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Psychiatry beyond the current paradigm
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Summary: A series of editorials in this Journal have argued that psychiatry is in the midst of a crisis. The various solutions proposed would all involve a strengthening of psychiatry's identity as essentially ‘applied neuroscience’. Although not discounting the importance of the brain sciences and psychopharmacology, we argue that psychiatry needs to move beyond the dominance of the current, technological paradigm. This would be more in keeping with the evidence about how positive outcomes are achieved and could also serve to foster more meaningful collaboration with the growing service user movement.
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“In reality, however, global mental health practice tends to be rooted in biomedical psychiatric frameworks and in psychopathological models, which construct mental distress as 'an illness like any other' for which a 'technical' solution is best suited (Bracken et al. 2012).”
From Throwing therapy at the problem mental health and humanitarian intervention in Palabek refugee settlement, northern Uganda (2023) · cites this paper as Bracken et al. 2012
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“the last decades have seen increasing pushback against the use and prescription of psychiatric treatment in the Global North (Bracken et al. 2012).”
From Throwing therapy at the problem mental health and humanitarian intervention in Palabek refugee settlement, northern Uganda (2023) · cites this paper as Bracken et al. 2012
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“The role of pharmaceutical companies in furthering this increase cannot be underestimated (Horwitz and Wakefield 2007;Bracken et al. 2012).”
From Throwing therapy at the problem mental health and humanitarian intervention in Palabek refugee settlement, northern Uganda (2023) · cites this paper as Bracken et al. 2012
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Toward a new architecture for global mental health
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“(Bracken et al., 2012, p. 431) These challenges and persistent areas of controversy point to the need for a broader research agenda in global mental health (Kirmayer & Crafa, 2014).”
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“However, the effectiveness of conventional treatments for depression is questioned: meta-analyses of drug treatments demonstrate minimal difference from placebo, comparisons of real and sham electroconvulsive therapy show little difference after a month, and the evidence for the use of specific cognitive interventions…”
BackgroundEmpirical evidence about recovery and mental health
Slade, M., & Longden, E. (2015) · BMC Psychiatry · doi:10.1186/s12888-015-0678-4 · Cited by 255
“Such frameworks have been deemed ‘a technological paradigm’ in that (1) mental health difficulties are believed to arise from disordered processes within the individual, (2) are modelled universally and causally, independent of an individual’s particular context, and (3) resulting interventions are applied and evaluat…”
BackgroundHoenders, R. H. J., Ghelman, R., Portella, C. F. S., Simmons, S., Locke, A., Cramer, H., Gallego-Pérez, D. F., & Jong, M. C. (2024) · Frontiers in Medicine · doi:10.3389/fmed.2024.1395698 · Cited by 175
No more psychiatric labels: Why formal psychiatric diagnostic systems should be abolished
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“Concerns that this is the case are being raised by an ever louder chorus of voices from both inside and outside of the profession.(17,18) Such contentions are given ballast not only by anecdote and by endorsement from senior academic psychiatrists and clinicians but by A dv an ce s in M ed ic al E du ca tio n an d P r…”
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“These findings do not represent novel discussions as the role and importance of the therapeutic relationship within mental health care has been well described in the academic literature [17] and the difficulties with providing a service that is primarily biomedical in nature for example have been frequently commented…”
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Walsh, D., & Foster, J. (2021) · Frontiers in Public Health · doi:10.3389/fpubh.2020.569539 · Cited by 127
“That is, experiences of distress are considered to be meaningful responses that can only be understood with reference to an individual’s life history and their particular social, cultural, and familial contexts (49, 50).”
BackgroundThe Psychiatrization of Poverty: Rethinking the Mental Health-Poverty Nexus
Mills, C. (2015) · Social and Personality Psychology Compass · doi:10.1111/spc3.12168 · Cited by 117
“…to poverty and forms of oppression, and d) many mental health diagnoses, and the medications that dominate treatment options, are highly disputed and critiqued (Bracken et al., 2012; Burstow, LeFrançois, & Diamond, 2014; Boyle, 1990/2002; LeFrançois, Menzies, & Reaume, 2013; Moncrieff, 2009).”
Competing Priorities: Staff Perspectives on Supporting Recovery
Boutillier, C. L., Slade, M., Lawrence, V. C., Bird, V., Chandler, R., Farkas, M. D., Harding, C. M., LARSEN, J. A., Oades, L. G., Roberts, G. A., et al. (2014) · Administration and Policy in Mental Health and Mental Health Services Research · doi:10.1007/s10488-014-0585-x · Cited by 126
“Mental health staff are encouraged to support the recovery of individuals living with severe mental illness (Department of Health 2011a, b; Department of health human services 2003) by transforming services towards a recovery orientation (Bracken et al. 2012).”
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Bemme, D., & D’souza, N. A. (2014) · Transcultural Psychiatry · doi:10.1177/1363461514539830 · Cited by 109
“leading some to speak of a general crisis of the discipline (Bracken et al., 2012; Kleinman, 2012).”
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“The ED field could represent an example of both crisis of psychiatry and its moderate effectiveness [9,10] with reductionist approaches also playing a role in this regard [11].”
BackgroundQ: Is Addiction a Brain Disease or a Moral Failing? A: Neither
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“Interestingly, a group of psychiatrists has recently written about what they perceive to be a crisis in their science and profession [31].”
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Aportaciones y Limitaciones del DSM-5 desde la Psicología Clínica
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“…focusing on showing that particular mental disorders (e.g., depression, schizophrenia, bipolar disorder) are not diseases, highlighting the limited efficacy and unrecognized harms of psychiatric drug interventions, and advocating collaboration with the service user movement (Bracken et al., 2012).”
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Ridley, S., Martin, R., & Mahboub, L. (2016) · Australian Social Work · doi:10.1080/0312407x.2016.1235718 · Cited by 56
“These concepts reflect the critical stance participants adopted toward the idea that “mental illness” involved individual pathology resulting from defective physiology or abnormal psychology (Bracken et al., 2012).”
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“That is why it is time for a paradigm shift (Bracken et al., 2012).”
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Bracken, P. J. (2014) · World Psychiatry · doi:10.1002/wps.20148 · Cited by 54
“What sort of knowledge can we have with regard to mental illness and what sort of expertise is possible? The current technological paradigm that dominates psychiatric thought (11) is based on the idea that episodes of mental illness arise from abnormalities in specific neural, or psychological, pathways or processes.”
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Gewurtz, R. E., Moll, S. E., Poole, J. M., & Gruhl, K. R. (2015) · Handbooks in health, work, and disability · doi:10.1007/978-1-4939-2920-7_13 · Cited by 56
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“The persistence of this viewpoint in the history of mental health services proves concerning (e.g., Bracken et al., 2012) and highlights the need for organizations to scrutinize their ways of working with these viewpoints in mind.”
BackgroundPsychiatrised Children and their Rights: Starting the Conversation
LeFrançois, B. A., & Coppock, V. (2014) · Children & Society · doi:10.1111/chso.12082 · Cited by 54
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“Critical psychiatrists such as Timini (2012) argue that a technological paradigm in which classification systems are forwarded and specific interventions designed—this ‘‘medicine of the mind’’ (Bracken et al., 2012)—ignores vital relationships, meanings, values, beliefs, and practices.”
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“This has been a matter of cross-professional concern for many years (e.g. Barker, 2011; Bentall, 2004; Berger, 2013; Boyle, 2002; Bracken et al., 2012; BPS, 2000, 2011; Coppock & Hopton, 2000; Johnstone, 2008; Moncrieff, 2010).”
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“The current paradigm in mental health treatment is avowedly neurobiological; however, in a recent series of editorials (Bracken et al., 2012; Kleinman, 2012; Priebe, Burns, & Craig, 2013), several prominent psychiatrists have suggested that a focus on the social factors associated with the…”
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van Westrhenen, N., Fritz, E., Vermeer, A., Boelen, P. A., & Kleber, R. J. (2019) · PLoS ONE · doi:10.1371/journal.pone.0210857 · Cited by 44
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McGuire, P. K., Sato, J. R., Mechelli, A., Jackowski, A. P., Bressan, R. A., & Zugman, A. (2015) · The Lancet Psychiatry · doi:10.1016/s2215-0366(15)00308-9 · Cited by 35
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“A widely-expressed view was that POD allows for a more intuitive, humanistic practice than currently, comparable to ‘‘post-technological psychiatry’’ outlined by Bracken et al. (2012), with increased emphasis on meanings, values and relationships.”
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“contextual aspects of care are crucial (Bracken et al., 2012; Dunacn et al., 2010).”
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“Other studies have found that it is common for presentation for treatment to occur many years after onset of an eating disorder, and into late middle-age [5, 8, 9], highlighting that a large population of people with eating disorders are not engaged with treatment.”
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Gómez-Carrillo, A., Lencucha, R., Faregh, N., Veissière, S. P. L., & Kirmayer, L. J. (2020) · BMJ Global Health · doi:10.1136/bmjgh-2020-002689 · Cited by 32
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“However, the evidence finds that ‘common factors’, such as developing a strong therapeutic alliance, are much more important than therapeutic technique in determining outcomes (Bracken et al., 2012; Duncan, Miller, Wampold, & Hubble, 2009; Wampold, 2001).”
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“many other criticisms of the traditional psychiatric project (Bentall, 2003; Bracken et al., 2012), the development of mental health law and policy has tended to be been underpinned by the premise that mental illnesses can be diagnosed and to some extent predicted, and that associated risks can and have to be managed.”
BackgroundDialogue as a Response to the Psychiatrization of Society? Potentials of the Open Dialogue Approach
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LA PSICOTERAPIA COMO CIENCIA HUMANA, MÁS QUE TECNOLÓGICA
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“Against this background of heterogeneity, overlapping co-morbidity and fading faith in the validity of descriptive classification systems [6], schizophrenia and related psychotic conditions are increasingly viewed as complex, polygenic diseases involving hundreds of forms of functional pathology.”
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Toward Conceptual Competence in Psychiatric Diagnosis: An Ecological Model for Critiques of the DSM
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“Many psychiatrists have called for a shift from the current paradigm of a mental health diagnosis that focuses on the biomedical cause of mental disorders because of evidence-based research (Bracken et al., 2012).”
BackgroundPsychodynamic psychotherapy, insight, and therapeutic action
Lacewing, M. (2014) · Clinical Psychology: Science and Practice · doi:10.1111/cpsp.12065 · Cited by 27
“Bracken et al. (2012) concurred, stating that “the evidence that nonspecific factors, as opposed to specific techniques, account for nearly all the change in therapy is overwhelming” (p. 431).”
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“The therapist recognized that suicidality could be understood differently, although her view seems common in current (biomedical) psychiatry (Bracken et al., 2012; Marsh, 2016).”
BackgroundFreedom to negotiate: a proposal extricating ‘capacity’ from ‘consent’
Brosnan, L., & Flynn, E. (2017) · International Journal of Law in Context · doi:10.1017/s1744552316000471 · Cited by 30
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Tendencias y necesidad clínica de los principios éticos
Stepke, F. L. (2014) · Revista de Psiquiatría y Salud Mental · doi:10.1016/j.rpsm.2014.11.001 · Cited by 26
Hellhammer, D. H., Meinlschmidt, G., & Pruessner, J. C. (2018) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2017.12.009 · Cited by 26
Political Pills: Psychopharmaceuticals and Neoliberalism as Mutually Supporting
Davies, J. (2017) · Springer eBooks · doi:10.1007/978-3-319-44911-1_8 · Cited by 27
Madness, childhood adversity and narrative psychiatry: caring and the moral imagination
Thomas, P., & Longden, E. (2013) · Medical Humanities · doi:10.1136/medhum-2012-010268 · Cited by 25
Self-citationLawn, S., Delany, T., Pulvirenti, M., Smith, A., & McMillan, J. R. (2016) · BMC Psychiatry · doi:10.1186/s12888-016-0791-z · Cited by 25
“[65] argued that the non-technical aspects of interventions (such as the development of meaningful, non-judgmental relationships) are as much involved in recovery as the therapies and psychiatric medications used to treat mental illness.”
BackgroundGlobal Side Effects: Counter-Clinics in Mental Health Care
Davis, E. A. (2017) · Medical Anthropology · doi:10.1080/01459740.2017.1367777 · Cited by 25
“See Bradley Lewis’s discussion of Stuart Kirk and Herb Kutchin’s texts, The Selling of the DSM: The Rhetoric of Science in Psychiatry (1992) and Making Us Crazy: DSM: The Psychiatric Bible and the Creation of Mental Disorders (1997), which Lewis takes as “now classic critiques of DSM-III” and of the science behind DSM…”
InfluentialLawn, S., Delany, T., Pulvirenti, M., Smith, A., & McMillan, J. R. (2015) · BMC Psychiatry · doi:10.1186/s12888-015-0653-0 · Cited by 24
“The Critical Psychiatry Movement [56] has argued that the non-technical aspects of interventions (such as the development of meaningful, non-judgmental relationships) are as much involved in recovery as the therapies and psychiatric medications used to treat mental illness.”
Factors Influencing Social Work Identity in Mental Health Placements
Smith, F., Harms, L., & Brophy, L. M. (2021) · The British Journal of Social Work · doi:10.1093/bjsw/bcab181 · Cited by 24
Murcott, W. (2014) · Journal of Psychiatric and Mental Health Nursing · doi:10.1111/jpm.12150 · Cited by 24
Timimi, S. B. (2015) · BJPsych Bulletin · doi:10.1192/pb.bp.114.047118 · Cited by 24
Self-citationUse of empathy in psychiatric practice: Constructivist grounded theory study
Ross, J., & Watling, C. (2017) · BJPsych Open · doi:10.1192/bjpo.bp.116.004242 · Cited by 24
DSM over time: From legitimisation of authority to hegemony
Romelli, K., Frigerio, A., & Colombo, M. (2015) · BioSocieties · doi:10.1057/biosoc.2015.1 · Cited by 23
Psychiatrists' understanding and use of psychological formulation: a qualitative exploration
Mohtashemi, R., Stevens, J., Jackson, P., & Weatherhead, S. (2016) · BJPsych Bulletin · doi:10.1192/pb.bp.115.051342 · Cited by 22
The psychedelic renaissance: the next trip for psychiatry?
Kelly, J. R., Baker, A., Babiker, M., Burke, L., Brennan, C., & O’Keane, V. (2019) · Irish Journal of Psychological Medicine · doi:10.1017/ipm.2019.39 · Cited by 21
“synergistically combining psychotherapy and psychopharmacology, this RCT has the potential to evolve treatments beyond the regrettable, but lingering, dichotomy of ‘biological’ and ‘psycho-environmental’ (Bracken et al. 2012; Dunlop et al. 2019).”
Mental Health, Legal Capacity, and Human Rights
(2021) · Cambridge University Press eBooks · doi:10.1017/9781108979016 · Cited by 21
Neuroscience and Humanistic Psychiatry: a Residency Curriculum
Griffith, J. L. (2014) · Academic Psychiatry · doi:10.1007/s40596-014-0063-5 · Cited by 21
“The threat that neuroscience research could constrict the scope of practice of psychiatrists to diagnostic and psychopharmacological roles would end the training of psychiatrists as broadly skilled clinicians who utilize language and relationship therapeutically [1, 2].”
The crisis in psychiatry: A public health perspective
Pingani, L., Luciano, M., Sampogna, G., Rosa, C. D., Pinna, F., Volpe, U., Vecchio, V. D., & Fiorillo, A. (2014) · International Review of Psychiatry · doi:10.3109/09540261.2014.931838 · Cited by 21
“…rethink research goals in psychiatry by involving the different categories of stakeholders from the early stages of the research processes, since research priorities are still not compliant with users ’ and carers ’ priorities and are very far from having a clinical utility (Bracken et al., 2012).”
BackgroundResponses to the Publication of the American Psychiatric Association’s DSM-5
Kinderman, P., Allsopp, K., & Cooke, A. (2017) · Journal of Humanistic Psychology · doi:10.1177/0022167817698262 · Cited by 21
“Both psychiatrists (e.g., Bracken et al., 2012) and psychologists (e.g., Kinderman, 2014) argue for reform; in the latter case arguing that: . . . services should . . . be based on the premise that the origins of distress are largely social . . . should replace “diagnoses” with straightforward…”
BackgroundTwamley, I., Dempsey, M., & Keane, N. (2020) · Journal of Mental Health · doi:10.1080/09638237.2020.1739238 · Cited by 21
“Many service users have reported their experience of traditional mental health services and psychiatry as disempowering (Bracken et al., 2012).”
BackgroundA systemic approach to understanding mental health and services
Cohen, M. (2017) · Social Science & Medicine · doi:10.1016/j.socscimed.2017.08.037 · Cited by 21
Daly, A., Ritunnano, R., Gallagher, S., Kirmayer, L. J., Dam, N. T. V., & Kleinman, J. J. (2024) · Frontiers in Psychology · doi:10.3389/fpsyg.2024.1390885 · Cited by 20
“Nevertheless, there have been recurrent calls for a paradigm shift that would privilege patients experience, focus on dynamic processes, and engage with the context of the patient’s lifeworld (Bracken et al., 2012; Rose and Rose, 2023; Scheffer et al., 2024).”
BackgroundSarasso, P., Francesetti, G., Roubal, J., Gecele, M., Ronga, I., Neppi-Mòdona, M., & Sacco, K. (2022) · Frontiers in Human Neuroscience · doi:10.3389/fnhum.2022.906188 · Cited by 21
Burgess, R. A. (2023) · Routledge eBooks · doi:10.4324/9781315623788 · Cited by 23
The role of psychiatry in modern medicine
Fiorillo, A., & Maj, M. (2018) · International Review of Psychiatry · doi:10.1080/09540261.2018.1436675 · Cited by 20
“…new techniques of molecular genetics and brain imaging have enabled a more detailed understanding of physiological and pathological brain functions, but these techniques have not led to the development of aetiology-based treatments for mental disorders (Bracken et al., 2012; Kingdon & Young, 2007).”
BackgroundYoung people's experience of the therapeutic alliance: A systematic review
Dimic, T., Farrell, A., Ahern, E., & Houghton, S. (2023) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.2885 · Cited by 19
Affective injustice, sanism and psychiatry
Lavallee, Z., & Gagné‐Julien, A. (2024) · Synthese · doi:10.1007/s11229-024-04731-8 · Cited by 19
“The biomedical approach to psychiatry refers to a paradigm that, in its strongest form, conceptualizes “mental illness” in terms of disordered mental states that are caused by abnormalities in underlying physiological or neurobiological systems (Bell & Figert, 2015; Bracken et al., 2012).”
Martean, L., & Evans, C. (2014) · Psychiatric Bulletin · doi:10.1192/pb.bp.113.044081 · Cited by 19
Self-citationPsychotherapy is an ethical endeavor: Balancing science and humanism in clinical practice
Allen, J. G. (2013) · Bulletin of the Menninger Clinic · doi:10.1521/bumc.2013.77.2.103 · Cited by 19
“For contemporary authority on this perspective, I cite Pat Bracken and colleagues’ passionate plea for humanism in psychiatry (Bracken et al., 2012).”
Background
Metadata
- Authors
- Bracken, P., Thomas, P., Timimi, S., Asen, E., Behr, G., Beuster, C., Bhunnoo, S., Browne, I., Chhina, N., Double, D., Downer, S., Evans, C., Fernando, S., Garland, M. R., Hopkins, W., Huws, R., Johnson, B., Martindale, B., Middleton, H., Moldavsky, D., Moncrieff, J., Mullins, S., Nelki, J., Pizzo, M., Rodger, J., Smyth, M., Summerfield, D., Wallace, J., & Yeomans, D.
- Affiliations
- University of Bradford (GB)
- Lincolnshire Partnership NHS Foundation Trust (GB)
- Central and North West London NHS Foundation Trust (GB)
- Southern Health NHS Foundation Trust (GB)
- Barnet Enfield and Haringey Mental Health Trust (GB)
- University College Dublin (IE)
- Cumbria Partnership NHS Foundation Trust (GB)
- Norfolk and Suffolk NHS Foundation Trust (GB)
- University of Bristol (GB)
- Nottinghamshire Healthcare NHS Foundation Trust (GB)
- London Metropolitan University (GB)
- Cumbria Northumberland Tyne and Wear NHS Foundation Trust (GB)
- University of Nottingham (GB)
- University College London (GB)
- Sheffield Health and Social Care NHS Foundation Trust (GB)
- St Ann’s Hospital (GB)
- Devon Partnership NHS Trust (GB)
- Bantry General Hospital (IE)
- Maudsley Hospital (GB)
- Peijas Hospital (FI)
- Leeds and York Partnership NHS Foundation Trust (GB)
- ORCID
- Venue
- British Journal of Psychiatry
- Publisher
- Royal College of Psychiatrists
- Published
- 2012-12
- Volume
- 201
- Issue
- 6
- Pages
- 430-434
- ISSN
- 0007-1250 (ISSN-L)
- 1472-1465
- OpenAlex
- W2142320986
- Cited by
- 474
- References
- 70
- Citations by year
- 2026: 16 · 2025: 10 · 2024: 12 · 2023: 19 · 2022: 17 · 2021: 58 · 2020: 28 · 2019: 28 · 2018: 35 · 2017: 52 · 2016: 41 · 2015: 79 · 2014: 51 · 2013: 27
- FWCI
- 444.93
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The British Journal of Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- UCL Discovery (University College London) (submittedVersion)
- Lenus, The Irish Health Repository (Dr Steevens Hospital Library) (submittedVersion)
- Funders
- Johns Hopkins University
- Royal College of Psychiatrists
- University College London
- University College Dublin
- London Metropolitan University
- Topics
- Social Sciences › Arts and Humanities › Philosophy › Mental Health and Psychiatry
- Health Sciences › Health Professions › General Health Professions › Mental Health and Patient Involvement
- Social Sciences › Psychology › Clinical Psychology › Historical Psychiatry and Medical Practices
- Keywords
- crisis in psychiatry, applied neuroscience, technological paradigms, evidence-based outcomes, psychopharmacology, brain research
- MeSH terms
- Mental Disorders, Electroconvulsive Therapy, Humans, Mental Health, Professional Practice, Psychiatry, Cognitive Behavioral Therapy, Knowledge, Recovery of Function, Biomedical Technology, Evidence-Based Practice
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