Towards an Integrated Psychiatry
During my time as a trainee psychiatrist I worked for a while for Dr William Sargant. As Dr Lynch points out, he was well known, even notorious, for his unrelenting advocacy of drugs and other physical treatments for mental illness, especially depression. His powerful personality helped him to achieve good short-term results, though the longer term outcomes appeared less favourable. In those days the psychoanalysts stood at the other poll. Their techniques, effective or not, were excessively time-consuming and therefore for the most part impractical. Dialogue between these two camps was scant and generally bad tempered or worse. As a result many patients got a raw deal.

How far we have come since then? This book provides little ground for complacency. As a GP, Terry Lynch recognised the harm done by the narrow biological focus of much medical practice, not only in mental health. Courageously, he began with himself, completing an MA in Humanistic and Integrative Psychotherapy before taking up work again as a GP with a special interest in mental health. ‘In practice, I work primarily as a psychotherapist. I prescribe medication when I believe it is appropriate to do so.’ (p. 7)

Pointedly, his first chapter concerns medical research. He draws out the poor quality of much published work, particularly though not exclusively in mental health. He highlights the careless use of statistics, and in particular the dependence of much research on the support of and implicit endorsement of the drug manufacturing companies. Using many examples, he identifies the poor quality of the evidence for many of the medications prescribed for mental illness, and the way in which single unreplicated studies are often used to market new drugs. Perhaps he might have emphasised that the rest of medical research is in little better case.

He goes on to debate whether ‘mental illness’ really exists. Unlike some commentators, he does not underestimate the importance of diagnosing and treating biological pathology, such as thyroid deficiency, but emphasises the need for a whole person approach. However, the need for psychiatrists to establish themselves as practising a ‘scientific’ specialism has led, he claims, to the unjustified assertion that mental distress can be equated with mental illness, and thus almost always has physical, biological or genetic causes. In general he challenges this, and uses poignant case examples in support. Along the way he analyses many of the groups of drugs used in psychiatric practice, pointing out their limited effectiveness, proneness to side-effects and often late recognised propensity for dependence.

A chapter is devoted to depression. He is critical of attempts to classify and provide operational definitions for the condition, the use of which he believes stultifies doctors’ ability to respond empathetically to their patients. The overuse by both psychiatrists and GPs of antidepressant medication is castigated, and the continuing controversy concerning the SSRIs, of which fluoxetine (Prozac) is an example, is given a personal touch as he describes his own intervention in the debate. In my view, the moving stories that follow might be illuminated by bearing in mind that ‘depression’ has three meanings which though they may overlap need as far as possible to be distinguished: a normal human response to adverse circumstances; a symptom of another condition, for example an underacting thyroid; and an illness per se to which biological and psychological elements play a part in both symptomatology and management. Overdiagnosis of the third category by doctors springs as much from lack of time, facilities and inclination as from poor training or a desire to ‘play God’.

Schizophrenia, manic depression, anorexia and bulimia, and substance abuse are analysed along similar lines. Evoking, listening to, and responding to the content and meaning for their lives of patients’ symptoms is what’s needed, rather than prescribing the latest drug peddled by the representative of the pharmaceutical company. Once again the account is enlivened by apposite though not necessarily representative case histories.

Within these two chapters the increasingly important place in the management of mental distress and illness of psychological interventions, in particular cognitive behavioural therapy and its relatives, might have been more fully acknowledged. The rest of the book is devoted to suicide: its causes and its prevention. He contrasts the tendency amongst doctors to explain suicidal behaviour by finding evidence of depressive illness with an approach based on understanding the person’s story in its own terms. Sensitively he unravels stories that enable to understand how vulnerable people can be driven to despair by circumstances, among which may sometimes be included ill-judged medical intervention. This distinction between explanation and understanding has in fact a long and resonant history within psychiatry, and every psychiatrist should strive to honour both aspects as he encounters people in distress.

This book is timely, and well-written. Its message is clear though inevitably perhaps somewhat oversimplified. He is right I believe to emphasise the often pernicious influence of the drug companies, who have a vested interest in medicalising mental distress, and some psychiatrists are still too willing to accept their embrace. However, I have witnessed great changes since the days when William Sargant was set against the Tavistock Clinic. Before retirement I spent ten years as an examiner for the Royal College of Psychiatrists. We expected trainees at the clinical examination to demonstrate the ability to develop and convey to us an account - however tentative - of why this person should be suffering in this way at this time, and to develop a comprehensive plan of management based on this formulation. Any candidate who ignored or distorted the central place of psychological and personal factors for both formulation and management would fail the examination. The challenge of day-to-day practice as a psychiatrist, and at a simpler though even more significant level as a GP, is to maintain the high standards that the examination reflected, while the obligation of management is to provide a setting which permits those standards to be met. Sadly, even today neither the challenge nor the obligation is reliably taken up. Many of us consider that a particularly encouraging development in the maturation of psychiatry is the establishment in 1999 of the Spirituality and Psychiatry Special Interest Group within the Royal College, which currently is one of the largest, fastest growing and most active of such groups.

How we respond to those amongst us in mental and emotional turmoil, particularly when such distress is linked with untoward or threatening behaviour, will always be difficult and controversial, since the issue impinges on fundamental questions concerning the nature and destiny of the individual, the relation between body, mind and spirit, and consciousness itself. This contribution is valuable, but its necessarily polemical emphasis overlays important and fascinating complexities which deserves more open debate.

Dr. Julian Candy is a retired psychiatrist who works in a hospice and has a deep interest in Goethe.