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No turf wars in mental health - put the patient first, says Adrian James

Dr Adrian James, Registrar at the Royal College of Psychiatrists, says there is no room for 'turf wars' in mental health care

There is no room for 'turf wars' in mental health care, says Dr Adrian James, Registrar at the Royal College of Psychiatrists


In recent times there have been growing calls from within the mental health arena for a shift towards a ‘therapies first’ approach in treatment. Indeed, at the start of July I spoke at a conference on Psychological Therapies for Severe & Prolonged Mental Illness in London, where many of the psychologists speaking were arguing in favour of ‘therapies first’.

This – or any – insistence on indicating a preference for one form of treatment over another doesn’t feel comfortable to me. It seems to put treatment type before patient.  Often, those arguing for the ‘therapies first’ approach claim that it’s what patients want, but that seems too reductive. I think patients want to be listened to. They want to be heard, and be given the opportunity to co-produce care plans. They want to have choices, and the information they need to help them make those choices, with evidence on effectiveness but also risks and side effects. They don’t want one single thing – they want to know what will work best for them, as an individual. We, as professionals charged with their treatment should want the same, and I know of no psychiatrist who would say psychological therapies should not be part of our therapeutic armoury  

When treating depression for example, NICE guidelines recommend that ‘treatment and care should take into account patients' needs and preferences’ and that ‘people with depression should have the opportunity to make informed decisions about their care and treatment, in partnership with their practitioners’. For those with mild to moderate depression, guidance is to offer individual self-help based on the principles of cognitive behavioural therapy (CBT), computerised CBT and/or a physical activity programme and to be steered by the patient’s preference. Only when symptoms are more severe or persistent is medication considered as a treatment.

Drug treatment

Even when a condition is severe enough to warrant drug treatment, for many moderate to severe mental health conditions, recommended treatment regimens include both medication and psychological interventions. For example, the 2014 NICE guidance on psychosis recommends that, for people with a first episode of psychosis, and those experiencing acute and subsequent episodes, an oral antipsychotic medication should be offered in conjunction with a psychological treatment. Those who want to try psychological interventions alone should, it adds, be advised that these are more effective when delivered in conjunction with antipsychotic medication.

All of us working in mental health know that when someone is extremely unwell, experiencing an acute psychotic episode and feeling frightened and overwhelmed by their symptoms, medication is an essential part of treatment. The psychologist I work with at my unit in Devon would not, for instance, expect me to suggest she enters the room and attempts a talking therapy with someone who is acting out of control and threatening violence. She would, quite rightly, expect us to provide medication in order to settle those symptoms, so that psychological therapies can then be used. 

Relapse rates also support the importance of medication as part of the response, where necessary. Early estimates from the big Leucht meta analysis (Leucht et al 2012), which published outcomes over a 12 month period, show 64 out of 100 people experience a return of their symptoms with no medication, a figure that was reduced to 27 in 100 where regular medication is used.

Turf wars

There are of course instances when it is only right that psychological therapies are used, the previous reference to mild depression being a good example of this, but my point is that there is no room for turf-wars here. It’s not one or the other – it’s a case of more of everything being needed.

Psychiatric practice encompasses biological, psychological and social approaches, bringing all areas of mental health treatment together. It is most certainly not just about the prescription of drugs. Indeed psychiatrists have led the way in developing many of the approaches used in psychological practice.  

What is needed now, in addressing severe and prolonged mental illness, is unity, and an overriding commitment to putting the patient at the centre. We need to pull together to offer service users everything that will help them. Only by celebrating the diversity in our work, and promoting what each of us can bring to the table, from both the psychiatric and psychological models, can we be truly ambitious in the care we provide.  It shouldn’t be ‘therapy first’, nor should it be ‘drug first’. It should only ever be patient first.


Leucht S, Tardy M, Komossa K, et al (2016) Antipsychotic drugs versus placebo for relapse prevention in schizophrenia: a systematic review and meta-analysis. The Lancet.  379, 2063–2071. 

Dr Adrian James, Registrar at the Royal College of Psychiatrists


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