The Charles Dickens Bicentenary
Born 200 years ago today, in Portsmouth, what difference did Dickens make, in the nearly-180 years since he started writing fiction and journalism?
Scrooge, Oliver Twist and Fagin are so familiar to us, that it’s perhaps easier to imagine some other writer(s) coming along and filling Dickens’s place on the broad-brush social reform issues, if he had been prematurely taken away by cholera or some other early nineteenth century affliction.
But there are so many other eccentric, strange, mentally unwell and physically disabled characters, who were also very well-known to millions of Dickens’s readers, perhaps even more so after his death, and well into the twentieth century. No other writer of fiction came close to creating awareness of these kinds of human diversity.
Just one example: probably the most severely, clinically, depressed character in Dickens is Bleak House’s Mr Jellyby. He sits with his head “against the wall” and almost never speaks. He’s a failure, and becomes bankrupt.
Illness and death occurs in most Victorian novels, and it is tempting to draw conclusions about the conscious and unconscious motives of the author from who suffers what. I’m uneasy about Dickens’s portrayal of the alcoholic Sydney Carton’s suicidal behaviour in A Tale of Two Cities (1). Dickens himself, in A Christmas Carol, draws attention to the fact that the crippled Tiny Tim “did NOT die”.
And the overwhelming majority of his eccentric and unwell characters do live on, sometimes bizarrely, but never in my view wholly implausibly. Mr Jellyby finds a friend, who talks about himself all the time. Most people would find this friend unbearable, but for some reason Mr Jellyby doesn’t: he listens, and he cheers up. Probably not a complete recovery, but enough to enjoy life again.
(1) http://drnmblog.wordpress.com/2011/09/02/a-far-far-better-ending-for-a-tale-of-two-cities/
Cosmetic surgery: an anti-capitalist issue, a feminist issue, or what?
The current concerns about easily-rupturing and possibly toxic PIP breast implants do not seem to be leading to much debate on: (1) Should psychotherapy for body image problems be made more available? (2) Should cosmetic surgery, in general, be more restricted?
In 2007, the BBC3 series Say No to the Knife did attempt to address this issue. It is no longer available on the BBC’s iPlayer, so I can’t check my own recollection that it was fairly superficial, offering not much more than styling and clothing tips Trinny and Susannah-style. No disrespect intended to those particular small screen goddesses, who probably never intended their message to be a universal panacea.
There were only seven episodes of Say No to the Knife, and we may never know why. Perhaps a further series would have risked drawing attention to poor NHS mental health services, which is likely to be a factor for some people seeking surgery in the UK.
Susie Orbach, well-known for her 1978 Fat is a Feminist Issue, addressed breast implants, liposuction and similar procedures in her 2009 book Bodies. Usual suspects appear: mistaken female bodily ideals, the market-driven, consumerist Western society and its commodification of emotion. Well, I respect the choice of anyone to opt out, as much as they can, from all of those things. But I know lots of people living ordinary Western lives, who wouldn’t think of having cosmetic surgery, so I somehow think there must be other causes as well.
Asylum History 1, Recent History 0
Last month’s radio programme about lobotomy (1) is interesting because it slightly departs from the usual historical scripts, which are: evil psychiatrists used lobotomy as a destructive form of social control, or well-meaning but weak ones rubber-stamped the decisions of others, such as Nurse Ratched in One Flew Over the Cuckoo’s Nest.
It emphasises that the inventor, and two of the main promoters of lobotomy were in fact not psychiatrists. Politician and neurologist Egas Moniz started the ball rolling. Then, American neurologist Walter Freeman, and the British surgeon Sir Wylie McKissock, both continued to do thousands of operations despite evidence for uncertain therapeutic results.
Historical radio and TV programmes about the bad aspects of the old asylum system (which I don’t advocate returning to, but will say it was always underfunded) are often a means, I think, of deflecting attention from current NHS mental health failings. Other occasional broadcasts about the mental health systems of second- or third-world countries generally have the same function.
At least this one is a little different. However, it seems to me that there is a clear parallel between lobotomy and another kind of invasive operation for a serious behavioural (and often psychiatric) disorder today.
Although obesity surgeons are not household names (yet), there has never been a proper trial of gastric banding or the more serious procedure of partial gastric reduction, despite thousands of operations being done annually (2). The rush to surgery is delaying the development of new non-surgical treatments, and the application of at least one recently developed and partially tested treatment (for obesity-linked ADD / ADHD).
The programme-maker did not draw attention to this obvious parallel. Was he or his boss warned off by England’s Department of Health, which for much of the last decade had surgeons both as chief medical officer and as a health minister? Or was it (perhaps more likely) BBC self-censorship?
BBC journalists don’t themselves seem to believe, any more, that the “licence fee” protects their independence because it is supposedly “not a tax”. But they continue to resist the suggestion that their work should be subject to the Freedom of Information Act.
So ordinary patients who have experienced poor results, infections or other complications from bariatric surgery, may never be able to discover the extent of any such BBC collusion. The same goes for relatives who, following one of the thankfully few deaths directly caused by bariatric surgery, may take a retrospective interest in how this surgical descendant of lobotomy was promoted.
(1) http://www.bbc.co.uk/iplayer/episode/b016wx0w/The_Lobotomists/
(2) See my previous pieces on obesity: http://drnmblog.wordpress.com/category/obesity/
Drafted 2nd December; final version 8th December
ADD / ADHD and cannabis
Some people with ADD / ADHD use cannabis regularly, and I have had patients who moved on to prescribed ADD / ADHD medication, finding it both more helpful and lower in unwanted effects than cannabis.
As the diagnosis of ADD / ADHD grows in the UK, I suspect this will become more of a factor in the debate about whether cannabis should be criminalised to a lesser extent, or even decriminalised altogether.
I don’t have a formal professional view either way on that issue, especially as I’m not a specialist in “Substance Misuse”. But I would say that the arguments of the leading UK advocate for reducing criminal sanctions on cannabis, Professor David Nutt, seem far from clear-cut.
On his Blog (http://profdavidnutt.wordpress.com), Professor Nutt suggests that the risk of increasing schizophrenia in young people, which could result from decriminalisation, is not of great concern. On his own figures, for every extra million young men using cannabis, about 200 might develop schizophrenia who wouldn’t otherwise do so.
His argument seems to be that alcohol use would probably decline (because of switching from alcohol to cannabis), and the benefits from that would outweigh any cannabis-related harms.
He might be right, but I think at least two aspects of the debate have not received as much attention as they should.
First, it does seem very difficult to compare the harm of an often devastating psychotic disorder, with alcohol-related problems. Is it really as simple as saying that improving and extending life for tens of thousands of people, by reducing their alcohol intake, logically outweighs the risk of ”only” a few hundred people developing schizophrenia?
Secondly, I think the wider debate about “harm reduction”, and Professor Nutt’s related view that UK medical doctors should be able to prescribe cannabis (as they can elsewhere in Europe) would benefit from an acknowledgement that medical prescribing of some mind-altering substances has been, and remains, too lax.
When UK general practitioners, from the mid-1990′s, were widely encouraged to prescribe antidepressants after little more than a ten-minute consultation, this state-approved practice was never properly tested. The concerns about misuse and harms of Seroxat and other antidepressants followed.
Of course, as a specialist prescriber of mind-altering substances myself (hopefully, always as a reasonable therapy), I have a direct vested interest. But it does seem to me that promoters of medication, whether natural or synthetic, branded or generic, freely available or eye-wateringly expensive, would generally be more credible if they listened to my (free) advice.
Back to School
I went back to school myself yesterday, starting an MA in Victorian Studies at Birkbeck College, part of the University of London. This follows on from my last blog piece, because quite a few other ”Dickens obsessives” have done this course, and some of those teaching on it seem to acknowledge similar afflictions…
Many of my patients, especially those with ADD / ADHD, have thought about picking up where things went wrong in their own education. This may mean going back to do a similar course to the one which they dropped out of; or deciding that was the wrong choice anyway, and studying something quite different.
Although I have dropped out of a couple of courses myself in the past, I’m pretty sure it won’t happen this time. To some extent this is because I believe that I understand my own mild ADD tendencies better (1): my nineteenth-century interest is not an “obsession” in the clinical sense of being related to obsessive-compulsive disorder (OCD), but more of a recurrent ADD / ADHD ”hyperfocus”.
(1) See http://drnmblog.wordpress.com/2010/04/16/how-mentally-healthy-should-mental-health-professionals-be/
A far far better ending for “A Tale of Two Cities”?
I am obsessed by the novels of Charles Dickens, although this is a mild-to-moderate rather than a severe obsession, because I have not read any of them more than two or three times. Nor have I properly read more than a small fraction of the dozens of biographies and book-length critical studies published since Dickens’ death in 1870.
The recent riots in London, after the riots in Paris of a few years ago, got me thinking about Dickens’ descriptions of mob violence and mob rule in A Tale of Two Cities. The capture and execution of French aristocrats by the revolutionary Government provides an opportunity for the alcoholic and morally ambiguous lawyer, Sydney Carton, to do something unselfish for once.
I usually disagree with the view that Dickens is an overly sentimental writer of fiction, in the sense of false or distorted emotions being used for propaganda (for example, to promote a non-progressive view of the role of women). But this charge may be correct when it comes to Carton’s fate in the novel: in helping an aristocrat (who he happens to physically resemble) to escape, he deliberately gets himself imprisoned.
On his way to the guillotine, he speaks one of Dickens’ best-known lines: “It is a far far better thing that I do, than I have ever done”.
But is it? Carton’s supposedly noble action can be seen as promoting the idea that alcoholics are inferior beings who cannot change their personalities or behaviour, and do the rest of us a favour when they choose to die. Such was the hybrid of mistaken science and morality which developed in the last decades of the nineteenth century, and went even further in twentieth-century Nazi Germany.
The novel could easily have been written differently, with Carton revealing his true non-aristocratic status, backed up with a hidden physical attribute or some other identifier. Dickens had been the leading English novelist for decades, and had the skill to produce any number of original, plausible and memorable plot-lines based on Carton’s keeping, or at least trying to keep, his head.
This post was drafted by 2nd September, and published at DrNMblog.wordpress.com on 6th October
Under-emphasising the negative, again*
When the comedian Rory Bremner talked about his possible ADHD in May this year, it attracted a lot of media attention. But I was uneasy, feeling that the half-hour BBC radio programme appeared to risk trivialising his problems: nearly forgetting his lines on stage, losing things, being a bit disorganised. Hardly a definite case for treatment in someone who is, after all, a very succesful entertainer.
There was no mention of his own past history of anxiety and depression (2), conditions which are well-documented as being linked to ADD / ADHD. In my experience, ADD / ADHD is often a direct cause of anxiety and depression, not least because disorganisation and impulsivity lead to negative life events.
A couple of weeks ago the mental health charity SANE launched its “Black Dog” campaign, to re-raise awareness of depression (3). Despite Bremner being a prominent part of SANE’s campaign, it attracted nowhere near the same media coverage nationally.
I have no idea whether Rory Bremner’s past problems with anxiety and depression had any link with ADHD. But it does seem worrying that the May BBC radio programme did not explore the possible harmful consequences of undertreatment.
*See The Gift of ADHD?, below at: http://drnmblog.wordpress.com/2011/03/20/the-gift-of-adhd/
(1) http://www.bbc.co.uk/programmes/b011c0nn
(2) http://scotlandonsunday.scotsman.com/features/Rory-Bremner-interview-When-satire.5362191.jp
(3) http://www.guardian.co.uk/society/2011/jul/24/mental-health-black-dog-sculpture-campaign
Drafted by 5th August 2011, published at DrNMblog.wordpress.com on 6th October 2011
NICE guidelines: now they really are “just guidelines”
Until recently, most of my ADD / ADHD patients who did well on a trial of medication, were then able to obtain further NHS prescriptions from their GP.
My website highlights the 2009 NICE (National Institute for Health and Clinical Excellence) ADHD guidelines, because the guidelines are strongly in favour of diagnosis and treatment choice. When NICE was set up as a state-funded body in 1999 there was a commitment, which was made legally stronger in 2005, that the NHS would be provided with enough money to follow its recommendations.
Last year, the new Government’s Conservative Health Secretary, Andrew Lansley, abolished this legal commitment for GP’s to follow NICE guidelines.
Under financial pressure to reduce prescribing, GP’s look at adult ADD / ADHD, and see that no medication is licensed. Unless the GP has direct experience of treatment benefits, this relatively new diagnosis inevitably becomes a target for cost reduction.
The fact is, medication licensing is really about the claims that a pharmaceutical company can make for its product, rather than what clinicians can prescribe (and the NICE guidelines are more relevant to that). But such distinctions make little difference to GP’s, especially when fully licensed ADD / ADHD treatment in children and teenagers is still often opposed by prominent NHS academic psychiatrists.
My own experience is that ADD / ADHD medication, together with counselling and psychotherapy which takes diagnosis properly into account, can improve interpersonal and work functioning enormously. If patients do have to fund diagnosis and treatment themselves, it is likely to be well worth it, as long as they have moderate or severe ADD / ADHD. Treatment could even be cost-effective if the ADD / ADHD is milder: what price can you put on better relationships?
Drafted by 2nd July 2011, published at DrNMblog.wordpress.com on 6th October 2011
Should weight-loss surgery be rolled out widely on the NHS, when effectiveness has been shown for less than 1 in 50?
So many adults become chronically obese, and we are now so aware of childhood obesity, that an overweight person’s history of normal weight and eating, or bulimia, or even anorexia nervosa, can be overlooked. The low cost of calories, and other “obesogenic” factors such as increased screen time and reduced exercise can also lead to therapeutic pessimism, despite nearly one-third of adults having normal weight (1).
Given the apparent failure of appetite suppressants and psychotherapy to treat obesity, a more hands-on surgical approach has gained a lot of ground (2). Reviews of bariatric surgery seem to make a well-founded case for wider use of this treatment: randomised controlled trials (RCT’s), the hallmark of proper testing, have been abundant.
But, despite well-documented cases of obesity remitting and relapsing in response to a range of interventions, sometimes with long intervals (Oprah Winfey, perhaps most famously), there has never been a single- or double-blind trial of bariatric surgery, compared with a true “placebo” which would be “sham” surgery: entering the abdomen under anaesthetic but making no further intervention.
Such genuine placebo-controlled surgical trials have been performed in many disorders where psychological factors have been felt to be significant (3). The RCT’s which give an impression of “a good evidence base” for bariatric surgery are mostly of one form of surgery compared with another, or surgery compared with a perhaps dubious non-medication-based intervention.
And anyway, according to a 2009 UK government-funded and -published meta-analysis, research into bariatric surgery has established its effectiveness for only 1 in 50 people who are at risk of health problems from being overweight: “The evidence base for the clinical effectiveness of bariatric surgery for adults with Class I [BMI30-35] or class II [BMI35-40] obesity is very limited.” (4).
Although I support bariatric surgery, and tried unsuccessfully to have it considered for one of my very obese learning disabled patients, four years ago, it appears to be at risk of being over-promoted for less severe disorders. Just like many other treatments in the history of medicine.
It is possible, in my view, that psychotherapists of all kinds (CBT, psychodynamic, 12-step-orientated) have simply not tried hard enough for a group of patients that attracts negative and even punitive public attention (5). Before proper randomised controlled trials of bariatric surgery, it must make sense to keep looking for non-surgical treatments.
(1) 31.7% of English adults were “normal weight” in 2006. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgry for obesity: a systematic review and economic evaluation. Picot et al. Health Technol Assess 2009: 1-190, 215-357. [p3]. Available at http://www.hta.ac.uk/execsumm/summ1341.htm
(2) See my Blog piece “No” to the knife, “Yes” to Ritalin? 6th August 2010: http://drnmblog.wordpress.com/2010/08/06/%e2%80%9cno%e2%80%9d-to-the-knife-%e2%80%9cyes%e2%80%9d-to-ritalin/
(3) Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial. Abbott et al. Fertil Steril 2004: p878. http://www.ncbi.nlm.nih.gov/pubmed/15482763
(4) See (1): p157. 67.1% of English adults were either “overweight” or “obese” in 2006, of which 2.2% (1.5% of the whole population) had aBMIabove 40. See (1) p3
(5) http://www.dailymail.co.uk/news/article-1298394/Call-overweight-people-fat-instead-obese-says-health-minister.html
[includes comments from the then Royal College of General Practitioners chairman, Professor Steve Field]
Drafted by 10th June 2011; published at DrNMblog.wordpress.com on 7th October 2011
Maybe there IS a market for nuanced writing about mental health
Manufacturing Depression: the Secret History of a Modern Disease had been in my “to read” pile for a few months. I was in no hurry, assuming from the title that it was a re-hash of the “marketing by pharmaceutical vested interests” arguments of David Healy and others.
But after a patient recommended it, I had a look. The author Gary Greenberg is a psychotherapist, who has episodes of severe depression himself, possibly related to his “inexhaustible penchant for dithering”. He tells a very interesting story, especially about taking part in a double-blind, placebo-controlled trial of an antidepressant. I will not reveal the ending, but do think the book should come with a bit of a health warning because the lack of black-and-white conclusions may make some readers irritated or even depressed.
Another thing I liked about Manufacturing Depression was Greenberg’s willingness to say that pharmaceutical companies and medication prescribers are not the only vested interests in the mental health “industry”. For example: “…even though I am a psychotherapist, I don’t think the only alternative is what I sell in my office one hour at a time”. And, as what Greenberg calls a “depression doctor” myself, I agree with his view that “Depression is surely an affliction, one that at least in some cases may well have a specific, although still undiscovered, brain pathology – a disease in the usual sense of that word.”.
Quotations from Manufacturing Depression: the Secret History of a Modern Disease (2010, Bloomsbury hardback): pages 365-6, 297-8, 13
