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lsjm 30 november 2009 volume 01
EDITORIAL
Alzheimer’s: The Future According to the 2009 World Alzheimer’s report (released 21st September)1, the number of Alzheimer’s sufferers will double every 20 years, reaching 115 million by 2050. So what are the options for the future cure, treatment, and prevention of this global health burden?
For the full references see thelsjm.co.uk.
Current opinion is that amyloid beta deposition, neurofibrillary tangles, and tau protein aggregates play a key role in the pathology of Alzheimer’s disease8. These aggregates were present in large numbers in Alzheimer’s patients, and it was assumed they were a direct cause of pathology. However, evidence is now emerging that these may serve a protective role, turning long held beliefs on their head9. Early diagnosis of Alzheimer’s preserves a greater level of patient function for longer periods of time, and reduces healthcare costs2. One approach to early diagnosis is non-invasive imaging, which may display structural changes before any symptoms begin to appear3. Biomarkers have also proved promising and may allow more accurate diagnosis of the early stages of disease4. However, the possibility of making such expensive and time consuming techniques available to the entire population is questionable, and the accuracy of the such methods is in doubt4. On a more positive note, we are now coming to the end of a five year Alzheimer’s Disease and Neuroimaging Initiative (ADNI) project, which examined patient’s using MRI, PET, and CSF10. Results are still being assessed, and should be released in the next few months but Michael Weiner, a neurologist working for the ADNI has described the results as “a phenomenal success.” Prevention is better than cure and there has been heavy focus on a potential Alzheimer’s vaccine5. Accumulation of a peptide known as ‘amyloid beta’ is thought to be responsible for the symptoms of Alzheimer’s disease, so this molecule has been focused on as a target11. Work done by Schenk et al.12 in 1999 showed promising results in mice, but when an amyloid beta vaccine was then tried in humans it was halted as some patients developed meningoencephalitic symptoms13. Two new approaches to a vaccine are in early development, firstly using amyloid beta monoclonal antibodies, and secondly using a DNA vaccination. Both of these approaches are in their infancy, with monoclonal antibodies entering clinical trials. If we are getting better at diagnosis, and there is not yet an efficient prevention, what about a cure? Currently there is no treatment for Alzheimer’s, however, there are some drugs used to limit its progression7, such as Aricept and Exelon. Development of pharmaceutical solutions to Alzheimer’s has been held up by the difficulty of crossing the blood brain barrier15, and there are no new ‘wonder drugs’ on the horizon. Heads are quite literally turning to a different approach to treatment, made famous by Terry Pratchett, who recently made a documentary about his own struggle with Alzheimer’s Disease6. His series featured what appeared to be a groundbreaking treatment that halted disease progression. This space age contraption was a helmet that uses infrared red light targeted at the brain, with an aim to increase cell growth. Although initial use of this helmet appears to have been positive, it is currently undergoing clinical trials, with eagerly anticipated results. So with a potential worldwide explosion in Alzheimer’s, the race to find a successful solution is on. The most desirable answer would surely be a cheap and safe vaccine that could be distributed globally, but how long will we have to wait?
Illustration: Ella Beese
Alexander Ross Section Editor Psychiatry
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NEWS
Innovation and News In Psychiatry Nicola Hood
Innovations take many different forms and should be judged on the value of their contribution to society, not their flash, razzmatazz or how they capture the medias or the public’s imagination. Unlike so much of our anatomy, the brain retains so many of its mysteries. This unfathomably complex organ, resulting from constant unrelenting interactions between genetics and our environments, en-
Source: Wellcome Images
It’s better to give… After surveying a range of patients with mental health illness, the Royal College of Psychiatrists were disappointed to discover over half did not receive any gifts or cards when they had been unwell. This notably differed from only a third who had not received similar offerings during a period of physical illness. Television presenter Trisha Goddard, who has been treated for both depression and breast cancer, said that this did not surprise her. Indeed the experience reported by service users resonated very much with that of her own. The college identified that one problem may have been that many of the existing cards available were not suitable, and have thus launched their own range as 4 out of 5 patients agreed a card would improve their recovery. The cards come in two designs and can be purchased here: http://tinyurl.com/yhluw92 Innovation and News In Psychiatry Chicken Tikka Masala for the brain? If Chicken Tikka Masala is your takeaway treat of choice, then your attention may be enticed by the theory Professor Doraiswarny presented at the annual meeting of the Royal College of Psychiatrists. It was proposed that curcumin, a component of the spice tumeric may significantly reduce the risk of dementia if ingested regularly. Although research is not yet completed, it appears curcumin may bind to amyloid plaques (thought to play a key role in dementia progression) and prevent their advancement. Early animal experiments have shown curcumin can dissolve existing plaques. Unfortunately for curry-lovers, dissenters maintain that levels in curry are well below those required to be statistically significant. Until the study is formally peer-reviewed, it seems unlikely curries will feature under the department of heath’s nutrition guidelines. Paid to be treated A novel new approach to improve patient attendance for treatment is being pioneered in London, where patients with bipolar disorder or schizophrenia are re-numerated £15 per anti-psychotic injection. The scheme, was introduced as yet another step in tackling the long standing problem of poor adherence, building on initial findings regarding oral medication that showed missing even one treatment in ten is correlated with an increase in hospital readmissions. Whilst a change in method of administration increased adherence, the often unfavourable side effects of antipsychotics meant overall levels remained unsatisfactory. Mind has criticized the trial; contending patients should be motivated to take their medication for the health benefits alone. The team at Queen Mary’s disagree, and insist that the ultimate benefits to the patient and their mental health justify their paternalistic approach.
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sures that developments in psychiatry are slow and faltering. It does not mean they are worthy of any less attention. With mental health escaping a finite definition (and instead remaining a continuum upon which we must all find our place) it is increasingly apparent that every new discovery, however small, is of relevance to all of us.
A Cocaine Vaccine Promising results have been observed at the Yale School of Medicine in a study targeted to reduce cocaine dependency. A cocaine vaccine was administered in a placebo controlled trial resulting in over half of trial participants having significantly reduced cocaine usage at six months (monitored by thrice weekly urine testing). The pharmacological mechanism involves mobilizing an antibody response and preventing cocaine crossing the blood brain barrier so that addicts do not experience a ‘high’ after using. Enticingly, scientists are already contemplating a similar vaccine design with other drugs of dependency. However, the charity Action on Addiction has urged caution, emphasizing that addiction has many psychosocial aspects which cannot be ignored if doctors are serious about achieving long-term large-scale impacts. Sweet Agression Cardiff School of Medicine recently published a study demonstrating a relationship between the amount of confectionery consumed in childhood and the aggressive tendencies in later life. Children who ate sweets or chocolate daily had a significantly higher rate of crime by their thirties than those who did not. However, it should be carefully questioned if a causal relationship exists, compared to a more plausible correlation between parenting styles regarding both diet and discipline.
lsjm 30 november 2009 volume 01
REPORT
Source: Wellcome Images
Changes to The Mental Health Act 1983 Angharad Woolley
Year 5 Medicine, St George’s University of London akwoolley@googlemail.com
Mental health disorders have the potential to affect anyone. The law is in place to define mental disorder, what treatment is given, and what rights are given to a person requiring treatment, given that by its very nature, such a disorder may impair the ability of an individual to make choices for themselves. In the context of our evolving healthcare system, particularly in such evocative areas as mental health, it is important that law keeps up to date with practice, and vice versa. Hence the recent modernisation of the 1983 Mental Health Act (MHA). The changes were a result of nine years of lobbying by the Mental Health Alliance. Changes have been made throughout the act and affect issues as diverse as what qualifies as a mental disorder and who may be given treatment, rules governing the power a parent has in decisions over their children’s mental health, the use of electro convulsive thereapy and increased rights of those in same sex civil partnerships in the eyes of the MHA. A new code of practice for the Mental Health Act came into force in November 2008. Although not legally obliged to abide by it, clinicians not following the code of practice should record their reasoning for doing so. Principles of the code of practice are: Purpose to treatment (improving disorder rather than just sedating) Minimising restriction of patient’s freedom Respect for individual cultural needs and values Maximal participation of patient, family and carers Efficient and effective use of resources The changes have been welcomed by those who lobbied for them although there are still more issues which continue to remain controversial. For example whether or not detention could be restricted to those who have lost mental capacity, as is already the case in Scotland.
Increased rights for young people From January 2008, young people aged 16 or 17 are able to consent to or refuse voluntary admission to hospital for treatment, without a parent being able to override their decision. Wider definition of mental disorder From November 2008, the previous categorisation of mental disorders (4 categories under the MHA 1983) will be dropped to incorporate the wider definition which will mean ‘any disorder or disability of the mind’. Although unlikely to increase the number of people able to be detained under the MHA, the change is hoped to open up treatment for those previously seen as untreatable, such as those with personality disorder.
More information on these and other changes recently made to the Mental Health Act is available on the Rethink website: http://www.rethink. org Rethink is a member of the Mental Health Alliance whose years of lobbying were crucial in bringing about these changes.
Further restriction of controversial treatments From November 2008, where a patient retains capacity to make decisions about their treatment, they may not be given ElectroConvulsive Therapy (ECT) without their consent being recorded on a certificate. Patients may make an advanced decision to refuse ECT at a time in the future where they may have lost capacity and this will only be overridden in the case of immediately necessary life-saving treatment. Supervised community treatment From November 2008 this will replace supervised discharge in the community, providing a framework to treat patients in the community. This is most likely to apply to patients who have a history of stopping medication after discharge. Facilitating patients to be aware of, and exercise their rights From April 2009, qualifying patients (including but not limited to anyone detained under the MHA for more than 72 hours) will be appointed an independent mental health advocate (IMHA) who will explain to them their rights and how to exercise them.
So what has changed? The most important changes to the act are summarised, in chronological order: Equality of Heterosexual and homosexual couples From December 2007, civil partners in same sex couples who have registered their partnership will be given equal status as a husband or wife and can therefore act as a nearest relative – a family member that is given important rights in the case of their relative being ‘sectioned’, which they may use in what they believe to be in the patient’s ‘best interests’, if they disagree with healthcare professionals.
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REPORT
Mental health care in prisons in England and Wales: its state and changes over the last decade Ilia Kantsedikas
Year 3 Medicine, Barts and the London I.kantsedikas@gmail.com doi:10.4201/lsjm.psy.005 For the full references see thelsjm.co.uk.
Mental health is a popular topic with a great deal of literature devoted to it and several campaigns dedicated to removing its associated stigma. However, mental healthcare in prison has been largely overlooked. This piece reviews the current trends in the field with the help of relevant publications.
commitment to match the services offered by the NHS, equality still had not been achieved by 1999 prompting an attempt at a radical overhaul of the system with the responsibility for health care provision transferred from HM Prison Service to the Department of Health by 2006.5 While it is too early to comment on the results of this reform, Hayton and Boyington have been cautiously optimistic in their early review of the changes it brought about.4
Background A report by John Howard (the prison reformer) published in 1784 is fascinating proof of how old the problem is. A more up-todate information source is the full survey of the mental health of prisoners in England and Wales undertaken by the Office for National Statistics.2
Insofar as mental health is concerned, it has been an area lagging particularly far behind the other areas of the prison health care. While it is now widely acknowledged that not all prisoners with a
The survey unequivocally shows an increased prevalence of mental illness among prisoners (Figure 1). For example 7% of sentenced men, 10% of men on remand and 14% of all female prisoners showed evidence of psychosis in the year prior to being interviewed – a figure far outweighing the rate of 0.5% observed in the general population.3 In the light of this it is pertinent to explore how mental health care is currently delivered in prisons. The prisons in the UK have the oldest civilian medical service, established as a result of John Howard’s work. Presumably for this reason, prisons were left outside of the National Health Service (NHS) remit when it was established in 1948. However as time progressed it became more evident that the needs of the prisoners were not being met by the existing system, largely due to shortfalls in staffing, training and equipment.4 Despite the explicit
Figure 1: Comparative prevalence of probable psychotic disorder in the UK, % (based on 2,3)
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REPORT mental health problem require a bed at a NHS forensic psychiatric unit, some of the practices deemed to be necessary regardless of the setting only very recently started to appear in the prison service. Another issue is the presence of the seriously ill inmates who do require treatment in a NHS unit, but whose transfer cannot be arranged within reasonable time. As psychiatric morbidity is known to increase in absence of treatment6 such a situation leaves inmates with an increased risk of a major illness. The research so far has identified two major areas underpinning this weakness – material problems and a lack of policy on mental healthcare in prison.7,8 These are often interlinked, as policy affects staffing and material provisions and input from those working in the system is bound to affect policy. This essay will attempt to highlight the key issues in these areas and explore what has been done to tackle them. Discussion Material problems, such as staffing issues and availability of resources are often the first to be cited when healthcare in prison comes under scrutiny. Although prison healthcare centres are commonly referred to as hospitals, they are often more akin to sick bays with primary health cover than an NHS hospital. Some of them do not even have beds of their own, although every prison has access to hospital beds by transferring inmates to a different prison. Another issue stemming from financial limitations is the lack of meaningful activities to occupy the patients during the day. A policy is in place stating that patients whose clinical state permits it are to spend 12 hours a day unlocked and out of their rooms with at least 6 hours a day devoted to therapeutic activity, such as education and developing interpersonal skills, however while this is the case in the NHS setting, none of the prisons inspected by Reed and Lyne met the standard.8 The shift in responsibility for prison health care to the Department of Health has led to an improvement in the availability of resources and funding;4 but discrepancies still remain in regional funding that cannot be explained by differences in salaries and costs alone (fig. 2).9 Staffing issues stem from both funding difficulties and policy decisions. For example health care officers with limited nurse training making up a quarter of the nursing workforce and receive little training on policy or practice in caring for prisoners with mental illnesses, which is likely to be due to financial constraints.7,8 On the other hand, while staff availability (and thus finances) plays a role in reduced levels of night staffing at the health care centres, its interaction with the security requirements (meaning that the duty nurse often cannot carry keys to the prisoners’ rooms and will need keys and the necessary extra security staff brought over from the main prison) and the lack of standard for night staffing are primarily responsible for limitation of rapid access to the patient. The multidisciplinary team approach which is commonplace in the NHS was also sadly lacking at the time of inspection, which relates back to the insufficient amount of time the patients were allowed to remain unlocked and lack of meaningful therapeutic activity – the staff necessary to deliver it were simply not in place.8 Community care within prison Apart from the practical problems of delivering quality mental health care in prison described above, a number of issues surrounding precisely what mental health care in prison should entail and how it ought to be delivered exist. An area where some progress has been seen lately is that of how prisoners can access mental health care. Previously it was a widely held belief that nearly
lsjm 30 november 2009 volume 01
Figure 2: Prison health care spending per inmate by region9 all prisoners with mental illness must be placed at the prison health centre. This notion has since been abandoned as it was recognised that the majority of mentally ill prisoners would have been treated in the community if they were free, meaning that they can remain in their general location provided the standard of care delivered is equivalent to the NHS.9 The recent prison health care reforms have attempted to enable this by establishing mental health in-reach teams, whose function is broadly equivalent to that of community mental health nurses.4 Initially these teams were geared towards the severely ill patients who have to remain in prison (for example while they are waiting for a bed in a forensic mental health facility); however their remit has been rapidly expanding to include less ill prisoners. It appears that implementing the other models of care that are found in the community such as assertive outreach will also fall on the in-reach teams.9 While this is a commendable effort to close the gap between the services available in the NHS and in prison, this expansion of the in-reach teams remit also raises the question of whether they will receive the appropriate support to avoid being overstreched. In light of this it is interesting that at least one publication suggests transferring all prisoners requiring specialist mental health care to the NHS either under the provisions of the Mental Health Act 1983 (MHA 1983) or on temporary license, thus avoiding the duplication of resources.8 Consent in this population Another area policy change that has recently come under the spotlight is the enforcement of treatment orders in non-consenting patients. At the moment treatment without consent can only be provided in emergencies or where common law can be used to justify necessity, since no part of a prison can be considered a hospital under MHA 1983. Evidence suggests this has been taken very literally in many prisons, resulting in patients lacking capacity due to their illness refusing treatment that can relieve their suffering until a place at an NHS facility (where they can be treated without consent according to MHA 1983) can be found for them. As previously mentioned the wait for beds at these facilities is often long, meaning that patients may remain untreated for prolonged periods of time potentially leading to increased morbidity. Earthrowl et al10 have explored the issue and proposed a policy that can be used to provide more extensive treatment to patients in the
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REPORT situation described above. While enforcing treatment may appear to be in breach of a patient’s human rights, it can be argued that it is in fact a balance between a patient’s right to autonomy and one’s right to receive treatment to relieve them of their illness. Earthrowl argues that the latter outweighs the former, a view which appears to be shared by the others in the profession.11 It is noteworthy that the proposed policy is not intended to replace treatment in a setting more suitable for a severely ill person, but rather as an interim measure to resolve the ethical dilemma of leaving a patient to suffer due to legal ambiguity.
entirely to the NHS as advocated by Reed. The relative merits of the two models and reasons for choosing one over another warrant further exploration. Given the progress made so far, turning our attention away from the issue of mental health care in prison will condemn the inmates to unjustified suffering. It is therefore paramount that this area of mental health care continues to receive funding and that further research is carried out into both policy and practical aspects of care to provide the best possible service. References
Conclusion Reviewing the literature devoted to mental health care in prison it is immediately obvious that there is a striking difference between the care available in the NHS and in prison. The reasons underlying this difference are inadequate financing and lack of coherent policy. The latter has been subject to attention recently with the focus in policy development shifting from HM Prison Service to the Department of Health, resulting in a number of positive changes. These changes have also brought some much-needed resources into prison health care, leading to introduction of methods that have been commonplace in the NHS. It can be argued that prison health services are becoming an extension of the NHS services, however more co-operation between the two services is required and a great deal of stigma must be overcome for this vision to reach its full potential. There is also evidence that financing still remains inadequate and the financial difficulties faced by the NHS may threaten the progress of this reform. A further interesting point was the difference in approach to mental health care for prisoners, either keeping it primarily in prison (which appears to be at the heart of government policy) or entrusting it
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2. 3.
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6. 7. 8.
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Howard J. The state of the prisons in England and Wales, with preliminary observations and accounts of some foreign prisons. Warrington; 1777 Singleton N, Meltzer H, Gatward R. Psychiatric morbidity among prisoners in England and Wales. London: Stationery Office; 1998 Singleton N, Bumpstead R, O’Brien M, Lee A, Meltzer H. Psychiatric morbidity among adults living in private households, 2000: summary report. London: Stationery Office; 2001 Hayton P, Boyington J. Prisons and health reforms in England and Wales. Am J Public Health 2006; 10: 1730-1733 doi:10.2105/AJPH.2004.056127 Joint Prison Service and National Health Service Executive Working Group. The future organisation of prison health care [online]. Available: http://www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/ DH_4006944 (accessed 16/4/2009); 1999 Michael-Titus A, Revest P, Shortland P. The nervous system. Edinburgh: Churchill Livingstone Elsevier; 2007 Reed J. Mental health care in prisons. Br J Psychiatry 2003; 182:287-288 doi:10.1192/bjp.182.4.287 Reed JL, Lyne M. Inpatient care of mentally ill people in prison: results of a year’s programme of semi-structured inspections. Br Med J 2000; 320:1031-1034 doi:10.1136/bmj.320.7241.1031 Brooker C, Duggan S, Fox C, Mills A, Parsonage M. Shortchanged: spending on prison mental health care [online]. Available: www.scmh.org.uk/pdfs/short-changed.pdf (accessed 16/4/2009); London: Sainsbury Centre for Mental Health; 2008 Earthrowl M, O’Grady J, Birmingham L. Providing treatment to prisoners with mental disorders: development of a policy. Br J Psychiatry 2003; 182:299-302 doi:10.1192/bjp.182.4.299
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lsjm 30 november 2009 volume 01
RESEARCH
Does ethnicity impact upon reporting of depression in London medical students? Rachel Baigel*, Deborah Ragol Levy, Robert Freudenthal, Daniel McNaughton, Sara Taha (all Year 4 Medicine, University College London) rachel.burns@ucl.ac.uk doi:10.4201/lsjm.psy.003
Abstract Background Mental illness, particularly depression, is responsible for a significant proportion of the world’s health burden. Psychiatric disorders, particularly depression with suicidal ideation, have long been known to be more prevalent amongst healthrelated occupations. Depression can present in a wide variety of ways. This study seeks to ascertain how ethnic differences impact on the presentation of depression in London medical students and what factors prevent students from seeking professional help. Methods An online questionnaire was distributed to pre-clinical medical students at University College London, Kings College London and Bart’s and the London School of Medicine. Students were asked to respond to four case vignettes describing different levels of depressive symptoms in a student. These were constructed based on the ICD-10 criteria for mild, moderate and severe depression with a control vignette that represented subclinical symptoms of depression. Students were asked how likely they would be to seek help from different services and the reasons that would prevent them from going to these services. Analysis of variance (ANOVA) tests were used to conduct statistical analysis. Findings Overall, the most common health-seeking behaviour was from friends, with the exception of Black African-Caribbean students, who were more likely to get help from their family. Seeking help from general practitioners, counsellors and university tutors was unpopular, even in severe depression. There were statistically significant differences between ethnic groups in attitudes towards seeking help from: a friend in both subclinical (p=0.032) and mild (p=0.043) depression; a relative in subclinical depression (p=0.047); a counsellor in mild depression (p=0.025), and from a university tutor in subclinical depression (p=0.04). When students were asked about the factors deterring them from seeking help for depression, 31% said they definitely wouldn’t seek help as they believed their grades would suffer as a result, 35% said they wouldn’t want the label of depression, and 33% said they believed that seeking help for depression could affect their medical career. Interpretation Our findings indicate that despite an abundance of services available, greater efforts should be made to increase student awareness of these services at induction and throughout medical school. Students should be familiar with the multiple presenting symptoms of depression and understand the ramifications of not seeking help. Greater efforts can be focused on students of Black African-Caribbean origin, who have been shown in this study to be less likely to seek help from professionals.
Introduction Mental illness, particularly depression, is responsible for a significant proportion of the world’s health burden. The World Development Report 1993 states that depression is the fifth most common cause of morbidity amongst women and seventh amongst men. The World Health Organization has predicted that by 2020, depression will be the second most common cause of disability worldwide after ischaemic heart disease1. Depression is commonly under-diagnosed with an estimated 56% of people worldwide exhibiting clear-cut features of clinical depression but receiving no treatment. An estimated 74% of Europeans are affected by mental illness but remain untreated2.
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Prevalence of depression varies across different socioeconomic and occupational groups. There is evidence that young people have the highest population prevalence for mental health problems and substance abuse, however, their use of primary care and specialist services tends to be lower compared to other population age groups3. This remains true amongst university students, where the high prevalence of anxiety and depression is thought to be related to social and academic factors. One study of Oxford University students reported higher rates of suicide than in the general population, with half of these students suffering from clinical depression4. University students are notoriously reticent in presenting depressive symptoms to healthcare services. One study involving six French universities highlighted that only 30.5% of students with psychiatric symptoms sought professional help in the previous twelve months5. Psychiatric disorders, particularly depression with suicidal ideation, have long been known to be more prevalent amongst healthrelated occupations, due to pressurised working environments and easy access to suicidal agents6. However, few studies have investigated the prevalence of psychiatric disorders amongst medical students compared to the rest of the student population.
ERRATUM Due to an administrative error, an early version of this article was included in Vol1 Issue 1. The final version has been included in this publication and is also available is available online at www. thelsjm.co.uk/psychiatry. The LSJM apologises for any inconvenience caused. *Conflicts of interest - Rachel Baigel is a panellist for LSJM Psychiatry
University students, particularly in London, are a heterogeneous group with a large proportion from ethnic minority backgrounds. It has been shown that presentations of depression are culturally dependent with somatic complaints dominating over psychological symptoms amongst non-Western cultures7. Within the UK it is unclear if the prevalence of depression is higher amongst ethnic minorities, with one study showing that whilst London Punjabi populations have a lower rate of diagnosis, they experience more depressive thoughts than their white counterparts8. Previous studies have explored the different factors that prevent presentation to healthcare services and suggest that many people hold stigmatising attitudes towards depression. The diagnosis of depression is commonly viewed as a sign of weakness9 and those diagnosed are often seen as being unpredictable and threatening. If the likelihood of self-presentation to healthcare services for depressive symptoms does vary between ethnicities, then de-stigmatising interventions that attempt to minimise these preventative factors can be targeted to the appropriate groups. It is likely that the burden of depressive illness amongst London medical students is high, however the interaction between ethnicity and presentation of clinical depression within this student group is complex and as yet unexplored. Therefore, this study aims to ascertain how this interaction impacts on the likelihood of selfpresentation to healthcare services when experiencing features of clinical depression.
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RESEARCH
Figure 2. For each vignette students were presented with the following statement: If you were experiencing these problems how likely would you be to see help from: please fill in 1-4 where 1 = wouldn’t go, 2 = might go, 3= would probably go, 4=would definitely go) Internet/books A friend A relative GP University counsellor Other counsellor University tutor Someone else not on this list, please specify ________
Figure 3. At the end of the questionnaire the participants were asked:
Methods To study the impact of ethnicity on help seeking behaviour for depressive symptoms, four vignettes were prepared which presented a fictional case study about a student (appendix). One vignette described a person with no symptoms of depression and the other three represented scenarios of mild, moderate and severe degrees of depression according to the ICD-10 classification of depression (figure 1). Whilst it would have been preferential to maintain the same triggers in each vignette, it was decided to vary the triggers in order to engage the respondents’ interest and increase the completion rate.
whether there were significant differences between the attitudes of medical students from different ethnic groups in seeking help for sub-clinical, mild, moderate and severe depression from internet/ books, friends, relatives, their GP, university counsellors, other counsellors or university tutors. ANOVA was used as this method allows the comparison of the means of multiple groups. ANOVA tests were also carried out to identify statistical differences between ethnicities regarding factors that would affect students seeking help for depression. In total 36 ANOVA tests were performed. Statistical significance of the results was defined to be at the 5% level of significance.
In relation to each vignette, participants were asked to score the likelihood of them seeking help from a range of services (figure 2). Participants were also asked to score the different factors that would affect their decision to attend these services (figure 3).
Where the ANOVA tests were significant, the results were divided into binary variables, with 0 representing ‘wouldn’t go’ and ‘might go’, and 1 representing ‘would probably go’ and ‘would definitely go’. Logistic regression analyses were then carried out to determine the situations in which ethnic categories had significantly different odds of seeking help compared to White British students (odds ratio - OR). This group was selected for comparison as it contained the greatest number of respondents.
This questionnaire was distributed to pre-clinical medical students (including undergraduate and graduate entry level students) at University College London Medical School, King’s College Medical School and Bart’s and the London School of Medicine. The latter two universities sent an email directly to the students’ account with a link to the questionnaire, whilst the first university requested that students participate through a weekly medical student newsletter. Distribution of the survey in undergraduate lecture theatres was considered, but it was felt that this might introduce a selection bias towards those that attended lectures. Nevertheless, some selection bias remained as students with an interest in depression may have been more likely to complete the questionnaire. Therefore, students were asked to state whether they had a personal and/or family history of depression. Some confounding factors remain; where students were educated, which respondents were overseas students, and if any had personal experience of working in the mental health sector. However, this data was not collected. The questionnaire was hosted online at www.surverymonkey.com and was accessible for a period of three weeks, from Monday 20th October to Monday 10th November. An incentive of £20 was made available to encourage responses, as evidence indicates that responses double when a monetary incentive is used10.
How likely would it be that the following factors prevented you from seeking help from the list above? 1-3 where: 1 = wouldn’t prevent me at all, 2 = might prevent me 3 = would definitely prevent me They would think less of me. I wouldn’t want other people interfering with my business. Wouldn’t want to waste their time. This could affect my career as a doctor. This could affect my grades or go on my university record. Wouldn’t want to have a label of “depression”. The opening hours wouldn’t suit me/I wouldn’t have time. The service is too far away. Another reason ___________
On entering the online domain, participants were presented with contact details of the counselling services of their respective institutions and were given the chance to opt out of the study at any point. Ethical approval, data protection and research governance was granted by the relevant departments at University College London. Statistical analysis was carried out using Stata Version 10. Ethnicities were grouped together under seven categories and analysis of variance (ANOVA) tests were performed to ascertain
Figure 1: The vignettes were constructed from the ICD-10 classification of depression. The vignette titles correlate with the ICD-10 criteria for mild, moderate and severe depression.
Symptoms
Mild
Moderate
Severe
depression
depression
Depression
X
X
X
X
Depressed mood
X
Loss of interest and enjoyment
X
Reduced energy with increased fatigability Reduced concentration and attention
X
X
X
Reduced self esteem and self confidence Ideas of guilt and unworthiness
X
X
Bleak and pessimistic views of the future Ideas or acts of self harm or suicide
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Disturbed sleep
X
X
Results This questionnaire was sent to 1760 students. 360 (21% of the study population) started filling out the questionnaire and 311 (86%) of these people responded to all the questions. 56% of respondents were second year students and 44% were first year students. 10% of the students had previously suffered from clinical depression and of these 33% suffered from mild, 27% from moderate and 9% from severe depression. (See figure 4 for more demographics.) Of the students who completed the questionnaire, 58% were female and 42% were male. All participants were aged 18-30, with 64% aged 19-20. The response rate of 18% fell only slightly below the expected response rate of an email survey of 20.7%.11 Data concerning the ethnic make-up of pre-clinical students in these medical schools was unavailable so it was not possible to ascertain how representative this sample was. The representation of ethnicities in the study was: White British 51%, Indian-Asian 16%, White Other 12%, Chinese 8%, Mixed Race 6%, Asian Other 5%, Black African-Caribbean 2% These ethnic categories were used in line with UK National Census 2001 categories12, however due to the small sample size in some of the minority populations it was necessary to group together Black African and Black Caribbean students. Overall, the Indian and Asian Other populations suffered the highest morbidity, with 50% of the subjects claiming to have experienced severe depression and the other 50% reporting moderate depression. The only other cases of severe depression occurred in the White British and White Other populations. In the
Figure 4: Demographic data of 311 respondants
Ethnicity
Percentage of each ethnicity who had been depressed
Percentage of total depressed
Severity of depression within each ethnic group Unknown
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Severe
Asian Other Black AfricanCaribbean Chinese
0.0%
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Mixed
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12.1%
75%
25%
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White British
7.7%
42.4%
29%
36%
29%
7%
White Other
17.8%
24.2%
38%
13%
38%
13%
50%
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RESEARCH Black African-Caribbean and mixed populations, all participants classified their depression as either mild or unknown. None of the students in the Asian Other population reported suffering from depression (see figure 4). There were 4 situations in which the ANOVA tests were significant and where Bartlett’s test indicated that the variances were not unequal, implying that the ANOVA test was appropriate to use (figure 5). In 3 of these situations, even though the ANOVA test was significant, no ethnicities were found to have significantly different odds ratios from the White British group (not shown). This implies that there is a significant difference between at least two of the groups excluding the White British group. The situations where both the ANOVA and the odds ratio were significant are shown in figure 7, where four bars are displayed for each ethnic group, representing the percentage of that group who selected each response. Figure 5: Significant findings with ANOVA test. For these vignettes there were statistical differences between the willingness of different ethnic groups in seeking help from the services indicated. Vignette Seeking help from: severe depression friend moderate depression friend mild depression friend unaffected
relative
P value P=0.048 P=0.015 P=0.015 P=0.04
One of the assumptions that ANOVA requires is that the different ethnic groups have equal variances. This can be tested using Bartlett’s test. When this test reaches significance it means that the variances are unequal, implying that the distributions for each of the categories are not identical. ANOVA can be thought of as a test of equality of distributions, so when the test for equality of variance fails, this is a good indication that the distributions are not the same, implying that there are differences between the categories. Unequal variance was found in 7 of the tests (figure 6). Figure 6: Situations where ANOVA failed due to unequal variance. As the variance of the data from the ethnic groups are non-identical, it is reasonable to suggest that there were differences in the willingness of the ethnic groups to seek help from the services stated for the mentioned vignettes. Vignette
Seeking help from:
severe depression moderate depression moderate depression mild depression
internet/books internet/books non-university counsellor internet/books
mild depression
non-university counsellor
unaffected unaffected
internet/books university counselor
Of the situations where there was unequal variance, 3 had significant odds ratios. These are illustrated in figures 8-10, with two bars for each ethnicity due to the binary nature of the data which is required to calculate the odds ratios. In cases where there was unequal variance with a non significant odds ratio, it can be concluded there were significant differences between at least two of the groups, excluding the White British group. ANOVA tests were also carried out to investigate whether the reasons for not seeking help differed between the ethnicities. None of these were found to be significant, implying that the reasons did not differ between ethnicities. However, the student population was unwilling to seek help due to stigma and concern about future careers and exam grades, regardless of ethnicity (see figure 11).
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Discussion & Conclusion The reasons that students present to welfare or healthcare services for depression are complex. This study attempted to ascertain what factors lead to some students presenting earlier than others, and to identify any correlations between the ethnicity of the students and their presentation. The results showed similar trends between the ethnic groups in reporting behaviours for depression. The Black African- Caribbean group deviated more from this trend than any other ethnic group. This was particularly notable in subclinical and mild depression, where help was commonly sought from friends. In subclinical depression, seeking help from a friend was the most popular choice among all the ethnic groups, with the exception of the Black African-Caribbean group, who were just as likely to seek help from their relatives. This shows that for subclinical depression most students felt that there was no need to approach a professional, whether a health professional or a university tutor, and felt that they could deal with their symptoms through a social context using friends and family for support. Students may feel that they do not need professional support or may feel more comfortable talking to friends and family who understand their cultural and religious background. This is supported by our findings that students were reluctant to seek help for depression due to accompanying stigma and concern about confidentiality (see below). In keeping with the trend for subclinical depression, all the ethnic groups were most likely to seek help from friends for mild depression, with the exception of the Black African-Caribbean group who sought most help from relatives. This could be attributed to the strong family values in these communities. Overall, there seems to be a reluctance to approach professionals, which is further evidence to support research looking into health seeking behaviours for psychiatric disorders in students13. In this study, the Black African-Caribbean students seemed more reluctant to seek help from any source. However, our study population of this ethnic group was small and therefore may not be truly representative of the Black African-Caribbean population we were surveying. In order to confirm our findings, these students could be compared to students of other ethnic groups on a larger scale. If it was confirmed that Black African-Caribbean students were less likely to seek help for depression, steps should be taken to introduce campaigns to increase awareness of these services and their confidential nature to these students to increase help seeking in this ethnic group. With regard to moderate depression, it was interesting to note that once again friends were the most popular choice for help amongst all ethnic groups. Therefore, even though the severity of the condition had increased, the health seeking behaviours remained the same. Students may be more inclined to seek help from friends due to the fact that they are commonly in their late teens, away from home and spend lots of time with their friends. As many students live with fellow university students it seems natural that they would share their problems with those who are closest to them. The only group who were likely to go to their General Practitioner (GP) were the Black African-Caribbean students for mild depression, where the GP was the most popular option after talking to a relative. However, this became the least popular choice in moderate depression, with a slight increase in popularity in severe depression. In other ethnic groups, although the GP was an unpopular choice overall, students were collectively more likely to go to the GP as the severity of their depression increased.
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Figure 7: This graph shows that for mild depression there were significant differences between the wouldn't go ethnic might gogroups. The responses of the White Other would probably go population towards not seeking help from would definitely tended go a friend in mild depression, whilst the White British population were more inclined to seek help from a friend OR 0.36 (CI 0.18,0.74). From the graph, every ethnic category were more likely to seek help from a friend than the White Other group.
Mild depression - Seeking help from a friend (P=0.015) 50 40 30 20 10
hit
e
Ot
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Percentage response of each Ethnic Category (%)
RESEARCH
might go
would probably go
would definitelty go
Severe - Seeking help from internet/books 100 80 60 40 20
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Percentage response of each Ethnic Category (%)
wouldn’t go
would probably/definitely go
Mild - Seeking help from internet/books 100 75 50 25
er O
ix
th
ed
an
W
In
hi
do
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O
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th
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sh
0
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Percentage response of each Ethnic Category (%)
wouldn’t/might go
Figure 8: Here there was unequal variance, but the odds ratios clearly show that the White British population would tend towards seeking help from the internet or books in severe depression, but wouldn't/might go would probably/definitely go that the Asian Other OR 0.03 (CI 0.00 - 0.26), Black African-Caribbean OR 0.08 (CI 0.01 - 0.70) and Chinese OR 0.13 (CI 0.05,0.37) populations would all tend not to use this form of help. From the graph, the Indian Asian, Mixed and White Other populations all appear to be inclined towards seeking help from the internet and books in severe depression.
would probably/definitely go
Unaffected - Seeking help from a university counsellor 100 80 60 40 20
er th
ed
O
ix
te
si -A
W
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do In
Figure 10: For this example there was unequal variance. Seeking help from a university councillor was unanimously unpopular for people who were wouldn't/might go unaffected by depression, but the mixed population would probably/definitely g were almost 4 times more likely to seek help from the university counsellor than the White British population OR 3.90 (CI 1.21 - 12.55)
Bl
ac
k
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C
ar
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As ia
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Percentage response of each Ethnic Category (%)
wouldn’t/might go
Figure 9: For this example there was unequal variance and all the ethnic categories tend towards not seeking help from the internet/books in mild depression. However, the Asian Other OR 0.11 (CI 0.01 - 0.86) and Chinese OR wouldn't/might go would probably/definitely go 0.14 (CI 0.03 - 0.60) groups were much less likely to use this modality for help than the White British population, and from the graph the Indian Asian group also mirrors the sentiments of the White British group. The Mixed and Indian Asian groups were more divided concerning this issue, but of the Black African-Caribbean population, none would consider seeking help from the internet/books for severe depression.
wouldn’t/might go
would probably/definitely go
a. My exam grades would suffer as a result of seeking help
33%
37%
b. Seeking help for depression could affect my medical career
42%
31%
27%
30%
Figure 11 (a-c): Reasons for not seeking help for depression a) 63% of students were concerned that their exam grades would be affected b) Many were concerned that it would affect their medical career. This corroborates with data from figure 10 which shows how unlikely students were to approach a university tutor c) many feared stigmatisation.
c. I would not the label of depression Would definitely prevent me going Might prevent me from going Would not prevent me from going
31%
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With the lack of presentation to health services, it seems that depression remains undiagnosed amongst students. When comparing students to the population, the same trend can be seen; people who are suffering from depression do not report it14. Consulting university tutors and counsellors for depression was universally unpopular. However, students of Chinese origin were more inclined to consult a university tutor for mild symptoms of depression than any other ethnic group. A medical degree requires frequent use of internet and library services, so it was interesting to see what role this played within medical students’ health seeking behaviours. Indian-Asian, White British and White Other groups consistently used this method more than other ethnic groups. The severity of the symptoms did not impact on the decision to use this resource in any ethnic group. It could be that being brought up in a Western society, with the internet as a popular source of information, would lead certain groups to use it more frequently. However, other factors need to be considered, as medical students may be more sceptical about the reliability of the internet as a source of information than the rest of the population. With many students being away from home for the first time, it is unsurprising that they may feel alone and experience depressive symptoms. It has been shown that overseas students experience more stress as they are away from family and often find it difficult to adjust to a new routine and interact with members of the host culture, and that this stress can sometimes trigger depression.15 As such, the overseas student population is a population that is particularly vulnerable to depression and should perhaps have been analysed separately. In this study we did not require students to state whether they were an overseas or a home student, and this could be helpful for further research. Overall, the study found that despite the diversity of the respondents to the questionnaire there were some unifying factors across all groups that prevented presentation of depressive symptoms. Seeking help from friends and family was always more popular than seeking help from tutors or counsellors. This was elucidated by the fact that 63% of respondents had concerns that seeking help for depressive symptoms would affect their medical career, whilst 69% of students were concerned that seeking help would result in an unwanted label of ‘depression’. These statistics are concerning as they highlight the stigma that exists within the medical world. Previous research into students’ attitudes to depression has demonstrated a lack of knowledge about the illness and the implications that a diagnosis and its subsequent treatment may, or may not, have16. Our study provides further evidence for misconceptions about depression amongst students. The fact that the majority of respondents fear that contact with welfare or health services will have negative implications for their future career has clear implications for the presentation of students with depression. This carries a significant risk of under-diagnosis and subsequent poor management of depression within this group. There are some confounding factors which mean that these results cannot be extrapolated to the remainder of the London student population. The vast majority of students studying medicine will have fully engaged, participated in and succeeded in the British education system and therefore may have adopted similar views and responses to depressive symptoms. In using medical students as a study population, we surveyed a highly educated, medically interested subsection of society, who have all been trained in the importance of confidentiality in a professional setting. We would expect this group to have greater
35%
34%
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RESEARCH immunity to society’s stigmatisation of depression than other social groups and understand that a medical professional is bound to keep patient’s details confidential. It is worrying that a large proportion of students in this study would not seek help due to stigma and concern about exam grades and future careers. We suggest that action should be taken in medical schools to promote a better understanding of the issues on confidentiality, as this would impact both on the care of future patients and the unwillingness of medical students to seek help in the knowledge that their disclosure would remain completely confidential. Such action would also help to improve the cost effectiveness of university counselling services. This study asked theoretical questions about the likelihood of students seeking help for depression. The majority of the students assessed claimed to have had no history of depression and therefore the study largely surveyed the attitudes of healthy students as to whom they would go to for help. To accurately address the question of how likely students are to present for help with depression, it would be important to interview and identify students who were depressed, classify their depression according to ICD-10 criteria, and then ask them how likely they would be to present to each service. These results would be far more accurate than the results obtained in this study, but would require a larger study population and greater amounts of time as each student would need to be interviewed to assess their mental state. Further research needs to be done to investigate why these attitudes persist in order to execute suitable interventions to tackle these potentially damaging attitudes amongst the London medical student population. This study surveyed a population where the majority of respondents had no history or diagnosis of depression. Focused research should be done amongst patients with diagnoses of depression to ascertain whether these attitudes also persist in that population group. Having achieved these results, it is important to address the negative attitudes of medical students to seeking help for depression. Universities should establish focus groups to gain some insight into how to improve their services, and should encourage medical students to present to mental health services when needed. The reluctance to present to mental health services may be ingrained prior to arrival at University. Therefore, it is important to assess the attitudes of children and teenagers towards seeking help for depression and to provide education at primary and secondary school level to combat this. A further study could provide students with information about confidentiality, particularly in relation to university counselling services, to assess if this information would improve the attitudes of students to seeking help. Perhaps, an audit on the use of university counselling and its success rates in preventing depressive sequelae would increase the students’ confidence in the service. Appendix 1 – Case Vignettes Vignette 1 – Severe depression Since your grandma passed away three months ago, you have noticed some changes in your daily routine. You wake at 5am despite feeling tired all the time. You have little energy and rarely cook for yourself. You are feeling down and have little interest in your university course. You remember an incident from the beginning of the summer when you left a shop with an apple and forgot to pay for it. You feel very guilty about this and feel that you have brought shame on your family. Sometime you hear voices talking about you and to you saying that you are worthless and you should turn yourself into the police for stealing the apple.
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Vignette 2 – Mild depression Since starting university over three weeks ago you have been feeling quite low. You are struggling to make it in for your 9am lecture, despite getting a reasonable night of sleep and you find that you are eating less and rarely make your own food. You find that you are going out a bit less in the evenings, but are finding it harder than usual to concentrate in lectures, and you no longer enjoy some of the things that used to. Vignette 3 – Unaffected by clinical Depression You have noticed that a few things have changed in the last couple of weeks running up to your first big set of exams. You wake earlier in the morning in order to make it to lectures, but oversleep a couple of days a week. Your eating habits have changed – you haven’t had much time to cook for yourself and find yourself skipping breakfast due to the morning rush and consequently nosh more during the day. Sometimes, especially towards the end of the day, you find it hard to concentrate in lectures. One evening in the last week you felt a bit down, and so you decided to go to the cinema and watch an upbeat film. Vignette 4 – Moderate depression Since your boyfriend/girlfriend broke up with you over a month ago, you’ve started to notice some changes. Your appetite has gone and you notice that your clothes are starting to look increasingly baggy. You feel tired a lot of the time, but still wake most mornings at about 5am. Things take you a lot longer than they used to, so often you just stay in your room. You begin to feel guilty about this and think that you don’t deserve anything better anyway. Your friends have been out partying and normally you would have loved to join them, but just don’t seem to enjoy the things you used to anymore. Acknowledgements Many thanks to Rebecca Landy for help with the Statistical analysis Thank you to Dr. Mary Howman for reviewing and editing the questionnaire. Thank you to Dr. Angela Hassiotis for her assistance with obtaining ethical approval. References 1.
2. 3.
4.
5.
6.
7. 8. 9.
10.
Bhugra et al. Globalisation and mental disorders. Overview with relation to depression. The British journal of psychiatry : the journal of mental science (2004) vol. 184 pp. 10-20 Thornicroft. Most people with mental illness are not treated. Lancet (2007) vol. 370 (9590) pp. 807-8 National Mental Health Report 1996, Fourth Annual Report. Changes in Australia’s Mental Health Services Under the National Health Strategy 1995–96. 1998 Canberra : Dept. of Health and Family Services, 1998. Hawton et al. Suicide in Oxford University students, 1976-1990. The British journal of psychiatry : the journal of mental science (1995) vol. 166 (1) pp. 44-50 Verger et al. Psychiatric disorders in students in six French universities: 12-month prevalence, comorbidity, impairment and helpseeking. Social psychiatry and psychiatric epidemiology (2009) pp. Meltzer et al. Patterns of suicide by occupation in England and Wales: 2001-2005. The British journal of psychiatry : the journal of mental science (2008) vol. 193 (1) pp. 73-6 Minhas FA, Nizami AT. Somatoform disorders: Perspectives from Pakistan. Feb 2006; International Review of Psychiatry. 18(1) (55-60) Ibid Bhugra et al. 2004 Barney et al. Exploring the nature of stigmatising beliefs about depression and help-seeking: implications for reducing stigma. BMC public health (2009) vol. 9 pp. 61 Edwards et al. Increasing response rates to postal questionnaires: systematic review. BMJ (2002) vol. 324 (7347) pp. 1183
For the full list of references see thelsjm.co.uk.
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INTERVIEW
What’s in a name?
In an interview, Richard Bentall challenges psychiatric diagnosis Andy Gray Year 4 Medicine, Cardiff atgray@gmail.com Introduction Professor Richard Bentall is a clinical psychologist who wants to revolutionize psychiatry. Author Sebastian Faulks recently named Madness Explained by Richard, written in 2004, as one of his favourite books. He calls himself an ‘anti-psychiatrist’ and argues that because psychiatric diagnoses are largely defunct, we should get rid of them. His basis for this argument is that the diagnoses psychiatrists use are actually very poor markers of outcome, including treatment response. This controversial argument has been made before, but largely by people without sufficient rigour or discipline to be taken completely seriously by the scientific community. Richard, however, is “committed to the scientific world view” and comes across as very well researched. What he really wants is to see psychiatry move forward like the rest of medicine has over the last fifty years. This busy man, found time to see me on a Friday afternoon in his office. He arrives a little late from his previous meeting, but is clearly pleased for this opportunity to get “the future psychiatrists” thinking about his work. The History “Emil Kraeplin was an austere, frightening German patriot who wrote awful, nationalistic poetry” begins Richard in a shortened and slightly alternative history lesson. He continues by saying that Kraeplin was also a “genius for his time”, who decided that in order for psychiatry to succeed, a classification system was needed. Perhaps interestingly, his brother was a botanist who classified plant species. Kraeplin went on to identify individuals that had the same symptom clusters and similar outcomes. He reasoned that they should also have the same brain pathology and aetiology, although these were probably beyond the scope of his research at the time. He was famous for first describing dementia praecox (schizophrenia), manic-depressive psychosis (bi-polar disorder) and paranoia (delusional disorder). Later, the ‘Neo-kraeplinians’ would develop the DSM (Diagnostic and Statistical Manual of Mental Disorders) based on Kraeplin’s concept. The DSM was to be purely descriptive and neutral, making it easy to use and less objective. Other than Post-Traumatic Stress Disorder (PTSD), which is classed by its aetiology, this is in theory true. But Richard argues that in practise this is not true; explaining that the problem is that users of the manual have assumed (along with Kraeplin) that the severe psychoses are genetically determined, biological issues.
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The Issue Like most self-respecting scientists Richard stumbled upon his field of interest slightly by accident. He told me how a distinguished psychiatrist was interviewing him for a job and asked, “What is the scientific validity for the schizophrenia concept?” Not quite yet the learned man in front of me, he replied badly and failed. Various clichés could describe the importance of this moment and the following process that led him to his current position: that the schizophrenia concept (amongst others) is rubbish. He tells me a joke, ‘Why does a psychiatrist diagnose schizophrenia?’ ‘So they can prescribe anti-psychotics of course!’ ‘Why does a psychiatrist diagnose delusional disorder?’ ‘So they can prescribe anti-psychotics of course!’ ‘Why does a psychiatrist diagnose bi-polar disorder?’ ‘Well… so they can prescribe Lithium! But, they tend to use antipsychotics…’ OK, so it wasn’t a funny joke. But he got his point across – diagnoses are not always useful. He tells me the literature is clear, diagnoses do not predict treatment response (in this field). Then Richard whips out his famous catchphrase: “the DSM is about as scientific as star signs!” The purpose of star signs is to tell you something about your future, like diagnoses. Problem is they don’t. Richard has been discussing this issue with psychiatrists for twenty years and apparently a “sense of crisis is emerging slowly”. “The idea that the DSM is seriously wrong is no longer regarded as a wacky, left-wing delusion” at least not by the academics. However, the DSM is often regarded as the bastion of modern psychiatry and certainly won’t disappear over night, even if there was a perfect alternative. The ‘Solution’ The idea that, for example, schizophrenia is more complicated than whether you have it or not isn’t new. However, the DSM still works on this principle. Currently debated is the dimensional classification system that will divide disorders into ‘dimensions’ allowing more meaningful diagnoses, with better predictions for treatment response. Richard thinks this is a step in the right direction, but his solution is far more radical. “Schizophrenia doesn’t exist!” he exclaims, querying the usefulness of diagnoses at all. He vies for a ‘complaintorientated approach’: don’t worry about a diagnosis; just write a list of the patient’s problems (“similar to the list that’ll be written
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Source: Richard Bentall
INTERVIEW under the diagnosis anyway!”) Amongst other benefits, “this will help healthcare professionals look after the patient’s problems, not their symptoms”. Richard sometimes tends to paint a bleak picture of today’s psychiatrists blindly prescribing and missing the issues that are actually causing the patient angst. He recently went to a ‘voice hearer’s conference’ in Europe and tells me that a lot of people hear voices, including lots of normal people (even doctors!) These people do not need their symptoms “aggressively stamped out by drugs with side effects”. Richard argues that it is much more important to deal with each of the patients’ own concerns, as “once the complaints are broken down and dealt with, there won’t be any schizophrenia left to treat!” I wondered whether with this approach problems might arise with deciding which complaints to treat. Fundamental to Richard’s work is the idea that psychiatric complaints are exaggerations of normal experiences. However, the issues dealt with here are a little more complex than, say, essential hypertension and the use of a diuretic or ACE inhibitor. Richard, with the slightly knowing gleam in his eye of a man who’s been asked this before, replies “but this is the crystal issue of psychiatry! Experiencing symptoms is not the problem, but rather the inability to function properly”. Homosexuality used to be part of the DSM, and PTSD was only recently added. Boundaries between normal and abnormal change; so don’t attach so much importance to them. Classical psychiatric symptomology can miss the real issues. A complaint is anything that is an issue for the patient (housing, relationships etc.) Richard tells me that the list of potential complaints is relatively small when dealing with severe psychoses (although this number will never stay the same for long). These include: hallucinations, delusions, thought disorder, negative symptoms, depression and anxiety. We’re often told being a doctor is about pattern recognition; medicine isn’t exactly chaos theory. I asked Richard whether patterns could re-emerge after being broken down. “Yes, it’s possible… I’m not against the principal of diagnoses… but the DSM just doesn’t work”. He tells me he would bump his head against the wall and cry, “why didn’t I think of that!” if someone came up with the perfect solution. In the mean time however, “we can make more progress by targeting complaints”. I also wondered whether removing the diagnostic labels would make it difficult for people to fit into the sick role. Apparently this is a rare problem, and in actual fact “most patients hate being told they have schizophrenia”. Therapy OK. So, we’ve binned diagnoses and now have lists of ‘complaints’. Frequently accused of disregarding the usefulness of antipsychotics, I wonder what Richard has in mind in terms of treatment possibilities. He sounds frustrated, “I am not against psychiatric drugs, I am just for the cautious use!” A self-proclaimed pragmatist he wants treatment that isn’t just built on the “current biobiobio model”. His argument is simple – drugs are overused, psychological interventions are underused; so change. To develop this point Richard tells me how the current use of anti-psychotics can be viewed as unethical. Although the effect of anti-psychotics in an acute crisis is remarkable, this only occurs in 70% of patients. However, 98% of psychotic patients are on these drugs, despite the high number of horrendous side effects. Moreover, “effects of long-term use may even increase the risk of relapse” and yet lifetime use is the most common treatment method. At this point Richard reminds me of his practical approach and states the obvious: “treatments
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should be given to those who benefit from them”. This goes on to include psychological interventions, which are legion. The relatively small amount of research done in this area makes it difficult to make accurate comparisons. However, the consensus is increasingly that such interventions are helpful, and at least as efficacious as drug treatment in mild to moderate disorders. Cognitive behavioural therapy is Richard’s speciality, and he gives me a quick run-through on how you might approach a paranoid patient. Firstly, of course, the problem list. The key then is to introduce them to skills that enable them to work out whether they are looking at things that frighten them in the best way possible. This does not include saying “I’m the expert and know what’s going on. You’re wrong, and I’m going to prove it to you”, but rather “You’re having some puzzling experiences and they seem strange to me. Let’s try and figure out whether there is another way of looking at them”. I ask Richard who he thinks will be performing these treatments in the future. He tells me that nearly forty years ago Hans Eysenck predicted a divorce between psychiatry and psychology. He thought psychiatrists would retain expertise in severe mental illness, and psychologists would become the experts on milder conditions (anxiety, depression). But, amongst other problems, the psychological needs of the psychotic patient were not best seen to in this manner. Richard believes “the future is clearly greater integration between psychiatry and clinical psychology. If we were starting from scratch, we’d probably design a hybrid profession”. He suggested that psychiatrists might develop more interest in psychological therapies, and likewise psychologists adopt roles traditionally restricted to psychiatrists (case management and even prescribing). “In the NHS of the future, professions will only hold skill monopolies by default. People should play roles that depend on their competencies, rather than according to which professional tribe they happen to come from”. Exciting vision or unobtainable idealism? Final Thoughts Richard gave a talk recently to a “rather pleasant and receptive group of psychiatrists”. Unfortunately, after the talk they turned round and said ‘Well… we can’t do anything to change… we must focus on drug therapy, otherwise the other doctors won’t take us seriously’. Richard replies, “Why this anxiety about surgeons looking down on you? Psychiatrists should celebrate the fact they are different”. In thirty years time will we look back and laugh at how scattered our approach to psychoses was? Hopefully we will have a better understanding of how mental illness works, and therefore how we can treat the problems it causes. But this is a complex issue probably in need of philosophers as much as psychiatrists or psychologists. Many critics say that Richard is correct to point out the validity issues of psychiatric diagnoses. However, they would claim that getting rid of them is not the answer, but rather more research to refine them. We shouldn’t forget, however, that Richard’s favourite ice cream is ‘hokey-pokey’ – vanilla mixed with broken up Crunchie.
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