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Professor Matthew Hotopf on ‘Where is psychiatry going?’

An interview with the new Executive Dean of the IoPPN

Professors Matthew Hotopf and Carmine Pariante

“I grew up in a family talking about philosophy and psychology”.

This is how the conversation starts with Professor Matthew Hotopf, the new Executive Dean of the Institute of Psychiatry, Psychology & Neuroscience (IoPPN) King’s College London, in an exclusive interview for Inspire the Mind. His father was an experimental psychologist, and his mother was actively involved in social causes, working in a housing charity. Yet, his first passion was medicine, not psychiatry.

“I always knew I wanted to be a doctor”, he continues. As a teenager, he was listening to the history of medicine in school, or watching the Body in Question, a formative TV series presented by Jonathan Miller in the late 70s.

His passion for psychiatry began as a medical student at Barts during his intercalated BSc in Psychology at UCL, and was consolidated by being exposed to two brilliant minds of psychiatry, Anthony Clare (“charismatic”) and Peter White (“a true gentleman and a friend”).

This is also the time when he developed his curiosity about the interface between mental and physical health, between medicine and psychiatry (many years later, this is still his overarching area of research and, as a liaison psychiatrist, his main clinical activity).

“As a medical student I saw patients with non-cardiac chest pain, functional neurological disorders or post-viral fatigue”. He remembers that these conditions were very challenging both for patients, who felt stigmatised by the implication that their symptoms were not real, and for the doctors, who were frustrated by the lack of effective treatment for these symptoms.

“How different is it today?”, I challenge him, mindful of the potential difficulties with patients with, for example, Long-Covid.

“The rhetoric on the separation between mental and physical health is much better, but there is a long way to go”, he cautions. He is worried that the already existing gap in mortality between psychiatric patients and the general population – some say between 10 and 25 years – has worsened with Covid, and that the integration between psychiatry and medicine remains unsatisfactory.

After medical school, Matthew started his psychiatry training at the Maudsley Hospital and the then-called Institute of Psychiatry. His teachers included the ‘who’s who’ of psychiatry: “Dinesh Bhugra, Stuart Checkley, Glyn Lewis, Alwyn Lishman, Anthony Mann, Robin Murray, Michael Rutter, Emily Simonoff, Simon Wessely…”. The famous MSc in Epidemiology at the London School of Hygiene and Tropical Medicine completed his training and opened the path for his career as a psychiatric epidemiologist, the study of the distribution and determinants of mental disorders in the population

Before asking about the specific challenges he wants to address at the IoPPN, I ask him what he thinks is the biggest challenge in psychiatry . He answers with no hesitation.

“Psychiatry has been forced to focus too much on risk”. He is worried that our clinical choices, for example, whether or not to accept a patient into services at all, or admit someone onto a psychiatric ward, are dictated by the risks posed by that person to themselves or others, rather than by providing something therapeutic. "You have to be pretty unwell to get any form of psychiatric care now – we have to ration access because resources are too thinly spread, and this means it’s difficult to intervene early. Often the trigger for a service to provide support and treatment only comes when someone is in real crisis.” The situation is even worse for inpatient care: “Only the most severe patients are admitted today”, he continues, “and because nationally beds have been so severely cut, virtually all patients are admitted using the legal framework of the Mental Health Act”. He does not doubt that the use of coercion is justifiable for most individual patients, but the effect of bed closures and a higher threshold for admission means that the hospital environment is stressful for both the patients and staff, and therefore the therapeutic relationship suffers. (I may add that, with 6,000 fewer hospital beds in psychiatry – a 25% drop – between 2010 and 2020, this situation will not be improving anytime soon).

Another crucial challenge is the unacceptable racial disparity in the access, experience and outcomes that Black communities face which was highlighted in the national Mental Health Act Review in 2018. Our clinical partner, South London and Maudsley NHS Foundation Trust, has been doing sterling work with The Patient and Carer Race Equality Framework (PCREF) which we hope will significantly improve trust and confidence in mental health services.

Professors Matthew Hotopf and Carmine Pariante

He is also worried by the “unhelpful” antipsychiatry narrative, which sometimes comes from members of the psychiatry community itself. This narrative centres around the notions that “mental disorders are socially constructed” and that biological approaches to their understanding and treatment are “inherently reductionist”.

“The former view often feels stigmatising of people in genuine distress”, he continues. As to the latter, it’s as though there’s some “fear that biology necessarily squeezes out social or psychological explanations, as though there is some zero-sum game”. His view (which I share) is that ‘’there are likely to be many routes to mental disorders, and complex problems require serious thought and open-mindedness. One of the great things about the IoPPN is the diversity of disciplines available to understand these alternative routes”

I push him on his ‘first 100 days agenda’ but he ignores the provocation. Instead, he lists the priorities that, as Executive Dean, he plans to address over the course of his mandate.

First, integrate “psychiatry, psychology and neuroscience, more, as the Institute’s name says”. “The “brain can change in so many different ways and for so many different causes; this is not reductionism, it’s reality”. So, “we are bringing together the great efforts across mental health and neuroscience that are ongoing in our institution, by planning an overarching focus and improving collaborations and integrations between groups.

“It’s a stretch to create meaningful models of mental disorders in animals to humans, but we can make it”, he says enthusiastically, before mentioning basic sciences approaches that I recognise immediately: “biomarkers, organoids, stem cells, optogenetics…”. As one of the few psychiatrists directly involved in basic science research in our institution, I am very happy that this is his priority number one.

Second, we must do “research that improves mental health at a population level, starting with the local population” – the 1.3M people in South London served by the South London and Maudsley NHS Foundation Trust. He wants to engender a “renewed, supercharged” relationship with the Trust and to do research that improves “primary prevention” (that is, decreasing the risk that mental disorders ever occur) and “secondary prevention” (that is, promoting early detection, diagnosis and treatment to avoid poor outcomes which so often affect people with mental disorders). The IoPPN needs to create the evidence to promote “changes in education, fiscal policy, criminal justice, work environment”, responding to the “communal needs” and focussing on social functioning.

Third, building on the imminent launch of the new Pears Maudsley Centre for Children and Young People, Matthew wants to address “the treatment gap for children and young people, with their enormous unmet needs”. He wants the IoPPN to provide the research that will distinguish those who will “benefit from an app or other digital intervention while on a waiting list” from those who “will require rapid access to the GP, psychological services or children and adolescent mental health services”.

“Last but not least”, Matthew sees education as central in the success of the IoPPN. “We have Early Career Researchers and a Research Festival”, he says, referring to the established tradition of an annual event celebrating research success across the diverse workforce of the Institute, “but where are the Early Career Educators and the Education Festival?”. Teaching should receive the recognition and prestige it deserves.

Professors Matthew Hotopf and Carmine Pariante

We are approaching the end of the interview. I have one more question.

“What is your worst fear?”

He smiles.

“The IoPPN is such a great place, and it is daunting to think that things may fluctuate in the wrong way just by chance”. (He uses the expression ‘regression to the mean’, which is used to explain how things naturally move between peaks and troughs to reach a medium).

“But”, he immediately adds, “I want to lead it exactly because it is such a great place, at a time in my life where I feel ready for this challenge”.


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