of the treatments listed above, who would advocate replacing medical approaches with psychological ones. They advocate both approaches, and often ask for alterations in medication to optimise clinical response. The medical and psychological approaches are at their most complementary in ‘concordance therapy’ which challenges feelings of embarrassment or feelings of being out of control when taking medication for a mental illness. While many therapists are trying to argue that taking a pill for a mental disorder in order to stay well is no different from taking a pill for epilepsy or diabetes, Channel Four’s programme is potentially undoing this work.

Mr May’s denial of the reality of a connection between disturbances of brain chemistry and disordered mental experiences also ignores the fact that careful psychiatric assessments can sometimes reveal that symptoms like hallucinations are due to epilepsy, prescribed medications, street drugs, infection (including HIV infection), hormone problems or brain tumours (to name but a few ‘medical’ causes of psychosis). What is the place of talking therapies in this context? Ignorance of the medical model in these cases would lead to a potentially reversible problem being overlooked: the illness would remain stubbornly ‘resistant’ to any so-called ‘treatment’.

May’s personal experiences of being admitted to an adolescent unit in his teens, and perhaps being treated over-zealously, may have biased his observations further. This was a time when the shift to community treatment was in relative infancy. Ironically, given May’s stance, advances in medical treatments have largely contributed to the closure of large psychiatric institutions and have allowed many more people to be managed at home.

In 2008 the majority of patients with psychosis who are ill enough to be hospitalised are detained under the Mental Heath Act due to being a risk to themselves or others. They represent the silent minority of service users with severe psychosis who anti-medication militants appear to ignore in order to promote their own perspective. Untreated, this group contribute disproportionately to the prison and homeless populations, make the headlines due to rare attacks on the public, and lead to government initiatives like ‘Supervision Orders’.

The need to detain such patients is often a consequence of sufferers presenting to services late in the development of their illness: scare stories about how psychiatric patients are treated in hospital, propagated without balance by people like Mr May, contribute to and perpetuate the problem. The more aggressive and disoriented you are when you finally reach services the more likely it is that services might resort to restraining you and sedating you in order to prevent injury to yourself and others. And so the problem is perpetuated.

Although the inpatient environment is far from perfect I believe that this is an issue of resources in most cases, and not due to an oppressive attitude in nurses. To add some balance: nurses in inpatient units are assaulted by psychiatric patients on a daily basis and take a huge number of ‘sick days’ due to stress. It is not a job that most people would relish.

Another reason why sufferers are likely to need hospital treatment is the high rate of use of drugs like skunk weed or crack cocaine (estimated at about 40% of all cases of schizophrenia in the West). The reasons for this are complex but include ‘self-medication’ and the slide down the social scale that is associated with untreated illness. These drugs interact with the same disordered brain systems that led to the development of the illness and make it more florid. Alternatively, the sufferer might just be unlucky in terms of their genetic make up, like the charming, intelligent and successful 21 year old university student who I treated as a young psychiatrist who suddenly developed severe, catatonic schizophrenia with no clear trigger.

These individuals are not among the cohort of people like Ruth or Rufus May who can carry on with their jobs as doctors or lecturers without medication. They might,however, be persuaded to stop their treatments as a result of imbalanced reporting of the benefits of psychological interventions alone. They might also disengage totally from traditional psychiatric services as ‘agents of medication’, thereby depriving themselves (ironically) of access to the social and psychological assistance which is often offered alongside the medical these days.

The consequences of letting psychosis persist while hiding the symptoms from others should not be under-estimated. Although Mr May recommended this course of action in Ruth’s case, most psychotic experiences are terrifying and lead to immense suffering. As mentioned above this can lead to damaging dependence on drugs or alcohol as a means of ’self-medicating’ Many people with psychosis become depressed and ten per cent of people with schizophrenia kill themselves, either as a reaction to psychotic experiences (”I’ll kill myself before they kill me”) or in the context of depression and identity confusion. Regrettably there is also a link with infanticide, violent crime and homicide, particularly among those who suffer ‘command hallucinations’.

Emil Kraepelin, who meticulously observed the outcomes for many sufferers of mental illness at turn of the last century, was quite clear about the poor prognosis, on average, for cases of psychosis over time. Schizophrenia that is left untreated by medication generally gets worse and can lead to what Kraepelin called ‘dementia preacox’ - the disintegration of the personality, with reduced motivation and initiative, flattened and blunted emotional responses to others, poverty of speech and self-neglect.

It is a testament to modern medical treatment approaches that the prognosis for psychotic disorder has improved since Kraepelin’s time and many sufferers can return to a normal level of functioning provided they remain on medication. It is believed that the earlier the illness is detected and treated with medication the better the long term prognosis: this has led to a global interest in detecting the ‘prodromal’ (early warning signs) of psychosis (listlessness, strange thinking, social withdrawal, brief isolated hallucinatory experiences) in teenagers and young adults before they become more unwell. “Early onset clinics” are now an established part of the NHS framework.

It is good that Rufus May and his patient ‘Ruth’, his single case study, have apparently not experienced any deterioration in their respective conditions since they were first diagnosed. However, I can point to many adult patients and their families who have been under my care who would defend their right to take medication as a preventative measure and would be prepared to tell their tale. Clozapine - a revolutionary antipsychotic medication - has improved the quality of life of many patients with severe illness immeasurably and, in some cases, it has facilitated a move from medium secure hospital back to the community. Medication is not perfect. There are side effects in many cases, but these need to be weighed up against the damage to the quality of life caused by untreated illness. It is often possible to find a medication, among the many that are available, which has insignificant side effects.

Those who are currently hailing Mr May as the next big advocate of psychiatric patients should note that being an ex-service user does not, on its own, make you an expert on the treatment of other service users. In fact, the opposite is often true. I wait with anticipation the outcome for Ruth. I hope that she will be one of the lucky ones, but May should follow up her case rather than ignore the consequences of his interventions. If she does not do well he should be brave enough to admit that he was wrong. As Professor Edzard Ernst, the champion of randomised controlled trials, would say: apparently harmless but hitherto unproven interventions are not harmless at all if they are used to replace interventions that have been proven to be effective. If psychiatrists can be accused of being too focussed on medical approaches to treatment, it is also true that psychologists can have a vested interest in over-estimating the power of talking therapies. I can not put it better than the review by Brian Viner: “Ruth eventually got her job back, but with the voice still in her head, and even May raised the possibility that, perhaps miming his own life a little too enthusiastically, he was in denial of the risks involved.”

Although I always support a holistic approach to managing mental health problems, I believe that we must be careful not to throw the baby out with the bathwater: we should not refuse medication which has been proven to be helpful for particular psychiatric illnesses just because some problems like milder depression, grief and childhood overactivity are being over-medicalised.

In the black and white world that most of us like to inhabit most of the time things are either good or bad for us. So, cream cheese is bad, broccoli is good. Natural things are good, artiicial things are bad. But things are never quite that simple. Without some dairy products you might get rickets, or your teeth might break. If you eat the naturally occuring Bella Donna plant you might die. Foxgloves can kill you in large doses but in small doses they can help treat an abnormal heart rhythm. So it is with drugs of abuse like cannabis. Just as the government was thinking about liberalising the laws on cannabis out came a load of evidence to suggest that it could unlock schizophrenia in vulnerable individuals. Hence there is a bit of back-tracking going on and there are calls for the re-classification to be reversed.

The truth is, however, that no two strains of cannabis plant are the same. The stuff that our elderly politicians were puffing in the sixties was milder than the homegrown skunk weed we have today. The chemical make up is different. Cannabis is a complex bunch of active and inactive chemicals, some clearly harmful and some potentially helpful. Overall, however, the picture is reasonably black and white, as cannabis is predominantly made up of two main chemicals - cannabidiol (CBD)) and tetra-hydro-cannabidiol (THC). It has been known for some time that THC can cause you to hallucinate and feel anxious. It has also been known for some time that CBD can reduce anxiety and block psychotic effects of THC. The hash of the sixties was relatively low in THC compared to the home grown hydroponic skunk weed of today - a substance genetically engineered to blow your mind.

More recent scientific work suggests that CBD not only blocks the harmful effects of THC but may have therapeutic potential in people with mental health problems. So, a researcher called Marcus Leweke at the Univeristy of Cologne has demonstrated that CBD can reduce psychosis in people with schizophrenia. In neuro-imaging studies, CBD might reduce brain responses to watching fearful faces.

Last Novemeber a group of researchers published a paper in Biological Psychiatry which demonstrated that boosting the protective and reparative brian chemical amandamide by blocking its metabolism might act to reverse depression. CBD has been shown to increase levels of amandamide in the brain.

So, on balance, inhaling modern cannabis weed will probably cause harmful effects on the brain which outweigh the benefits. However, separating the chemical components of cannabis is easy in the laboratory and could lead to real therapeutic breakthroughs. Therefore, the complex make up of cannabis is a potential Pandora’s box. In particular, CBD might reach the parts that other drugs can not reach. If we can avoid the predictable media hysteria attached to using drugs of abuse in therapeutic settings cannabis seems to have a rosy future.