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.
(2) See my previous pieces on obesity: https://drnmblog.wordpress.com/category/obesity/
Drafted 2nd December; final version 8th December
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.
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
Psychotherapy has been in the news recently, with the announcement that a further 400 million pounds will be made available through the so-called IAPT (Improving Access to Psychological Therapies) programme.
But although the government has stated the money is “new”, a senior IAPT adviser has been sacked, apparently for saying that is “a lie” (1). Certainly, savings are to be made elsewhere in the NHS mental health budget.
Somewhat lost in the discussion has been a shift away from the idea that IAPT is just about CBT (cognitive-behavioural therapy). In theory, IAPT has for years accepted that Interpersonal Therapy (IPT), and couples therapy, are just as valid for problems such as depression and anxiety.
At a seminar on IAPT eighteen months ago, a regional manager told me that it was proving difficult to recruit therapists for these approaches. That seems to be changing, and the British Psychoanalytic Council’s recent comments appear to be positive about psychodynamic therapies gaining significant funding alongside CBT (2).
In my view that is a good thing. Since the early 1990’s, I have been sceptical of the established NHS wisdom that psychodynamic treatments had been demonstrated to be generally inferior.
Does NHS “General” Practice support adequate assessment and treatment of mental and behavioural problems?
I have never met anyone working within the NHS who believed that more than a minority of UK general practitioners have a great interest in mental health issues. As a trained and qualified GP myself, I have much affection and regard for my non-specialist colleagues. But unfortunately because their views are often so much in line with mainstream opinion (hence those persistently high “public trust” ratings?), that can sometimes include a dismissive approach to human frailties.
A confidential survey of GP’s, published last week by the leading mental health charity Rethink, appears to have confirmed this (1). The new government wants general practitioners to decide on funding priorities for specialist services, and over three quarters are happy to do this for physical conditions, but less than a third want to be involved in mental health.
This is despite GP’s having a very negative view of existing specialist mental health services. When asked “To what extent would you feel confident in the quality of care one of your relatives would receive if they were referred to the appropriate NHS services” only 50% said they would feel confident for depression (as against 92 – 95% for physical conditions). For obsessive-compulsive disorder (OCD) the figure was 32% and for post-traumatic stress disorder it was a miserable 22%.
I don’t blame GP’s for not wanting to take on the re-funding of NHS mental health services. To do so in the current financial climate would probably mean advocating cuts to clinical services for physical conditions, which would be deeply unpopular. Privately, many of them support their better-off patients seeing independent non-NHS specialists, which in itself at least expresses a degree of discontent with the current situation.
But keeping this issue at arms length might lead patient groups to further question the ordinary good sense, even the fairness, of general practitioners. Rethink continues to highlight a previous survey as showing that “23% of people with mental illness report experiencing discriminatory treatment from GPs” (2). It could be a good time for the minority of GP’s with a special interest in mental health issues to become a majority.
(2)http://www.mentalhealthshop.org/products/rethink_publications/stigma_shout_survey.html# Quotation from (1). In this 2008 survey psychiatrists did not do much better, which I would interpret as further evidence for the inadequacy of NHS services.
Nick Clegg has apologised for using the word “nutters” to describe the conservatives’ East European allies in the 22nd April leaders’ debate: ”I am acutely aware that the stigma of mental health causes great distress to many people and my use of language that could be considered derogatory was entirely unintentional.”
This seems a bit strange, because much of the language used in these events is pre-planned. Also, only four weeks before the debate, the mental health charity Rethink obtained an agreement from Mr Clegg, together with the other leaders, not to use “mental health slurs” during the election campaign (1).
Less than a year ago the former Labour minister, Denis MacShane, made exactly the same point about the Conservative allies, but using the more derogatory “loonies and wierdos”. This was in the House of Commons, where there appears to be a guideline against “insulting, coarse, or abusive language”, but perhaps significant is the qualification “particularly as applied to other Members [of Parliament]” (2).
Back in 2006 David Cameron talked about UKIP as being “fruitcakes, loonies and closet racists, mostly”. UKIP’s Nigel Farage demanded an apology over the racism allegation, but interestingly he said that “fruitcakes and loonies” was fine, because “we have a sense of humour”.
So Nick Clegg may have thought that his own language was an improvement on “loonies”.
(2) Some Traditions and Customs of the House: House of Commons Information Office. January 2009