Archived Comments for:
England's new Mental Health Act represents law catching up with science: a commentary on Peter Lepping's ethical analysis of the new mental health legislation in England and Wales
In his response to my article on the Ethical Analysis of the Mental Health Act 2007 for England and Wales, Dr. Maden points out the changed scientific basis for violence in psychiatry. He points to changes in society’s priorities regarding the protection of the public as well as better treatments for patients with psychopathy. I fully agree with him that the amount of knowledge we have gained about the association between mental health and violence has risen enormously over the last ten years. Evidence is, however, still contradictory with regard to many aspects of violence in the mentally ill. This was comprehensively shown by Whittington’s summary of current knowledge published last year (Richter & Whittington, 2006), other authors support this view. My main issue with Dr. Maden’s response is, however, not any kind of dispute with his scientific evidence. It is more with his defence of utilitarianism. I never claimed in my analysis that utilitarianism is not a legitimate way forward. In fact, I did specifically not lament the demise of individual rights in favour of utilitarianism. I pointed out that this is politically and ethically legitimate.
Ethical analysis
My issue was with the way that the Government argued for the changes they have now brought in. Many pages in many journals and internet sites have been written about the advantages and disadvantages of becoming more utilitarian and Dr. Maden has added his own very valuable and useful thoughts to that debate. This does not, however, get to the core of the ethical analysis, which is primarily concerned with the type of argument that has been made by the people who propose the new legislation. Such an analysis looks at whether the changes that have been made can be supported by the premises that have been put forward by the people who suggest the change. The ethical analysis is less concerned with the rights or wrongs of the eventual outcome but more with the process that led to that outcome. I am pleased to see that Dr. Maden does not argue with my analysis that the Mental Health Act 2007 for England and Wales is more utilitarian in most aspects than the 1983 Act, although as we both mentioned there are some aspects of the new Act which are less utilitarian than the 1983 Act. However, I would maintain that when analysing the process ethically the argument that the Government has put forward for the new Act is not ethically sound. It may be pragmatic, it may be politically astute and it may take into account new scientific developments, but the main point for an ethical analysis is whether the changes (or ethically speaking: the consequences) follow directly from the premises. As I mentioned in my original article there is little evidence that Care in the Community has failed as claimed by the Department of Health in 1998. I fully understand the history that has led to the development of the 1983 Act including the appalling murder of Mr. Zito as well as the development of the Section 25 of the 1983 Act, but there is still no proof that Mental Health Act changes will prevent any of these disasters, which are fortunately, as Dr. Maden noted as well, relatively rare and not really changing in absolute numbers. Most homicide inquiries point towards lack of communication between services rather than Mental Health Act failures. They certainly do not suggest that institutionalisation would have been the answer to prevent any of those disasters. It is very unclear whether any of the new measures will protect the public or whether previous disasters could have been prevented with the new legislation.
I need to repeat that it is politically entirely legitimate to make these changes and I personally welcome some of them. My criticism is regarding the ethical process. I do not believe that the Government has the evidence to support their premises that were used to justify the change of the Act. Furthermore, the changes (or consequences) do not follow directly from the premises. It is in that sense that the new Act is unethical. This does not imply that it cannot be politically astute, taking into account new evidence or welcomed by some professionals. In fact, I assume that most professionals welcome at least parts of the changes.
Richter D and Whittington R (2006) Violence in mental Health Settings. Causes, Consequences and Management. Springer, New York
Dr. Peter Lepping, MD MRCPsych MSc
Consultant Psychiatrist and Honorary Senior Lecturer
Competing interests
none
Involuntary neuroleptic (antipsychotic) psychiatric drugs may result in brain damage.
David Oaks, MindFreedom International
18 September 2007
Any serious debate in 2007 about the topic of involuntary psychiatric procedures ought to include the following fact:
For years, many studies have indicated that long-term high-dosage neuroleptic (also known as antipsychotic) psychiatric drugging may induce structural brain damage. This damage can include actual shrinkage of areas of the brain associated with higher-level functions, what makes us human.
In his commentary, "England's New Mental Health Act Represents Law Catching Up with Science," Anthony Maden demands that "ethical advocates of a change to capacity-based legislation are under an obligation to deal with the science."
However, I note that proponents of involuntary psychiatric procedures seldom explain clearly to colleagues, the public, patients or their families, the full implications of these procedures. It is undeniable that involuntary psychiatric procedures often involve psychiatric drugging, and that neuroleptic psychiatric drugs are often used in such circumstances.
Therefore, the impact, risks and efficacy of neuroleptics are relevant. There are debates about these topics, including that there are effective alternatives other than neuroleptics. However, I wish to focus on one particularly relevant risk.
In the last decade or two, countless medical articles have raised warning flags that long-term high-dosage neuroleptic use is associated with structural brain change. Please understand that I, and the nonprofit organization I direct, MindFreedom International, are pro-choice. Many of our members choose to take prescribed psychiatric drugs, including neuroleptics, others do not.
But we are all united in speaking up for basic human rights, and a fundamental human right for patients, their family and society itself is the right to know. It is a horrible medical catastrophe that knowledge about neuroleptic-induced structural brain damage is today largely confined to the medical field itself. As a human rights activist for the past 31 years, and as an individual who has personally experienced involuntary neuroleptic drugging, I maintain that this disaster amounts to a kind of "Greenhouse effect" of the mind, and some day the public will want to know why they were not informed.
Similar to the controversy about the environmental Greenhouse effect, there are industry defenders who are sowing doubt about the claims here, that long-term high-dosage neuroleptic use is associated with structural brain changes. Even though there are brain scan and autopsy studies showing these changes, some still try to deny these changes by claiming the underlying "mental illness" must be reasonable for the brain changes. This does not explain, however, why medical studies on animals can replicate similar structural brain change. Did these animals all miraculously develop "mental illness"?
Why is neuroleptic-induced structural brain damage so important? Try a simple thought experiment. If any medical authority recommended that thousands of individuals out in the community receive involuntary psychosurgery -- actual surgical destruction of healthy brain tissue to change behavior -- there would be automatic outrage. Why? Because when force is combined with a procedure that is so profoundly intrusive and irreversible and damaging to the core part of our being as psychosurgery, the general public intuitively understands that coercing these procedures would be unethical.
Today, there are many studies showing that long-term high-dosage neuroleptics can actually result in such severe structural brain changes, that these changes can include shrinkage of the parts of our brain associated with high-level cognition. As anyone who is knowledgeable in this field is aware, there are many such studies showing that long-term high-dosage neuroleptics are associated with structural brain change.
I will just mention one such study, because it involves both an older-type neuroleptic and a newer atypical neuroleptic.
In this study, three groups of monkeys each were given haloperidol, olanzapine or sham for a 17 to 27 month period. There was an 8 to 11 percent reduction in mean fresh brain weights in both drug-treated groups compared to sham.
The differences were seen in all major brain regions, especially in the frontal and parietal regions in both gray and white matter.
There was a general shrinkage effect of approximately 20% and a highly significant variation in shrinkage across brain regions.
When I have raised concerns about studies like this with defenders of coerced psychiatric drugging I have been surprised at the response. One hypothesized that perhaps such brain shrinkage is helpful. Another hypothesized that such shrinkage is not literally "damage." Still another hypothesized the brain would snap back afterwards.
All of these debaters, despite the absurdity of their defense, miss the main point.
To repeat, yes, I understand some may still choose to take a neuroleptic despite these risks; if they are fully informed and offered a range of alternatives, that is not the issue here. However, any debate about the ethics of involuntary psychiatric procedures must include a discussion about the fact that long-term high-dosage neuroleptics literally have a similarity to chemical psychosurgery.
The fact that any large library has the information I am discussing on its medical side, but not in the popular media side, is an indictment of the core values and ethics of the entire medical profession. This is a human rights emergency, and calls for immediate attention.
In the 1800's, a medical model was utilized to help consolidate power of those leading the mental health system. It is time now for democracy to get more hands on with the mental health system. We cannot continue to abandon mental health policy to rule by a small group of experts.
There are many other arguments against forced psychiatric procedures, especially on an outpatient basis, but I am focusing upon this central point about neuroleptic structural brain change because it is so important, and is so frequently totally ignored by those defending forced psychiatric drugging.
For decades psychiatry has searched for proof of a "chemical imbalance" for any major psychiatric disorder. While they have not found proof of any chemical imbalance, those of us in the human rights field have discovered an enormous power imbalance. People on the "sharp end of the needle" in the mental health system are among the most silenced, disempowered, and oppressed in society.
Due to decades of community organizing among thousands of psychiatric survivors and our allies internationally, the powerless clients are finding ways to speak out.
I applaud the president of the World Psychiatric Association, Dr. Juan Mezzich, who has recently joined with us in calling for open mediated dialogue between organizations representing psychiatric survivors and psychiatric professionals.
The Influence of Chronic Exposure to Antipsychotic Medications on Brain Size before and after Tissue Fixation: A Comparison of Haloperidol and Olanzapine in Macaque Monkeys.
by Dorph-Petersen KA, Pierri JN, et al. from University of Pittsburgh.
Reply: Is the New British Health Act Keeping Up with Science?
Beverly Honold, Mind Freedom International
2 January 2008
Dr Maden asks the "humanistic" community to offer a valid rejoinder to the utilitarianism of the Mental Health Act in Britain, July 2007. I appreciated his assertion that "the consensus of medical opinion remains that compulsory treatment is appropriate for only a minority of patients whether the diagnosis is schizophrenia or personality disorders". It seems not to "suit" us as a caring society to cast our nets using legal frameworks to cover the "whole" gamut of persons who at one time, or even several times, are diagnosable. As a psychiatric survivor, the various legal rights and freedoms have been of importance enabling me to take the necessary steps of correction and growth in the spirits of persistence and autonomy to assure my recovery as a fully functioning member of my society. I retain hope for, in Britain as well as in North America, a one size does not fit all approach to the problems of an ever increasingly complex society!
Ethical analysis looks at process not outcome
12 September 2007
COMMENT
In his response to my article on the Ethical Analysis of the Mental Health Act 2007 for England and Wales, Dr. Maden points out the changed scientific basis for violence in psychiatry. He points to changes in society’s priorities regarding the protection of the public as well as better treatments for patients with psychopathy. I fully agree with him that the amount of knowledge we have gained about the association between mental health and violence has risen enormously over the last ten years. Evidence is, however, still contradictory with regard to many aspects of violence in the mentally ill. This was comprehensively shown by Whittington’s summary of current knowledge published last year (Richter & Whittington, 2006), other authors support this view. My main issue with Dr. Maden’s response is, however, not any kind of dispute with his scientific evidence. It is more with his defence of utilitarianism. I never claimed in my analysis that utilitarianism is not a legitimate way forward. In fact, I did specifically not lament the demise of individual rights in favour of utilitarianism. I pointed out that this is politically and ethically legitimate.
Ethical analysis
My issue was with the way that the Government argued for the changes they have now brought in. Many pages in many journals and internet sites have been written about the advantages and disadvantages of becoming more utilitarian and Dr. Maden has added his own very valuable and useful thoughts to that debate. This does not, however, get to the core of the ethical analysis, which is primarily concerned with the type of argument that has been made by the people who propose the new legislation. Such an analysis looks at whether the changes that have been made can be supported by the premises that have been put forward by the people who suggest the change. The ethical analysis is less concerned with the rights or wrongs of the eventual outcome but more with the process that led to that outcome. I am pleased to see that Dr. Maden does not argue with my analysis that the Mental Health Act 2007 for England and Wales is more utilitarian in most aspects than the 1983 Act, although as we both mentioned there are some aspects of the new Act which are less utilitarian than the 1983 Act. However, I would maintain that when analysing the process ethically the argument that the Government has put forward for the new Act is not ethically sound. It may be pragmatic, it may be politically astute and it may take into account new scientific developments, but the main point for an ethical analysis is whether the changes (or ethically speaking: the consequences) follow directly from the premises. As I mentioned in my original article there is little evidence that Care in the Community has failed as claimed by the Department of Health in 1998. I fully understand the history that has led to the development of the 1983 Act including the appalling murder of Mr. Zito as well as the development of the Section 25 of the 1983 Act, but there is still no proof that Mental Health Act changes will prevent any of these disasters, which are fortunately, as Dr. Maden noted as well, relatively rare and not really changing in absolute numbers. Most homicide inquiries point towards lack of communication between services rather than Mental Health Act failures. They certainly do not suggest that institutionalisation would have been the answer to prevent any of those disasters. It is very unclear whether any of the new measures will protect the public or whether previous disasters could have been prevented with the new legislation.
I need to repeat that it is politically entirely legitimate to make these changes and I personally welcome some of them. My criticism is regarding the ethical process. I do not believe that the Government has the evidence to support their premises that were used to justify the change of the Act. Furthermore, the changes (or consequences) do not follow directly from the premises. It is in that sense that the new Act is unethical. This does not imply that it cannot be politically astute, taking into account new evidence or welcomed by some professionals. In fact, I assume that most professionals welcome at least parts of the changes.
Richter D and Whittington R (2006) Violence in mental Health Settings. Causes, Consequences and Management. Springer, New York
Dr. Peter Lepping, MD MRCPsych MSc
Consultant Psychiatrist and Honorary Senior Lecturer
Competing interests
none
Involuntary neuroleptic (antipsychotic) psychiatric drugs may result in brain damage.
18 September 2007
Any serious debate in 2007 about the topic of involuntary psychiatric procedures ought to include the following fact:
For years, many studies have indicated that long-term high-dosage neuroleptic (also known as antipsychotic) psychiatric drugging may induce structural brain damage. This damage can include actual shrinkage of areas of the brain associated with higher-level functions, what makes us human.
In his commentary, "England's New Mental Health Act Represents Law Catching Up with Science," Anthony Maden demands that "ethical advocates of a change to capacity-based legislation are under an obligation to deal with the science."
However, I note that proponents of involuntary psychiatric procedures seldom explain clearly to colleagues, the public, patients or their families, the full implications of these procedures. It is undeniable that involuntary psychiatric procedures often involve psychiatric drugging, and that neuroleptic psychiatric drugs are often used in such circumstances.
Therefore, the impact, risks and efficacy of neuroleptics are relevant. There are debates about these topics, including that there are effective alternatives other than neuroleptics. However, I wish to focus on one particularly relevant risk.
In the last decade or two, countless medical articles have raised warning flags that long-term high-dosage neuroleptic use is associated with structural brain change. Please understand that I, and the nonprofit organization I direct, MindFreedom International, are pro-choice. Many of our members choose to take prescribed psychiatric drugs, including neuroleptics, others do not.
But we are all united in speaking up for basic human rights, and a fundamental human right for patients, their family and society itself is the right to know. It is a horrible medical catastrophe that knowledge about neuroleptic-induced structural brain damage is today largely confined to the medical field itself. As a human rights activist for the past 31 years, and as an individual who has personally experienced involuntary neuroleptic drugging, I maintain that this disaster amounts to a kind of "Greenhouse effect" of the mind, and some day the public will want to know why they were not informed.
Similar to the controversy about the environmental Greenhouse effect, there are industry defenders who are sowing doubt about the claims here, that long-term high-dosage neuroleptic use is associated with structural brain changes. Even though there are brain scan and autopsy studies showing these changes, some still try to deny these changes by claiming the underlying "mental illness" must be reasonable for the brain changes. This does not explain, however, why medical studies on animals can replicate similar structural brain change. Did these animals all miraculously develop "mental illness"?
Why is neuroleptic-induced structural brain damage so important? Try a simple thought experiment. If any medical authority recommended that thousands of individuals out in the community receive involuntary psychosurgery -- actual surgical destruction of healthy brain tissue to change behavior -- there would be automatic outrage. Why? Because when force is combined with a procedure that is so profoundly intrusive and irreversible and damaging to the core part of our being as psychosurgery, the general public intuitively understands that coercing these procedures would be unethical.
Today, there are many studies showing that long-term high-dosage neuroleptics can actually result in such severe structural brain changes, that these changes can include shrinkage of the parts of our brain associated with high-level cognition. As anyone who is knowledgeable in this field is aware, there are many such studies showing that long-term high-dosage neuroleptics are associated with structural brain change.
I will just mention one such study, because it involves both an older-type neuroleptic and a newer atypical neuroleptic.
In this study, three groups of monkeys each were given haloperidol, olanzapine or sham for a 17 to 27 month period. There was an 8 to 11 percent reduction in mean fresh brain weights in both drug-treated groups compared to sham.
The differences were seen in all major brain regions, especially in the frontal and parietal regions in both gray and white matter.
There was a general shrinkage effect of approximately 20% and a highly significant variation in shrinkage across brain regions.
When I have raised concerns about studies like this with defenders of coerced psychiatric drugging I have been surprised at the response. One hypothesized that perhaps such brain shrinkage is helpful. Another hypothesized that such shrinkage is not literally "damage." Still another hypothesized the brain would snap back afterwards.
All of these debaters, despite the absurdity of their defense, miss the main point.
To repeat, yes, I understand some may still choose to take a neuroleptic despite these risks; if they are fully informed and offered a range of alternatives, that is not the issue here. However, any debate about the ethics of involuntary psychiatric procedures must include a discussion about the fact that long-term high-dosage neuroleptics literally have a similarity to chemical psychosurgery.
The fact that any large library has the information I am discussing on its medical side, but not in the popular media side, is an indictment of the core values and ethics of the entire medical profession. This is a human rights emergency, and calls for immediate attention.
In the 1800's, a medical model was utilized to help consolidate power of those leading the mental health system. It is time now for democracy to get more hands on with the mental health system. We cannot continue to abandon mental health policy to rule by a small group of experts.
There are many other arguments against forced psychiatric procedures, especially on an outpatient basis, but I am focusing upon this central point about neuroleptic structural brain change because it is so important, and is so frequently totally ignored by those defending forced psychiatric drugging.
For decades psychiatry has searched for proof of a "chemical imbalance" for any major psychiatric disorder. While they have not found proof of any chemical imbalance, those of us in the human rights field have discovered an enormous power imbalance. People on the "sharp end of the needle" in the mental health system are among the most silenced, disempowered, and oppressed in society.
Due to decades of community organizing among thousands of psychiatric survivors and our allies internationally, the powerless clients are finding ways to speak out.
I applaud the president of the World Psychiatric Association, Dr. Juan Mezzich, who has recently joined with us in calling for open mediated dialogue between organizations representing psychiatric survivors and psychiatric professionals.
We will never be silenced again.
Sincerely, David W.Oaks, Director
MindFreedom International
www.mindfreedom.org
Medical study source:
CITATION:
The Influence of Chronic Exposure to Antipsychotic Medications on Brain Size before and after Tissue Fixation: A Comparison of Haloperidol and Olanzapine in Macaque Monkeys.
by Dorph-Petersen KA, Pierri JN, et al. from University of Pittsburgh.
Source: Neuropsychopharmacology 9 March 2005
More citations:
www.mindfreedom.org/kb/psychiatric-drugs/antipsychotics/neuroleptic-brain-damage/
Competing interests
None.
Reply: Is the New British Health Act Keeping Up with Science?
2 January 2008
Dr Maden asks the "humanistic" community to offer a valid rejoinder to the utilitarianism of the Mental Health Act in Britain, July 2007. I appreciated his assertion that "the consensus of medical opinion remains that compulsory treatment is appropriate for only a minority of patients whether the diagnosis is schizophrenia or personality disorders". It seems not to "suit" us as a caring society to cast our nets using legal frameworks to cover the "whole" gamut of persons who at one time, or even several times, are diagnosable. As a psychiatric survivor, the various legal rights and freedoms have been of importance enabling me to take the necessary steps of correction and growth in the spirits of persistence and autonomy to assure my recovery as a fully functioning member of my society. I retain hope for, in Britain as well as in North America, a one size does not fit all approach to the problems of an ever increasingly complex society!
Respectfully submitted: Beverly Honold
Competing interests
No competing interests