OR WAIT null SECS
In this interview with Dr Aftab, Dr Huda discusses his views on the medical model in psychiatry, the misconceptions surrounding it, its strengths and limitations, and its relationship with other frameworks.
CONVERSATIONS IN CRITICAL PSYCHIATRY
Dr Ahmed Samei Huda works as a consultant psychiatrist in the National Health Service in a deprived area to the east of Manchester in the UK. In addition to general adult psychiatric patients, much of his clinical work is devoted to the Early Intervention in Psychosis (EIP) service. Although he is from Scotland, he has lived in England for half of his life and has also spent about a year working as a psychiatrist in Australia. He is the author of The Medical Model in Mental Health: An Explanation and Evaluation (Oxford University Press, 2019).
Dr Huda describes that he was struck by the disparity between the views of various academics and those of clinicians at the coalface regarding the medical model and its application to psychiatry (“at the coalface” is a British expression which means being directly engaged in a professional activity rather than talking about it in a managerial or theoretical way). This served as his motivation for writing The Medical Model in Mental Health. The book describes how he understands the medical model as it exists in clinical practice, and how this medical model is applied to mental health compared with general (internal) medicine with a focus on diagnosis and treatment. He argues that in many respects, there is a greater degree of overlap between psychiatry and general medicine than is realized by many critics with regards to the nature of diagnostic constructs and effectiveness of treatments. The volume is among the very few book-length examinations of the subject, especially from the perspective of a clinician.
Aftab: Can you briefly describe your conceptualization of the medical model in psychiatry? What do you think are some common misconceptions about psychiatry’s relationship with the medical model?
Huda: The medical model is about identifying the relevant information that will help the patient in their presenting predicament in order to help them make informed choices to achieve their desired therapeutic goals (which may be cure or relieving distress or preventing some undesired outcome and so on). The first common misconception is that it is a disease-based model whereas it is actually a pattern recognition model. Doctors take a history to find out what happened to the patient as the best source of relevant information supplemented by examination and investigations. This results in a clinical picture which is matched to the diagnostic construct which fits closest. A diagnosis is not a certain fact—it is an opinion as to the information most relevant to helping the patient and is always provisional.
This diagnostic construct carries probabilistic information such as likely outcomes, treatments and chances of success, important complications to beware of and other conditions that are likely to be present. Values are important in deciding what types of problems are suitable for medical help, but these values are more likely to be shared for general medical conditions than psychiatric conditions. In psychiatry these values are often more disputed.
Another common misconception is that general medical diagnosis is completely different from psychiatric diagnosis whereas there is substantial overlap in reliability of agreement over diagnosis, the nature of the condition being classified (clear-cut syndromes, spectrums with health, spectrums of conditions, etc), lack of knowledge of causes and pathological mechanisms, usefulness in clinical practice, high rates of co-occurrence of conditions and the impact of social factors.
Some people also have the notion that that medications in general medicine aim to cure, their mechanisms of action are always fully understood, and they are highly effective in contrast to psychiatric medication. The reality is that medical as well as psychiatric interventions have a variety of aims aside from cure, such as relieving distress, prevention (such as vaccination), inducing a compensating state or preventing deterioration. We don’t always know much about how some general medical treatments work not just psychiatric treatments. There is also an overlap in effectiveness between general medical treatments, psychiatric medications and psychotherapy. Most of my colleagues whom I surveyed prescribe psychiatric medications on the basis of empirical evidence of effectiveness with the acceptance that how the benefit is achieved is often not known.
Aftab: When it comes to conceptual frameworks, we can distinguish between the descriptive and normative aspects of the discussion, ie, what the medical model looks like in practice, and what the medical model should be like. Are there any aspects of the medical model as it currently exists that you think should be different? Are there deficiencies we can improve upon?
Huda: “Many a slip twixt cup and lip” applies here. Whereas we are supposed to be collaborative and patient-centered this often doesn’t happen—more obviously in compulsorily detained patients but also in voluntary patients. For millennia doctors” main therapeutic benefit was the placebo effect so maintaining an air of authority and omnipotence could be argued to be beneficial but society has moved on and working together with patients as equals should be our goal such as using their favored treatment goals not our own. Related to this we need to work harder at incorporating patients’ views when we revise our diagnostic classifications and into what research we do, its aims and methodologies.
We need to be more observant. I worked with a nursing assistant who said that when the patients moved from an asylum-style ward with filthy carpets and furniture to a former geriatric ward that was cleaner, there was a dramatic improvement in patients' behavior in many respects yet this type of information is often missing in our textbooks even though it should be obvious—treat people as too unimportant for clean surroundings and they will behave inappropriately.
We also need to be more responsive to iatrogenic harm. I grew up in an asylum where my mum worked as a doctor and could see first-hand the negative effects of institutionalization on blunting drastically the potential of people and the harmful consequences of long-term excessive doses of medication. Another problem with the medical model is that we have a tendency to dominate or assume we should be in charge but we need to be more open to care models where we are either not involved or only see people if there is a need for our expertise. One final point—we must not reduce illness (of any type mental or physical) to only disease. Our aim is to help people not merely their bodies.
Aftab: You show that psychiatric diagnoses and treatments fare similarly to diagnoses and treatments in a lot of other areas of medicine. I think you make the case for that persuasively. But not all criticisms of psychiatry make this distinction between psychiatry and rest of the medicine. Many critics may well accept your description of the medical model but may dispute the fact that psychological suffering should be viewed through the medical model. What are your thoughts on that line of criticism?
Huda: In my book I say “there are multiple models of viewing people’s problems, and multiple ways of helping people with these problems. The medical model is not necessarily the best way to view or help a problem.” Doctors are used to working in multidisciplinary teams with different professionals and their particular models of conceptualizing and methods of helping patients. So, for some patients the medical model will not be helpful or even harmful. Often patients require the help from several different models and professionals to help them with often complex predicaments.
Some people do not wish the use of the medical model to be so prevalent in mental health services. Leaving aside the historical contingencies there are good practical reasons why this is so. Tyrer1 in the UK found that consultant psychiatrists had 5 to 10 times as many patients as other mental health professionals. This is because the medical model with brief appointments and using diagnosis and other heuristic methods as well as use of medication instead of spending 50 minutes weekly providing therapy allows doctors to see many patients and work in emergencies including overnight.
Aftab: You write that teaching of medicine focuses on practices and facts, and not on their conceptual foundations, that doctors are typically reflective about their actions and feelings, and not on underlying concepts. "Thus, they may have stereotyped and limits views of what a diagnosis is, or the fact that illness and disease are always objective entities clearly demarcated from health." An implication of this is that the doctors in their communications with patients and the public can be unwitting proponents of biomedical reductionism and disease essentialism. I am advocate of “conceptual competence” in medical training2 and have been involved in teaching philosophy of psychiatry to trainees, and my experience has been that many trainees and psychiatrists have a very essentialistic understanding of disease concepts. Do you think medical educators should try to remedy such thinking?
Huda: I teach classification to the psychiatry trainees of the North West of England and as part of that I do try to talk about the varied nature of medical conditions. As I have said earlier, we use categories as they fit with human psychology well but many health problems are dimensional—often on a continuum with health with no clear demarcation between health and sickness as well as being on multiple dimensions of attributes of medical interest.
I think nosology should be taught at medical school so that all doctors can be aware of the nature of medical conditions for example they are not all diseases or illnesses. Pregnancy is not an illness, but doctors see pregnant women because they or their fetuses may develop medical illnesses or problems for instance. Doctors in other specialties often encounter problems that we are already familiar with in psychiatry—such as what is the best way to draw thresholds to define conditions (for example defining renal failure) and how to take into account co-occurrence of conditions (such as talking about hypertension, hypercholesterolemia and type 2 diabetes as if they were completely separate conditions).
Other important lessons from philosophy such as how to recognize valid and invalid arguments would also be valuable—denying the antecedent or affirming the consequent is frequently found in medical and mental health literature. Most medical schools include some sociology but medical students should also be taught to recognize cultural biases in their thinking.
Aftab: One of the more commented upon passages from your book states: “It was doctors’ professional authority (ie, their ability to be held to account by relevant authorities, their ethical codes of behavior, and their ability to be administrators) rather than sapiental authority (ie, knowledge of mental health problems and effective treatments) that led to them being put in charge of asylums in the 19th century. If psychologists or social workers existed as highly developed professions with professional authority during the Victorian era, then perhaps they would have become asylum superintendents instead of doctors.” This was an intriguing thought for me. This alternative history would’ve unfolded in very interesting ways. Do you think there are any current aspects of psychiatric practice that would be better served if they were primarily managed by psychologists?
Huda: This alternative history would certainly be different with its own gains and losses. Mental health services would probably have had a greater focus on listening and identifying and helping with traumatic events. Less use of medication would mean less adverse effects and problems with withdrawals. There would probably be a greater focus on community work and less use of detention as it would be harder to justify detention as psychosocial interventions require some willingness to participate. Given the current under-representation of ethnic minorities in clinical psychology, I doubt there would have been any reduction in institutional racism in mental health services. There would have been a greater focus on research on psychosocial causes and mechanisms but I’m skeptical if there would have been more research on adverse effects of psychotherapy which is a highly neglected field currently. Non-diagnostic classifications would likely have been more prevalent.
For those conditions which respond better to psychosocial approaches, such as anxiety and mild to moderate depressive disorders, a psychology led service can be beneficial, with more efficient access to psychotherapy instead of long waiting lists like we currently have. But this would also require there to a lot more psychotherapists (and perhaps more group therapy). Antidepressants can be used as second line if therapy is ineffective. For those meeting criteria for personality disorders, a psychological approach can help avoid stigmatizing labels and offer a focus on dealing with trauma and its psychological consequences. A mix of individual and group approaches promptly delivered rather than multiple contacts with psychiatric services of a “firefighting” nature focusing on risk and brief appointments spaced weeks/months apart can be much more helpful.
Aftab: On Twitter, you are known as a prominent defender of current psychiatric practices against critics, yet I believe your book reveals a far more critical mind. I suspect if you weren’t spending most of your energies defending psychiatry, you might actually have been a critic yourself of the reductionistic and unreflective tendencies within our profession. What do you think?
Huda: I will mention a few problems. We have not paid due attention to the adverse effects of psychiatric medications. Even accurate information on frequency of some severe adverse effects is lacking. A patient first described to me antidepressant withdrawal in the mid-90s yet we still have no accurate estimate of the prevalence of severe withdrawals (or an uncontested definition) for each antidepressant drug so we can inform our patients of the risk. Apart from lack of good data, there is a lack of clinics and other services to support victims of severe withdrawals. Our studies on the effectiveness of antidepressants vs placebo for preventing relapse of depression have probably overestimated the benefit because some of the relapses in the placebo group may actually be due to withdrawals; the actual benefit is still likely to be clinically significant but less than that for effective psychotherapy. We also have little idea of the frequency of persistent and/or severe cognitive impairment after electroconvulsive therapy which is a serious gap in knowledge.
Another issue is to reduce measuring treatment effectiveness to reducing symptoms or preventing exacerbations of symptoms. It relies on the assumption that for all patients reducing what we describe as symptoms is their priority and that reducing them will produce other benefits such as improving quality of life, functioning and preventing other outcomes such as suicide. Of course, we need some standardization of outcomes in studies but as in all of medicine we need to increase patient participation in study design to study outcomes that patients themselves value not what we think they should value. We also need to further clarify what we mean by apparently straight forward terms as “quality of life” and “functioning” as they involve a lot of implicit values. There is also suspicion of the concept of “recovery” as many patients feel it has been used to discharge distressed and vulnerable people from services.
Aftab: You write that you prefer the term “condition” over terms such as “disorder” and “disease,” because the term carries less philosophical baggage. By condition you mean that this is a state in a person that “may come to the attention of health services but does not mean that this state is definitely an illness or disease, or even a state that should be regarded as a primarily a health problem (instead of, for example, a social problem).” By calling psychiatric disorders as conditions, are you acknowledging that there is sufficient room for debate regarding whether these conditions are diseases or disorders with underlying dysfunctions, or even that they are best understood as medical conditions? If so, that’s a prominent departure from psychiatric practices which label most diagnoses as disorders and often encourage the rhetoric of calling psychiatric illnesses as “brain diseases.”
Huda: A problematic reductionism in our field is the tendency to “disease” talk—using language such as treating mental disease, depression is a disease, schizophrenia is a serious mental disease. Maybe the intent is to equalize the status of mental illness with general medical illness but to me it is inaccurate terminology and we should as professionals try to be accurate. For me, a diagnostic construct is a disease when people meeting criteria for the diagnostic construct have shared differences in structure and/ or processes compared to people who don’t meet the criteria for the diagnostic construct. Given the heterogenous nature of the depression construct there is not this commonality of differences in structure and/ or process. For schizophrenia there is more evidence of such changes such as increased presynaptic dopamine activity,3 but this is not found in everyone meeting these diagnostic criteria, and it is also found in some people meeting manic psychosis.4 So to call diagnostic constructs such as depression or schizophrenia a “disease” is to give a misleading picture of what we know about these conditions.
Many others and Wakefield view disorder and diseases as a dysfunction (a purportedly value neutral term which can include biological or psychological dysfunctions) that is negatively valued. Both disorder and disease carry negative connotations. If you tell someone their personality is disordered, well, that’s fighting talk where you are armed with medical terminology and they are defenseless—there’s nothing more personal than personality (leaving aside that these are arguably not disorders of personality per se rather than psychological reactions to trauma in the context of other vulnerability factors). Both disorder and disease carry the assumption of something “wrong” or “dysfunctional” located within the individual.
Many situations or state of affairs regarded as suitable for the attention of helping professionals do not meet the criteria for disease or disorder. Pregnancy is an obvious example. If one has high blood pressure or blood sugar due to a mixture of diet, lack of exercise, genetic and other factors is that really dysfunction or an expected outcome of a complex set of interactions (though of course high blood pressure or sugar may cause problems as a result including pathological changes or other dysfunctions)? Moving to mental health problems, many of them have no proven dysfunctions. They are states of affairs though that are regarded as appropriate to seek help from helping professionals of various kinds—usually because of associated distress, reduced functioning and/or risks of adverse outcomes. Is it possible to have any dysfunction in uncomplicated grief? Some people will argue that there are no dysfunctions in many mental health problems whilst others are convinced that they are present.
Aftab: You endorse a version of “promiscuous realism,” indicating that the medical model is simply one way of conceptualizing a condition, and it is not necessarily the best way to view or help a problem. I suppose one problem with our current practice of medicine is that when a condition is medicalized, the narrative becomes completely dominated by the medical perspective. For instance, in certain circles it would be completely taboo to say that the medical model is not necessarily the best way of viewing depression. The system wants us to accept that depression is a medical disorder in some real, fundamental way, not simply that it can be viewed as a medical disorder. The system is willing to support services such as psychotherapy or social interventions as long as appropriate lip service is paid to the disorder language. Imagine a grant funding application that begins by saying that depression is not necessarily a medical disorder… it would never get funded! What are your thoughts on this state of affairs?
Huda: Social factors are the biggest determinant of all health including physical health. Conceptualizing the consequences of social factors, a health problem is a bigger motivator to change things—hence the big investments in clean drinking water and reducing substandard housing to improve health. This is because reducing illness and improving health is a more common shared value than seeking social justice. NHS England already has a target to eliminate child abuse but as far as I can see there is no implemented strategy to do this. Public health is a great example in this regard with a focus of interventions on social factors to improve mental and physical health. To quote the great Virchow, “Medicine is a social science and politics is nothing else but medicine on a large scale. Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution.”5
As a pragmatist I recognize that sadly many people are not motivated to reduce social inequality or injustice. I work with the grain of people. Recent electoral history has shown that rational calculation and social justice are on the losing end. We can continue as Virchow would say to inform people and politicians of the consequences of their decisions but they are more likely to change them if they are framed as health consequences. People with mental health problems are more likely to get access to benefits if they are regarded as health problems. I am aware I may be accused of guild self-interest but if mental health problems are framed only as say social problems then it is likely that the services to help people with these problems will be even more underfunded and inadequate.
In terms of research and clinical practice it’s important that “medical” is not the same as “biological” and the psychiatry curriculum and practice in the UK has been “biopsychosocial” for decades. Saying something is a “medical” problem doesn’t mean only doctors should see and treat them, other models of helping may be superior. Given the complexity of the brain it is likely that only a prolonged and highly expensive research program has a chance of delivering benefits to patients. It makes economic let alone intellectual sense to broaden out the research budget to examine psychological and social factors properly which are likely to provide benefits to patients at lower cost. You can’t eliminate psychology from mental health and social factors are the biggest determinants of all health. Greater representation of psychologists and sociologist/ social workers on mental health research funding bodies along with more patients as it is their interests that should be paramount.
Aftab: Your view that framing issues fundamentally as social problems (vs medical problems) will lead to these issues being underfunded and inadequately addressed reflects a certain pessimism about our societal priorities, which is likely justified. However, I am also rather pessimistic about the notion that framing issues as health problems necessarily (or even in most cases) leads to social issues being addressed in a more satisfactory manner. My pessimism is based on what has happened with psychiatric disorders over the last 3 decades. We have seen billions of dollars invested in the development of pharmaceutical compounds and additional billions on neuroscience, but there has been very little investment in public health approaches. To borrow words from Allan Horwitz6, we have left untouched social structures that do not provide meaningful jobs, a decent living, or equitable social arrangements. I don't think biopsychosocial thinking has done much to rectify this situation just because the model is too eclectic to offer any meaningful guidance. I'd say we have a tremendous ethical imperative to ensure that medicalization is not hijacked by those who seek to profit from it. Yet, as far as I can tell, we have failed miserably in this regard.
Huda: Firstly, as Virchow5 says we should make people aware of the important social factors that need addressed—not just politicians but the wider public. This is what public health does for many health problems. Psychiatrists such as Professor Rob Poole have written books on the importance of social factors on mental health. In my book I have a chapter on social factors and health. The Royal College of Psychiatrists does mention the importance of social issues in its commissioning advice. We could all do more though to raise awareness of the social dimensions of all health in the population generally. We can take the lead in this as psychiatrists as along with public health we are the medical specialty with greatest awareness of the importance of social factors. Now the US is a strange place where drug companies advertise directly to patients to turn them into consumers, which shouldn’t be allowed, and the US health system can almost be described as being criminal. Thirdly, we need to do more research on social factors and publicize the results. It must be said that even if we had this just society, more houses and so on, some people would still have mental illness and would benefit from treatment including medication.
Aftab: We have had some personal correspondence regarding the use of the word “critical,” especially when it functions as a form of self-identification. I think there is much to learn from critical perspectives, and I have great respect for many critical psychiatrists and psychologists, such as Dr Sandra Steingard and Dr Lisa Cosgrove, both of whom are past interviewees in my series. However, one of my goals through this series has also been to demonstrate the wide variety and the broad sources of critical perspectives within the profession, including from individuals who may not self-identify as being “critical.” What are your thoughts on the use of the term “critical” and what do you think of such efforts to adopt a broader understanding of what critical implies?
Huda: The adoption of the term “critical” by a subset of opinions is problematic. I think it’s a “glamorous” term in academia especially the social sciences indicating a sort of rebellion with a self-image of protecting the vulnerable from an oppressive mainstream with Foucault as their idol (who was pretty ropey when it came to historical accuracy). As a viewpoint this school of thought is often highly skeptical of the role of “natural science techniques” in mental health but they haven’t come up with a better alternative method for discovering causes or evaluating effectiveness of treatments.
There are other views of what “critical” is. In medicine, critical appraisal is the means by which we examine how solid the evidence is for assertions such as the effectiveness of a treatment. We rarely have certainty, more often we have degrees of confidence. The techniques in critical appraisal are meant to be used in this way but are sometimes misemployed by some to bash treatments they don’t like (such as by setting unrealistically high thresholds and excluding evidence instead of saying the evidence is of a certain quality or lacks certain important features) whilst adopting the opposite attitude to approaches they favor. Another view of “critical” is the idea that one must be prepared to change beliefs if more accurate evidence or superior concepts are available, a critical attitude that is rarely enacted.
I think it’s important for everyone to be critical—of their own assertions and concepts as well as those of others. We can always do things better, listen better, think better. Our knowledge is uncertain, our concepts vague, our potential for pointless or even harmful interventions is great, awareness of implicit values guiding decisions is crucial and awareness of whether our involvement in people’s lives is warranted is needed on a case by case basis. There are plenty of legitimate and accurate critiques of psychiatry to be made without resorting to badly applied “critical” theories and hyper-skepticism about natural sciences.
Aftab: Some critics, including some well-known psychopharmacologists, bring up the possibility that due to the development of oppositional tolerance there is a subset of patients with schizophrenia in whom the long-term use of antipsychotic medications can result in a chronification of illness and worse functioning? What do you think of this hypothesis?
Huda: Firstly, it’s important to note that chronicity and frequent recurrence in psychosis has been noted in the pre-antipsychotic era. Secondly, there are two points here—one is the pathophysiological pathway you suggest and the other is a “black box” empirical observation. Dopamine super-sensitivity leading to relapse is a credible explanation for a biological mechanism for why people eventually relapse despite continued use of antipsychotics.7 I don’t think it’s a credible reason for inducing chronification in many as the dynamic response causing increased sensitivity to dopamine could also go in the opposite direction and we already know frequent recurrence occurred prior to the use of antipsychotics, too.
Of course, in some individuals it may well cause a chronic recurrent pattern that was never going to happen otherwise but the percentage of people in which this happens is unknown and based on my clinical experience it is probably a small percentage of people. In EIP I see people with low prolactin who are not in relapse as well as people with high prolactin who are in relapse (both the opposite of what would be predicted if dopamine super-sensitivity was the major reason for relapse). The counter of this is that dopamine super-sensitivity may be more of a problem for patients who have been treated for many years not the 3 years they are under EIP but usually I find many people have either an established relapsing pattern before the end of their 3 years with EIP or we have stopped antipsychotics and they seem ok but may relapse years later whilst off medication.
The “black box” empirical observation is that trying to stop antipsychotics after the first episode of psychosis has resolved and remained well for 6 months does seem to improve long term functioning in the Wunderink study.8 Leaving aside methodological issues (such as the stopping antipsychotics group seemed to have less people with schizophrenia which is associated with worse prognosis and it seems that the outcome assessments were not blinded to treatment group) the other point is that there weren’t major differences between the stopping medication group and continuing medication group in terms of average dose of antipsychotics and percentages of people who had managed to stop medication entirely by the end of the study. So it seems that stopping antipsychotics after the first episode is the best policy but I think stopping after 12 months is better than 6 months may be too soon and increase relapse risk. Sadly most people relapse and need to go back on antipsychotics but the lowest effective dose should be used to minimize negative effects on functioning.
The AESOP first-episode psychosis study9 suggests many people improve between 5 to 10 years so a trial of stopping medication—again at that point is a reasonable strategy. An American study in the 1960s randomized patients who had been on long term antipsychotics to another antipsychotic, placebo or barbiturate and noted that several patients in the placebo group did not relapse.10 The major issue is to use the minimum effective dose and to consider stopping medication gradually if there has been a sufficient relapse free period except if severe risks associated with relapse.
Aftab: You write: “I disagree with location of dysfunction within the individual as the dysfunction may be located within their environment, including social network, or the actions of others causing an appropriate response, but individual factors may modify this response.” Can you elaborate on your thinking here?
Huda: Causation of medical problems in general can often be multifactorial and complex and mental health conditions tend to be exemplars of this. As for dysfunction specifically, well I’m not sold on there always being individual dysfunction being present. Let’s use the analogy of metabolic syndrome conditions—the blood pressure and blood sugar may be the expected response to the situation of the individual—their diet, level of activity, psychosocial situation and genetics—it is not a dysfunction but the expected function but accepted the consequences frequently associated may be harmful (atheroma, damaged eyes/kidneys, etc). Similarly, the emotional/ cognitive responses to stressors like bullying, sexual abuse and trauma may be expected and even adaptive in ways but some of the consequences may be harmful—high levels of distress suicide risk, substance use, and so on.
The assumption that the problem is always located within the individual may not always hold—if someone is experiencing bullying or other adverse stressors due to the actions of others and is distressed as a result is the dysfunction located within them or the people who are causing them the distress? To put it simply, the assumptions contained within the terms disorder or disease are not regarded as being true by many professionals for lots of the problems that are regarded as suitable for the attention of helping professionals (not just mental health problems) so I prefer the term condition which still sounds a bit “medical” but seems the least worse term as I take it to mean a state that is thought suitable for the attention of helping professionals.
Aftab: Thank you!
The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of Psychiatric Times®.
Dr Aftab is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the Psychiatric Times® Advisory Board. He can be reached at email@example.com or on twitter @awaisaftab. Dr Aftab and Dr Huda have no relevant financial disclosures or conflicts of interest.
1. Tyrer P., Al Muderis O., & Gulbrandsen G. Distribution of case-load in community mental health teams. Psychiatr Bull. 2001;25:10-12.
2. Aftab A, Waterman GS. Conceptual Competence in Psychiatry: Recommendations for Education and Training. Academic Psychiatry. 2020 [Epub ahead of print]. https://pubmed.ncbi.nlm.nih.gov/31989541
3. Howes OD, Kambeitz J, Kim E, et al. The nature of dopamine dysfunction in schizophrenia and what this means for treatment: Meta-analysis of imaging studies. Arch Gen Psychiatry. 2012;69:776-786.
4. Jauhar S, Nour MM, Veronese M, et al. A test of the transdiagnostic dopamine hypothesis of psychosis using positron emission tomographic imaging in bipolar affective disorder and schizophrenia. JAMA Psychiatry. 2017;74(12):1206-1213.
5. Friedlander E. Rudolf Virchow on pathology education. Accessed September 4, 2020. http://www.pathguy.com/virchow.htm
6. Horwitz AV. Transforming normality into pathology: the DSM and the outcomes of stressful social arrangements. J Health Soc Behav. 2007;48(3):211-22.
7. Chouinard G, Jones BD. Neuroleptic-induced supersensitivity psychosis: Clinical and pharmacologic characteristics. Am J Psychiatry. 1980;137:16-21.
8. Wunderink L, Nieboer RM, Wiersma D, et al. Recovery in remitted first-episode psychosis at 7 years of follow-up of an early dose reduction/discontinuation or maintenance treatment strategy: Long-term follow-up of a 2-year randomized clinical trial. JAMA Psychiatry. 2013;70:913–920.
9. Morgan C, Lappin J, Heslin M, et al. Reappraising the long-term course and outcome of psychotic disorders: The AESOP-10 study. Psychol Med. 2014;44: 2713–26.
10. Casey JF, Bennett IF, Lindley CJ, et al. Drug therapy in schizophrenia: Aa controlled study of the relative effectiveness of chlorpromazine, promazine, phenobarbital, and placebo. Arch Gen Psychiatry. 1960;2: 210-220.