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Mental health lessons from the 1890’s

 

“Health is the primary duty of life”, according to Algy’s domineering aunt in The Importance of Being Earnest; and such is the unhealthy effect of the aunt and other relatives on his mood, that in order to see them no more than once a week, Algy invents a friend who is in such poor health himself that he requires frequent visits.

Earnest was written and first performed in 1894-5. So, appropriate to the last decade of the nineteenth century, during which logical paradoxes were explored by scholars in mathematics and psychology, Algy’s approach to life is both serious (good mental health is necessary) and non-serious (he rather enjoys the deceptions involved) at the same time.

The play involves the eating of cucumber sandwiches, bread and butter, and muffins. Algy eats so much, in fact, that one wonders how well his ‘imaginary invalid’ strategy really works. Were it not for the romantic ending where he gets engaged to be married and then presumably is happy thereafter, concern about Algy becoming obese due to what we might now call ‘comfort eating’ would be justified.

His friend Jack doesn’t overindulge, perhaps because he’s too busy with his own deception of being the carefree Ernest at weekends, while working hard and being a serious magistrate in the week. Unlike Algy, Jack is lucky enough not to have any domineering relatives to hinder his own dutiful pursuit of health. And he’s happy in the end, 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: https://drnmblog.wordpress.com/category/obesity/

Drafted 2nd December; final version 8th December

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: https://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

“No” to the knife, “Yes” to Ritalin?

 

Obesity surgery has grown in the UK, as it has worldwide. But unless it can be shown that it saves money which could be transferred from elsewhere (diabetes care, for example), less than 5% of eligible patients might receive NHS operations in the next few years.

With couple of internet searches, today I found plenty of advertisements for self-funded surgery, including centres in India and Central America. The demand is clearly huge.

On Wednesday this week Joan Bakewell’s Radio 4 medical ethics programme addressed the previously little-publicised problems with obesity surgery (1). In particular, careful follow-up is needed as banding operations may need to be repeated or redone. For patients who go abroad, continuity of care may be less than optimal if they need to turn to the UK NHS later.

A study published last year (in a Nature group journal) suggested ADD / ADHD may be a significant, and treatable, cause of obesity (2). One third (78/242) of patients in an independent Toronto weight loss clinic were found to have ADD / ADHD, and with treatment they lost 10% of body weight. That is as good as obesity surgery.

More research is of course needed, but I find the idea that some people with ADD / ADHD overeat makes clinical sense. Many of my patients, successfully treated, get on with their lives more effectively, and find they “snack” less. Because the underlying dissatisfaction and discomfort is reduced, so is the need for “comfort eating”.

In my view this treatment effect is separate from the “appetite suppressant” effect, which is often transient anyway, of medications such as methylphenidate and amfetamine.

Interestingly, another large study on obesity, recently published in The Lancet (3), showed good results for a medication combination which included bupropion (available in the UK only as the smoking cessation drug Zyban, but more widely used in the US for years). Bupropion is thought by many developmental disorder specialists to be effective in ADD / ADHD.

I am sure we will see many overweight and obese people in the UK considering whether they might have ADD / ADHD. Surely having assessment and possibly treatment in London is a reasonable thing to try, before flying off for surgery in Cancun or Delhi (4) ?

 

 

(1) http://www.bbc.co.uk/programmes/b00t6zqs#synopsis

(2) http://www.nature.com/ijo/journal/v33/n3/abs/ijo20095a.html

(3) http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2960888-4/abstract#

(4) No disrespect to Mexican or Indian surgeons intended at all. The point is about continuity of care. It also seems possible to me that people with severe ADD / ADHD might have a poor outcome with apparently successful surgery: I understand this is not uncommon.

How mentally healthy should mental health professionals be?

People drawn to the “helping professions” are often seen as having problems of their own. Whether this is really true, in a clinical sense, for just a few individuals or more widely is difficult to know. When I first had experience of psychiatry as a student in the mid-1980’s this was a fairly common subject of discussion.

It seems to have gone more underground now, presumably as a result of the  widening of the “worried well” concept in official NHS thinking. Psychiatrists, psychologists, nurses and others may be less willing to risk being seen as self-obsessed whingers, when they work in services focused on “severe and enduring illness”.

Will ADD / ADHD prove to be any easier for us to be more open about? With 2 million adults in the UK having the severe or moderate condition, and another 8 million with less clearly defined milder problems, the numbers are similar to common disorders such as depression and obesity.

For someone like myself, now working independently, it is relatively easy to acknowledge mild ADD, which has probably been a causative factor for depression in the past. I have not had major symptoms for nearly two decades, and believe that I have developed mental resilience. However, given that most of my current practice comes from the growth in adult ADD / ADHD, a semi-experimental trial of a non-stimulant remains a possibility.

But for those still working in the NHS, a more cautious approach might be wise, especially at a time when spending cuts and political rhetoric create uncertainty. Managers keen to prove themselves as more than pen-pushing bureaucrats can respond to “stop moaning” calls from the top (1) in unpredictable ways.

 

 

(1) http://www.bmj.com/content/337/bmj.a932.extract

Published at www.DrNM.org.uk on 16th April 2010, and transferred to DrNMblog.wordpress.com on 7th October 2011

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