Samei Huda, the author of this book, a prolific tweeter @SameiHuda, is primarily a clinical psychiatrist rather than an academic. The book is written to try to justify what he recognizes as his intrinsic bias in favor of the medical model in psychiatry. From his point of view, psychiatry shouldn’t be caricatured as unscientific, treating non-existent diseases with ineffective and toxic drugs. Contrasting the rest of medicine as scientific and treating known diseases effectively unnecessarily polarizes debate.

Huda makes the case that many of the concerns about psychiatric diagnosis and its treatment effectiveness also occur in general medicine. Illness and disease are not always clearly demarcated from health. Huda’s medical model is biopsychosocial, by which he means it incorporates psychological and social factors as well as biological. Assessment leads to differential diagnoses that are open to review in clinical practice. Identification of clinical syndromes has been associated with their underlying pathology in some but not all cases even in medicine. Causative factors can be complex. Treatment should be based on the best quality evidence.

Following this explanation of the medical model, Huda moves on to what he calls the ‘hinge’ of the book, its second part, where he considers criticism of psychiatric diagnosis and treatment by focusing on an article by Kinderman et al (2013) entitled ‘Drop the language of disorder’. He frames the concerns of the article into a series of questions, which he uses to compare diagnostic constructs of psychiatry with general medicine in the third part of the book. Similarly, for criticisms of psychiatric treatment, he uses the book by Joanna Moncrieff  (2009) entitled The myth of the chemical cure to create a smaller number of questions to compare psychiatric treatments with treatments in general medicine. I don’t think Huda can say he has dealt with all of psychiatric criticism by focusing on such selective references, however exemplary the choice he has made may be.

It is true that some critics of psychiatry would prefer that mental health practice became non-medical. Huda therefore provides a useful comparison of general medicine and psychiatry.  He recognizes some but not total overlap between psychiatry and general medicine for all of the questions asked.

This is not an easy book to read. Critiques of psychiatry are generally dismissed as flawed without very thorough argument, although Huda occasionally acknowledges the value of some points. Using general medicine as a comparator to psychiatry doesn’t really allow him to consider critiques of medicine in general.

The book is verbose and it is difficult to distill Huda’s argument at times. I think the book would have benefitted from reducing the word length to make it more incisive. Even the conclusions to each chapter could have been more precise. Having set up the structure for the third part of the book, Huda valiantly pursues each question but it’s not always very clear what we are to make of the partial overlap between psychiatry and the rest of medicine. If the book was intended as a textbook for students of the medical model in psychiatry, I’m not convinced they will necessarily find it very easy to use. I think maybe they’re more supposed to take the message that the complexity of the book has rebuffed any criticisms of psychiatry and they don’t need to worry about them.

Psychiatry of course is not separate from the rest of medicine. In fact it’s even been argued by Bill Fulford (1989), for example, that psychiatry is the preeminent medical specialty. But the fundamental critique of psychiatry is that it has a tendency to reduce mental illness to brain disease. This issue isn’t really dealt with in the book, apart from pointing out that there are examples in medicine where biological mechanisms are not always known. Huda thinks that basing psychiatric diagnostic constructs on mechanisms or causes should lead to improved clinical utility. Although he recognises that realizing this is not inevitable, it is what he hopes for to improve psychiatric treatments. Nonetheless, he does accept that currently the medical model in psychiatry is not a disease-based model.

Huda at least partially justifies his emphasis on the medical model because he only has 15 minutes for review outpatient appointments. This means he tends to concentrate on medication management. I appreciate the difficulty of his clinical work in dealing with the demands of psychiatric patients. I do wonder though whether he needs to break out of this restrictive practice style. Practice, of course, needs to be patient-centered where the expertizes of the doctor and the patient come together. This is the true model that doctors need to follow.

References

Fulford, K.W.M. (1989) Moral theory and medical practice. Cambridge University Press

Kinderman, P., Read, J. Moncrieff, M. & Bentall, R. (2013) Drop the language of disorder. Evidence Based Mental Health 16: 2-3

Moncrieff, J. (2009) The myth of the chemical cure: A critique of psychiatric drug treatment. Basingstoke: Palgrave Macmillan

© 2019 Duncan Double

Duncan Double is a retired consultant psychiatrist. He blogs on critical psychiatry at http://criticalpsychiatry.blogspot.com.