Thursday, February 4, 2021

Embodied Embedded Enactive Psychiatry: What are the Implications of 3E Cognition for Psychopathology

Embodied, embedded, enactive (3E) cognition offers a radically different framework for understanding the mind. It has emerged over the last 30 years as a result of insights from an eclectic mix of disciplines including ecological psychology, robotics, dynamical systems theory and philosophy. Central to 3E cognition is its rejection of classical computationalism associated with the standard cognitive sciences which views the mind or cognitive processes as analogous to that of a digital computer, solving problems by implementing often complex algorithms through the amodal manipulation of symbols, largely uninfluenced by its physical body or the external environment.

3E cognition instead emphasises that cognition emerges from the role of the brain in a body, embedded in an environment that is actively explored and interacted with and is best described from a dynamical systems perspective.

Given the explicit and implicit influence standard cognitive science has had on psychiatry, its conceptualisation of the mind and mental illness and its subsequent treatment, it is worth considering what the implications of 3E cognition might for our understanding of psychopathology.

Presented by Dr Chris Meechan (@chrismeechan2) for the West of Scotland Speculative Psychiatry Group on 15/10/20

Tuesday, February 2, 2021

Philosophy Psychiatry Psychology - Upcoming Events

There are some great free online events in philosophy of psychiatry coming up this year, so I thought I'd try and get some of them all in one place. Please see the blog's 'events' page for future updates.

What: The West of Scotland Speculative Psychiatry Group aims to create a space for psychiatrists to reflect on the future direction of Psychiatry. We aim to take a broad and pluralistic approach, incorporating speakers from a variety of different specialties to address the breadth of conceptual, philosophical, technological, clinical and scientific issues that are inexorably enmeshed within the field of mental health.

When: Presentations are open to West of Scotland Psychiatrists (DM me @chrismeechan2) and are usually the last Thursday of the month. Future presentations will be available to all on the SPG youtube channel. Upcoming speakers include Dr Awais Aftab (@awaisaftab), Dr Samei Huda (@sameihuda) and Dr Duncan Double (@DBDouble).

My talk on the implications of embodied, embedded, enactive cognition for psychopathology can be found here

What: A series of webinars on philosophy of psychiatry organised by Anne-Marie Gagné-Julie (Biomedical Ethics Unit, McGill University Canada Research Chair on Epistemic Injustice and Agency) and Sarah Arnaud (Université du Québec à Montréal, Canada Research Chair on Epistemic Injustice and Agency). Previous talks are available on the website. Speakers include Jerome Wakefield, Rachel Cooper and Peter Zachar.

When? Every two weeks on Thursdays from Jan 21st to June 24th 17:30 -19:00 (GMT)

Register here

What: A theoretical laboratory in phenomenology and mental health. "The activities of PhenoLab are divided in two different kinds: internal presentations, delivered by the participants of the group, and external presentations, for which we invite guest lecturers who have an expertise on certain topics related to phenomenology and mental health."

When: Tuesdays from January to March 15:45-16:45 (GMT)

Please contact to receive the Zoom link

What: "A possible synthesis using wellbeing and active inference. WARNING: MAY CONTAIN MATHS. Dr Foreman (@Foreman1David) will be talking through making the medicine of subjectivity a little more objective." Organised by @TLteaching

When: 3rd February 19:00-20:00 (GMT)

Register here

What: Monthly discussion group organised by Clinical Psychologist Dr Chris Jones (@clinpsychris). 

When: 24th Feb 19:00 - 20:30 (GMT). This month - What is mental Disorder? An essay in philosophy, science and values by Derek Bolton.

DM @clinpsychris for zoom link and password

What: "Gabriel Mendes will discuss the history of the Lafargue clinic and its importance in public health and battles against desegregation."
When: 24th Feb 20:00-21:30 (GMT)
Register here

What: What is next for radical theories of embodiment? Cross-cultural and interdisciplinary approaches in philosophy and cognitive science.

When: 26 - 27th February

For access please email

What: Author of "A Philosophy of Madness", Dr. Wouter Kusters (@kstrw), presents “Mystics and Psychotics: About the Search for a Religion without Tradition, for a Time without History.” 

Tuesday, July 7, 2020

Electroconvulsive Therapy for Depression: A Review of the Quality of A Review of the Quality of ECT versus Sham ECT Trials and Meta-Analyses

ECT continues to be utilised as a treatment for life threatening and 'difficult to treat' Depression amongst other psychiatric disorders. Whilst it is approved by NICE and the FDA, it remains a controversial treatment to some. John Read et al 2020 have recently published a review of the quality of ECT versus sham ECT trials and meta-analyses. They conclude “The quality of most SECT–ECT studies is so poor that the meta-analyses were wrong to conclude anything about efficacy, either during or beyond the treatment period” and, given its side effect profile should be “immediately suspended” until better quality RCTs have been conducted. 

This review assesses the quality of the Read et al review. It is a review of the quality of A Review of the Quality of ECT-SECT RCTs and Meta-Analyses.

The quality of the review was assessed based on the principles of evidence based medicine and research methodology that would be found in any basic undergraduate textbook.

A number of methodological flaws were identified. The review was not systematic, it did not use multiple databases for search terms, no inclusion/exclusion criteria were listed, there appears to be 1 meta analysis unaccounted for (given the authors identify 5 from 14 and describe why 8 were not included) and the limitations section does not include any limitations of the paper itself.

Two more significant issues were identified - one logical and the other methodological. 

The first is that the authors’ conclusion does not follow from their premise. Even if it were demonstrated that the quality of the ECT-SECT RCTs is so poor as to be useless, this ignores the significant amount of additional research which contributes to the evidence base for efficacy of ECT, for example RCTs of ECT Vs Pharmacological interventions. In other words the authors erroneously conflate placebo RCTs and meta-analyses being the top of the hierarchy of evidence with being the only form of evidence. 

The second issue is with regards to the 24 point quality scale. The scale “...combined the “risk of bias” domains of the Cochrane Handbook Risk of Bias Tool...with other criteria relating to quality of design and reporting, and some criteria specific to ECT research”. However, the 2011 paper that this is taken from specifically states “Do not use quality scales [to assess risk for bias]. Quality scales and resulting scores are not an appropriate way to appraise clinical trials…". Second, the scale is not validated, which means we don't know if it is any good at assessing what it claims to assess. Furthermore, there are reasons to think it isn't valid due to the different variables chosen. For example, an RCT that did not assess quality of life and did not have more than 50% female with a mean age of 50 or more would lose the same amount of points (2) as an RCT that did not randomize or report its randomization process, the latter being far more significant in causing bias. It is particularly ironic that the authors include "validated depression scale" as a variable in a quality scale that itself is not validated. Third, the authors do not specify in advance what score would be considered low enough to demonstrate ‘such poor quality’. This means we cannot make any meaningful inferences from the results of the quality scale which, according to the paper that half of it was taken form, shouldn’t have been used in the first place.

The quality of the Read et al paper is so poor that the authors were wrong to conclude the quality of the ECT-SECT RCT evidence base is so poor that it cannot be utilised to meaningfully assess efficacy. It is remarkable this was published in a peer-reviewed journal. Given the high mortality risk of patients with life threatening depression and suffering associated with difficult to treat Depression, the failure to determine that the RCT evidence base is so poor as to be useless, means that its use should be continued until a series of well designed, methodologically rigorous systematic reviews demonstrate the evidence base is of such poor quality it cannot be used to make decisions about efficacy.

Whilst this review strongly criticises the methodology, results and conclusions of the Read et al paper, it says nothing of the actual evidence base for ECT, nor a number of important associated issues such as effects on long term autobiographical memory and factors influencing informed consent. In spite of the poor quality of this paper are there still questions for ECT to answer to? This will be discussed in the next post.